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PHM 703: Crit Care/Heme/Onc > Onc 1: Onco Emergencies > Flashcards

Onc 1: Onco Emergencies Flashcards

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1
Q

types of onco emergencies

A
  • metabolic: hypercalcemia of malignancy and TLS
  • hematologic: febrile neutropenia
  • sturcutral
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2
Q

hypercalcemia of malignancy most comon in pts with what type of cancer(s)

A
  • NSCLC
  • squamous cell cancer of head and neck
  • breast cancer
  • urolithial carcinomas
  • multiple myeloma
  • ovarian cancers
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3
Q

calcium levels in hypercalcium of malignancy

A

use corrected calcium = 0.8 (4 -albumin) + serum Ca

  • mild: Ca 10.5-11.9
  • moderate: 12-13.9
  • severe: >14
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4
Q

relevant labs in hypercalcemia of malignancy (except for Ca, that got it’s own slide)

A
  • serum phos
  • SCr
  • PTH
  • PTHrP
  • VitD
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5
Q

presentation of hypercalcemia of malignancy: renal

A
  • polydipsia
  • polyuria
  • dehydration
  • decreased GFR
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6
Q

presentation of hypercalcemia of malignancy: GI

A
  • constipation
  • anorexia
  • N/V
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7
Q

presentation of hypercalcemia of malignancy: neuro

A
  • lethargy
  • confusion
  • irritability
  • muscle weakness
  • seizure
  • stupor
  • coma
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8
Q

presentation of hypercalcemia of malignancy: cardiac

A
  • shorted QT
  • widened T wave
  • heart block
  • asystole
  • arrhythmias
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9
Q

hypercalcemia of malignancy MOA

A
  • humoral (most common)
  • bone invasion
  • rare causes: Vit D tox and ectopic PTH
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10
Q

Hypercalcemia of malignancy: humoral MOA

A
  1. increased PTHrP
  2. increased renal tubular reabsorption of Ca
  3. increased phos excretion in urine

  • PTH: decreased
  • PTHrP: increased
  • 1,25 (OH)2 D: decreased or normal
  • 25(OH)D: lol any
  • Phos: decreased
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11
Q

Hypercalcemia of malignancy: bone invason MOA

A
  1. tumor cell releases cytokines
  2. activation of osteoclasts and bone reabsorption
  3. secretion of Ca

  • PTH: decreased
  • PTHrP: decreased
  • 1,25 (OH)2 D: increased
  • 25(OH)D: decreased or normal
  • Phos: decreased
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12
Q

Hypercalcemia of malignancy: vit D intox MOA

A
  1. malignant cells increased VitD too much
  2. increased produciton of calcitrio
  3. increased Ca reabsopriton

  • PTH: decreased
  • PTHrP: decreased
  • 1,25 (OH)2 D: increased
  • 25(OH)D: increased
  • Phos: increased or normal
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13
Q

Hypercalcemia of malignany: ectopic PTH

A
  • PTH: increased
  • PTHrP: decreased
  • 1,25 (OH)2 D: increased
  • 25(OH)D: decreased or normal
  • Phos: decreased
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14
Q

Hypercalcemia of malignany: ectopic PTH common pts

A
  • pts with hx of head and neck irradiation
  • hx of chronic Li therapy
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15
Q

Hypercalcemia of malignany: bone invasion common pts

A
  • multiple
  • metastatic breast cacer
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16
Q

Hypercalcemia of malignancy: Vit D tox common pts

A

hodgkin
s

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17
Q

Hypercalcemia of malignany: humoral common pts

A
  • squamous cell carcinomas
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18
Q

differnet therapies for hypercalcemia of malignany

A
  • increase Ca excretion: IV NS (diuretics in pts who are fluid restricted or volume overloaded)
  • decreased intestinal absorption of Ca: glucocorticoids
  • decreased bone resorption: IV denosumab, SQ calcitonin, IV bisphosphonates (pamidronate, zoledronic acid)
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19
Q

IV NS admin in hypercalcemia of malignany

A

1-2 L bolus then infusion at 200-500 ml/hr

decreases Ca by 1-1.5 mg/dL in first 24h

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20
Q

Diuretic admin in hypercalcemia of malignany

A

lasix 20-40mg

decrease Ca by 05-1.0 mg/dL

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21
Q

GC MOA in treating hypercalcemia of malignany

A

inhibit 1-alpha-hydroxylase and decrease 1,25(OH)2 D

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22
Q

GC admin in hypercalcemia of malignany

A
  • prednisone 60mg/day 10D
  • hydrocortisone 200-400mg/day 3-4D then prendisone 10-20mg/day 7D
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23
Q

sq denosumab MOA in treating hypercalcemia of malignany

A

binds to RANKL -> inhibit interaction between RANKL and RANK -> prevent osteoclast formation

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24
Q

SQ denosumab admin hypercalcemia of malignany

A
  • 120mg SQ QW up to 3x (if hyperCa persists after initial 3, can wait 2 weeks then start 120mg SQ Q4W)
  • no renal adjustment needed
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25
SQ denosumab ADR
- increased risk of infection - increased bone fracture risk - osteonecrosis of jaw - musculoskeletal pain - HA - hypo Ca, phosphours
26
SQ calcitonin MOA in treating hypercalcemia of malignancy
inhibit osteclastic bone reabsorption and increases excretion of Ca, phosphours, Na, Mg, K
27
SQ calcitonin admin in hypercalcemia of malignancy
- use in combo with IV hydration or bisphosphonates - 4U/kg IM or SQ Q12H (if hyper Ca persists, can increase to 8U/kg) - do NOT exceed use >48 hrs dt rsik of tachyphylaxis
28
SQ calcitonin ADR
- hypoCa - face flushing
29
IV bisphophonates MOA in treating hypercalcemia of malignancy
iniibit osteoclast activity
30
pamidronate dose
- corrected Ca 12-13.5: 60-90 mg IV over 2-24H - corrected Ca > 13.5: 90 mg IV over 2-4 h - retreatment: PRN at same dose in 7 days ## Footnote not recommended if SCr >3 or CrCl < 30 - if pt is gonna use though, do so at a slower infusion rate
31
zoledronic acid dose
- corrected Ca >12: 4mg IV - retreatment PRN in 7 days ## Footnote not recommended if SCr . 4.5 - if pt is gonna use though, can use a lower dose (2mg) and infuse over 30-60min
32
why do the IV bisphonates have a 7 day wait period before redosing if needed in the treatmnet of hypercalcemia of malignancy
takes about 7 days to fully respond to that first dose
33
IV bisphonates ADR
- increased risk of boone fracutres - musculoskeletal pain - flu-like illness - osteonecrosis of jaw - hypo: Ca, phosphours, Ca, Mg, K - nausea - anemia - infusion site reaciotn
34
TLS is seen in pts with what type of cancer
- non-hodgkins - AML - acute lymphoblastic leukemia - Burkitt's
35
non-cancer TLS risk factors
- elevated baseline uric acid - nephropathy - hypotension - left ventricular dysfunciton - HF
36
Tumor lysis syndrome (TLS)
much cancer cells lyse/die at the same time -> - increease in K, uric acid, phosphate - decrease in Ca ## Footnote cytokine release -> inflammmation 0> AKI
37
presentation of increased K
- fatigue - cardiac arrest - EKG abnormality
38
presentaiton of icnreased uric acid
- AKI - crystal nephropathy
39
presentaiton of increrased phosphate
- AKI - GI upset - AMS
40
presentation of decreased Ca
- AMS - seizre - arrhytmias - tetany/spasms
41
lab TLS
2 or more of the following within 3 days before or 7 days after chemo ## Footnote - K: > 6 or 25% increase from baseline - uric acid: > 8 or || - phopshate: >4.5 or || - Ca: < 7.0 or 25% decrease from baseline
42
clincal TLS
lab TLS + one of the following ## Footnote - AKI - seizures, neurmuscular irritability - cardiac arrhythmia
43
treatment of hyperK in TLS
**EKG continouosu monitoring** ## Footnote - loops - calcium - insulin - bicarb - SPS - hemodialysis or CRR
44
hyper phosphate treatment in TLS
IV fluids +/- diuretics
45
hypo Ca treatment in TLS
do NOT treat unless pt is *symptoatic* - then give ca gluconate ## Footnote usually resolves with treatment of hyperphos
46
TLS ppx
- lab montiroign Q4-6H - fluids: NS 150-300 ml/hr (do NOT use bicarb) - uric acid specific: allopurinol and rasburicase
47
allopurinol MOA
- prevent hypoxathine from turning into xanthinge - and prevents xanthine from turning into uric acid ## Footnote prevents formation of uric acid, does NOT break down uric acid
48
rasburicase MAO
breaks dow uric acid
49
treatment of low risk TLS
monitor
50
treatment of intermediate risk TLS
- hydration - allopurinol - if hyper uric acid persits, can slap on rasburicase
51
treatment of high risk TLS
- hdyration - rasburicase then allopurinol
52
allopurinol dose in TLS
- 300mg/m^2/day or 10mg/kg/day divided Q8H - OR 300mg QD ## Footnote no renal adjustment for TLS UNLESS pt has known kidney disease
53
allopurinol ADR
- SJS/TEN - otherwise well tolerated
54
rasburicase admin in TLS
- 0.15-0.2 mg/kg/dose IV QD up to 5D (OR a flat dose of 1.5mg or 3mg once with a repeat dose if uric acid remains >7.5) ## Footnote when measuring uric acid level, obtain a "rasburiacse uric acid" - blood sample put in ice bath to preven further degradation of uric acid
55
rasburicase ADR
- hemolysis in pts with G6PD deficiency - peripehral edema - skin rash - abdominal pain - consptation/diarrhea
56
definition of a fever
- 38.3 C - or > 38C for over an hr
57
definition of neutropenia
- ANC < 500 - ANC < 1000 and expected to drop to < 500 in 48h
58
when does febrile neutropenia usually occur
1 week after chemo admin
59
febrile neutropenia risk factors
- > 65 receiving full chemo - pre-existinng / persistent neutropenia - bone marrow infltration with tumor - recent surgery and/or open wounds - liver dysfunction (bili > 2) - renal dysfunction ( CrCl< 50) - gender: female - low BMI or BSA - hx of chemo or radiation - poor performance status - comorbiditeis - genes
60
neutropenia antimicrobial ppx: when to give
- cancer pt with low risk for infection: only if hx of HSV - at intermediate risk: consider bacterial, fungal (and PJP), and give viral during neutropenia - at high risk: consider fungal (and PJP), and give bacterial and viral during neutropenia | remember that this is (neutropenia) ppx for before febrile
61
bacterial (febrile neutropenia) ppx for pts with neutropenia
- levofloxacin - cefopodoxime - cipro - penicillin K
62
fungal (febrile neutropenia) ppx for pts with neutropenia
- fluconazole - posaconazole - voriconazole - isavuconazole - micafungin ## Footnote PJP: bactrim
63
viral (febrile neutropenia) ppx for pts with neutropenia
acyclovir
64
what to do when a pt presents with *febrile* neutropenia
collect the following - CBC - cxray - urinalysis: if abnormal -> urine culture - blood culture: 1 from periphery the other from central (helps identify source of infection) - viral diagnostics
65
MASCC score
used to determine if a pt risk level for complicatios (high score = lower risk)
66
febrile neutropenia - MASCC score >21: treatment
- **if NOT on fluoroquinolone ppx**: levaquin, moxifloxacin, or augmentin + cipro - **if ON fluoroquinolone ppx**: cefepime
67
febrile neutropenia - MASCC score <21: treatment
give empriric IV ABX: zosyn, cefepime or meropenem (reserve meropenem if hx of ESBL)
68
when to do MRSA coverage for febrile neutropenia
only if pt has - catheter-related infusion - PNA - mucosititis - skin/soft tissue infection - hemodynamic insufficiency - sepsis
69
febrile neutorpenia MRSA agents
- vanco - linezolid - dapto
70
when to do fungal coverage for febrile neutropenia
- hematologic malignancy - hemodynmically unstable - s/s sepsis - if neutropenia expected ot last > 7days | don't forget to collect fungal markers/collectors
71
febrile neutorpenia fungal agents
same as ppx + liposomal amphotericin B
72
cancer pts who are at low risk for infection | determines if they get microbial ppx for neutropenia (NOT febrile yet)
- standard chemo regimens for most sold tumors - anticipated neutropenia < 7 days
73
cancer pts who are at intermediate risk for infection ## Footnote determines if they get microbial ppx for neutropenia (NOT febrile yet)
- autologous hematopoietic cell transplant - lymphoma - multiple myeloma - CLL - purine analog therapy - anticipate neutropenia 7-10D - Car T-cell therapy
74
cancer pts who are at high risk for infection ## Footnote determines if they get microbial ppx for neutropenia (NOT febrile yet)
- allogenic hematopoietic cell transplant - acute leukemia - alemtuzumab therapy - moderate to severe graft versus host disease - anticipate neutropenia > 10 days

PHM 703: Crit Care/Heme/Onc (16 decks)

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