Oncological Emergencies Flashcards by Roshan Patel

What is neutropenic sepsis?

Life-threatening complication of anti-cancer treatment

How well did you know this?

Not at all

Perfectly

When do you diagnose neutropenic sepsis

neutrophil count <0.5 and

temp >38 on 2 readings OR other signs/symptoms of sepsis

How well did you know this?

Not at all

Perfectly

When does neutrophil count typically reach its lowest in sepsis?

5-10 days post chemo

How well did you know this?

Not at all

Perfectly

What most commonly causes neutropenic sepsis?

Gram + cocci

How well did you know this?

Not at all

Perfectly

When should you suspect a patient may have neutropenic sepsis?

Feeling unwell and having anti-cancer therapy

How well did you know this?

Not at all

Perfectly

What questions must you ask a patient if you are worried about neutropenic sepsis?

Chemo regime - time since last dose
Recent blood products?
Lines in situ?

How well did you know this?

Not at all

Perfectly

What do you examine on a patient with ?neutropenic sepsis?

Cardio
Resp
Lymph nodes
Lines
focus on causes - GI exam

How well did you know this?

Not at all

Perfectly

What investigations should you ask for if you queery sepsis?

Neutrophil count
Culture from vein and any lines
Blood film
D-Dimer - DIC?
LFT U&amp;E CRP
Sputum culture
Urine analysis

How well did you know this?

Not at all

Perfectly

How is neutropenic sepsis treated?

IV Tazocin (piperacillin with tazobactam)

How well did you know this?

Not at all

Perfectly

A patient in hospital with neutropenic sepsis has been treated with IV tazocin for 2 days without change, what do you do?

Change antibiotic

How well did you know this?

Not at all

Perfectly

A patient in hospital with neutropenic sepsis has been treated for 5 days but there is still no change, what do you do?

Consider fungi/parasite causes

How well did you know this?

Not at all

Perfectly

How can neutropenic sepsis be prevented?

Prophylactic fluroquinolone
Dose reduction
Prophylactic G-CSF - not routinely offered
Stop treatment

How well did you know this?

Not at all

Perfectly

When should anti-biotics be started?

As soon as you suspect sepsis! Don’t wait for blood results

How well did you know this?

Not at all

Perfectly

What cancers commonly cause MSCC?

Lung
Breast
Prostate

How well did you know this?

Not at all

Perfectly

How many patients tend to get MSCC?

10% of patients with spinal mets

How well did you know this?

Not at all

Perfectly

What are the consequences of early MSCC?

Cord compression –> oedema –> venous congestion

How well did you know this?

Not at all

Perfectly

What are the consequences of late MSCC?

Irreversible vascular injury –> cord necrosis

How well did you know this?

Not at all

Perfectly

What signs are indicative of metastatic spinal cord compression?

Back pain - worse on waking and aggravated by straining
Spinal tenderness
Limb weakness
Sensory loss
Incontinence
Generally unwell
Spasticity
Babinski +ve
Palpable bladder

How well did you know this?

Not at all

Perfectly

What is the prognosis for MSCC?

30% live >1 year

How well did you know this?

Not at all

Perfectly

How is MSCC investigated?

MRI within 24 hours

How well did you know this?

Not at all

Perfectly

How is pain suggestive of metastases investigated?

MRI within week

How well did you know this?

Not at all

Perfectly

How is MSCC managed?

Bed rest with neutral spine alignment need to be (log rolled)
Dexamethasone (unless lymphoma suspected)
Analgesia
Bisphosphonates (myeloma, breast and prostate mets only)
Definitive treatment: Decompression or radiotherapy within 24hrs
Supportive care - VTE prophylaxis, catheter, bed sore management, temperature checks

What is the tole of radiotherapy in MSCC management?

Relieve compression of spine and nerves - cause cell death

Pain relief and stabilise neurological deficit

When is SVCO seen?

External compression from Lung cancer but can be from lymphoma

What signs and symptoms are indicative of SVCO?

``` Breathlessness Face and upper limb oedema Headache Choking sensation Lethargy Neck vein distention Raised JVP Increased RR ```

How is SVCO investigated?

CXR - mass | CT contrast

How is SVCO managed?

Steroids Stent Chemo/radio - depend on cause

What is extravasation?

Leakage of IV drugs into extravascular space leading to nearby tissue damage

Why are chemo agents susceptible to causing extravasation?

Poorly soluble in aqueous media and are vesicant

How can extravasation be prevented?

Ensure IV fluid runs without resistance Stop infusion if pain at injection site Don't leave infusion unattended if highly vesicant Immediately stop infusion if suspicion

How common is hypercalcaemia in cancer patients?

Affect upto 1/3 Esp. lung, breast, renal, myeloma and T cell lymphoma

What is hypercalcaemia associated with?

Uncontrolled disease progression

Why does hypercalcaemia occur?

Osteolysis Humoral mediators Dehydration

Explain how cancers cause osteolysis and how this causes hypercalcaemia

Tumour cells of lytic bone mets produce cytokines to activate osteoclasts --> bone resoption --> increase calcium Phosphate normally remain normal

Explain how cancers affect humoral mediators and how this causes hypercalcaemia

systemic release factors which activate osteoclasts (PTHrP) Phosphate low

How does dehydration affect hypercalcaemia?

Exacerbate any underlying hypercalcaemia

How does hypercalcaemia present?

Vague, non-specific symptoms Can be acute or over long time

What symptoms may be seen in hypercalcaemia?

``` N&V Malaise Drowsiness Weakness Depression Anorexia Abdo pain Constipation Pancreatitis Polydipsia and dehydration Renal colic - stones Arrhythmias ```

What investigations would be requested for hypercalcaemia?

Corrected serum Ca - allow for hypoalbuminaemia Renal function Electrolytes

How is hypercalcaemia managed?

Rehydrate Monitor Bisphosphonates

What electrolyte distubances are seen in tumour lysis syndrome?

Hyperuricaemia Hyperphosphataemia Hyperkalaemia Hypocalcaemia

When does tumour lysis syndrome occur?

Within hours to days of chemo

What is tumour lysis syndrome?

Metabolic disturbances and renal impairment due to lysis of rapidly proliferating tumour cells

Why do patients get hyperuricaemia in TLS? What does it cause?

Nucleic acids are released and metabolised It causes crystal deposits in renal tubules --> AKI

In TLS, what happens to phosphate and calcium and why?

Phosphate is released - high phoshpate Phosphate precipitate with calcium - low calcium

What do calcium phosphate precipitates lead to?

Calcium phosphate deposition in: Renal tubules - AKI Skin - Gangrene Heart - Arrhythmia

What complication can hyperkalaemia lead to?

Arrhythmias

What are the main risk factors for TLS?

Large volume disease Chemosensitive Haematological malignancy Poor renal function

How can TLS be prevented?

Keep hydrated | Allopurinol or Rasburicase

How is TLS managed?

Correct electrolytes Monitor fluid balance Assess need for haemodialysis

What is the mechanism of action of allopurinol and rasburicase in regards to TLS

Allopurinol - prevents uric acid formation | Rasburicase - metabolises uric acid to allantoin which is water soluble and can be excreted by the kidneys

How could you manage a suspected line infection?

Line locks - if not systemically very poorly can give high concentration abx (commonly gentamicin) through the line to sterilise it and save it from needing removal

When would a bone scan for bony metastasis not be useful?

Multiple myeloma - bone scan works by picking up areas where there is increased uptake of radioactive traced indicating osteoblastic activity. Multiple myeloma produced purely lytic lesions so it is not useful.

What should you do in a suspected line infection?

``` Give Teicoplanin (provides gram +ve cover) Can do line lock with high dose Gentamicin ```