Tumor Lysis Syndrome (TLS)
Destruction (lysis) of large number of tumor cells that may be present on diagnosis or caused by cancer treatment (chemotherapy, radiation or biological therapies)
What is DIC?
DIC is a consumptive coagulopathy precipitated by underlying disease, infection, trauma -> widespread intravascular thrombosis -> organ damage and failure
simultaneous consumption of platelets and coagulation factors -> hemorrhage, shock
What is neutropenia
ANC less than 0.5
What is SIADH?
Hyponatremia with inappropriately concentrated urine
Occurs when a patient presents with very high WBC count (AML, CML)
What electrolyte abnormalities do you expect to see in pt with TLS:
Hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia
Associated with
Malignancies- leukemias, APML, Mucin-Secreting Adenocarcinomas of prostate, lung & breast
Severe sepsis
Trauma
Obstetrics conditions
what is considered a neutropenic fever?
38.1 or higher
Cause
Malignancy: Small Cell Lung CA
Concerning side effects
intravascular sludging
leukostasis--> thrombus formation
tissue damage
end organ damage
death
Most commonly seen with which hematologic malignancies?
Acute Leukemia & High Grade Lymphomas
Clinical manifestations:
Clinical signs and symptoms of bleeding and thrombosis (bleeding gums, nosebleeds, GI bleeds)
Dyspnea/Tachypnea (PE?)
Hemoptysis
Lethargy and confusion
Its your pts first neutropenic fever, what do you do? what orders do you expect?
page team 911
-2 sets blood cultures (draw within 1 hour of fever)
-antibiotics start within 1 hour (must start after blood cultures)
-tylenol
-Ucx
-CXR
-lactate (pending other vs)
SIADH Clinical Manifestation:
fatigue, AMS, weakness, seizures, coma, death
Clinical manifestations, list 4:
Fever, dizziness, blurry vision, confusion, delirium, tachypnea, dyspnea, pulmonary infiltrates, acute renal failure
What can severe TLS lead to?
Renal failure, arrhythmias and seizures
Lab findings:
Low or rapidly decreasing platelet counts
Prolonged coagulation tests
Low plasma levels of fibrinogen
Increased markers of fibrin formation and degradations (D dimer)
Peripheral smear showing shistocytes
When do you recheck VS?
1hr post intervention, and as long as there is a deviation (i.e. hypotensive, febrile)
Treatment:
Fluid restriction, hypertonic saline infusion, IV lasix, NaCL tabs, renal consult
Diagnostic findings
WBC >100k
platelet count falsely high
pseudohypoxemia
serum glucose artificially low
pseudohyperkalemia
Treatment options for K, Uric Acid, calcium, phos:
Hydration
Hyperkalemia: kayexalate, lokelma, loop diuretics
Hyperphosphatemia: hydration, renal diet (restrict phos), phosphate binding agent
Hyperuricemia: hydration, strict I&Os, allopurinol, rasburicase
Hypocalcemia: calcium gluconate
Supportive therapy:
platelet transfusion, Fresh frozen plasma replacement (brings down the INR), cryoprecipitate infusion (fibrinogen replacement), vitamin K (myphyton)
when is lactate ordered & what is considered elevated & how often do you repeat?
Lactate is ordered when pt is hemodynamically unstable or continues to be febrile and has change in other vs
Lactate is considered elevated 2 and above
every 4-6 hours or after interventions (sometimes sooner than 4 hrs post fluid bolus)
Nursing Management
Monitor serum and urine electrolytes, administer hypertonic saline, free water restrictions, seizure/safety precautions
Treatment
Cytoreduction (hydroxyurea)
Leukapheresis
prevent TLS
plt transfusions (for plts <20k)
correct coagulopathies
avoid pRBC transfusions
treat underlying cause