Fuqan 8/12/20
Furqan September 2019
Heme/Onc Emergencies
Emergencies in Hematology and Oncology
Tumor lysis syndrome
What is it? A constellation of metabolic derangements resulting from the death of neoplastic cells and release of their intracellular content.
Diagnosis
Cairo-Bishop Criteria: 2 or more of the following criteria between 3 days prior and 7 days after initiation of therapy
Hyperuricemia
From breakdown of nucleic acids
>8 m g/dl or 25% increase from baseline
Hyperphosphatemia
· Release of organic and inorganic phosphate
· >/=4.5 mg/dl or 25% increase from baseline
§ Hypocalcemia
· Secondary to hyperphosphatemia
· </= 7 mg/dl or 25% decrease from baseline
§ Hyperkalemia
· >/= 6.0 mEq/L or 25% increase from baseline
Clinical tumor lysis: presence of above criteria plus one or more of the following:
§ Creatinine >/= 1.5 upper limit normal
§ Cardiac arrhythmia
§ Seizure
§ Sudden Death
· Treatment/Prophylaxis
o Low risk disease:
§ Laboratory monitoring </=q24 hours
§ Hydration: PO vs. 2-3 L/m^2/day normal saline
§ +/- Allopurinol
o Intermediate risk disease
§ Laboratory monitoring: 4 hours after therapy then every 6-12 hours
§ Hydration: 2-3 L/m^2/day normal saline
§ Allopurinol +/- Rasburicase
o High risk disease
§ Laboratory monitoring: every 4-6 hours
§ Hydration: 2-3 L/ m^2/day normal saline
§ Allopurinol + Rasburicase
Hyperviscosity Syndrome
· What is it? Abnormally high paraproteins, cell contents, or cells in serum leading to increased blood viscosity
· Clinical picture: bleeding or thrombosis, neurologic symptoms, congestive heart failure
· Diagnosis: clinical symptoms with elevated plasma viscosity
o Normal 1.4-1.8 centipoise, symptoms typically present >4-8 cP
· Treat with emergent plasmapheresis
Immune Checkpoint Inhibitor Toxicity
· Autoimmune adverse events are most common during first 12 weeks of therapy but may occur up to 6 months after discontinuation of treatment
· Adverse events can involve almost any organ system with varying incidences and rates of fatality
o Most common adverse event: colitis (25% of patients treated with Ipilimumab)
o Highest rate of fatality following adverse event presentation: myocarditis (20-50% mortality)
· Therapy
o Mild adverse events: monitoring vs. low dose corticosteroids
o Moderate-severe events: high dose corticosteroids