Heme/Onc Emergencies

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