ONCOLOGIC EMERGENCIES

SVCS, SMS
Effusion, Tamponade
Massive hemoptysis,
Pneumothorax,
Pneumomediastinum Intestinal Obstruction
Tumor Lysis Syndrome
Perforation
Hypercalcemia

ONCOLOGIC Raised ICT

Hyperleukocytosis
CNS toxicity of chemotherapy
(Pulmonary and CNS) EMERGENCI
ES

Cytopenias
Febrile neutropenia

Hypertension
Hematuria, Oliguria, ARF
Hemorrhagic cystitis
 SVC syndrome and Superior Mediastinal Syndrome

• Compression, obstruction or thrombosis of SVC (SVCS) along with tracheal

compression (SMS)
• MCC: NHL and ALL
• Clinical features:
Cough, dyspnea, chest pain, orthopnea
Dysphagia, hoarseness, wheezing, facial puffiness
Pleural/pericardial effusion
CO2 retention (anxiety, confusion lethargy, headache, syncope)
 Evaluation and Management
• History, P/E
• IV access in LOWER LIMBS
• CBC/PS/BMA
• Minimum handling, no sedation, sitting up, face mask
• Intubate if life threatening
• CT scan as soon as possible
• Hydrate, start Allopurinol, Monitor for TLS, I/O monitoring
• Pericardiocentesis/pleural tap
 Evaluation and Management
• Chest X-Ray with lateral view  Mediastinal widening, tracheal compression
and effusion
• CT (may be prone)  delineate mediastinal mass, width and compression
• TISSUE DIAGNOSIS IS ESSENTIAL, least invasive and NO SEDATION
• Bone Marrow Aspiration  for diagnosis, under LA
• Pleural/Pericardial/ Ascitic fluid exam mostly therapeutic, may be diagnostic
(NHL)
• Echo and PFT, Beta- hCG and AFP
 Evaluation And Management

• If diagnosis, not established  STEROIDS

• Other drugs for cyto-reduction : Cyclophosphamide, VCR and
Anthracyclines
• No role of radiotherapy
 SMS/SVCS on clinical
assessment
MEDIASTINAL
MASS
Diagnosti CBC/Initial studies Not
c Diagnostic

TREA D/D, Assess risk of

T Anesthesia

HIGH RISK: LOW RISK: Biopsy

Empirical and treat
chemotherapy

Reassess after 4-6 hr

 Hyperleukocytosis
• TLC >1,00,000/mm3
• All children with CML, 5-20 % in AML and 9-13 % in ALL
• CLINICALLY SIGNIFICANT: >2, 00,000/ mm3 for AML and > 3,00,000
/mm3 for ALL and CML
• POOR PROGNOSTIC MARKER
• FATAL: CNS bleed, thrombosis, pulmonary leukostasis and complications of
tumor lysis
• Increased viscosity ( PCV, leukemic aaggregates and thrombi)
 CLINICAL FEATURES

Asymptomatic Lungs
CNS
• Headaches • Dyspnoea
• Blurred vision • Cyanosis
• GI bleed • Seizures • Hypoxia
• Priapism • Coma • Acidosis
• Hemopericardium • Stroke • Pulmonary bleed
• Dactylitis • Papilledema • F/O SMS
• RAO/RVO
 Management

• Goals of therapy:
1. Reduction of WBC count
2. Reducing Blood viscosity
3. Preventing and treating complications
• Hydration, no tranfusions, alkalinisation of urine and Allopurinol
 Investigations

• CBC, RFT, LDH

• Coagulation profile, PS, Immunophenotyping
• CXR
• CT scan head and chest and BM as per requirement
 Treatment

• Hydration (2-4 X maintenance)

• Alkalinisation with NaHCO3
• Allopurinol (250-300 mg/m2/day in three divided doses)
• Target Platelets: 20,000/mm3
• I/O monitoring, TLS monitoring, electrolytes, renal function
• Chemotherapy : as soon as child stable (metabolically and
hemodynamically)
• No role of PCI
 Tumor Lysis Syndrome
• Death of tumor cells and release of contents
• Metabolic derangements:
HYPERURICEMIA (nucleic acids with renal excretion, later precipitate)
HYPERPHOSPHATEMIA (malignant cells , acidosis)
HYPERKALEMIA (intracellular cation)
HYPOCALCEMIA (Ca X P >60, precipitates, low Ca)
UREMIA (Uric acid and CaPO4 crystals in renal microvasculature)
 Tumor Lysis Syndrome
• Burkitt’s, Lymphoblastic lymphoma (T-cell)
• Usually 12-72 h after starting therapy, occasionally aprior
• RISK FACTORS:
TUMOR related PATIENT BIOCHEMIC
related AL
High tumor load Hyperleukocytosis High Uric acid
High chemo sensitivity Renal disease High LDH, P
Advanced stage Dehydration Low pH
Kind of malignancy
• BISHOP AND CAIRO CLASSIFICATION:
LABORATORY TLS: 2 or more of the following 3 days before and 7 days after start of
chemotherapy
1. Uric Acid: more than equal to 476 micmol/L (8 mg/dL) OR 25 % increase from baseline
2. Potassium: more than equal to 6 mmol/L (6 mEq/L)OR 25 % increase from baseline
3. Phosphorus: more than equal to 2.1mmol/L (6.5 mg/dL) OR 25 % increase from
baseline
4. Calcium: less than equal to 1.75 mmol/L (7.0 mg/dL) OR 25 % decrease from baseline
CLINICAL TLS: LTLS + 1 or more of:
1. Creatinine: 1.5 or more times the ULN
2. Cardiac Arrythmias/death
3. Seizure
 MANAGEMENT
• Identify patients at risk
• Clinical exam and history: abdominal pain/vomiting/back
pain/diarrhoea/cramps/spasms/tetany/seizures/altered sensorium
• Baseline lab evaluation
• IV HYDRATION: 2-4 times maintenance (0.25% NS + 5%D + 40-80 mEq/L of
NaHCO3 WITH NO KCl
• Stop NaHCO3 when HCO3 >30 mEq/L or Urine pH >7.5
 MANAGEMENT

• DIURETICS: ONLY if urine output <60 ml/kg/h OR third space accumulation

with oliguria
• CHOICE: Mannitol f/b Furosemide
• HYPERURICEMIA: Allopurinol or Rasburicase (0.2 mg/kg/day) (ADD
AFTER HYDRATION)
• HYPERKALEMIA: Ca Gluconate/ Insulin-Dextrose/ Kayexalate
• HYPERPHOSPHATEMIA: Al(OH)3 15 ml 4-8 hrly
• HYPOCALCEMIA: TREAT ONLY IF SYMPTOMATIC
 MANAGEMENT

• TARGETS OF THERAPY:
Clinically stable
Uric Acid <7
Urine sp. Gravity <1.010
Urine pH 7-7.5
• Start chemotherapy
• RRT : HD of choice if volume overload, ARF OR failure of medical
management
 Febrile neutropenia

• Fever defined as single oral/axillary temperature more than 101 degree F or two
consecutive readings more than 100 in a 12 h period lasting for at least one hour
In a child with ANC <500/ mm3 or <1000 /mm3 with an expected decline.
• Focus to identify the FOCUS: Oropharynx, lungs, perianal area, catheters, skin
and soft tissue.
 ETIOLOGY

BACTER FUNGI VIRUSES OTHERS

IA

Gram + Gram - • Candida • HSV • Toxoplasma

• Arpergillu • VZV • Cryptospori
• Staph • Enteroba s • CMV dium
• Strep cteriaceae • Mucor • Pneumocyst
• Enterococ • Pseudom is
cus onas

10-30 % of cases yield a microbiological

diagnosis
 MANAGEMENT

• Baseline clinical assessment, sensorium, focal deficit, obvious focus of infection

• CBC, B/C, ABG, CXR

• Cultures: Urine and Blood is MUST. Site specific: stool, pus,

catheter
• Testing for PCP, atypical organisms
• Monitoring: fever, neutropenia, clinical status, secondary infections
 ANTIMICROBIAL THERAPY
• Empirical broad spectrum A/B of choice: Pip-Taz/ Cefoperazone-Sulbactam
and Amikacin
• If CXR s/o CAP/PCP : additional cover to be started
• Antifungals or antivirals in case of clinical and lab clues
• NO RESPONSE AFTER 48h: ADD VANCOMYCIN
• Empirical Vancomycin: CRBSI / on intensive chemotherapy/ severe mucositis/
known organisms with sensitivity to Vancomycin/ hypotension
• NO FUTHER RESPONSE AFTER 48h: ADD CARBEPENEMS
 MANAGEMENT
• Further worsening warrants addition of ANTIFUNGALS
• All children to be given COTRIMOXAZOLE prophylaxis
• Repeat blood cultures to be sent before EVERY ANTIBIOTIC CHANGE.
• SUPPORTIVE MANAGEMENT:
Blood components
Nutritional support
Growth factors
 ASSESSMENT AT
48h
LOW RISK: HIGH RISK:
ANC expected to Neutropenic for
resolve in 7 days more than 7 days

• Afebrile for • Persisting fever or afebrile

24h • C/S +
• Clinically well • NO evidence of Bone
• Cultures sterile Marrow recovery
• Evidence of
recovery with
rising
polymorphs
Afebrile at d7: Febrile at d7:
Discharge, stop IV or Oral A/B Continue IV A/B,
IV A/B, Oral A/B from day care till add antifungals
till ANC>0.5 ANC >0.5
 SUMMARY

• Patients with cancer are at constant risk of complications and oncological

emergencies attributed both to the disease and effects of chemotherapy
• Careful and frequent monitoring is the KEY to prevention and early detection
and treatment for these complications
THANK YOU