Oncologic emergencies for the internist - Cleveland Clinic Journal of ...
Oncologic emergencies for the internist - Cleveland Clinic Journal of ... Oncologic emergencies for the internist - Cleveland Clinic Journal of ...
Not available for online publication.See print version of theCleveland Clinic Journal of Medicineedly to damage the surrounding tissues.Extravasation is important because largeareas of skin may break down, leading to poorcosmetic results, secondary infection, andcontractures if the injury is over a joint.The most common culprits are vesicants,which cause blisters when they contact skin.Anthracyclines (eg, doxorubicin and idarubicin)and vinca alkaloids (eg, vincristine andvinorelbine) are the most common vesicantsused in clinical practice.If the patient is complaining of pain orproblems during vesicant infusion, the infusionshould be stopped, the line aspirated toremove residual drug, and an antidote (ifavailable) instilled through the line (TABLE 3). 33If using a port, disconnect the infusion line; ifusing a temporary intravenous line, discontinueit. Compression of the site should be avoidedas this may spread the remaining drug furtherout from the injection site. The use ofheat, ice, and antidotes depends on the specificchemotherapeutic drug.If a patient presents to an internist withpain at an injection site, with or without redness,shortly after a chemotherapy infusion, heor she should be referred to his or her treatingoncologist urgently.Neutropenic feverNeutropenic fever is common, and if it is leftuntreated the mortality rate is 50%. 34Neutropenia is defined as a neutrophilcount lower than 0.5 ×10 9 /L (500/mm 3 ), orless than 1.0 × 10 9 /L and expected to declinebelow 0.5 soon. A fever is defined as a singletemperature of 38.3˚C (101.0˚F) or higher, ora temperature of 38.0˚C (100.4˚F) or higherlasting over 1 hour.A complete fever workup should be completed,and then antibiotics should be startedpromptly. All patients should receive a broadspectrumantipseudomonal drug such as ceftazidime.They also should receive vancomycinto cover resistant gram-positiveorganisms if any of the following is present:severe mucositis, catheter infection, currentquinolone prophylaxis, hypotension, orknown colonization with resistant gram-positiveorganisms. Often, despite a comprehensivesearch, the cause is never found; however,it is essential to start antibiotics immediatelyupon noting a neutropenic fever. Antibioticsshould be continued until the absolute neutrophilcount exceeds 0.5 × 10 9 /L and thepatient is afebrile.It is important for the patient and all ofhis or her contacts to routinely wash theirhands.DehydrationOften overlooked, dehydration is a serious riskand is very common in cancer patients becauseof cachexia caused by the disease or its treat-Stop theinfusion if thepatientcomplains ofpain duringvesicantinfusionCLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 69 • NUMBER 3 MARCH 2002 217
ONCOLOGIC EMERGENCIESKRIMSKY AND COLLEAGUESment. Dehydration is associated with deliriumin 30% of cancer patients and is linked toshorter survival. 35 Common treatment-relatedcauses include emesis, diarrhea, and mucositis.For example, in some series of colon cancerpatients, 36 approximately 50% required achange in treatment because of dehydrationand 20% required intravenous fluids.An internist can improve a patient’s qualityof life by providing supportive care withfluids, antiemetics, and antidiarrheal drugsand by communicating with the oncologist todiscuss adverse effects that may require achange in treatment.■ REFERENCES1. Hande KR, Garrow GC. Acute tumor lysis syndrome inpatients with high grade non-Hodgkin’s lymphoma. Am JMed 1993; 94:133–139.2. Flombaum CD. Metabolic emergencies in the cancerpatient. Semin Oncol 2000; 27:322–334.3. Conger JD, Falk SA. Intrarenal dynamics in the pathogenesisand presentation of acute urate nephropathy. J ClinInvest 1977; 59:786–793.4. Zusman J, Brown DM, Nesbit ME. Hyperphosphatemia,hyperphosphaturia, and hypocalcemia in acute lymphoblasticleukemia. N Engl J Med 1973; 289:1335–1340.5. Rigas DA, Duerst ML, Jump ME, Osgood EE. The nucleicacids and other phosphorous compounds of humanleukemic leukocytes: relation to cell maturity. J Lab ClinMed 1956; 8:356–378.6. Ettinger DS, Harker WG, Gerry HW, Sanders RC, Saral R.Hyperphosphatemia, hypocalcemia, and transient renalfailure: results of cytotoxic treatment of acute lymphoblasticleukemia. JAMA 1978; 239:2472–2474.7. Flombaum C. Electrolyte and renal abnormalities. In:Groeger JS, editor: Critical Care of the Cancer Patient,2nd ed. St Louis, Mosby Year Book, 1991:140–164.8. Mundy GR, Guise TA. Hypercalcemia of malignancy. Am JMed 1997; 103:134–145.9. Morton AR, Lipton A. Hypercalcemia. In: Abeloff MD,Armitage JO, Lichter AS, Niederhuber JE, editors. ClinicalOncology. New York: Churchill Livingstone,2000:719–733.Anaphylaxis and capillary leakSome systemic treatments such as interleukin-2 (IL-2) may cause severe hypotension, especiallywhen given at high doses intravenously.The mechanism is decreased systemic vascularresistance and leakage out of vessels, leading tointravascular volume depletion. Somehypotension is seen in up to 70% of patientsreceiving IL-2 in high doses, and 3% experiencelife-threatening degrees of hypotension. 37Close monitoring in an intensive care unit iswise before starting such high-dose therapy.The treatment is to not give more IL-2until the patient recovers and to provide supportivecare with intravenous fluids andphenylephrine. IL-2 in low doses rarely causessuch hypotension.Hemorrhagic cystitisSome chemotherapeutic drugs have toxicmetabolites that are excreted by the kidneyand can cause severe bladder hemorrhage. Acommon example is acrolein, which is formedby the metabolism of cyclophosphamide andifosfamide.Hemorrhagic cystitis is more commonwhen urinary output is low, because low urineoutput increases the concentration of acroleinin the urine and the duration that the bladdermucosa is exposed to it. Therefore, hydratingthe patient before chemotherapy is an importantpreventive measure. Another preventivemeasure is to give mesna during chemotherapyinfusion. 38If hemorrhage is severe, exsanguinationmay result. Blood transfusions and a urologyconsult are essential. Continuous bladderinfusions via a three-way catheter are commonlyused to prevent bladder clots andalso to flush out any remaining urothelialtoxins. Measures as drastic as formaldehydebladder infusions or cystectomy are rarelyneeded.10. Warrell RP. Metabolic emergencies. In: DeVita VT, HellmanS, Rosenberg SA, editors. Cancer: Principles and Practiceof Oncology. Philadelphia: Lippincott Williams & Wilkins,2001:2633.11. Gurney H, Grill V, Martin TJ. Parathyroid hormone-relatedprotein and response to pamidronate on tumor inducedhypercalcemia. Lancet 1993; 341:1611–1613.12. Pecherstorfer M, Schilling T, Blind E, et al. Parathyroidhormone-related protein and life expectancy in hypercalcemiccancer patients. J Clin Endocrinol Metab 1994;78:1268–1270.13. Wimalawansa SJ. Significance of plasma PTH-rP inpatients with hypercalcemia of malignancy treated withbisphosphonate. Cancer 1994; 73:2223–2230.14. Adams JS, Fernandez M, Gacad MA, et al. Vitamin Dmetabolite-mediated hypercalcemia and hypercalciuriapatients with AIDS- and non-AIDS-associated lymphoma.Blood 1989; 73:235–239.15. Breslau NA, McGuire JL, Zerwekh JE, Frenkel EP, Pak CY.Hypercalcemia associated with increased serum calcitriollevels in three patients with lymphoma. Ann Intern Med1984; 100:1–6.16. Klein B, Bataille R. Cytokine network in human multiplemyeloma. Hematol Oncol Clin North Am 1992;6(2):273–284.17. Mundy GR, Guise TA. Hypercalcemia of malignancy. Am JMed 1997; 103:134–145.18. Dodwell DJ, Howell A, Morton AR, Daley-Yates PT,Hoggarth CR. Infusion rate and pharmacokinetics ofDehydration iscommon andoftenoverlooked incancer patientsCLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 69 • NUMBER 3 MARCH 2002 221
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Not available <strong>for</strong> online publication.See print version <strong>of</strong> <strong>the</strong><strong>Cleveland</strong> <strong>Clinic</strong> <strong>Journal</strong> <strong>of</strong> Medicineedly to damage <strong>the</strong> surrounding tissues.Extravasation is important because largeareas <strong>of</strong> skin may break down, leading to poorcosmetic results, secondary infection, andcontractures if <strong>the</strong> injury is over a joint.The most common culprits are vesicants,which cause blisters when <strong>the</strong>y contact skin.Anthracyclines (eg, doxorubicin and idarubicin)and vinca alkaloids (eg, vincristine andvinorelbine) are <strong>the</strong> most common vesicantsused in clinical practice.If <strong>the</strong> patient is complaining <strong>of</strong> pain orproblems during vesicant infusion, <strong>the</strong> infusionshould be stopped, <strong>the</strong> line aspirated toremove residual drug, and an antidote (ifavailable) instilled through <strong>the</strong> line (TABLE 3). 33If using a port, disconnect <strong>the</strong> infusion line; ifusing a temporary intravenous line, discontinueit. Compression <strong>of</strong> <strong>the</strong> site should be avoidedas this may spread <strong>the</strong> remaining drug fur<strong>the</strong>rout from <strong>the</strong> injection site. The use <strong>of</strong>heat, ice, and antidotes depends on <strong>the</strong> specificchemo<strong>the</strong>rapeutic drug.If a patient presents to an <strong>internist</strong> withpain at an injection site, with or without redness,shortly after a chemo<strong>the</strong>rapy infusion, heor she should be referred to his or her treatingoncologist urgently.Neutropenic feverNeutropenic fever is common, and if it is leftuntreated <strong>the</strong> mortality rate is 50%. 34Neutropenia is defined as a neutrophilcount lower than 0.5 ×10 9 /L (500/mm 3 ), orless than 1.0 × 10 9 /L and expected to declinebelow 0.5 soon. A fever is defined as a singletemperature <strong>of</strong> 38.3˚C (101.0˚F) or higher, ora temperature <strong>of</strong> 38.0˚C (100.4˚F) or higherlasting over 1 hour.A complete fever workup should be completed,and <strong>the</strong>n antibiotics should be startedpromptly. All patients should receive a broadspectrumantipseudomonal drug such as ceftazidime.They also should receive vancomycinto cover resistant gram-positiveorganisms if any <strong>of</strong> <strong>the</strong> following is present:severe mucositis, ca<strong>the</strong>ter infection, currentquinolone prophylaxis, hypotension, orknown colonization with resistant gram-positiveorganisms. Often, despite a comprehensivesearch, <strong>the</strong> cause is never found; however,it is essential to start antibiotics immediatelyupon noting a neutropenic fever. Antibioticsshould be continued until <strong>the</strong> absolute neutrophilcount exceeds 0.5 × 10 9 /L and <strong>the</strong>patient is afebrile.It is important <strong>for</strong> <strong>the</strong> patient and all <strong>of</strong>his or her contacts to routinely wash <strong>the</strong>irhands.DehydrationOften overlooked, dehydration is a serious riskand is very common in cancer patients because<strong>of</strong> cachexia caused by <strong>the</strong> disease or its treat-Stop <strong>the</strong>infusion if <strong>the</strong>patientcomplains <strong>of</strong>pain duringvesicantinfusionCLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 69 • NUMBER 3 MARCH 2002 217
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