UNM Heme/Onc

How does ALL typically present?
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Terms in this set (20)
How does ALL typically present?
Presents acutely with:

-Fatigue 2/2 anemia
-Bleeding/Bruising 2/2 Thrombocytopenia
-Infection 2/2 neutropenia
What are other presenting symptoms of ALL? (List 4 items)
-"B symptoms" of fever, night sweats, weight loss
-Lymphadenopathy/hepatosplenomegaly
-MSK Pain (nocturnal)
-Headache/neuropathy 2/2 meningeal involvement leading to increased ICP
What body systems can be implicated in a pt with neutropenic fever?
-Bacteremia is most common
-Other sources: GI, Urinary Tract, Respiratory, Skin
What are the most common bacterial pathogens responsible for neutropenic fever?
1) Gram Positives: Coag negative staph, Strep viridians, Staph aureus (including MRSA)

2) Gram Negatives: E. coli, Klebsiella, Pseudomonas, Acinetobacter, Enterobacter
Besides bacteria, what other pathogens can be responsible for neutropenic fever?
-Fungi: less common, but Candida is most likely out of fungi

-Viral: HSV and Varicella-zoster
In a pt with neutropenic fever, what are special considerations to ask about in the history?
-Infection exposures
-Chemo agents used and stage (to anticipate length of neutropenic episode)
-Site specific symptoms
-Antimicrobial prophylaxis
-IV Catheters
In a pt with neutropenic fever, what on the physical exam should you focus on? (List 6 items)
1) Oral Mucosa/Peridontium
2) Pharynx
3) Lower Esophagus
4) Lungs
5) Skin (including sites of vascular access, bone marrow aspirate sites, tissues around nails)
6) Perineum and anus
What is initial antibiotic therapy for a pt with neutropenic fever?
Cefepime 50mg/kg/dose IV Q8H
Ceftazidime 100-150mg/kg/day IV Q8H
Imipenem 50mg/kg/day IV Q6H
When would you add Vancomycin to empiric therapy for a pt with neutropenic fever? (List 5 reasons)
1) Clinically worsening despite Cefepime
2) Gram positive bacteria in blood culture while awaiting ID and susceptibility
3) Catheter-related blood stream infection evidenced by cellulitis around catheter entry sit, or chills/rigors with infusion through central line lumen
4) Skin and soft tissue infection
5) Severe oral mucositis or recent exposure to high dose Ara-C
When should you discontinue empiric antibiotics for a patient with neutropenic fever? (List 3 reasons)
1) Negative blood cultures for at least 48 hours
2) Afebrile for at least 24 hours
3) Evidence of marrow recovery (ANC >500 for 2 consecutive days or ANC >1000 for 1 day or rising APCs for at least 2-3 days)
What is the discharge criteria for a patient with neutropenic fever? (List 6 reasons)1) Negative blood cultures for at least 48 hours 2) Afebrile for at least 24 hours 3) Evidence of marrow recovery (ANC rising) 4) No signs of localized infection 5) Performance scale rising back to baseline 6) Around the clock caregiver available at home, at least 1 hour from the hospitalWhat are the 4 most common chemotherapy complications?1) Mucositis: Chemo impairs ability of mucosal lining to regenerate. Most commonly associated with methotrexate and anthracylcines. Treat with Maalox + Benadryl +/- Lidocaine. 2) Pain: Can be from chemo or tumor, treat with narcotics. Do NOT give tylenol due to potential to mask fever. 3) Neuropathy: Stocking glove pattern, associated ankle pain, foot drop/tripping 4) Cytopenias: Due to bone marrow suppression by chemo. Ask attending who gets GCSFWhat are the most common cancers associated with Tumor Lysis Syndrome (TLS)?1) Burkitt's Lymphoma 2) Lymphoblastic Lymphoma 3) Acute Lymphoblastic Leukemia (T-Cell) 4) Blue Round TumorWhat are the main metabolic abnormalities associated with TLS?1) Hyperkalemia (>6) 2) Hyeruricemia 3) Hyperphosphatemia (>6.5) 4) Hypocalcemia (<1.5)What is the hydration strategy for the management of TLS?D5 1/4NS + 20-40 mEq/L of NaHCO3 at 2-4x maintenance to maintain the following: 1) Urine Specific Gravity <1.010 2) Urine Output >100 mL/m2/hr 3) Urine pH 6.5-7.5What is the management of TLS induced Hyperuricemia?-Allopurinol (prevents formation of uric acid by inhibiting xanthine oxidase) -Rasburicase (breaks down uric acid into allantoin)What condition is Rasburicase contraindicated in?G6PD DeficiencyWhat is the management of TLS induced Hyperkalemia? (List 6 items)1) NO K IV/PO 2) NaHCO3 1-2 meq/kg/IV 3) Insulin and glucose 4) Calcium chloride 5) Kayexalate 6) Dialysis if all else failsWhat is the management of TLS induced Hyperphosphatemia? (List 3 items)1) Restrict phosphate in diet (dairy, coke, peanut butter are big ones) 2) Use phosphate binders (amphogel and renagel) 3) Maintain Urine Output greater than 3mL/kg/hrWhat is the management for TLS induced Hypocalcemia?Give 10mg/kg of elemental Ca for symptomatic hypocalcemia.