SNOT, SNEEZES, & CHILDHOOD DISEASES · emergencies and important nursing interventions for each....

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ONCOLOGIC EMERGENCIES

Karla Wilson RN MSN FNP CPON®

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• Recognize abnormal laboratory results

and associated nursing implications.

• Recognize the most common oncologic emergencies and important nursing interventions for each.

• Implement practices designed to improve the quality of life for patients and families affected by childhood cancer.

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• Occur at diagnosis or at any point in treatment process

• Life-threatening

• Arise as: – metabolic/hormonal problems

– result of obstruction/pressure

– consequence of cytopenias

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HYPERLEUKOCYTOSIS

• Definition – peripheral WBC >100,000/mm3

• Associated Malignancies – AML/ALL

– CML

• Clinical Presentation – SOB/tachypnea/cyanosis

– blurred vision/papilledema

– ataxia/agitation/confusion

– delirium/stupor

Photo courtesy of Dr. C-H. Pui

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HYPERLEUKOCYTOSIS

• Medical Management – IV hyperhydration (~3000 mls/M2/day)

– maintain urine output at 1-2 mls/kg/hr

– NaHCO3/allopurinol/rasburicase

– correct electrolytes

– leukapheresis/exchange transfusions

– blood product support

– anti-leukemia treatment

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HYPERLEUKOCYTOSIS

• Nursing Management/Interventions – assess cardiopulmonary/neurologic status

– monitor fluid/electrolyte balance

– recognize change in status/implement appropriate interventions

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HYPERLEUKOCYTOSIS

• Potential Complications – hemorrhage/intracranial bleed

– pulmonary leukostasis

– metabolic alterations

– renal failure

– sudden death

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TUMOR LYSIS SYNDROME (TLS)

• Definition – rapid breakdown of malignant cells causing

inadequate renal function manifested by: • hyperuricemia (uric acid > 8 mgs/dl)

• hyperkalemia (K+ >6 mEq/ml)

• hyperphosphatemia (PO4 > 10 mgs/dl)

• hypocalcemia (Ca++ < 8 mgs/dl)

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Hyperuricemia

Uric acid crystals

CYTOTOXIC THERAPY/ SPONTANEOUS TUMOR CELL BREAKDOWN

Tumor Cell Lysis

Hyperkalemia

Ventricular arrhythmia

Death

Renal Failure

Dialysis

Hyperphosphatemia

Calcium/phosphate crystals

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TLS

• Associated Malignancies – B cell leukemia/Burkitt’s lymphoma

– T cell leukemia/lymphoma

– leukemia with WBC > 100,000/mm3

– neuroblastoma (rare)

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TLS

• Clinical Presentation – RAPID ONSET

– abdominal pain/cramping/fullness/vomiting/ascites

– back/flank pain/oliguria/anuria

– cardiac arrhythmias/tachycardia/pleural effusion

– numbness/tingling/tetany

– weakness/fatigue

– altered level of conscience

– seizures

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TLS

• Medical Management – IV hyperhydration (~3000 mls/M2/day)

– urine alkalization • NaHCO3/allopurinol/rasburicase

– correct electrolyte/metabolic abnormalities

– +/- dialysis

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TLS

• Nursing Management/Interventions – accurate I&O/monitor weights

– monitor urine pH/specific gravity

– assess for symptoms of hypocalcemia • Chvostek’s sign

• Trousseau’s

– patient/family support

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SEPTIC SHOCK

• Definition – systemic response to pathogenic micro-organisms

and endotoxins in the blood

– leads to perfusion, cellular hypoxia, and death

– usually associated with gram negative organisms arising from endogenous flora

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SEPTIC SHOCK

• Risk factors – ANC < 100/mm3

– prolonged neutropenia (> 7 days)

– immunosuppression

– asplenism

– infancy

– mechanical device

– poor skin integrity/mucositis

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SEPTIC SHOCK

SYMPTOM SEPSIS SEPTIC SHOCK

VITAL SIGNS

Temperature: < 360 C or > 380 C

HR: tachycardia

RR: tachypnea

BP: normal

Temperature: < 360 C or > 380 C

HR: tachycardia

RR: tachypnea

BP: hypotension unresponsive to fluid resuscitation

PHYSICAL CHANGES

Warm, flushed skin

Weak/malaise

Adequate urine output

Cool, clammy skin

Bilateral rales, hypoxia

Anasarca

Oliguria anuria

MENTAL STATUS

CHANGES Minor confusion/restlessness

Confusion, anxiety, agitation, delirium, LOC

SEPSIS VERSUS SEPTIC SHOCK

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COMPENSATED SEPTIC SHOCK HYPERDYNAMIC

Early stage of shock Patient usually pancytopenic Often initial presentation May not appear “sick”

CHILLS/FEVER

SLIGHT PO2

SLIGHT PERFUSION

BEGINNING URINE OUTPUT

EARLY SIGNS CONFUSION

10% BLOOD VOLUME

NORMAL RESPIRATORY RATE

NORMAL BP

NORMAL PULSE

TRUNK WARM, PINK

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COMPENSATED SEPTIC SHOCK HYPERDYNAMIC

Intermediate stage of shock Patient usually pancytopenic Appears “sick” May need intubation Still reversible

CHILLS/FEVER THIRST

PULMONARY CONGESTION

PERFUSION CLAMMY

URINE OUTPUT

OBVIOUS CONFUSION ANXIETY

15-20% BLOOD VOLUME

RESPIRATORY RATE HYPOXIA

NORMAL BP

NORMAL PULSE

SKIN COOL/MOTTLED

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DECOMPENSATED SEPTIC SHOCK CARDIOGENIC

Late stage of shock Patient usually pancytopenic Organisms often gram negative Metabolic/lactic acidosis May not be reversible

DELERIUM COMA

>25% BLOOD VOLUME/ CARDIAC OUTPUT

PROFOUND HYPOXIA

SEVERE BP

RAPID THREADY PULSE

TRUNK COOL/MOTTLED

RESPIRATORY FAILURE PULMONARY EDEMA

HEMORRHAGIC LESIONS IN GI TRACT/DIC

OLIGURIA RENAL FAILURE

COLD EXTREMETIES

PERIPHERAL EDEMA

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SEPTIC SHOCK

• Medical Management – symptom management

• pressor support medications

– fluid boluses/hyperhydration • isotonic crystalloid solution (NS) • 20 mls/kg IV

– blood product support – +/- dialysis/ventilator support – treat underlying cause – antibiotics/+/- antifungal agents – +/- CXR

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SEPTIC SHOCK

• Nursing Management/Interventions – obtain blood cultures

– administer IV antibiotics

– close monitoring of VS

– identify early trends

– good communication with team


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DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

• Definition – alteration in blood clotting mechanisms with amounts

of thrombin and plasmin in the circulation • platelets • prothrombin • fibrinogen

• Manifested by

– diffuse intravascular coagulation – tissue ischemia

• Risk Factors – malignancies – infection – trauma

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DIC

• Clinical Presentation – petechiae/ecchymosis/purpuric rash

– diffuse bleeding

– plt count <20,000/mm3

– PT/PTT 1 1/2-2 times normal

– fibrinogen < 75,000 mgs/dl

– D-dimer > 500 g/L

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DIC


– blood product

– clotting factor replacements

– +/- heparin

• Nursing Management/Interventions – accurate patient assessment

– communicating lab values/findings


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TYPHLITIS

• Definition – inflammation of the cecum leading to necrotizing

colitis caused by bacterial invasion of the mucosa • most commonly occurs in neutropenic leukemic patients

• Risk Factors – severe/prolonged neutropenia

– acute leukemia induction

– infection/mucositis

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TYPHLITIS

• Clinical Presentation – profound neutropenia/fevers

– severe RLQ abdominal pain/distended abdomen

– high pitched “tinkling” bowel sounds

– N&V/diarrhea

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TYPHLITIS

• Medical Management – broad spectrum antibiotics

– supportive management/bowel rest

– radiology evaluation

– +/- surgery


– pain management/abdominal girths

– oral/skin/peri-anal care


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SPINAL CORD COMPRESSION SCC

• Definition – neurological emergency

– occurs in ~ 5% of patients

– usually NOT life threatening

– goal is to preserve neurological function

• Risk Factors – primary CNS tumor of the spinal cord

– neuroblastoma

– lymphoma

– metastatic sarcoma

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SCC

• Clinical Presentation – pain which may be local, referred, or diffuse

– motor deficits • weakness/ataxia

• hypotonic/hyporeflexia

• paralysis/muscle atrophy

– sensory deficits • bowel/bladder dysfunction

• loss of pain/temperature sensation

• paresthesia

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SCC

• Medical Management – neuro exam/MRI

– steroids

– +/- surgical decompression/XRT

– treat underlying disease


– positioning/ROM/skin care

– safety related to altered mobility


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SUPERIOR VENA CAVA SYNDROME SVCS

• Definition – compression of superior vena cava (SVC)

• Risk Factors – tumors arising in the anterior mediastinum

or involving mediastinal lymph nodes • NHL, Hodgkin’s disease, T cell ALL, thoracic

neuroblastoma, germ cell tumor

– obstruction of airway

– thrombosis

Tracheal deviation

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SVCS

• Clinical Presentation – cough/dyspnea/orthopnea

– wheezing/stridor

– anxiety/confusion

– edema/plethora

– cyanosis of face/neck/upper arm/chest

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SVCS


– treat underlying cause

– +/- steroids/XRT

• Nursing Management/Interventions – accurate respiratory assessment

– O2

– head of bed


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SIADH • Definition

– continuous release of ADH without a relationship to plasma osmolality with Na++

leading to cerebral edema/seizures

• Associated with: – in urine output/ in weight without edema

– hyponatremia & H2O intoxification

• Risk Factors – vincristine/cyclophosphamide

– CNS tumors/ALL

– trauma/surgery

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SIADH

• Medical Management – restrict fluids

– treat symptoms/underlying cause

• Nursing Management/Interventions – know “high risk” population

– accurate assessment/I&O/weights

– understand significance of labs


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ANAPHYLAXIS

• Definition – hypersensitivity reaction to foreign proteins – occurs within seconds/minutes of administration

or at any point during infusion

• Risk Factors – IV medications/infusions/chemotherapy/IVIG – ABX/antifungals – repeated blood product infusions – radiographic contrast media – latex hypersensitivity

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ANAPHYLAXIS

• Clinical Presentation – erythema/flushing/urticaria/pruritis

– anxiety/agitation

– wheezing/dyspnea

– laryngeal edema/stridor

– tachycardia

– N&V/diarrhea

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ANAPHYLAXIS

• Medical Management – administer “test” doses of high risk medications – pretreat with diphenhydramine/hydrocortisone – +/- steroids/cimetidine – epinephrine readily available

• Nursing Management – know risk potential of drug/patient – maintain airway/02

– stop infusion immediately – have emergency drugs/equipment accessible – STAY CALM!!!!!

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CONCLUSION

• Child diagnosed with cancer devastating experience

• Life-threatening event – added stress to a family in crisis

• Excellent nursing assessment – helps minimize severity of oncologic

emergencies

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CASE STUDY

• Jose, a 10 year old with AML, who has a double lumen VAD is on day 9 of induction chemotherapy

• He presents with c/o a sore throat and fever of 101.30 F

• What do you do first?

• VS show BP 80/46, HR 124, RR 28

• Labs: WBC 0.2, HGB 7.4, PLTS 54K

• What other labs might be obtained?

–Chem panel, possibly DIC screen

• What would you expect to be done next?

–Begin IVF’s @ 1.5-2 times maintenance

–Initiate ABX, always alternating lumens

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CASE STUDY

• After ABX begun BP 60/34, HR 130, RR 26 • Skin cool, cap refill > 5 seconds • What do you suspect?

–Septic shock/release of endotoxins

• What might be next step?

–Rapid infusion (s) NS at 20 ml/kg

• What other fluids might be given?

–+/- albumin

–pRBC 10-15 ml/kg when available

–Pheresis pack of platelets

• BP now 90/68, HR 110, RR 22

• Skin warm, pink, cap refill < 3 seconds

• What is most likely organism?

–Alpha strep in AML patients

–Gram negative bacteria

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BIBLIOGRAPHY

Abraham, E., et al. (2000). Consensus conference definitions for sepsis, septic shock, acute lung injury, and acute respiratory distress syndrome: time for a reevaluation. Crit Care Med.; 28: pp. 232-235.

Albin, A. R. (Ed). (1997). Supportive care of children with cancer. Current

therapies and guidelines from the children’s cancer group. (2nd ed). Baltimore: The John Hopkins University Press.

American Academy of Pediatrics (2000). Redbook 2000: Report of the

committee of infectious diseases (25th ed.). Elk Grove, IL: AAP. Bartlett, J. (2002). Pocket book of infectious disease therapy (11th ed.).

Baltimore: Lippincott, Williams, & Wilkins. Brant, J. M. (2002). Rasburicase: An innovative new treatment for

hyperuricemia associated with tumor lysis syndrome. Clinical Journal of Oncology Nursing, (6). pp. 12-16.

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BIBLIOGRAPHY

Carcillo, J. A., et al. (2002). Clinical practice parameters for the hemodynamic support of pediatric and neonatal septic shock. Crit Care Med.; 30(6).

Chernecky, C. C. & Berger, B. J. (Eds.) (1998). Advanced and critical

care oncology nursing: Managing primary complications. Philadelphia: WB Saunders.

Flounders, J. A. (2003) Oncology emergency modules: Spinal cord

compression. ONF January/February online exclusive. Volume 30 number 1. Retrieved February 2003 from ONS Online.

Hockenberry-Eaton M. J. (1998). Essentials of pediatric oncology

nursing: A core curriculum, Glenview IL: APON. Otto, S. E. (2001). Oncology Nursing (4th ed.). St. Louis: Mosby.

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BIBLIOGRAPHY Pizzo, P. & Poplack, D. (Eds.) (2002). Principles and practice of

pediatric oncology (4th ed.). Philadelphia: Lippincott Williams & Wilkins.

Secola, R, Cairo, M., Bessmertony, O., & Bergeron, S. (2002). Tumor

lysis guidelines. COG Nursing Clinical Practice Committee. Truini-Pittman, L., & Rosetto, C. (2002). Pediatric Considerations in

tumor lysis syndrome. Seminars in oncology nursing. (18): 3. pp. 17-22.

Weiner, M. A. & Cairo, M. (Eds.). (2002). Pediatric hematology oncology

secrets. Philadelphia: Hankey and Belfus Inc. Wilson, K. D. (2002). Oncologic emergencies. In Baggott, C. R., Et al.

(Eds.). Nursing care of children and adolescents with cancer (3rd ed.). Philadelphia: WB Saunders.

SNOT, SNEEZES, & CHILDHOOD DISEASES · emergencies and important nursing interventions for each....

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