Leukapheresis Supportive Care in Pediatric Oncology irantextbook.ir 93df
6.8 Other Treatment Modalities
for Cytoreduction Many older studies have utilized more conserva- tive measures with success in cytoreduction for patients with HL. Such interventions may have a non-inferior impact on early death as compared to more invasive and expensive interventions such as leukapheresis.6.8.1 Hyperhydration
Randomized controlled trials are lacking in regard to the benefi ts of hyperhydration although multiple small studies, especially in pediatric ALL, have shown signifi cant decre- ment in the WBC count with hydration alone, obviating the need for leukapheresis Maurer et al. 1988 ; Lascari 1991 ; Nelson et al. 1993 , Basade et al. 1995 .6.8.2 Hydroxyurea
Berg et al. 1979 reported on an adult cohort of 87 AML patients who were pretreated with large doses of hydroxyurea and found no difference in early death or long-term outcome in those with and without HL. Hydroxyurea was effective in rapidly lowering the WBC count in the majority of patients. Grund et al. 1977 similarly showed that hydroxyurea was effective in decreasing WBC count in a small cohort of adult patients with acute leukemia.6.8.3 Cranial Irradiation
Cranial radiotherapy has been noted as an effec- tive cytoreductive technique for intracerebral leukostasis in both children and adult patients Gilchrist et al. 1981 ; Ferro et al. 2014 . Ferro et al. 2014 successfully utilized whole-brain radiation therapy to alleviate neurologic symp- toms in an adult cohort with AML and HL. Maurer et al. 1988 showed no benefi t of cranial irradiation in a pediatric ALL cohort with WBC 200 × 10 9 L. Chang et al. 2007 utilized cranial irradiation and leukapheresis in adult patients with AML and HL and found no decrease in acute ICH or improved survival. Due to long- term neurologic sequelae, especially in young patients i.e., 6 years, and risk for secondary malignancy, cranial irradiation has fallen out of favor New 2001 .6.9 Other Supportive Care
Considerations6.9.1 Potential Laboratory
Discrepancies6.9.1.1 Pseudohyperkalemia Hyperleukocytosis has been noted to cause pseudo-
hyperkalemia due to increased fragility of blasts leading to cell rupture and increased potassium in the plasma sample. Cell lysis can occur secondary to minor mechanical stress such as pneumatic tube transport, prolonged tourniquet placement, vacu- tainer collection, manual shaking or centrifugation. Delayed analysis can also lead to hyperkalemia. Venous blood gas samples are a simple way to avoid such spurious results Dimeski and Bird 2009 .6.9.1.2 Pseudohypoxemia Due to the rapid consumption of oxygen by leu-
kemic blasts, it is vital that blood gas samples be kept on ice and analyzed immediately to prevent spurious results Fox et al. 1979 ; Hess et al. 1979 ; Shohat et al. 1988 ; Charoenratanakul and Loasuthi 1997 . Generally the patient’s clinical condition and pulse oximetry reading will corre- late, obviating the need for blood gas measure- ment. Gartrell and Rosenstrauch 1993 note that methemoglobinemia may be underreported at diagnosis in patients with HL; modern pulse oximetry should correlate with blood gas results in these cases.6.9.1.3 Pseudohypoglycemia Consumption of glucose by excess leukocytes
can lead to pseudohypoglycemia in patients with HL Elrishi et al. 2010 . Samples that are kept cold and run promptly can avoid this potential spurious result.6.9.1.4 Pseudothrombocytosis Leukemic blast lysis can lead to cell fragmenta-
tion which automated counters may read as plate- lets leading to an artifi cial increase in the platelet count. Since DIC is a common presentation with HL and platelet transfusion may be required to prevent bleeding with underlying true thrombo- cytopenia, it is important to examine the periph- eral smear if the automated platelet count reading does not correlate with previous values or the sta- tus of the patient.6.9.2 Transfusion Practice with
Underlying Hyperleukocytosis As described by Lichtman 1973 , blood viscosity is usually unaltered in HL secondary to a decrease in the erythrocrit concomitant with the increased leukocrit. Therefore, blood transfusion should be avoided as it can lead to increased risk of leukosta- sis by increasing blood viscosity. Harris 1978 noted that the mean hemoglobin concentration was signifi cantly higher in adult AML patients who suf- fered an early death with three patients dying soon after blood transfusion. Therefore, asymptomatic patients should not be transfused and in general hemoglobin concentration should be maintained below 10 gdL Harris 1978 . Evidence regarding this recommendation in ALL patients is less clear Lowe et al. 2005 ; Vaitkevičienė et al. 2013 .6.9.3 Anesthetic Procedures
Due to the risk of pulmonary complications, anesthesia should be undertaken with extreme care in the patient with HL but is often required due to the need for diagnostic procedures such as lumbar puncture and bone marrow aspiration. Fong et al. 2009 retrospectively reviewed 52 pediatric cases with HL that required anesthesia; 3 children required postanesthesia intensive care and 13 had less serious adverse events, all of a respiratory nature. In patients with respiratory distress or mediastinal mass at presentation, con- sideration should be given for utilizing peripheral blood for leukemia cytomorphology and cytoge- netics rather than bone marrow aspiration Vaitkevičienė et al. 2013 .6.10 Summary
Although signifi cant gains have been made in the treatment of pediatric leukemia, notably ALL, APL, and CML, HL continues to pose risk both in regard to early death and decreased long-term survival. An evidence basis for sup- portive care guidelines is lacking in HL; yet, even without such consensus, intensive support- ive care has signifi cantly improved early death, especially in AML patients. Many patients who ultimately have early death present with fea- tures, chiefl y ICH, for which no intervention will likely improve survival. Additionally, many therapies that have been suggested have no impact on overall survival; in fact, secondary to the underlying aggressive phenotypes, the over- all survival is often shorter with HL. Based on the available evidence, we present our recom- mendations in Table 6.1 . In general, prompt cor- rection of coagulopathy, hypofi brinogenemia, thrombocytopenia, and hyperuricemia and rapid initiation of hydration and antileukemic therapy are vital management strategies for all patients with HL. References Azoulay É, Canet E, Raffoux E et al 2012 Dexamethasone in patients with acute lung injury from acute mono- cytic leukaemia. Eur Respir J 39:648–653 Basade M, Dhar AK, Kulkarni SS et al 1995 Rapid cyto- reduction in childhood leukemic hyperleukocytosis by conservative therapy. Med Pediatr Oncol 25:204–207 Berg J, Vincent PC, Gunz FW 1979 Extreme leucocyto- sis and prognosis of newly diagnosed patients with acute non-lymphocytic leukaemia. Med J Aust 1: 480–482Parts
» Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Introduction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» History and Physical Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Defi ning the Risk for Serious
» Initial Laboratory Evaluation Diagnostic Evaluation
» Chest Radiography CXR A supine CXR may identify pleural effusions,
» Computed Tomography CT Radiographic Imaging
» Magnetic Resonance Imaging MRI
» Positron Emission Tomography PET
» Aspergillus Galactomannan GMN Biomarkers for Invasive
» 1,3-β- Biomarkers for Invasive
» Polymerase Chain Reaction PCR
» Viral Studies Diagnostic Evaluation
» Invasive Procedures: Diagnostic Evaluation
» Adult FN Guidelines Empiric Management
» Monotherapy Versus Combination Therapy
» Which Monotherapy to Choose A Cochrane review of antipseudomonal beta-
» Alterations in Initial Empiric FN Antibiotic Management
» Outpatient Management of FN Although there remains a lack of one uniform
» Choice of Empiric Antifungal Therapy
» Duration of Antimicrobial Empiric Management
» Endovascular Sources Empiric Management
» Adjunctive Treatment Empiric Management
» Emergence of Resistant Empiric Management
» Red Blood Cell Administration
» Granulocyte Transfusion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hemolytic Transfusion Risks of Blood Product
» Infection and Sepsis Risks of Blood Product
» Allergic Reactions Risks of Blood Product
» Febrile Nonhemolytic Risks of Blood Product
» Transfusion-Related Acute Risks of Blood Product
» Transfusion-Associated Risks of Blood Product
» Iron Overload Risks of Blood Product
» Laboratory Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» General Management Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Alkalinization Urinary alkalinization has been a long-standing
» Allopurinol Allopurinol inhibits xanthine oxidase, an enzyme
» Rasburicase Rasburicase, recombinant urate oxidase, converts
» Renal Interventions Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pathophysiology Superior Vena Cava
» History and Physical Exam SVCSSMS should be suspected in a patient
» Imaging Studies The diagnosis of SVCSSMS is often made on
» Other Studies Tissue is required to make a defi nitive diagnosis
» Treatment Superior Vena Cava
» History and Physical Exam Small pericardial effusions are frequently asymp-
» Imaging and Other Studies The presence of a pericardial effusion can be
» History and Physical Exam Many patients with small pleural effusions are
» Imaging Studies When a pleural effusion is suspected, a chest
» History and Physical Exam Patients with pheochromocytoma typically have
» Laboratory Studies The diagnosis of pheochromocytoma is best made
» Imaging Studies Clinical Presentation
» Pulmonary Leukostasis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Presentation Spinal Cord Compression
» Differential Diagnosis Spinal Cord Compression
» Imaging MRI of the spine can help narrow the differential
» Surgery Surgery in spinal cord compression can be uti-
» Radiation Therapy The advantages of external beam radiation ther-
» Outcomes Spinal Cord Compression
» Presentation Altered Mental Status
» Initial Management Altered Mental Status
» Metabolic The metabolic causes of AMS or seizure in pedi-
» Chemotherapy-Associated Neurotoxicity Differential Diagnosis
» Posterior Reversible Encephalopathy Syndrome
» Outcomes Altered Mental Status
» Initial Management Increased Intracranial
» Soft Tissue A large meta-analysis of published data suggests
» Cerebrospinal Fluid Hydrocephalus is an excess of CSF within the
» Hemorrhage and Thrombosis Differential Diagnosis
» Idiopathic Intracranial Hypertension Differential Diagnosis
» Presentation of Stroke Cerebrovascular Disease
» Differential Diagnosis Cerebrovascular Disease
» Etiology of Stroke in Pediatric
» Ischemic Stroke After an ischemic stroke is diagnosed, the patient
» Hemorrhagic Stroke Hematomas can expand over several hours from
» Acute Lymphoblastic Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Myelogenous Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Promyelocytic Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Chronic Myelogenous Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Tumor Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Leukapheresis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hyperhydration Other Treatment Modalities
» Hydroxyurea Other Treatment Modalities
» Cranial Irradiation Other Treatment Modalities
» Pseudohyperkalemia Hyperleukocytosis has been noted to cause pseudo-
» Pseudohypoxemia Due to the rapid consumption of oxygen by leu-
» Pseudohypoglycemia Consumption of glucose by excess leukocytes
» Pseudothrombocytosis Leukemic blast lysis can lead to cell fragmenta-
» Transfusion Practice with Other Supportive Care
» Anesthetic Procedures Other Supportive Care
» Neutropenic Enterocolitis Gastrointestinal Infection
» Perirectal Abscess Gastrointestinal Infection
» Gastrointestinal Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pancreatitis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Bowel Obstruction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Abdominal Compartment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» ALL Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Other Malignancies Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Central Venous Catheters Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diagnosis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nociceptive Pain Types of Pain
» Neuropathic Pain Types of Pain
» World Health Organization Pharmacologic Treatment
» Intermittent Opioid Use Pharmacologic Treatment
» Long-Acting Opioids Pharmacologic Treatment
» Breakthrough Dosing Pharmacologic Treatment
» Opioid Rotation Pharmacologic Treatment
» Patient-Controlled Analgesia Pharmacologic Treatment
» Constipation Side Effects of Opioids
» Nausea and Vomiting Nausea and vomiting are rare opioid side effects
» Pruritus Pruritus is a common side effect of opioid use
» Sedation Side Effects of Opioids
» Confusion and Agitation Renal and hepatic function should be checked
» Respiratory Depression When dosed appropriately, opioids rarely result
» Myoclonus Patients receiving very high doses of opioids for
» Urinary Retention Urinary retention can be caused by any opioid but
» Calcium Channel Blockers Neuropathic Pain
» Serotonin and Norepinephrine Neuropathic Pain
» Tricyclic Antidepressants Neuropathic Pain
» Interventional Techniques Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vincristine-Related Peripheral Oncology-Specifi c Pain
» Osteonecrosis Oncology-Specifi c Pain
» Post-lumbar Puncture Oncology-Specifi c Pain
» Mucositis Pain Oncology-Specifi c Pain
» Pathophysiology of Emesis Chemotherapy-Induced
» Principles of Emesis Control in the Cancer Patient
» Emetogenicity of Chemotherapy Chemotherapy-Induced
» Dopamine Receptor Antagonists Classes of Antiemetics
» Corticosteroids Classes of Antiemetics
» Cannabinoids The plant Cannabis contains more than 60 differ-
» Other Antiemetic Agents Antihistamines
» Alternative Therapies Ginger Classes of Antiemetics
» Management of CINV Management of CINV Table
» Special Considerations Anticipatory Nausea and Vomiting
» Radiation-Induced Nausea Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Initiation The initiation stage occurs immediately following
» Primary Damage Response Pathophysiology of Oral Mucositis
» Signal Amplifi cation Pathophysiology of Oral Mucositis
» Ulceration Ulceration is the phase with the most clinical sig-
» Healing Pathophysiology of Oral Mucositis
» Clinical Course of Oral Mucositis
» Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Palifermin Prevention and Treatment
» Low-Level Laser Therapy Prevention and Treatment
» Glutamine Prevention and Treatment
» Cryotherapy Prevention and Treatment
» Oral Care Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Infections Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nutrition Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Dietary Counseling Nutrition Intervention
» Appetite Stimulants Nutrition Intervention
» Enteral Tube Feeding Nutrition Intervention
» Parenteral Nutrition Nutrition Intervention
» Nutrition and Survivorship Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Neutropenia Hematologic Toxicity
» Management of Thrombocytopenia Hematologic Toxicity
» Management of Anemia Hematologic Toxicity
» Somnolence Syndrome Central Nervous System
» Lhermitte’s Sign Central Nervous System
» Skin Complications Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Mucositis Head and Neck
» Ear Complications Head and Neck
» Laryngeal Complications Head and Neck
» Dysphagia and Esophagitis Gastrointestinal
» Nausea, Vomiting and Anorexia
» Pneumonitis Major Organ Infl ammation
» Pericarditis Major Organ Infl ammation
» Hepatitis Major Organ Infl ammation
» Nephropathy Major Organ Infl ammation
» Cystitis Major Organ Infl ammation
» Risk Stratifi cation Prevention of Bacterial
» Adult Data Antimicrobial Approaches
» Pediatric Data Data regarding the utility of bacterial prophylaxis
» Risks of Prophylaxis Prevention of Bacterial
» Guidelines and Current Usage of Antibacterial Prophylaxis
» Protocols for Line Placement and Care
» Antibiotic and Ethanol Locks
» Chlorhexidine Cleansing Chlorhexidine gluconate CHG is a bactericidal
» Future Directions Prevention of Bacterial
» Risk Stratifi cation Prevention of Fungal
» Approaches to Antifungal Prophylaxis
» Guideline Recommendations for Antifungal Prophylaxis
» Limitations of Current Options for Antifungal Prophylaxis
» Risks of Prophylaxis Prevention of Fungal
» Biomarkers Prevention of Fungal
» Future Directions Prevention of Fungal
» Risk Stratifi cation Prevention of Pneumocystis
» Approaches to PCP Prophylaxis
» Summary of the Recommendations
» Future Directions Prevention of Pneumocystis
» Postexposure Chemoprophylaxis Prevention of Viral Infections
» Suppressive Therapy Prevention of Viral Infections
» Future Directions Prevention of Viral Infections
» Hand Hygiene Infection Control Practices
» Mandatory Vaccination Infection Control Practices
» Hospital Isolation Practices Infection Control Practices
» Visitor Screening Policies Infection Control Practices
» Work Restriction Infection Control Practices
» Cytomegalovirus CMV Status of Transfused Blood
» Treatment of Myelosuppression with
» Prevention of Febrile Neutropenia, Delay
» Treatment of Febrile Neutropenia
» Treatment of Myelosuppression Clinical Usage of Myeloid Growth Factors
» Comparison of Granulocyte Colony-Stimulating Factor
» Optimal Dosing Adult guidelines recommend dosing of 5 mcgkg
» Route of Administration Optimal Administration of Colony-Stimulating Factors
» Optimal Timing Optimal Administration of Colony-Stimulating Factors
» Erythropoietin Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Interleukin-11 Platelet Growth Factors
» Thrombopoietin Receptor Agonists Platelet Growth Factors
» Immune Status Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Status During Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Recovery After Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immunization Practice Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diphtheria, Tetanus, and Acellular Pertussis
» Pneumococcal Conjugate Vaccine Recommendations
» Hemophilus Infl uenzae Type b
» Inactivated Infl uenza Vaccine Although in a Cochrane review Goossen et al.
» 2009 H1N1 Pandemic Vaccine Seven studies have reported on effi cacy of the
» Live Attenuated Infl uenza Vaccine
» Meningococcal Conjugate Vaccine Recommendations
» Varicella Zoster Virus Recommendations
» Recommendations Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Treatment of Hypogammaglobulinemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vaccination of Household Contacts
» Peripherally Inserted Central Catheter
» External Tunneled Central Venous Catheter
» Implanted Port Types of Central Venous
» Catheter Insertion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Exit Site Infection Infection
» Prevention of Infection Infection
» Drug Precipitate or Lipid Residue Occlusion Thrombotic Occlusion
» Evaluation of Catheter- Related Thrombosis
» Treatment of Catheter- Related Thrombosis
» Special Considerations During Anticoagulation Therapy
» Contraindications of Anticoagulant Therapy
» Skin Antisepsis Catheter Maintenance
» Central Venous Catheter Dressings
» Hub Care Catheter Maintenance
» Central Venous Catheter Flushing and Locking
» Chlorhexidine Bathing Chlorhexidine has been shown to be effective in
» Antiseptic Needleless Connectors and Antiseptic
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