Laboratory Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
3.3 General Management
Guidelines Prevention is the key component of TLS manage- ment in high-risk patients and hyperhydration i.e., 3 Lm 2 day is the most important prophy- lactic intervention although randomized evidence supporting its benefi t is lacking due to the risk of withholding such therapy in high-risk patients Table 3.3 Coiffi er et al. 2008 ; Tosi et al. 2008 . Intravenous fl uids should ideally be started 24 h prior to the initiation of cytotoxic therapy. Fluid status must be monitored vigilantly taking into account the patient’s daily fl uid balance, urine output, laboratory evidence of renal function and physical exam evidence of fl uid overload i.e., change in weight, edema, dyspnea, rales or gal- lop rhythm. Dilute urine output, defi ned as 100 mlm 2 h 4 mlkgh for infants with a urine specifi c gravity 1.010, should be estab- lished prior to the initiation of chemotherapy and should be maintained at such levels during the acute phase of therapy Coiffi er et al. 2008 ; Tosi et al. 2008 . Loop diuretics and mannitol can be utilized to maintain good urine output but should be avoided in patients with evidence of hypovole- mia Coiffi er et al. 2008 ; Tosi et al. 2008 . Frequent laboratory monitoring is necessary to assess for evidence of LTLS and risk of CTLS. Uric acid, phosphate, potassium, calcium and creatinine levels should be checked prior to the initiation of cytoreductive therapy. The frequency of monitor- ing thereafter must be tailored to each individual patient and may be required as often as every 4–6 h in patients exhibiting signifi cant LTLS worrisome for the development of CTLS or as infrequently as every 24 h in lower- risk patients Coiffi er et al. 2008 ; Tosi et al. 2008 . Guidelines recommend fol- lowing LDH levels as a marker of decreasing tumor burden and TLS risk although it is unclear if this is really necessary to appropriately assess the patient Coiffi er et al. 2008 ; Tosi et al. 2008 . In addition, patients who develop hyperkalemia and hyper- phosphatemia or who have poor urine output despite vigorous hydration should undergo renal ultrasound to rule out renal parenchymal involve- ment or obstructive uropathy. Electrocardiographic ECG monitoring may be warranted if the patient has either hyperkalemia i.e., potassium ≥6 mEqL or hypocalcemia Table 3.2 Risk factor stratifi cation for clinically signifi cant tumor lysis syndrome at disease presentation in pediatric patients a High risk for CTLS Stage IIIIV Burkitt lymphoma with LDH ≥2× ULN andor bulky retroperitoneal disease ALL with WBC ≥200 × 10 9 L and uric acid ≥11.0 mgdL b Hyperphosphatemia Hypocalcemia Hyperkalemia Oliguria Renal involvement in leukemia or lymphoma Low risk for CTLS Non-lymphomatous solid tumors Hodgkin lymphoma Chronic myelogenous leukemia Acute myelogenous leukemia Stage III NHL ALL in children 10 years of age with WBC 20 × 10 9 L and no mediastinal mass or splenomegaly Intermediate risk for CTLS All others not classifi ed as low or high risk CTLS clinical tumor lysis syndrome, LDH lactate dehydrogenase, ULN upper limit of normal, ALL acute lymphoblastic leukemia, WBC white blood cell, LTLS laboratory tumor lysis syndrome, NHL non-Hodgkin lymphoma a See text for detail, level of evidence 1B for all categorizations per Guyatt et al. [2006]; see Preface b WBC 25 × 10 9 L or LDH ≥2× ULN without LTLS is not a risk factor for TLS in ALL patients A. Marsh et al. Table 3.3 Pharmacologic interventions for the treatment of tumor lysis syndrome a Condition Level of evidence b General management Intravenous fl uids D5W 12NS infused at 3 Lm 2 day without potassium or calcium 1C Sodium bicarbonate 20–40 mEqL if the patient has HU or risk for HU; can decrease to 14NS if on 40 mEqL or more of sodium bicarbonate 2C Urinary alkalinization not required if utilizing rasburicase 1B Urinary alkalinization should not be initiated with concomitant hyperphosphatemia 1A Laboratory monitoring Monitor potassium, phosphorus, calcium, uric acid, BUNcreatinine every 4–6 h in patients at high risk for tumor lysis 1C Can wean labs to every 12–24 h as tumor burden decreases over 3–7 days 1C Hyperuricemia Allopurinol c 1B In all patients not receiving rasburicase; unclear evidence in low-risk patients 10 mgkgday PO divided Q8h to a maximum of 800 mgday Rasburicase d 1B Rasburicase prophylaxis should be limited to patients with evidence- based risk factors see Table 3.2 ; specifi cally stage IIIIV BL patients with elevated LDH ≥2× ULN andor bulky retroperitoneal disease, hyperleukocytic ALL WBC ≥ 200 × 10 9 L with severe hyperuricemia uric acid ≥11.0 mgdL or hyperuricemia not improving with hyperhydration, urinary alkalinization and allopurinol alone 0.03–0.05 mgkg IV × 1; subsequent doses not usually required but can be given if uric acid again 8 mgdL in high-risk patients Hyperphosphatemia Aluminum hydroxide 1C Avoid in patients with renal insuffi ciency Children: 50–150 mgkgday PO divided Q4–6 h Adolescents: 300–600 mg PO TID Sevelamer 1C Administer with each meal Children: dosing not well established Adolescent dosing based on phosphorus level mgdL: 5.5 and 7.5: 800 mg PO TID ≥7.5 and 9: 1200 mg PO TID ≥9: 1600 mg PO TID Calcium carbonate use with caution as can increase calcium-phosphate product and risk for calcium phosphate precipitation 1C Children: 30–40 mgkgdose with each meal Adolescents: 1–2 g with each meal Hyperkalemia Calcium gluconate, 100–200 mgkg IV slow infusion with ECG monitoring 1C Sodium polystyrene sulfonate, 1 gkg in 50 sorbitol PO Q6h max dose 15 g 1C Regular insulin + D25W, 0.1 unitkg insulin max 10 units + 2 mlkg 0.5 gkg D25W IV over 30 min 1C Albuterol 1C Inhaled via nebulizer 25 kg: 2.5 mg Inhaled via nebulizer 25–50 kg: 5 mg Inhaled via nebulizer 50 kg: 10 mg 3 Tumor Lysis SyndromeParts
» 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
Show more