Pseudohypoxemia Due to the rapid consumption of oxygen by leu-
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: 480–482 Blum W, Porcu P 2007 Therapeutic apheresis in hyper- leukocytosis and hyperviscosity syndrome. Semin Thromb Hemost 33:350–354 Bug G, Anargyrou K, Tonn T et al 2007 Impact of leu- kapheresis on early death rate in adult acute myeloge- nous leukemia presenting with hyperleukocytosis. Transfusion 47:1843–1850 Bunin NJ, Pui CH 1985 Differing complications of hyperleukocytosis in children with acute lymphoblas- tic or acute nonlymphoblastic leukemia. J Clin Oncol 3:1590–1595 Bunin NJ, Kunkel K, Callihan TR 1987 Cytoreductive procedures in the early management in cases of leuke- mia and hyperleukocytosis in children. Med Pediatr Oncol 15:232–235 Cairo MS, Coiffi er B, Reiter A et al 2010 Recommendations for the evaluation of risk and pro- phylaxis of tumour lysis syndrome TLS in adults and children with malignant diseases: an expert TLS panel consensus. Br J Haematol 149:578–586 Camacho LH, Soignet SL, Chanel S et al 2000 Leukocytosis and the retinoic acid syndrome in patients with acute promyelocytic leukemia treated with arsenic trioxide. J Clin Oncol 18:2620–2625 Carpentieri U, Patten EV, Chamberlin PA et al 1979 Leukapheresis in a 3-year-old with lymphoma in leu- kemic transformation. J Pediatr 94:919–921 Castagnetti M, Sainati L, Giona F et al 2008 Conservative management of priapism secondary to leukemia. Pediatr Blood Cancer 51:420–423 Chang MC, Chen TY, Tang JL et al 2007 Leukapheresis and cranial irradiation in patients with hyperleuko- cytic acute myeloid leukemia: no impact on early mor- tality and intracranial hemorrhage. Am J Hematol 82:976–980 Charoenratanakul S, Loasuthi K 1997 Pseudohypoxaemia in a patient with acute leukaemia. Thorax 52:394–395 Coiffi er B, Altman A, Pui CH et al 2008 Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol 26:2767–2778 Creutzig U, Ritter J, Budde M et al 1987 Early deaths due to hemorrhage and leukostasis in childhood acute myelog- enous leukemia: associations with hyperleukocytosis and acute monocytic leukemia. Cancer 60:3071–3079 Creutzig U, Zimmermann M, Reinhardt D et al 2004 Early deaths and treatment-related mortality in chil- dren undergoing therapy for acute myeloid leukemia: analysis of the multicenter clinical trials AML-BFM 93 and AML-BFM 98. J Clin Oncol 22:4384–4393 da Costa CM, de Carmargo B, Gutierrez y Lamelas R et al 1999 Cardiac tamponade complicating hyperleuko- cytosis in a child with leukemia. Med Pediatr Oncol 32:120–123 de Botton S, Coiteux V, Chevret S et al 2004 Outcome of childhood acute promyelocytic leukemia with all- trans- retinoic acid and chemotherapy. J Clin Oncol 22:1404–1412 De Santis GC, de Oliveira LC, Romano LG et al 2011 Therapeutic leukapheresis in patients with leukostasis secondary to acute myelogenous leukemia. J Clin Apher 26:181–185 Del Vasto F, Caldore M, Russo F et al 1982 Exchange transfusion in leukemia with hyperleukocytosis. J Pediatr 100:1000 Dimeski G, Bird R 2009 Hyperleukocytosis: pseudohy- perkalemia and other biochemical abnormalities in hyperleukocytosis. Clin Chem Lab Med 47:880–881 Dutcher JP, Schiffer CA, Wiernik PH 1987 Hyperleukocytosis in adult acute nonlymphocytic leu- kemia: impact on remission rate and duration, and sur- vival. J Clin Oncol 5:1364–1372 Eguiguren JM, Schell MJ, Crist WM et al 1992 Complications and outcome in childhood acute lym- phoblastic leukemia with hyperleukocytosis. Blood 79:871–875 Elrishi MA, Simpson AI, Bradley EJ et al 2010 Artifactual hypoglycaemia secondary to leukaemoid reaction. Pract Diab Int 27:62–63 Ferro A, Jabbour SK, Taunk NK et al 2014 Cranial irra- diation in adults diagnosed with acute myelogenous leukemia presenting with hyperleukocytosis and neu- rologic dysfunction. Leuk Lymphoma 55:105–109 Fong C, Fung W, McDonald J et al 2009 Anesthesia for children with hyperleukocytosis a retrospective review. Paediatr Anaesth 19:1191–1198 Fox MJ, Brody JS, Weintraub LR 1979 Leukocyte lar- ceny: a cause of spurious hypoxemia. Am J Med 67:742–746 Frankel SR, Eardley A, Lauwers G et al 1992 The “reti- noic acid syndrome” in acute promyelocytic leukemia. Ann Intern Med 117:292–296 Gartrell K, Rosenstrauch W 1993 Hypoxaemia in patients with hyperleukocytosis: true or spurious, and clinical implications. Leuk Res 17:915–919 Gaynon PS, Angiolillo AL, Carroll WL et al 2010 Long- term results of the children’s cancer group studies for childhood acute lymphoblastic leukemia 1983–2002: a Children’s Oncology Group Report. Leukemia 24:285–297 Gilchrist GS, Fountain KS, Dearth JC et al 1981 Cranial irradiation in the management of extreme leukemic leukocytosis complicating childhood acute lympho- cytic leukemia. J Pediatr 98:257–259 Giles FJ, Shen Y, Kantarijian HM et al 2001 Leukapheresis reduces early mortality in patients with acute myeloid leukemia with high white cell counts but does not improve long term survival. Leuk Lymphoma 42:67–73 Gregory J, Kim H, Alonzo T et al 2009 Treatment of children with acute promyelocytic leukemia: results of the fi rst North American intergroup trial INT0129. Pediatr Blood Cancer 53:1005–1010 Grund FM, Armitage JO, Burns CP 1977 Hydroxyurea in the prevention of the effects of leukostasis in acute leukemia. Arch Intern Med 137:1246–1247 Guglielmi C, Martelli MP, Diverio D et al 1998 Immunophenotype of adult and childhood acute pro- myelocytic leukaemia: correlation with morphology, type of PML gene breakpoint and clinical outcome. A 6 HyperleukocytosisParts
» 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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