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Oncologic Emergencies

Anne Bailey, MN, RN, OCN, CE, BC

Definition:

• Life Threatening medical emergencies caused by cancer or the treatment of the cancer.

• Usually occurs initially when disease first manifest or late the disease trajectory.

Objectives:

• Identify patients at risk for oncologic emergencies

• Review pathophysiology of event

• Recognize associated signs and symptoms

• Assessment

• Interpret diagnostic evaluation and appropriate interventions

• Review management across the continuum of care

• Patient and family education

Bleeding and Thrombosis

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Bleeding and Thrombosis

• Description: Bleeding can result from a reduction in platelets, an alteration in clotting factors, a paraneoplastic syndrome, infection, hepatic problems, or a combination of all these factors. Venous thromboembolism (VTE) includes both deep vein thrombosis (DVT) and pulmonary embolism (PE).

Bleeding & Thrombosis

• Incidence: Bleeding can occur with any type cancer but especially in patients with advanced cancer and those patients with hematologic malignancies. Annual incidents of VTE is five times greater in patients with cancer than general public.

Clinical Manifestations

• Signs of bleeding including petechiae, ecchymoses, bruising, epistaxis, hemoptysis, hematemesis, melena, hematuria, vaginal bleeding.

• Signs of DVT including unilateral swelling of extremity, edema, warmth, localized pain, vein dilation, limb color changes,

• Signs of PE including dyspnea, pleuritic pain, tachypnea, apprehension, tachycardia

Evaluation/Diagnostic Tests

• Bleeding; CBC (hct & platelets), coagulation tests.

• DVT D-dimer, venous duplex US, CT scan

• PE; computed tomography pulmonary angiogram, ventilation/perfusion scans.

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Treatment Modalities

• Bleeding: transfusions, vitamin K therapy, vasopressive hormones, mechanical measures

• VTE: Prophylaxis with low-molecular-weight heparin

Nursing Management

• Recognition of early signs and symptoms of bleeding or coagulation is key in the nurse’s assessment

• Bleeding precautions are implemented for at risk patients.

• Nursing measures are instituted to prevent VTE in hospitalized patients and those at risk.

• VTE is the most preventable cause of death in hospitalized patients.

Outcome

• Patients with cancer are at high risk for bleeding and VTE. Early recognition and initiation of appropriate treatment are crucial to patient outcome. Those at risk for VTE are considered for pharmacologic prophylaxis, balancing the risk of VTE with the increased risk of bleeding.

Disseminated Intravascular Coagulation

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Disseminated Intravascular Coagulation (DIC)

• Description: Disseminated intravascular coagulation (DIC) is always precipitated by an underlying pathologic condition. It is a coagulation disorder involving widespread intravascular thrombosis leading to organ damage and failure and simultaneous consumption of platelets and coagulation factors leading to hemorrhage.

DIC Incidence

• Associated mostly with severe sepsis, trauma and obstetric conditions.

• Also seen in Acute Promyelocytic Leukemia (APL)

• Mucin-secreting adenocarcinomas of prostrate, lung, and breast.

Pathophysiology of DIC

• In DIC the balance between clot formation (Thrombosis) and clot dissolution (fibrinolysis) is disrupted

• Procoagulation activation

• Fibrinolytic activation

• Inhibitor consumption

• Cytokine release

• Cellular activation

• Biochemical evidence of end organ damage

Clinical Manifestations

• Clinical signs and symptoms of bleeding and thrombosis.

• Can be silent and undetected or acute and severe

• Signs are dependent of the etiology

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Symptoms of DIC

• Petechiae

• Purpura

• Hematomas

• Cyanosis

• Wound bleeding

• Blood oozing (Severe case)

Treatment Modalities

• Effective treatment of the underlying disorder is key.

• Supportive therapies include blood component replacement therapy to control bleeding

• Therapy will be based on clinical and lab findings

Nursing Management

• Careful physical assessment to recognize subtle signs of bleeding or thrombosis.

• Close monitoring of vital signs, oxygenation, fluid status, and lab results.

• Administration of blood products

• Patient education about prevention, recognition and reporting.

Review Question:

• Sepsis is a common cause of disseminated intravascular coagulation (DIC). Which of the following most accurately describes how sepsis causes DIC?

1. Sepsis causes viruses to thrive, and viruses cause DIC.

2. Endotoxins released from bacteria activate the coagulation cascade.

3. Sepsis and bleeding occur simultaneously in patients who are immunosuppressed.

4. Antiangiogenesis factors are released during periods of sepsis, which leads to DIC.

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Hypercalcemia of Malignancy

Hypercalcemia

• Para-neoplastic syndrome characterized by elevated serum calcium

• Hypercalcemia of malignancy (HCM) is a complex metabolic disorder that most commonly develops as a consequence of pathologic destruction of bone mediated by factors released by malignant cells.

Incidence and Etiology

• Reported in 10 – 30% of patients with cancer

• May be the presenting element of cancer

• Most common malignancies

– Breast Cancer

– Lung Cancer

– Multiple Myeloma

Pathophysiology

• Primary abnormality is an excessive increase in osteoclastic activity and elevated renal absorption of calcium

• Parathyroid hormone related protein is released by solid tumors and secreted by cancer cells. This is considered humoral and accounts for 80% of total incidence of hypercalcemia.

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Other Mediators of Bone Destruction

• Bone destruction through both direct and indirect actions

– Parathyroid hormone

– Cytokines

– Growth factors

Why is this a problem?

• If hypercalcemia is severe (>14 mg/dL) and untreated, about 50% of patients will progress to renal failure, severe dehydration, and coma.

Clinical Presentation, Signs & Symptoms

• Multiple and non-specific

• Lethargy

• Confusion

• Anorexia

• Nausea

• Constipation

• Polyuria

• Polydipsia

Evaluation & Diagnostic tests

• Lab draws; calcium, albumin, or ionized calcium

• BUN, Serum Creatinine, phosphorus, magnesium, and potassium

• EKG changes

• Appropriate radiographic imaging tests

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Interpretation of Serum Calcium

• Normal lab values in adult patients:

• Calcium (serum):

– 8.5-10.5 mg/dL

• Calcium (Ionized) Serum:

– 4.5 – 5.6 mg/dL

Degree of Hypercalcemia

• Mild: Serum Calcium 10.5 – 12 mg/dL

• Moderate: Serum Calcium 12 – 14 mg/dL

• Critical: Serum Calcium 14 mg/dL or greater

Treatment Modalities

• Controlling the malignancy is the most effective treatment

– Hydration

– Calcitonin

– Bisphosphonates

Nursing Management

• Monitor for Signs & Symptoms of hypercalcemia

• Vital Signs

• Monitor for arrhythmias

• Patient education

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Review Question:

Which of these statements is not true in regards to hypercalcemia in malignancy?

1. It is a rare complication

2. Early manifestation of the syndrome are insidious, including fatigue, muscle weakness, and depression, and easily overlooked as manifestations of the disease.

3. Biphosphonates are frequently used in the treatment of malignancy induced hypercalcemia because of their ability to interfere with osteoclastic activity.

4. A complication of malignancy induced hypercalcemia includes sudden decreased GFR and acute kidney failure, neuropsychiatric disturbances.

Infusion Reactions

Infusion Reactions

• Anaphylaxis & Hypersensitivity

• Description: Systemic reactions that occur in response to infusions of IV agents that stimulate a variety of immune-and non-immune-modulated responses.

• Defined as an adverse immunologic response to the exposure of an agent that can result in a life threatening reaction.

Anaphylaxis

• Rapid onset with respiratory, cardiovascular, cutaneous or GI manifestations

• An allergic IgE mediated immediate hypersensitivity reaction

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Hypersensitivity

• Hypersensitivity reactions have a 5% incidence with chemotherapy treatment. Monoclonal antibodies are associated with cytokine release.

Common Chemotherapy Infusion Reactions

• Rituximab and Paclitaxel are the most common cause of infusion reactions.

• Most reactions occur during the first cycle administration of drug.

• Reactions can occur despite pre medications.

• A good predictor of possible drug reaction is a history of reaction to same drug in recent past.

Premedication

• Dependent upon severity and cause of the reaction.

• Pre medications may include acetaminophen, antihistamines (Diphehydramine), corticosteroids, epinephrine and H2 antagonists-cimetidine, ranitidine.

Clinical Manifestations Signs and Symptoms

• Itching

• Urticaria

• Wheezing

• Bronchospasm

• Angioedema

• Hypotension

• Pain

• Feeling of impending doom

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Signs & Symptoms Continued

• Less Common

– Nausea

– Vomiting

– Diarrhea

– Rhinitis

– Headache

– Substernal pain

– Back pain

– Seizure

– Metallic taste

Example of Protocol for Hypersensitivity Reaction Interventions

• Stop the infusion

• Call for help

• Stay with the patient

• Assess the airway & Vital Signs

• Infuse NS IV or IV solution as ordered

• Oxygen

• Administer Diphenhydramine 50 my IV slowly

• Administer Solumedrol 125 mg IV

• Nebulizer of albuterol

• IV Epinephrine if severe

Nursing Management

• Stop the infusion

• Perform accurate patient assessment, including Vital Signs.

• Remain with the patient

• Administer rescue medications or medication for symptom management.

Review Question:

• What are the three most important nursing interventions when you first recognize an infusion reaction?

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Sepsis & Septic Shock

Sepsis & Septic Shock

• Description: Occurs as a result of an overwhelming infection (bacterial, viral, or fungal) to which the body fails to provide an adequate immune response.

Incidence:

Kills one in four patients hospitalized with sepsis each year.

Risk is higher in patients with malignancies compared to other causes.

Severe sepsis occurs more frequently in patients with hematologic malignancies.

Incidence

• Hematologic malignancies 66.4/1,000

• Solid tumors 7.6/1,000

Presenting Characteristics

• Oral temp greater than 100.4

– Note patients can be hypothermic

• Heart rate above 90

• Respiratory rate above 20 /min

• WBCs greater than 12,000 or less than 4,000 with more than 10% bands

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Septic Shock: Hemodynamic Instability

• Fever, chills

• Tachycardia, Tachypnea

• Mental status changes

• Persistent hypotension despite vigorous fluid resuscitation

Risk factors

• Cytopenia

• Malignancy with related immunosuppression

• Age less 1 year, greater than 65 years

• Loss of skin, mucosal integrity

• Long ICU stay

• Indwelling devices

• Diabetes

• Renal, hepatic, cardiovascular, pulmonary disease

Pathophysiology

• Systemic response to infection, endotoxins, or exotoxins

• Toxins activate the coagulation cascade and complementary systems

• Complement systems release vasoactive mediators

Clinical presentation

• Vital Signs

• CNS assessment

• Cardiovascular

• Pulmonary

• GI

• Renal

• Hepatic

• Skin

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Nursing Management

• If fever;

• Identify quickly

• Assess most common sites, often asymptomatic

• Cultures to verify source of infection

Nursing Management continued

• Prompt IV antibiotics within one hour of recognition

• Think EARLY & ADEQUATE

• Fluid resuscitation and central IV access

• Delay in restoring circulation increases mortality and morbidity

• Large volumes (6-20 L) rapid IV infusion

• Tight Glycemic control

• ICU transfer

Nursing Management continued

• Early detection and intervention are critical in preventing the progression of infection to septic shock. Nurses caring for immunosuppressed patients must maintain a high index of suspicion for the onset of infection and provide meticulous nursing care to minimize the risk of progression.

Possible Complications

• Multiple Organ Dysfunction

• DIC

• Acute Lung Injury/ARDS

• Renal Failure

• Death

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Case Study

• Mr. Winston is a 76 yo male admitted with stage IIIB Non-Small Cell Lung Cancer. He is emaciated, with 20 pound weight loss over last 3 months. He has a long term history of ETOH abuse and COPD. He recently quit smoking after a 60 pack year history. His is on Paciltaxel and Carboplatin. He comes into the Infusion Center for routine f/u on day 10.

• Assessment He states he’s not feeling well, and cannot get warm since this am. He is confused and hot his usual perky self. His skin is pale and clammy.

• Vital Signs; T 38.2, HR 125, RR 24, BP 88/49

Case Study Continued

• Labs show WBCs 1.2 & Polys .34 Neutropenic

Treatment includes;

Admission to med surg unit

Blood Cultures

IV Hydration

Frequent VSs

IVABs.

Case Study

• Mr. Winston becomes more hypotensive and less responsive, an RRT is called and he is transferred to ICU.

• ICU treatment includes;

– Central Line placement

– Rapid IV fluid resuscitation

– Foley

– Labs and ABGs.

SIADH

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SIADH

• Syndrome of Inappropriate Anti-Diuretic Hormone

– Hyponatremia caused by an abnormal secretion of ADH

– Intravascular volume is normal, urine osmolality is high (concentrated) compared with serum osmolality

– ADH causes water retention, which leads to decreased sodium and inability to excrete dilute urine.

Etiology and Incidence

• Develops in 1 – 2 % of patients with cancer

• Malignant tissue inappropriately secretes ADH

• Most commonly associated with lung cancer

Other Causes

• Chemotherapy

• Medications

– Antidepressants

– Antibiotics

Normal Physiology of Water Regulation

• 60 – 80% of body weight is water

2/3 is Intracellular

including Potassium & Phosphate

1/3 is Extracellular is 1/3

Including Sodium and Chloride

– Normal role of ADH is to conserve body water by reducing the output of urine

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Risk Factors

• Malignant conditions (especially small cell lung cancer)

• Neurologic conditions

• Medications

Clinical Manifestations

• Anorexia

• Nausea

• Myalgia

• Headaches

• Severe neurologic complications

Signs & Symptoms

• Early:

• Mild hyponatremia Na 115-130 mEq/L

• Fatigue and weakness

• Nausea, vomiting, anorexia, thirst, diarrhea

• Headaches, lethargy, confusion, irritability

• Decreased urine output

• Myalgias, muscle cramping

Signs & Symptoms

• Late:

• Altered mental status

• Confusion, personality changes

• Psychosis

• Seizures

• Progressive lethargy

• Coma

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Diagnostics & Treatment

• Confirm hypo-osmolar state by checking serum osmolality.

• Assess for S/S of cerebral edema

• Determine the duration (more or less than 48 hours).

• Assess the extracellular fluid volume status

• Check urine osmolality

Diagnostics & Treatment

• Assess for underlying cause for Oncology Patients

– Chemotherapy

– Assess for other medications and nutritional intake

Nursing Management

• Fluid restriction of 500-1000 ml per day

• Oral care

• Safety measures if confused

• Implement seizure precautions as necessary

Review Question:

• State three early signs and symptoms of SIADH.

• What do the initials SIADH stand for?

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Spinal Cord Compression

Spinal Cord Compression

• Description: Occurs when tumor invades or extends into the epidural space or pathologically collapsed vertebral bone fragments impinge on the spinal cord.

Spinal Cord Compression

• “Spinal cord compression is one of the most dreaded complications of cancer and is a true emergency. Without prompt diagnosis and appropriate intervention, spinal cord compression leads to devastating neurologic disability and death. It is a relatively common complication, affecting 5-14% of all patients with cancer at some point in their disease.”

Spinal Cord Compression

• Incidence: 1. Associated mostly with solid tumors that metastasize

to bone:

2. Cancers associated with risk for Metastatic Spinal Cord Compression (MSCC).

Breast 15-20%

Lung 15-20%

Prostate 15-20%

Multiple Myeloma 10-15%

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Clinical Manifestations

• Back Pain is the earliest symptom

• progressing to;

• Motor weakness

• Sensory loss

• Autonomic dysfunction (bowel & bladder)

• paraplegia

Evaluation/Diagnostic Tests & Treatment Modalities

• Immediate magnetic resonance imaging of the entire spine is the imaging modality of choice.

• Corticosteroids initially for all patients.

• Definitive therapy follows using decompressive surgery and spinal stabilization and/or radiation therapy as indicated.

Nursing Management

• Care coordination of;

• Pain relief

• Prevention of injury and further neurologic damage

• Mobility and safety

• Bowel & bladder management

• Preparation for further treatment, surgery

• Rehab to maximize function & mobility

• Patient & family education

Outcomes

• Prompt recognition, diagnosis and treatment are essential to preventing irreversible loss of function and paralysis.

• Nurses caring for patients with cancer must maintain a high index of suspicion for this complication, especially following reports of new-onset back pain.

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Review Question:

• What are the top three cancers associated with risk for Metastatic Spinal Cord Compression (MSCC)?

• What is the earliest symptom of spinal cord compression in cancer patients?

Superior Vena Cava Syndrome

Superior Vena Cava Syndrome

• Description: Occurs when tumor compresses or invades the superior vena cava (SVC) or a thrombus develops within. Blood return from the head and upper body is obstructed, producing a syndrome of venous congestion. Cardiac output is reduced because of decreased blood return to the heart.

SVC Syndrome

• Incidence: Associated mostly with chest malignancies near the SVC or surrounding lymph nodes.

– Lung Cancer

– Lymphomas

– Breast Cancer

– Metastatic tumors, vena caval catheters

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Clinical Manifestations

• Dyspnea is the most common symptom from congestion and low Cardiac Output (CO).

• Congestion causes edema of upper body-face, neck, chest or right arm worse in am.

• Dysphagia, headache, sensorium changes

• Skin mottling, diminished pulses, oliguria from decreased CO.

Evaluation/Diagnostic Tests & Treatment Modalities

• Chest CT with contrast is the definitive diagnostic test

• Immediate bolus of Radiation for radiosensitive tumors (Hodgkin disease, non-small cell lung cancer).

• Immediate Chemotherapy for Chemotherapy sensitive tumors (Lymphoma, small cell lung, testicular cancer).

Nursing Management

• Priorities include;

• Airway protection

• Cardiovascular support

• Comfort and antianxiety measures

• Avoid patient lying flat, IVs in swollen upper extremity, BPs may be different in swollen extremities.

Outcome

• Few patients die of this syndrome, but the morbidity and distress it causes can be profound. It may present at the onset of disease but also commonly occurs with recurrent or refractory disease. Management depends on the individual goals of care the each patient.

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Review Questions

• What are the most common malignancies associated with SVC syndrome?

– Small cell and non small cell lung cancers

– Non-hodgkin lymphoma

– Esophageal cancer

Tumor Lysis Syndrome

Tumor Lysis Syndrome

• Description: Destruction or lysis of large numbers of tumor cells following cytotoxic therapies causes the release of potassium, phosphorus, and uric acid into the systemic circulation.

Incidence & General Risk Factors

• Large bulky tumor or disease with high tumor burden and/or rapidly proliferating cells

• Aggressive non-Hodgkin lymphoma

• Chronic myeloid leukemia

• Solid tumors

• Greatest risk occurs early in the treatment period when the WBC count and tumor burden are high

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Pathophysiology

• Metabolic incident occurs after cell lysis

– Intracellular components released into circulation

– Rapid release of potassium, uric acid, and phosphorus

Problems with Electrolyte Abnormalities

• Uric acid Kidney Failure

• Hyperphosphatemia Hypocalcemia

• Hyperkalemia Cardiac Symptoms

Assessment

• Most Important: Identify patients at risk

• CBC: WBC and platelets

• Chemistry: including serum uric acid

• UA: urine pH and uric acid crystals

• EKG

• Vital signs, I&O, weight

Nursing Management

• Identification of patients at risk for TLS, patients in early treatment for hematologic malignancies.

• Frequent monitoring of Lab values

• Aggressive hydration and diuresis

• Medication prophylaxis

-Allopurinol po/IV

-Rasburicase

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Treatment of Hyperkalemia

• Kayexalate

• Potassium levels greater than 6.5-high risk cardiac /EKG changes

• Hyperphosphatemia

• Hypocalcemia

• Cardiac changes

• Hyperuricemia

Case Study

• Mrs. B is a 58 y.o. female with a past medical history of DM, hypertension and knee problems.

• HPI; she has a large swelling in her neck, she reports dysphagia for last 6 months, 15 pound wt loss, & came to ED with difficulty breathing.

• Workup SHOWS diagnosis of Diffuse B Cell Lymphoma, admitted for initial Chemotherapy and airway management.

• Treatment plan; Six cycles of R Chop – Rituxan, Cyclophosamide, Doxorubicin, Vincristine & Prednisone. She was also started on Allopurinol 600 mg daily.

Case Study Pre Chemo labs

• CBC WBC 7.9 K/ul 4.3-10 Hgb 13.6 g/dl 11.5-15.5 Hct 40.1 5 36-45 Plt 311 K/ul 150-400

Chemistry Na 132 mEq/L 133-145 K 5.0 mEq/L 3.3-5.1 Cl 100 mEq/L 96-108 CO2 29 mEq/L 22-29 Glucose 253 mg/dL 70-105 BUN 28 mg/dL 6-20 Creatinine1.5 mg/dL 0.5-1.2 Ion CA 2.8 mEq/L 2.4-2.6 Mg 2.0 mg/dL 1.6-2.5 Phos 3.3 mg/dL 2.7-4.5 LDH 736 U/L 0-249 Uric Acid 9.5 mg/dL 3-8.3

Case Study Day # 3

• Despite anti-emetics and IV hydration, Mrs. B’s intake is poor due to nausea and sore throat. Her Urine output was 200 cc last 8 hours.

• Post Chemo Labs

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Case Study Post Chemo Labs

• CBC • WBC 16.9 K/ul 4.3-10 • Hgb 12.6 g/dl 11.5-15.5 • Hct 38.0 % 36-45 • Plt 275 K/ul 150-400 • Chemistry • Na 130 mEq/L 133-145 • K 5.7 mEq/L 3.3-5.1 • Cl 100 mEq/L 96-108 • CO2 29 mEq/L 22-29 • Glucose 253 mg/dL 70-105 • BUN 28 mg/dL 6-20 • Creatinine1.9 mg/dL 0.5-1.2 • Ion CA 1.8 mEq/L 2.4-2.6 • Mg 2.0 mg/dL 1.6-2.5 • Phos 7.7 mg/dL 2.7-4.5 • LDH 525 U/L 0-249 • Uric Acid 9.5 mg/dL 3-8.3

•

Case Study Day #4

• By day four Mrs. B’s labs have normalized

• She is eating and drinking well

• Her neck mass has decreased by half size

• She is going home and will f/u in one week

• She will continue on Allopurinol until she sees her Primary Care provider in two weeks.

Review Question:

• A possible complication of Tumor Lysis Syndrome (TLS) is;

a. Hypokalemia

b. Bowel obstruction

c. Acuter sepsis

d. Acute renal failure

Review Question

• Tumor Lysis Syndrome (TLS) is a complication of cancer therapy. TLS occurs most commonly in tumors that are;

a. Large and rapidly dividing

b. Slow growing and radiosensitive

c. Small and rapidly dividing

d. Slow growing and chemo sensitive