Transcript Intro to Ratnoff and Weisman Service by Alyson Michener

Ratnoff and Weisman
Alyson Michener, PGY2
Internal Medicine
University Hospitals Case Medical Center
Logistics
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Ratnoff
Hem/onc attending
1 resident, 2 interns
Intern cap is 8
Short, medium, long, happy
Team room is Seidman 3
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Weisman
Hem/onc attending or
hospitalist
1 resident, 2 interns
Intern cap is 8
Short, medium, long, happy
Team room is Seidman 4
Common admissions
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Sickle cell
Pain control, nausea, vomiting
Failure to thrive
Cord compression
Tumor lysis
Malignancy workup
Hypercalcemia
SVC syndrome
Constipation
Neutropenic fever
General medical problems
Hints and tricks
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E-mail your patient’s primary oncologist
Review oncology notes in portal
Know treatment history
Ordering a peripheral smear
Sickle cell care path, OARRS
Ratnoff/Weisman Top 5
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5.
Neutropenic fever
Sickle cell
Cord compression
Tumor lysis
Pain management
A 37-year-old woman is evaluated in the emergency department for fever and
rigors of 4 hours’ duration. Medical history is significant for acute lymphoblastic
leukemia for which she completed multiagent chemotherapy 10 days ago. Her
medical history is otherwise noncontributory, and she takes no other medications.
On physical examination, temperature is 38.8, blood pressure is 110/60 mm Hg, pulse
rate is 100/min, and respiration rate is 16/min. On pulmonary examination, the lungs
are clear. The remainder of the physical examination is unremarkable. Laboratory
studies indicate a leukocyte count of 0.3µL with 0 neutrophils. The remaining
laboratory studies are normal.
A chest radiograph is normal. Blood and urine cultures are obtained.
Which of the following is the most appropriate next step in management?
A. Administer granulocyte-macrophate colony-stimulating factor
B. Await culture results before starting antimicrobial therapy
C. Begin piperacillin-tazobactam
D. Begin vancomycin
Neutropenic fever
• Neutropenia: ANC <1500 cells/microL; Risk of infection rises with ANC
<500 cells/microL
• Infectious etiology identified in 20-30% of episodes
• Common organisms: S. epidermidis, S. aureus, Pseudomonas and other
gram negatives
Neutropenic fever: Management
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2 sets of blood cultures
Cultures from other sites if clinical suspicion
CXR if respiratory sx
Initial monotherapy with zosyn, cefepime, or meropenem
Vancomycin for some indications
Treatment is typically continued at least until ANC > 500
Adding antifungals
AG Freifeld et al. Clinical practic guideline for the use of antimicrobial agents in neutropenic patients with
cancer: 2010 update by the infectious diseases society of america. Clinical Infectious Diseases. 2011. 52(4): 56-93.
Hematopoietic growth factors in
neutropenic fever
G-CSF and GM-CSF
• Can be used prophylactically when risk of neutropenic fever is high
• IDSA: not recommended for treatment
• ASCO: can be considered in some instances
TJ Smith et al. Recommendations for the use of wbc growth factors: american society of clinical oncology
clinical practice guideline update. Journal of Clinical Oncology. 2015. 33:28 (3199-3212)
A 29-year-old man is evaluated in the emergency department for dyspnea and diffuse severe
pain in the arms, legs, back, and chest of 2 days’ duration. He has sickle cell anemia and
experiences painful episodes one to two times per year. He also has a history of acute chest
syndrome and has known erythrocyte alloantibiodies. In addition to increased fluid intake at
home, he has been taking oral morphine sulfate, 30mg twice daily, with no relief. He also takes
folic acid.
On physical examination, temperature is 36.8, blood pressure is 153/65 mm Hg, pulse rate is
108/min, and respiration rate is 20/min. Oxygen saturation is 98% with the patient breathing
ambient air. The patient is hunched over in pain, and he is diffusely tender to touch.
Cardiopulmonary, abdominal, and neurologic examinations are normal.
Laboratory studies show hemoglobin 7.2 g/dL, leukocyte count 11,900/µL with a normal differential,
platelet count of 199,000/µL, reticulocyte count 5.4%, and lactate dehydrogenase of 420 units/L.
The patient has alloantibodies to antigens C, E, and K on blood typing and screening.
In addition to intravenous hydration and incentive spirometry, which of the following is the most
appropriate initial treatment?
A.
B.
C.
D.
Erythrocyte exchange transfusion
Erythrocyte transfusion
Intravenous meperidine
Intravenous morphine
Sickle cell complications
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Pain crisis (vaso-occlusive crisis)
Acute chest
Stroke
MI
VTE
Splenic sequestration
Priapism
Retinopathy
Infections
Managing a vaso-occlusive crisis
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Labs: CBC, retic, LDH, CMP, CRP, UA, T&S
Check for carepath
Fluids
Pain medication
Incentive spirometry
A 21-year-old woman is admitted to the hospital with a sickle cell pain crisis. Over the next 48
hours, she develops worsening dyspnea, chest pain, and fever. She takes daily folic acid
supplementation and morphine delivered by a patient-controlled analgesia device with bolus and
demand infusions.
On physical exam, temperature is 38, blood pressure is 123/65 mm Hg, pulse rate is 118/min, and
respiration rate is 22/min and labored. There is no jugular venous distension. Cardiopulmonary
exam discloses decreased bilateral breath sound at the lung bases, but no crackles or S3. There is
no peripheral edema.
Laboratory studies show hemoglobin 6.2 g/dL, leukocyte count 6900/µL with a normal differential,
MCV 84 fL, platelet count 179,000/µL and reticulocyte count 4.4%. Oxygen saturation is 86% with
the patient breathing oxygen, 3 L/min by nasal cannula. Chest radiograph shows multilobar
infiltrates not present on admission chest radiograph. An electrocardiogram demonstrates sinus
tachycardia with no ST changes.
Broad spectrum antibiotics are begun, incentive spirometry is initiated, and morphine is continued.
Which of the following is the most appropriate additional treatment?
A. Erythrocyte transfusion
B.
Fluid bolus
C. Furosemide
D. Hydroxyurea
Acute chest
• Fever, chest pain, hypoxemia, wheezing, cough, or respiratory distress
with a new pulmonary infiltrate on CXR
• May see drop in hemoglobin
• Management
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Analgesia
Oxygen
Incentive spirometry
Antibiotics
Simple transfusion
Urgent exchange transfusion
Evidence-based management of sickle cell disease. Expert panel report, 2014.
http://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/sickle-cell-disease-
Pain management
• Pain affects 70-80% of patients with advanced malignancy
• Pain is often undertreated
• Can be related to the malignancy or the treatment
A Caraceni et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based
recommendations from the EAPC. The Lancet: Clinical Oncology. 2012. 13:2 (58-68).
Assessment of pain
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History
Pain syndrome
Pathophysiology and etiology of pain
Extent of malignancy and plan for further treatment
Goals of care
Related symptoms
Cancer pain syndromes
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Hemorrhage
Pathologic fracture
Obstruction/perforation
Mucositis
Neuropathy from chemotherapy
Post radiation
Tumor invasion
Treatment of cancer pain
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Can include disease-modifying therapies and symptomatic treatment
Opioid analgesics
Non-opioid analgesics
Adjuvant analgesics
Non-pharmacologic treatment
Opioid analgesia
• Start with short acting
o Tramadol
o Oxycodone
o Hydromorphone
• Patient controlled analgesia
• Transition to a long acting agent
• Palliative care consult
Other issues in pain management
• Adjuvant therapy
o Anticonvulsants (gabapentin)
o Antidepressants (desipramine and nortriptyline)
o Corticosteroids
• Opiate side-effects
o Constipation
o Nausea
o Itching
E Bruera and HN Kim. Cancer Pain. JAMA. 2003. 290:18 (2476-2479).
A 78-year-old man is hospitalized for a 1-week history of progressive and severe back pain and
weakness in both legs. He describes a sense of “heaviness” in his legs and has had an increasing
difficulty climbing stairs and getting out of a chair. Medical history is significant for asymptomatic
multiple myeloma that his been followed with periodic examinations and laboratory studies; his last
assessment was 3 months ago and was stable.
On physical exam, vital signs are normal. He has point tenderness over the T10 and T11 vertebral
bodies, decreased lower extremity muscle strength (3+/5), increased reflexes isolated to both
lower extremities, and bilateral extensor plantar responses. The remainder of the physical
examination is unremarkable.
Laboratory studies are significant for a serum hemoglobin level of 6.5 g/dL and a serum calcium
level of 13mg/dL.
MRI of the thoracic and lumbar spine shows a vertebral body mass and extension into the epidural
space at T12 and compression of the spinal cord.
Which of the following is the most appropriate initial step in treatment?
A. Biopsy of the epidural mass
B.
Decompressive surgery
C. IV glucocorticoids
D. Multiagent chemotherapy
E.
Radiation therapy
Malignant spinal cord compression
Compression of the dural sac and its contents (spinal cord and/or cauda
equina) by an extradural tumor mass
• ~3% of hospitalized cancer patients per year
• Most commonly seen in lung cancer, breast cancer, prostate, multiple
myeloma
• 20% initial presentation of malignancy
• Outcome is dependent on pretreatment neurologic status
DA Loblaw, J Perry, A Chambers, and NJ Laperriere. Systematic review of the diagnosis and management of malignant extradural spinal cord
compression: the cancer care ontario practice guidelines initiative’s neuro-oncology disease site group. Journal of Clinical Oncology. 2005. vol 23 no 9
(2028-2037).
Assessment
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Back pain
Weakness
Difficulty walking
Increased deep tendon reflexes
Bladder and bowel incontinence
Management
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MRI entire spine
High dose dexamethasone (10 mg IV stat followed by 4mg Q6)
Call spine (ortho or neurosurgery)
Call radiation oncology
Pain control
Urinary catheterization
Metastatic spinal cord compression: diagnosis and management of patients at risk of or with metastatic
spinal cord compression. NICE clinical guidelines, No. 75. 2008.
A 27-year-old man is evaluated in the emergency department for a 1-week history of bruising and
gingival bleeding with flossing. He has no significant medical history and takes no medications. On
physical exam, temperature is 37.5, blood pressure is 110/80 mm Hg, pulse rate is 80/min, and
respiration rate is 14/min. Scattered ecchymoses and cutaneous petechiae are present. There is
no lymphadenopathy or splenomegaly.
Laboratory studies
Leukocyte count
150,000/µL
Platelet count
20,000/µL
Creatinine
4 mg/dL
Fibrinogen
Normal
Phosphorus
8 mg/dL
Peripheral
blood smear shows 70%
myeloblasts.
Urate
12circulating
mg/dL
Which of the following is the most appropriate treatment?
A. Fresh frozen plasma
B.
High-volume normal saline hydration and rasburicase
C. Multiagent chemotherapy
D. Platelet transfusion
Tumor lysis syndrome
• Metabolic derangements from abrupt release of cellular components
after rapid lysis of malignant cells
• Most common with hematologic malignancies
• Findings
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Hyperuricemia
Hyperkalemia
Hyperphosphatemia
Hypocalecemia
Uremia
Acute renal failure
Tumor lysis syndrome diagnosis
• CTLS: LTLS + renal insufficiency, arrhthmias/sudden death, seizures
Electrolyte derangements
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Hyperphosphatemia – nausea, vomiting, diarrhea, lethargy, seizures
Hypocalcemia – cardiac arrhythmia, hypotension, tetany, cramps
Hyperkalemia – arrhythmias, fibrillation, cardiac arrest
Uremia
Management of TLS
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Fluids, fluids, fluids
Treat hyperkalemia and electrolyte derangements
Alkalinization?
Allopurinol
Rasburicase (recombinant urate oxidase)
Dialysis
B Coiffier, A Altman, C Pui, A Younes, and MS Cairo. Guidelines for the management of pediatric and adult tumor
lysis syndrome: an evidence-based review. Journal of Clinical Oncology. 2008. 26(16): 2767-2778.
Rasburicase
• Contraindicated in patient’s
with G6PD deficiency
• 0.1-0.2 mg/kg daily for 1-7 days
• Length of therapy based on
uric acid levels
• Check uric acid levels 4 hours
after administration
B Coiffier, A Altman, C Pui, A Younes, and MS Cairo. Guidelines for the
management of pediatric and adult tumor lysis syndrome: an evidencebased review. Journal of Clinical Oncology. 2008. 26(16): 2767-2778.
References
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A Caraceni et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based
recommendations from the EAPC. The Lancet: Clinical Oncology. 2012. 13:2 (58-68).
AG Freifeld et al. Clinical practic guideline for the use of antimicrobial agents in neutropenic
patients with cancer: 2010 update by the infectious diseases society of america. Clinical Infectious
Diseases. 2011. 52(4): 56-93.
B Coiffier, A Altman, C Pui, A Younes, and MS Cairo. Guidelines for the management of pediatric
and adult tumor lysis syndrome: an evidence-based review. Journal of Clinical Oncology. 2008.
26(16): 2767-2778.
DA Loblaw, J Perry, A Chambers, and NJ Laperriere. Systematic review of the diagnosis and
management of malignant extradural spinal cord compression: the cancer care ontario practice
guidelines initiative’s neuro-oncology disease site group. Journal of Clinical Oncology. 2005. vol 23
no 9 (2028-2037).
E Bruera and HN Kim. Cancer Pain. JAMA. 2003. 290:18 (2476-2479).
Evidence-based management of sickle cell disease. Expert panel report, 2014.
http://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/sickle-cell-disease-report%20020816.pdf
Metastatic spinal cord compression: diagnosis and management of patients at risk of or with
metastatic spinal cord compression. NICE clinical guidelines, No. 75. 2008.
TJ Smith et al. Recommendations for the use of wbc growth factors: american society of clinical
oncology clinical practice guideline update. Journal of Clinical Oncology. 2015. 33:28 (3199-3212)