WVU NSG 460 Immunology II Exam 5 Content

Oncologic Emergencies

Febrile Neutropenia

-decreased neutrophils

-determined by ANC (absolute neutrophil count)

-if ANC is < 1500 = neutropenic

Who might be neutropenic?

-patients who have cancer, especially leukemias, lymphomas, and multiple myeloma

-recent chemotherapy or bone marrow transplant (within the past year)

-congenital hematologic disorders (rare but possible)

-reactions to certain medications such as NSAIDs & broad-spectrum ABX

Why is a neutropenic fever a medical emergency?

-21% of neutropenic patients will have serious complications secondary to infection

-mortality 4 to 30 % in cancer patients

-patients can deteriorate very rapidly if broad spectrum ABX are not initiated

Assessment for Febrile Neutropenia

Neuro

-altered mental status

Oral

-mucositis

-the mouth is a common site of infection

-note the change in color of the mouth

Lungs

-pneumonias are common (esp. fungus)

-need to get a sputum culture

Possible Abnormalities w/ Febrile Neutropenia

Gastrointestinal

-N/V

-diarrhea

-rash/abscess near the peri area

Genitourinary

-urinary tract infections

Musculoskeletal/Integumentary

-rash

-abscess

Other

-central line infections

Diagnostics for Febrile Neutropenia

-obtain 2 sets of blood cultures (both aerobic and anaerobic)

-obtain a CBC with diff, electrolytes, BUN/Cr, glucose, Mg, Ca, Phos, and PT/INR

-obtain a CXR and UA with the cultures

^we get the chest XR to check for pneumonia

Nursing Tips

-need to perform sterile technique with blood and urine cultures

-we need to obtain blood from two different sites

Nursing Interventions for Febrile Neutropenia

-ensure IV access (many cancer patients have central lines or PICCs)

^first nursing intervention

-broad spectrum ABX

^priority intervention

-give tylenol if patient is febrile (check to see if liver function labs are good)

-IV hydrocortisone may be ordered

^helps with inflammatory process, but can make a patient more immunocompromised

Tumor Lysis Syndrome (TLS)

-oncologic emergency that occurs with rapidly growing cancer, usually a blood/marrow cancer (acute leukemia, high grade lymphoma)

-the rapidly growing cells also die rapidly

-the cancer cells burst spilling potassium, phosphorus, and uric acid into the bloodstream

^the spilling of K+ is a major thing we need to monitor

Main Concerns with TLS

-electrolyte abnormalities

-renal failure

*K+ & phos can clog the renal tubules and cause an AKI

Diagnostics for TLS

-management of TLS is strongly dependent on lab values and correcting electrolyte and uric acid problems

-hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia

^calcium and phos are inversely related

Treatment of TLS

-IV access, preferably central lines (large bore)

-correct hyperkalemia, hyperphosphatemia, and hypocalcemia

^tx calcium because it will correct phos

-aggressive hydration (dilutes high conc. of electrolytes)

Review: Correcting Hyper K+ w/ TLS

-lokelma

-ca gluconate

-insulin + D50

-kayexalate

Review: Correcting Uric Acid w/ TLS

-administer gout medications

^colchicine (acute) & allopurinol (chronic)

^rasburicase if severe

-increase hydration to flush out the kidneys

-ventilatory support may be necessary when metabolic acidosis is present

^when the body has gone past compensation

-dialysis may be indicated in severe cases

Resolution of TLS

-TLS resolves with proper management and treating the underlying cause (cancer)

-if left untreated or in severe cases, TLS can cause death

Malignancy Associated Hypercalcemia

-multiple solid tumor cancers as well as malignant lymphoma and myeloma

-increased release of calcium from bone is the main factor contributing to hypercalcemia in cancer patients

^give meds to keep calcium in check

Severe Hypercalcemia

-can cause life-threatening complications such as acute renal failure and coma

-normal Ca: 8.5 to 10

Management

-fluid replacement and lasix

-then administer bisphosphonate

^Fosamax

Fosamax

-medication that helps move calcium from the bloodstream back into the bones

Superior Vena Cava (SVC) Syndrome

-the superior vena cava is responsible for the venous drainage of the head, neck, arms, and upper thorax

^syndrome can cause swelling in the face

-any pathologic process that encroaches on the thin-walled SVC causing obstruction of venous retrun to the heart can result in SVC syndrome

-lung cancer is the most common cause

-lymphoma is the second most common cause

-together they represent 94% of cases

Signs and Symptoms of SVC Syndrome

-SOB (most common)

-facial swelling or head fullness

-cough

-arm edema

-cyanosis

Management of SVC Syndrome

-oxygen (initial nsg intervention)

-diuretics

-high dose steroids

-radiation provides good palliation in the majority of patients

*we can also raise the HOB up to assist the patient

Malignant Spinal Cord Compression

-neoplastic invasion of the space between vertebrae and spinal cord (epidural invasion)

-frequent complication of malignancy

Statistics

-prostate cancer: 90%

-breast cancer: 74%

-lung cancer: 45%

Signs and Symptoms of Malignant Spinal Cord Compression

-back pain is the most common and earliest symptom, affecting up to 95% of patients

-a hx of persistent worsening back pain in a patient with cancer warrants urgent investigation

Dx/Tx of Malignant Spinal Cord Compression

-immediate MRI of the whole spine (initial nsg intervention)

-treated w/ surgical resection & radiation

-delays in starting treatment may result in irreversible loss of neurologic function including paraplegia

Pericardial Tamponade

-pericardial effusions from cancer (usually metastatic) are the most common cause of cardiac tamponade

-can inhibit both the filling and emptying of the heart if severe

-since the fluid is decreased in the heart, we will have decreased CO

Treatment of Pericardial Tamponade

-pericardiocentesis or surgical drainage

-once stabilized, definitive treatment of the pericardial effusion must be undertaken (pericardectomy)

-greater than 60% risk of reaccumulation

Massive Pulmonary Embolism

-cancer of any kind is a major risk factor for DVT/PE

^inflammation causes procoagulation factors

-patients with cancer undergoing surgery are two to three times more likely to develop postoperative venous thrombosis

Bleeding/DIC

-bleeding in the cancer patient can result from thrombocytopenia, abnormalities in coagulation factors, or drug therapy

-DIC can result from sepsis or a direct effect of the cancer

SIADH

-most frequently associated with small-cell lung cancer

-optimal therapy is related to the treatment of the underlying malignancy

Increased Intracranial Pressure

-may be caused by primary brain tumors or metastases

-lung, breast, and melanoma are the most common tumors that metastasize to the brain

-the tumor mass and surrounding edema or intratumoral bleeding may produce increased ICP

Sepsis and Septic Shock

SIRS

-systemic inflammatory response syndrome

-systemic response to clinical insult

^trauma, infection, pancreatitis, ischemia, malignancy, or shock

SIRS Criteria

-temp >38 or <36

-HR >90

-RR >20

-WBC >12,000

*any 2 suggest an early SIRS response

What is SOFA?

-used for SIRS

-it stands for sequential organ failure assessment (SOFA)

-monitors PF ratio, coagulation, LFTs, CV components, and kidney function

Sepsis Overview

-SIRS response to a documented or suspected infection

-systemic response to infection (mental status change, hypo/hyperthermia, tachycardia, tachypnea, "looks sick")

-sepsis is one type of SIRS

Septic Shock Overview

-sepsis w/ hypotension, oliguria, lactic acidosis, and other severe perfusion abnormalities are resistant to fluid resuscitation

^no matter how bad the shock is, the fluid will not respond to the body

-the end point is multiple organ dysfunction syndrome (MODS)

Infections

-pneumonia

-cellulitis

-IV drug abuse (gram +)

-intraabdominal

-UTI (gram -)

Sepsis/SIRS Pathology

-sepsis is an acute hyper-inflammatory response

-multiple pro-inflammatory mediators (tumor necrosis factor, nitrous oxide, cytokines) and anti-inflammatory mediators are released in response to insult

Pathology

-the goal is an appropriate inflammatory response to restore homeostasis... HOWEVER

-proinflammatory mediators overwhelm anti-inflammatory mediators causing...

1. widespread vasodilation

2. capillary leakage

3. coagulation issues

Septic Shock

-profound vasodilation and capillary permeability causes severe hypoperfusion

-50% mortality

-250,000 deaths every year

^more than from AIDS, breast cancer, and colon cancer combined

Septic Shock and MODS

-myocardial depression

-hepatocyte damage

-gut permeability (leakage of intestinal contents into the bloodstream)

-decreased renal perfusion

-pulmonary capillary permeability that leads to ARDS

-procoagulation (DIC)

Early Clinical Symptoms

-mental status changes (may be subtle)

-always suspect sepsis in the ill patient with mental status changes

-in the "elderly" a simple UTI can trigger sepsis

*watch for confusion!! ; don't just view it as sundowning

Increased Temp?

-unreliable sign

^hypothermic is more predictive than a fever

-can be normal or even decreased, especially in very old, very young, or immunocompromised

^these are the people who become septic

Warm Shock

-arteries in septic shock vasodilate

-its called warm shock b/c when its warm our arteries vasodilate

-feel warm and look ruddy

Hyperdynamic .v. Hypodynamic Phases of Septic Shock

Hyperdynamic

-afterload decreases

-CO increases

-preload decreases

because of the decreased preload, THEN

Hypodynamic

-afterload increases

-CO decreases

Management (1) of Sepsis/Septic Shock

-prevent

-oxygen, intubation, ventilation

^done because of the work of breathing

-fluids (often a lot)

-treat infections

^administer ABX therapy ASAP no Rocky b/c it prevent the continuation of illness

^every hour delay in ABX increases mortality by 8%

-vasopressors

^for profound vasodilation

-steroids (controversial)

Why are steroids controversial?

-yes they provide anti-inflammatory properties, however they also cause immunosuppression

Current Thinking

-if the patient is still in septic shock and on corticosteroids or a pressor...

-give hydrocortisone 50 to 100 mg IV

Management (2) of Sepsis/Septic Shock

-nutrition

^support the healing process, as well as prevents translocation of bacteria

-control hyperglycemia (keep below 140)

-administer Xigris

Xigris

-the only anti-sepsis drug

-$104,000 a dose

-can cause severe bleeding

Kidney Transplantation

Kidney Transplant Background

-the five-year survival rate for dialysis hovers around 35%, but for kidney transplantation, it is well beyond 80%

-the reason for that is dialysis simply does not provide the biological functions of a healthy kidney

Tissue Typing

-human lymphocyte antigens (hia) surface of leukocytes

-they distinguish self from non-self

-they try to match tissues so closely that we avoid chances of having rejection

The best HLA match is between ______________ _________.

identical twins

The second best HLA match is between ________________.

siblings

Where Does the Kidney Come From?

1. cadaver (can be from a living will or driver's license)

2. living related donor

3. living unrelated donor

True or False: The hardest part of surgery is removing the old, non-functioning kidney rather than transplanting the new kidney

FALSE

Post-Transplant Nursing Implications

-fluid status and blood pressure

-urine output

-urine leak (can leak through the anastomosis site)

-constipation

-pain is not usually a major problem

Rejection

Hyperacute

-rare now due to tissue typing

-typically a reaction that happens in the OR

Acute

-most common

-if this occurs, administer steroids

Acute Rejection

-many, if not all, kidney transplant recipients experience an episode of acute rejection

Signs/Symptoms

-malaise

-low grade temp

-tenderness over the graft site

-edema

-weight gain

-increasing creatinine

^ usually > 2.0 or 0.2 > than baseline

Major Indicators of Acute .v. Chronic Rejection

Acute Rejection

-vasculitis/tubulitis

-responds well to prednisone, because it is an inflammatory response

Chronic Rejection

-not treatable

-proteinuria

-increasing Cr

Organ rejection that takes place within minutes to hours is called ___________.

hyperacute

Immunosuppression

-pre-operative induction: solumedrol, azithropine, IV cyclosporine (this is the initial immunosuppression)

-maintained on prednisone, PO cyclosporine, cellcept prograf (this is long-term immunosuppression)

-many taper prednisone

Complications of immunosuppresion

-skin cancer (need to teach on over-exposure to the sun)

-hyperglycemia: very common

-PCP

-CMV

-gastroenteritis

-GI sx

*kind of looks like HIV infection symptoms

Home Care post transplant

-caution with groups

-no meeting with sick people

-watch BP and blood sugar

-temp of 38!

Stem Cell Transplant (SCT)

SCT Overview

-is the transplantation of bone marrow stem cells, usually derived from peripheral blood or umbilical cord blood

-it is most often performed for patients with certain cancers of the bone marrow, such as leukemias, multiple myeloma, aplastic anemia, lymphomas

Stem Cells Can Be Donated Via...

-allogeneic: from another (best form is from a sibling)

-autologous: from self (collect from their own bone marrow and then its frozen)

-syngeneic: donor is an identical twin with a perfect tissue match

*recently MUD (match unrelated donor) transplants have become more common

The Goal for SCT

-the goal is to totally eliminate cancer cells

-side effect is elimination of bone marrow cells

-almost total bone marrow suppression

-the patient at this point has very few functioning RBC's, WBC's, and platelets

How Do We Get Stem Cells

-obtained from bone marrow or blood

-it has become more common to obtain stem cells for blood

-plasmapheresis

Procedure for stem cells

Induction

-reduce disease with chemo/radiation

-also stimulates stem cell production

Harvest

-gather stem cells via bone marrow aspiration or plasmapheresis

Consolidation

-radiation/chemo in mega dose to destroy abnormal cells

Infusion/Transplant/Rescue

-harvested stem cells are administered like blood product

Recovery

-transplanted cells produce new bone marrow cells

-if they take they will produce cells for the rest of person's life

Interventions in Recovery Stage (SCT)

-fluid/electrolyte management (acute)

-stomatitis and severe N/V

-bleeding: platelets commonly administered

Infection (SCT)

-nursing: surgical scrub then good handwashing

-multiple antimicrobials

-herpes virus/fungals

Graft .v. Host Disease

-graft fights with host

-we want the graft to win

-acute GVHD effects primarily skin, GI, and liver

^rash, N/V, and watery green heme (+) diarrhea

Graft Failure or Rejection

-not as common as with solid transplants

-cell counts don't rise

-unfortunately usually fatal

-sepsis and multiorgan failure

-ATN/ARDS/DIC

Discharge from Hospital transplants

-immunosuppressives for one year: cyclosporine, prednisone, fk506; then attempt to wean

^autologous transplants do not need immunosuppressives

-neupogen: helps with the production of WBC's

Immune Reactions

Bees, Hornets, Wasps

-relatively common cause of allergic reactions

-severity ranges from local swelling and pain to true anaphylaxis

-types of inflammation: local and systemic

Urticaria

-another term for hives

Mild Allergic Reaction

-histamines are at the root of issue

Treated

-benadryl: antihistamine

^if you don't have benadryl on hand, you can give pepcid

-prednisone: anti-inflammatory

Mast Cells and Basophils

-mast cells release histamines when the allergen is encountered in the tissue

-basophils release histamines when the allergen is encountered in the bloodstream

*histamine released from both basophils and mast cells in allergic reactions

Anaphylaxis

-airway issue

-laryngospasm (upper airway)

-bronchospasm

-hypotension (severe vasodilation)

-all caused by a massive histamine release

Severe Allergic/Anaphylaxis

-O2 (may need intubation to guard the airway)

-epinephrine 0.03 cc (SQ or IV): helps with bronchoconstriction and supports BP

-solumedrol (anti-inflammatory)

-benadryl and pepcid (antihistamine)

-albuterol (bronchodilator)

-fluids/vasopressors (shock support)

Ticks

-lyme disease

-spirochete transmitted by tiny tick (deer/mouse)

Removing a Tick

-use tweezers, pull the entire tick off in a smooth motion

Deer Tick

-watch for people who live in wooded areas

-prevalent in North-East

Stages of Lyme Disease

Stage 1

-flu-like symptoms

-round erythematous lesion

-erythema mirgans

Stage 2

-4 wks later

-10 to 15%

-neurological and/or cardiac symptoms (heart blocks)

Stage 3

-weeks or years later

-60%

-migratory large joint arthritis

Treatment of Lyme Disease

-PO/IV ABX shorten symptoms and prevent later illness

^doxycycline