Oncological Emergencies + neutropenic sepsis

Which cancers most commonly cause MSCC?

Prostate, breast, and lung.

What are early symptoms of MSCC?

 Back pain, motor weakness (paresis), sensory changes, gait disturbance, hyperreflexia.

 Initial pharmacological management of MSCC?

Dexamethasone 16mg + analgesia.

Why is D-dimer not used in oncology?

It is often falsely elevated in malignancy.

What is the role of G6PD testing in TLS management?

 Needed before rasburicase (risk of haemolytic anaemia in deficiency). Rarely done in emergencies as results take ~3 weeks.

 Symptoms of hypercalcaemia?

Polyuria, thirst, confusion, renal impairment, nephrolithiasis, arrhythmias, muscle weakness.

 First-line treatment for hypercalcaemia? and What drugs are used if fluids are insufficient?

• IV saline 0.9% (4–6L/24h).

• Bisphosphonates (zoledronic acid), calcitonin, denosumab.

Symptoms of immune-related myasthenia gravis?

Ptosis, diplopia, dysarthria, dysphagia, limb weakness, respiratory paralysis

 Drugs to avoid in myasthenia gravis?

Macrolides, quinolones, gentamicin, beta-blockers, anticholinergics, statins, tetracyclines.

 How does febrile neutropenia differ from neutropenic sepsis?

FN = fever + neutropenia; NS = sepsis criteria + neutropenia (life-threatening organ dysfunction).

What is the “3 in 3 out” approach to sepsis management?

• Three out: blood cultures (central + peripheral, or 2 peripheral if no central), lactate, urine output.

• Three in: oxygen (if required), IV antibiotics, IV fluids.

 First-line antibiotics for neutropenic sepsis?

 Antipseudomonal β-lactam (e.g. piperacillin-tazobactam).

When should vancomycin be added in neutropenic sepsis?

 Suspected catheter infection, skin/soft tissue infection, pneumonia, or haemodynamic instability

Role of GCSF in neutropenic sepsis?

Continue prophylaxis; consider in profound FN (ANC <0.1). No mortality benefit when added to antibiotics.

what is sepsis

life threatening organ dysfunction caused by dysregulation of host response to infection

what is neutropenia?

ANC < 1.0 x 10⁹/L

severe neutropenia as ANC < 0.5 x 10⁹/L

profound neutropenia as < 0.1 x 10⁹/L.

Define neutropenic sepsis

Defined as a temperature of greater than 38.3°C (or 38°C for over 2 hours) or any symptoms and/or signs of sepsis, in a person with an absolute neutrophil count of 0.5 x 10⁹/L or lower.

what are risk factors for sepsis

•Age ≥75yr or ≤1yr

•Recent trauma, surgery or invasive procedure within the last 6 weeks

•Recent SACT in the last 6 weeks

·Immunocompromised (e.g., chemotherapy, sickle cell disease, AIDS, splenectomy, long-term steroids)

·Haemodialysis

•Autologous stem cell transplants <6 months

•Allograft stem cell transplant <2 years

•Indwelling lines or catheters

•Breaches of skin integrity (e.g., burns, cuts, blisters, skin infections)

•Intravenous drug misuse

•Alcohol dependence

•Diabetes mellitus

•Pregnancy (and the 6 weeks after delivery/termination/miscarriage)

what is recommended monotherapy for neutropenic sepsis

Antipseudomonal b-lactam agent

what is GCSF and when is it used?

Granular columnar stimulating factor

• Primary prophylaxis with a CSF starting in the first cycle and continuing through subsequent cycles of chemotherapy

• recommended in patients who have an approximately 20% or higher risk for febrile neutropenia on the basis of patient-, disease-, and treatment related factors