Docstoc

TUMOR LYSIS SYNDROME

Document Sample
TUMOR LYSIS SYNDROME Powered By Docstoc
					TUMOR LYSIS SYNDROME


   SANDY KELLY, MSN, RN-BC, OCN
This weekend I…

 1.   Went hiking/biking to
      see the trees turning
      colors
 2.   Studied for ONI
 3.   Bought my season ski
      pass
 4.   Vegged out like an
      ultimate couch potato
GOAL

   Provide the oncology
    nurse with
    assessment and
    nursing intervention
    skills for the patient
    at risk for Tumor
    Lysis Syndrome.
OBJECTIVES

•   Explain the pathophysiology of elevated blood
    levels of uric acid, phosphate, and potassium
•   Recognize the patient at risk for TLS
•   State five monitoring parameters for the
    patient at risk
•   State the goal for treatment
•   State what drug is used to treat high uric acid
    level
•   List five ways nurses can manage patient care
TUMOR LYSIS SYNDROME
   A condition that can occur after treatment of
    a fast-growing cancer, especially certain
    leukemias and lymphomas (cancers of the
    blood). As tumor cells die, they break apart
    and release their contents into the blood.
    This causes a change in certain chemicals in
    the blood, which may cause damage to
    organs, including the kidneys, heart, and
    liver.
METABOLIC ONCOLOGIC
EMERGENCY
   Potentially life
    threatening
    metabolic imbalance
    due to the rapid
    release of
    intracellular
    potassium,
    phosphorus, and
    nucleic acid into the
    blood as a result of
    rapid tumor kill
DEFINITIONS
   Tumor Burden
    •   Number of cancer cells, the size of a tumor, or the
        amount of cancer in the body
    •   Tumor load
   Growth Fraction
    •   How fast the tumor cells reproduce
   Tumor Lysis
    •   Tumor cells dies and break apart
    •   Cell Kill
During Tumor Lysis, the following
is released into the blood:

 1.   WBC, RBC,
      Platelets
 2.   K+, phosphorus,
      nucleic acid
 3.   K+, Ca++, NA+
 4.   Tumor Growth
      Factor, Tumor Lysis
      Factor, K+
INCIDENCE
               Hematologic
                malignancies
               Large bulky tumors
               Large growth
                fractions
                •   Acute and chronic
                    leukemia
                •   High grade
                    lymphomas
LARGE GROWTH FRACTION
TUMORS


               Burkitt lymphoma
               T-Cell ALL
               AML
               CLL
               CML
               Hodgkin’s lymphoma
TUMOR LYSIS & CELL KILL
LYMPHOMA
Tumor Burden
RISK FACTORS
Pretreatment
   Dehydration
   Renal Compromise
   Poor urinary output
   Bulky abdominal disease
   Lymph node involvement
   Labs
    •   Elevated WBC
    •   Elevated uric acid
    •   Elevated potassium
    •   Elevate phosphorus
    •   Elevated LDH
TUMOR CELL NUCLEUS


    Nucleic Purines
    Phosphate
    Calcium
    Potassium
CELL KILL IS TREATMENT RELATED

   Chemotherapy
   Biotherapy
   Hormone therapy
   Surgery
   Radiation
   Spontaneous
    occurrence
The patient who may be at highest
risk for TLS is…

 1.   Dx of non-Hodgkin’s
      lymphoma and severe
      neuropathies
 2.   Dx of breast cancer and
      hx of renal insufficiency
 3.   Dx of CML and elevated
      WBC
 4.   Dx of AML, elevated
      WBC and hx of renal
      insufficiency
CLINICAL MANIFESTATIONS


   Initially asymptomatic
   Symptoms appear as electrolyte
    imbalances
   Develop 24-48 hours after initiation of
    treatment
    • Chemotherapy
    • Radiation
PATHOPHYSIOLOGY

Rapid cell
 destruction

   Hyperuricemia
   Hyperphosphatemia
   Hypocalcemia
   Hyperkalemia
    HYPERURICEMIA

   Nucleic acid purines
   Overwhelms kidney’s ability to secrete uric
    acid
   Precipitates in renal tubules
   Crystallization and obstructive uropathy
   Decreased GFR
   Renal failure
   Levels exceed 10mg/dl
HYPERURICEMIA
Levels 10-15 mg/dl
   Malaise
   Nausea
   Vomiting
   Fatigue
   Weakness
   Flank pain
   Gout
   Pruritus
   Compromised renal function
COMPROMISED RENAL FUNCTION



                 Oliguria
                 Anuria
                 Azotemia
                 Uric acid neuropathy
HYPERURICEMIA

Levels exceeding 20 mg/dl
   Renal failure
   Edema
   Hypertension
   Hematuria
   Crystaluria
   Profound azotemia
   Anuria
   Acute/chronic renal failure
HYPERPHOSPHATEMIA

   Intracellular release with tumor kill
   Ca+ binds to phosphorus
   Low Ca+ levels
   Ca+ phosphate salts precipitate in renal
    tubules
   Obstruction
   Possible renal failure
    HYPERPHOSPHATEMIA



   Anuria
   Oliguria
   Azotemia
   Edema
   Acute renal failure
HYPOCALCEMIA


                  Ca+ binds
                   to
                   phosphorus
                  Inverse
                   relationship
                   between
                   phosphorus
                   and Ca+
HYPOCALCEMIA
   Twitching
   Paresthesia
   Muscle cramps
   Carpopedal spasms
   Anxiety
   Depression
   Confusion
   Hallucinations
   Tetany
   Cardiac: ventricular arrhythmias, heart block, cardiac
    arrest
    HYPERKALEMIA


   Intracellular release due to tumor cell kill
   Potentially the most life threatening
   Potential for cardiac arrhythmias and
    depressed cardiac function
   Symptoms seen when K+ > 6.5meq/L
HYPERKALEMIA
6-72 hours after treatment
Levels above 6.5 mEq/L
Cardiac:
 Tachycardia
 P and T wave changes
 V Tach, V Fib
 Heart depressant: heart block, bradycardia, cardiac
   arrest
HYPERKALEMIA
   Nausea
   Vomiting
   Twitching
   Paresthesia
   Weak paralysis
   Diarrhea
   Lethargy
   Syncope
   Muscle cramps
   Increased bowel sounds
TLS EFFECTS
PATIENT ASSESSMENT
             Lab
              CBC
              BUN
              Creatinine
              Ca+
              Phosphorus
              Serum uric acid
              UA
What does an elevated WBC count in
the presence of a patient with cancer,
tell you?

 1.   They have a high
      tumor burden
 2.   They have a
      bleeding disorder
 3.   They have renal
      insufficiency
 4.   They are septic
PATIENT ASSESSMENT

 EKG
 Vital Signs

 Weight

 I&O
TREATMENT GOAL


   Early identification and correction of
    electrolyte imbalance
PREVENTION

 Identify at risk
  patients
 Monitor lab

 Hydration

 Loop diuretics
PREVENTION
   Medication prophylaxis
    • Allopurinol
   Urinary alkalization
    • Sodium bicarbonate
   Medication history
    • Avoid nephrotoxins
   Nutrition hx
    • Avoid electrolyte supplements if levels are
      normal
PRETREATMENT RATIONALE
   Poor urinary clearance of lysed tumor
    cells
   Large number of malignant cells in the
    system
   Treatment may overwhelm capacity of
    renal system
   Preexisting metabolic conditions may
    potentiate dangerous levels of
    circulating metabolites
Rx-HYPERURICEMIA


 Allopurinol
 Rasburicase

 Hydration

 Diuresis

 Dialysis
Rx- HYPERPHOSPHATEMIA


   Phosphate binding agents
   Aluminum containing antacids
   Ca+ self corrects when phosphate is
    corrected
Rx- HYPERKALEMIA
   K+< 6.5 mEq/L
    • Kayexalate
   K+>6.5mEq/L
    • Ca+ gluconate or Ca+ chloride
    • Sodium bicarbonate
    • Insulin-glucose therapy
    • Loop diuretics
NURSING MANAGEMENT

Prevention
   Identify patients at risk
   Identify pretreatment risks
   Review medications and eliminate those
    that contribute to increased potassium
    and phosphorus
    PREVENTION

   Review diet and nutrition supplements
   Potassium
   Phosphorus
   Prophylactic hydration and diuresis as ordered
    •   0.9% NS
   Prophylactic medication
    •   Loop Diuretics
    •   Allopurinol
    •   Rasburicase
NURSING MANAGEMENT
Recognition
   Weight
   I&O
   Vital signs
   Electrolytes
   EKG
   Urinalysis
   Patient symptoms
   Hypersensitivity reaction to chemotherapy
NURSING MANAGEMENT
            Intervention
               Lab
               EKG
               Vital signs
               Urine output
               Medications as ordered
               Dialysis
               Patient education
               Hospital admission
               Transfer to ICU
High uric acid levels are
dangerous because…

 1.   It can cause gout
 2.   Hyperuricemia can
      cause mental
      changes
 3.   It can crystalize and
      block renal flow
 4.   It can cause cardiac
      arrhythmias
High phosphate levels are
dangerous because

 1.   It can cause gout
 2.   Causes high Ca+
      levels
 3.   Causes anxiety and
      hallucinations
 4.   Precipitates in the
      renal tubules
Hyperkalemia is dangerous
because…

 1.   May cause cardiac
      arrhythmias
 2.   May cause gout
 3.   May cause anxiety
      and hallucinations
 4.   May precipitate in
      the renal tubule
ADMISSION/TRANSFER TO ICU

   Continuous EKG and hemodynamic
    monitoring
   Frequent monitoring of lab
   Hemodialysis
   Fluid and electrolyte management
PATIENT EDUCATION

   Prevention
   Risk factors
   Signs and symptoms
   Treatments
   Dietary considerations
   When to seek medical
    help
   Importance of follow-up
SUMMARY
   TUMOR LYSIS SYNDROME

    Potentially life threatening metabolic
    imbalance due to the rapid release of
    intracellular potassium, phosphorus, and
    nucleic acid into the blood as a result of
    rapid tumor kill
The organs most effected by TLS
include…


 1.   Liver, lungs, kidney
 2.   Brain, lungs, kidney
 3.   Heart, liver, lungs
 4.   Brain, heart, kidney
Management of the ICU patient
with TLS include…
 1.   Ventilator, ABGs,
      cardiac pacemaker
 2.   Frequent assessment,
      hemodialysis, fluid and
      electrolyte monitoring
 3.   Ventilator, antibiotics,
      electrolye monitoring
 4.   Frequent assessment,
      Chemotherapy,
      hydration
TUMOR LYSIS SYNDROME



   Prevention
   Early identification
   Treatment
   Patient Education

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:107
posted:11/19/2011
language:English
pages:53