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Tumor Lysis Syndrome

Tumor Lysis Syndrome. Carol S. Viele RN, MS Clinical Nurse Specialist Hematology-Oncology-Bone Marrow Transplant. Definition. Potentially fatal metabolic complication that occurs in some patients with cancer Can result in potentially life threatening metabolic and electrolyte abnormalities.

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Tumor Lysis Syndrome

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  1. Tumor Lysis Syndrome Carol S. Viele RN, MS Clinical Nurse Specialist Hematology-Oncology-Bone Marrow Transplant

  2. Definition • Potentially fatal metabolic complication that occurs in some patients with cancer • Can result in potentially life threatening metabolic and electrolyte abnormalities

  3. Pathophysiology • Involves a complex series of events related to the liberation of intracellular contents from tumor cells and inability of the kidneys to excrete and maintain normal serum composition

  4. Manifestations • Usually occurs within 24-48 hours after initiation of chemotherapy and may persist for 5-7 days post therapy • May occur as early as 6 hours post chemotherapy administration

  5. Tumor Types • Non-Hodgkins lymphoma • Burkitt’s • High grade T-cell • Acute Leukemia’s • Acute Promyelocytic leukemia • Acute lymphoblastic leukemia • Chronic Lymphoblastic leukemia • Solid tumors • Small cell lung cancer • Breast cancer

  6. Symptoms • Cardiac: • Presence of S3 • Bradycardia • Heart Block • Cardiac Arrest

  7. Symptoms • Neuromuscular: • Weakness • Lethargy • Cramping • Tetany • Chvostek’s sign • Trousseau’s sign • Convulsions

  8. Symptoms • Renal: • Oliguria • Renal Insufficiency • Flank pain • Weight gain • Edema • Renal failure

  9. Symptoms • Gastrointestinal: • Nausea • Vomiting • Diarrhea • Constipation

  10. Hyperuricemia • Results from tumor cell destruction • Most common signs and symptoms: • Nausea and vomiting • Azotemia • Oliguria • Anuria • Decreased urine pH • Uric acid crystals found in urinalysis

  11. Hyperkalemia • Results from rapid destruction of cells • Most common signs and symptoms • EKG changes • Peaked t waves • Flat p waves • Wide QRS complexes • Bradycardia • Ventricular tachycardia • Ventricular fibrillation • Asystole • Pulseless electrical activity

  12. Hyperkalemia • Results from rapid destruction of cells • Most common signs and symptoms • Weakness • Twitching • Increased bowel sounds • Nausea • Diarrhea

  13. Hyperphosphatemia • Most common signs and symptoms • Hypocalcemia • Renal failure • Azotemia • Ologuria • Anuria • Hypertension • Edema

  14. Hypocalcemia • Results from hyperphosphatemia and the inverse relationship between calcium and phosphorous • Most common signs and symptoms • EKG changes • Prolonged QT • Inverted T waves • Ventricular dysrhythmias • Heart block • Cardiac arrest

  15. Hypocalcemia • Neuromuscular signs and symptoms • Tetany • Twitching • Paresthesias • Seizures • GI Symptoms • Diarrhea

  16. Diagnostic Tests • Chvostek • Tapping the cheek below the temple where the facial nerve emerges

  17. Diagnostic Tests • Trousseau Sign • Occluding the arterial blood flow in the arm with the blood pressure cuff for one to five minutes, if the thumb adducts and the phalangeal joints extend the test is positive

  18. Prevention • Identify patients at risk • Monitor for all electrolyte abnormalities • Administer allopurinol, • Decrease uric acid levels by interfering with purine metabolism through the inhibition of the enzyme xanthine oxidase that is essential for the conversion of nucleic acids to uric acid • Alkalinization of the urine • Prevent as much as possible renal damage • Sodium bicarbonate solution • Decreases the risk of renal obstruction, however urinary alkalinization should be used cautiously because of risk of precipitation in the kidneys of calcium-phosphorous binding and the risk of hypocalcemic induced neuromuscular irritability

  19. Prevention • Rasburicase- recombinant urate oxidase- • Reduces the uric acid pool • Reduces existing uric acid • Prevents the accumulation of xanthines and hypoxanthine • Does not require alkalinization • Facilitates phosphorous excretion • Dosing: • IV over 30 minutes • 0.2 mg/kg IV QD or BID

  20. Management • Hydration • 3 Liters daily • Aggressive hydration starting 1-2 days prior to chemotherapy and continuing for a few days post chemotherapy

  21. Management • Diuretics: • Furosemide • Renal dose Dopamine- 2-4 mcg/kg • Prevents: • Fluid overload • Electrolyte imbalance • Complications of uric acid buildup

  22. Management • Hyperkalemia • Kayexalate with sorbitol • PO • Rectal • Calcium Gluconate • Sodium bicarbonate • Hypertonic dextrose and regular insulin • Albuterol (Ventolin) or another beta stimulant

  23. Management • Dialysis: Hemodialysis/CVVH/CRRT( Requires ICU Care) • Used for patients unresponsive to preventive measures and electrolyte corrections • Used to remove uric acid • Used in patients with: • Serum potassium >6 mEq/L • Uric acid >10 mg/dl • Phosphorous > 10 mg/dl • Symptomatic hypocalcemia • Presence of volume overload

  24. Medication Management • Avoid nephrotoxic medications • Avoid agents which block tubular reabsorption of uric acid • Aspirin • Probencid • Thiazide diuretics • Radiographic contrast containing iodine

  25. Nursing Interventions • Symptom management • Maintenance of fluid status • Review of systems • Cardiac via EKG • Neurologic • Neuromuscular • Gastrointestinal • Renal

  26. Nursing Interventions • Monitorweights at least daily • Daily EKG’s • Monitor for altered level of consciousness • Strict I&O • Check pH of urine with each void, goal is to keep pH >7.0 • Monitor for signs and symptoms of nausea and vomiting, administer antiemetics as ordered

  27. References • Jeha,S., Pui, C. ‘Recombinant Urate Oxidase (Rasburicase) in the Prophylaxis and Treatment of Tumor Lysis Syndrome, Ronco,R. Rodeghiero, F. (eds) Hyperuricemic Syndrome: Pathophysiology and Therapy, Contrib Nephrol, Basel,Karger,2005,Vol 147,pp69-79

  28. References • Reid-Finlay,M. Kaplow, R. ‘Leukemia and Bone Marrow Transplantation’, Schell,H., Puntillo, K., Critical Care Nursing Secrets, Hanley and Belfus, Inc, Philadelphia 2001,p. 209-215 • Zobec,A., ‘Tumor Lysis Syndrome’, Oncology Nursing Secrets, Hanley and Belfus, 2008, p. 557-560

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