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TABLE 98.11 COMPLICATIONS OF HEMATOPOIETIC STEM CELL TRANSPLANT Complication Clinical findings Management Acute graft versus host disease (GVHD) Skin Erythematous rash Classic involvement of palms and soles GI tract Colitis, sometimes bloody diarrhea Abdominal pain Liver Elevated bilirubin, alkaline phosphatase, transaminases Hepatomegaly Right upper quadrant tenderness Immunosuppressive medications chosen only in consultation with experts in stem cell transplant Aggressive management of infections and fevers given immunosuppression intrinsic to GVHD Hydration as needed for dehydration from colitis Assessment of anemia secondary to bloody diarrhea Caution using drugs metabolized in the liver if hepatic GVHD present Chronic GVHD Pulmonary Hypoxia Shortness of breath Liver (as above) Eye dryness Mouth dryness Skin Sclerodermatous changes Contractures Infection Bacterial Gram positive Gram negative Viral Endogenous Varicella zoster Herpes simplex Epstein–Barr virus Cytomegalovirus Adenovirus Exogenous Empiric broad-spectrum antibiotics for fever All patients to be considered functionally neutropenic and immunocompromised until they have been off all immunosuppressive medications for at least mo Aggressive imaging to follow-up and localizing Influenza signs or symptoms elicited through history and Parainfluenza physical examination Respiratory syncytial virus Bacterial and fungal cultures Adenovirus as well as viral studies of Fungal blood, urine, sputum Disseminated candidemia Spinal tap not required Invasive aspergillosis Thrombotic Acute form displays classic thrombocytopenic pentad purpura Fever Hemolytic anemia Thrombocytopenia Renal failure Neurologic symptoms Rarely can evolve into chronic hemolytic uremic syndrome–like picture Manage as TTP would be managed outside of the stem cell transplant setting Central to the mission of the emergency clinician approaching a child with advanced cancer should be establishing the current goals of care This can occur in two major ways: The preferences of the patient and/or family members may already be documented in the medical record Often, these preferences have been explored during previous hospitalizations or clinic appointments with the patient’s primary oncology team In many cases, the outcome of such discussions may now be written in the form of a Do-Not-Resuscitate (DNR) order or an outpatient/home form or order meant to establish limits for resuscitation Insight into the patient’s and family’s goals of care may be gained by direct communication with the oncologist who knows the patient best During the visit to the ED, the clinician should ask the patient/family open-ended questions to allow for an open expression of preferences During this conversation, if the patient has documented preferences already expressed in the medical record, the clinician should inquire whether there have been any recent changes to these preferences Changes sometimes occur and medical staff unacquainted with the patient often feel uncomfortable embarking upon these discussions, even though patients and family members usually welcome the opportunity to communicate in this way Approaching patients with advanced cancer requires the clinician to acknowledge that sometimes patient/family preferences not seem aligned with those of the healthcare team For example, the clinician may encounter a patient who is clearly within hours or days of death but who still “wants everything done,” including cancer-directed therapy and aggressive management such as intubation or resuscitation On the other hand, the clinician may instead face a patient with seemingly good functional status and quality of life who declines further diseasedirected treatments Cases may exist anywhere in between these two extremes It is the clinician’s responsibility to provide honest and complete information and elicit the patient’s beliefs and wishes to facilitate decision making that most reflects the wishes of the patient and family Once decisions are made, it is then the duty of the clinician to help carry out those wishes Patients with advanced cancer may have clear preferences regarding admission to the hospital While some patients and families may have adequate services in place to remain in their homes, some will still desire inpatient management as a form of respite Initiation of a management plan intended to reduce symptoms is always an appropriate step The kind of intervention best able to reduce symptoms must be chosen based on the goals of care Patients with advanced cancer have often received large amounts of opioids in the past and may therefore require larger doses of pain medications than routinely administered to children in the ED (see “Pain” section) It is imperative for the clinician to increase the opioid dose until an efficacious dose is reached Opioids may also be carefully titrated to treat shortness of breath or other respiratory symptoms Diagnostic workup and specific management beyond symptom control should be undertaken in a manner consistent with the goals of care If the patient’s focus is only on comfort, then additional testing should be considered only if it will help identify a reasonable strategy to optimize that comfort Consider, for example, a patient who presents for pain management but who is also cachectic and dehydrated The clinician may wonder whether checking serum electrolytes and initiating rehydration are indicated If the stated goals of care are comfort, then these measures should be omitted since electrolyte disturbances rarely cause pain or discomfort and hydration often will prolong the suffering associated with severe pain at the end of life Indeed, hydration could increase edema or secretions that would actually decrease quality of life As an additional example, consider a patient presenting with a malignant pleural effusion causing severe respiratory distress Under other circumstances, the management of a large effusion might be immediate placement of chest tube In this case, the clinician might instead ask, “How will a chest tube help this patient and does it match what he/she wants?” This change in thought process is often extremely hard for healthcare providers whose experience and training not ... TTP would be managed outside of the stem cell transplant setting Central to the mission of the emergency clinician approaching a child with advanced cancer should be establishing the current