CURRENT ESSENTIALS OF CRITICAL CARE - PART 10 potx

This page intentionally left blank 277 19 Oncology/Oncologic Emergencies Leukemia, Acute 279 Spinal Cord Compression 280 Superior Vena Cava (SVC) Syndrome 281 Tumor Lysis Syndrome 282 5065_e19_p277-282 8/17/04 10:16 AM Page 277 This page intentionally left blank Leukemia, Acute ■ Essentials of Diagnosis • Pancytopenia: weakness, fatigue from anemia; bleeding (gingi- val, epistaxis) from thrombocytopenia; infection from ineffec- tive leukocytes • No characteristic examination findings; fever; pallor, petechiae, retinal hemorrhages, gingival hypertrophy (monocytic sub- types), lymphadenopathy and splenomegaly (acute lymphoblas- tic leukemia, evolution from chronic myelogenous leukemia); rarely extramedullary leukemic involvement (chloroma) • Peripheral blood smear may have no, little, or marked increase in white blood cells; thrombocytopenia; Ͼ30% blasts in bone marrow • Distinguish acute myelogenous leukemia (AML) from acute lymphoblastic leukemia (ALL) by Auer rods (AML), histo- chemical markers; cytogenetics may have prognostic importance • AML has 7 subtypes; acute promyelocytic leukemia (APL, AML-M3) associated with disseminated intravascular coagu- lopathy (DIC), spontaneous hemorrhage ■ Differential Diagnosis • Aplastic anemia • Leukemoid reaction • Bone marrow infiltration with tumor, microorganisms ■ Treatment • High-dose chemotherapy based on cell type followed by pro- longed pancytopenia requiring aggressive transfusions of red cells, platelets • Careful hand washing, avoid intramuscular injections; long-term “tunnel” catheter may be helpful • Evaluate neutropenic fever; treat with empiric antibiotics • Anticipate tumor lysis syndrome; treat with IV fluids, allopuri- nol • APL may respond to all-trans retinoic acid (ATRA) and che- motherapy • Selected patients may benefit from bone marrow transplantation ■ Pearl ATRA treatment of APL may be complicated by retinoic acid syndrome in 6–27%, with fever, weight gain, hypotension, renal failure, pul- monary edema, and pleural and pericardial effusions. Reference Massion PB et al: Prognosis of hematologic malignancies does not predict in- tensive care unit mortality. Crit Care Med 2002;30:2260. [PMID: 12394954] Chapter 19 Oncology/Oncologic Emergencies 279 5065_e19_p277-282 8/17/04 10:16 AM Page 279 Spinal Cord Compression ■ Essentials of Diagnosis • Dull aching axial back pain that may radiate to arms or legs; band-like discomfort around chest; worse at night; aggravated by movement • Neurologic deficits depend on level of involvement: 70% tho- racic, 20% lumbar, 10% cervical; typically begins with motor impairment; high cervical cord lesions may be life-threatening; thoracic cord lesions have truncal sensory level, lower extrem- ity weakness, autonomic dysfunction; lumbosacral cord lesions may have radiculopathy and loss of reflexes or conus syndrome • Acquire imaging studies as soon as possible; MRI, or CT myel- ogram • May be first manifestation of malignancy; most common are cancers of lung, breast, prostate, lymphoma, multiple myeloma • Epidural spinal cord compression develops from direct meta- static spread of cancer to vertebral body or from paravertebral location with extension into epidural space ■ Differential Diagnosis • Intervertebral disk herniation • Spinal cord infarction • Benign neoplasms • Multiple sclerosis • Transverse myelitis • Epidural abscess • Paraneoplastic syndrome • Carcinomatous meningitis ■ Treatment • Corticosteroids should be started as soon as diagnosis suspected; delay may lead to progression of neurologic deficit • External beam radiation to involved area • Chemotherapy based on underlying malignancy • Surgery indicated for spinal instability or bone deformity, fail- ure to respond to radiation therapy, radioresistant tumor, at- lantoaxial compression, solitary spinal cord metastasis • Monitor changes in neurologic exam closely ■ Pearl Epidural spinal cord compression should be considered in any patient with cancer and axial skeletal pain as pain is the most common early symptom. Reference Daw HA et al: Epidural spinal cord compression in cancer patients: diagnosis and management. Cleve Clin J Med 2000;67:497. [PMID: 10902239] 280 Current Essentials of Critical Care 5065_e19_p277-282 8/17/04 10:16 AM Page 280 Superior Vena Cava (SVC) Syndrome ■ Essentials of Diagnosis • Compression, invasion, or thrombosis of SVC; most commonly caused by malignancy • Headache, dizziness, sensation of fullness in head • Distention of neck and anterior chest wall veins • Facial plethora and edema • Cyanosis and edema of upper extremities • Dyspnea may occur from airway compression • Diagnosis made on clinical grounds in majority of cases • Chest radiographs, tomography, CT scans define extent of me- diastinal involvement • Tissue diagnosis needed to establish etiology and guide thera- peutic options • Etiologies: malignancy with lung cancer and lymphoma most common; benign causes include aortic aneurysm, fibrosing me- diastinitis, tuberculosis, pyogenic infection, radiation changes; thrombotic complications from intravascular catheters ■ Differential Diagnosis • Angioedema • Thyroid goiter • Histoplasmosis • Syphilitic aneurysm of aorta • Upper extremity deep vein thrombosis ■ Treatment • Chemotherapy treatment of choice for small cell lung cancer, lymphoma, germ cell tumors • Radiation therapy only option for all other tumors • Symptom relief measures: elevating head of bed, oxygen • Secure patency of airway with stents if needed to prevent tra- cheal compression • Corticosteroids may help decrease edema and secondary in- flammatory reaction • Saphenous vein bypass grafting useful in selected patients • Diuretics, anticoagulants, thrombolytic agents are of little help and may actually be dangerous ■ Pearl Mortality is related to the underlying malignancy rather than the pres- ence of superior vena caval obstruction. Reference Markman M: Diagnosis and management of superior vena cava syndrome. Cleve Clin J Med 1999;66:59. [PMID: 9926632] Chapter 19 Oncology/Oncologic Emergencies 281 5065_e19_p277-282 8/17/04 10:16 AM Page 281 Tumor Lysis Syndrome ■ Essentials of Diagnosis • Recent administration of chemotherapy for treatment of a rapidly proliferating malignancy with massive destruction of neoplastic cells; described in Burkitt lymphoma and some leu- kemias without precipitating chemotherapy • Lysis of cells leads to hyperkalemia, hyperphosphatemia, hy- peruricemia • Hyperphosphatemia associated with hypocalcemia • Hyperuricemia can cause uric acid nephropathy, renal failure • Symptoms related to metabolic and electrolyte changes • Complications: electrocardiographic changes, cardiac arrhyth- mias, tetany, convulsions, oliguria, muscle cramps, lethargy ■ Differential Diagnosis • Burkitt lymphoma • Acute lymphocytic leukemia • Chronic lymphocytic leukemia • Solid tumors • Spontaneous necrosis of malignancies ■ Treatment • Aggressive volume resuscitation • Prevention of hyperuricemia with allopurinol before adminis- tration of chemotherapy • Appropriate treatment for hyperkalemia and hyperphosphatemia • Alkalinization of urine (pH 7.0–7.5) while serum uric acid lev- els are elevated • Hemodialysis for life-threatening electrolyte abnormalities and renal failure ■ Pearl High leukocyte and platelet counts may cause pseudohyperkalemia due to lysis of these cells after blood collection. No electrocardio- graphic abnormalities will be seen, and plasma instead of serum potassium should be followed. Reference Gobel BH: Management of tumor lysis syndrome: prevention and treatment. Semin Oncol Nurs 2002;18:12. [PMID: 12184047] 282 Current Essentials of Critical Care 5065_e19_p277-282 8/17/04 10:16 AM Page 282 283 20 Pregnancy Acute Fatty Liver of Pregnancy 285 Amniotic Fluid Embolism 286 Asthma in Pregnancy 287 Preeclampsia and Eclampsia 288 Pulmonary Edema in Pregnancy 289 Pyelonephritis in Pregnancy 290 Septic Abortion 291 5065_e20_p283-292 8/17/04 10:14 AM Page 283 This page intentionally left blank Acute Fatty Liver of Pregnancy ■ Essentials of Diagnosis • Hepatic dysfunction associated with liver biopsy demonstrating microvesicular fatty infiltration of hepatocytes • Nausea, vomiting, varying degrees of epigastric and right upper quadrant pain, anorexia, malaise • Most commonly occurs in third trimester and immediate post- partum period • Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) usually Ͻ1000 IU/L; alkaline phosphatase and bilirubin increase, albumin decreases, WBC elevated, coagulopathy con- sistent with disseminated intravascular coagulopathy (DIC), hy- poglycemia • Increased incidence in first pregnancies, twin gestations • Complications: fulminant hepatic failure, hypoglycemia, con- sumptive coagulopathy, renal failure, cerebral edema, pancre- atitis, spontaneous labor, fetal demise ■ Differential Diagnosis • Preeclampsia/eclampsia • Acute hepatic rupture • Budd-Chiari syndrome • Viral hepatitis • Cholestasis of pregnancy • HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) • Fulminant hepatic failure secondary to medications ■ Treatment • Continuous fetal monitoring until delivery • Maintain patent airway if mental obtundation present; normal- ize intravascular volume status; correct electrolyte disturbances; dextrose infusions to support hypoglycemia; correct hemato- logic and coagulation abnormalities • Delivery should be performed as soon as patient stabilized; de- lays can result in fetal demise from uteroplacental insufficiency or hypoglycemia; clinical improvement typically follows • Supportive measures: nutritional support to prevent hypo- glycemia; consider lactulose or other ammonia reducing agents if encephalopathic; administer vitamin K if coagulopathic ■ Pearl AFLP can present with such nonspecific findings as nausea, vomit- ing, and right upper quadrant pain that the diagnosis can be over- looked with drastic consequences including fulminant hepatic failure if treatment is delayed. Reference Sandhu BS et al: Pregnancy and liver disease. Gastroenterol Clin North Am 2003;32:407. [PMID: 12635424] Chapter 20 Pregnancy 285 5065_e20_p283-292 8/17/04 10:14 AM Page 285 [...]... decreased colloid oncotic pressure, predispose to the development of pulmonary edema Reference Siscione AC et al: Acute pulmonary edema in pregnancy Obstet Gynecol 2003 ;101 :511 [PMID: 12636955] 290 Current Essentials of Critical Care Pyelonephritis in Pregnancy ■ Essentials of Diagnosis • • • • • • • • ■ Differential Diagnosis • • ■ Intra-amniotic infection Appendicitis • • Renal stones Cholecystitis... Hg in a pregnant woman may be a sign of impending respiratory failure during a severe asthma exacerbation as the normal range of PaCO2 in pregnancy is 28 to 32 mm Hg Reference Graves CR: Acute pulmonary complications during pregnancy Clin Obstet Gynecol 2002;45:369 [PMID: 12048396] 288 Current Essentials of Critical Care Preeclampsia and Eclampsia ■ Essentials of Diagnosis • • • • • ■ Differential... 225 Acetazolamide, 66 Acid-base disorders, mixed, 67 See also specific disorders Acidosis, 55, 100 , 210, 213, 232 anion gap, 65, 67 metabolic, 26, 62, 65, 69, 124 respiratory, 68, 100 , 105 , 109 Activated partial thromboplastin time (aPTT), 39, 40, 41 Acute chest syndrome, in sickle cell anemia, 81 Acute respiratory distress syndrome (ARDS), 10, 78, 93, 253, 274, 286 management of, 68 mechanical ventilation... blockers, 57, 115, 116, 119, 203 Calcium level, correction of, 53 Calorie needs, increased, 16, 172 See also Nutrition Calorimetry, indirect, 16 Candidiasis, 140, 259 Capnography, 10 Carbamazepine, 270 Carbicarb, in metabolic acidosis, 65 Carbon dioxide, partial pressure of (PaCO2), 109 , 202, 287 in mixed acid-base disorders, 67 monitoring of end-tidal, 10 in respiratory acidosis, 68 in respiratory alkalosis,... patients, 27 Nystagmus, 203, 233, 240, 256 O Obesity, 17, 155, 180 intra-abdominal infection in, 143 respiratory failure associated with, 107 Obesity-hypoventilation syndrome (OHS), 17, 86, 107 Obstipation, 162, 170, 175 Obstruction of eccrine sweat glands, 267 large-bowel, 170 small-bowel, 175 Obstructive sleep apnea (OSA), 17, 103 , 107 Obstructive sleep apnea syndrome, 87, 8787 Obtundation, in infectious...286 Current Essentials of Critical Care Amniotic Fluid Embolism ■ Essentials of Diagnosis • • • • • • • ■ Differential Diagnosis • • • • ■ Dyspnea and hypotension followed by sudden cardiovascular collapse Greatest risk during active labor; also reported after vaginal or Cesarean delivery, following termination of first or second trimester pregnancy Coagulopathy,... respiratory failure due to COPD, 105 Respiratory alkalosis, 69, 239 Respiratory compromise, in snakebite, 255 Respiratory distress, 81, 94, 136 Respiratory failure, 56, 83, 86, 105 , 109 , 192 in acute lung injury, 95 from arterial hypercapnia, 108 fulminant, 66 hemoptysis in, 96 in HIV-infected patients, 153 from neuromuscular disorders, 106 nonpulmonary causes of, 108 pleural effusions associated with,... pregnancy, 289 in respiratory failure, 106 , 107 , 109 in scleroderma, 220 in status asthmaticus, 110 Oxygen, partial pressure of (PaO2), in elderly patients, 11 Oxygenation goal, in mechanical ventilation, 98 Oxygen saturation, 5, 20 Oxygen therapy, 87, 93 for hypervolemia, 63 in inhalation injury, 82 pulse oximetry during, 20 Oxygen toxicity, on mechanical ventilation, 101 Oxyhemoglobin, 247 P Pacemaker,... failure associated with, 107 thoracostomy for, 85 Pleuritic chest pain, 90, 120 in HIV-infected patients, 153 pleural effusions associated with, 88 in pneumonia, 136 Pneumocystis jiroveci pneumonia (PCP), 151, 153 Pneumomediastinum, 97, 101 , 230 Pneumonia, 99, 149, 152, 220 ARDS associated with, 93 aspiration, 95 community-acquired, 137 end-tidal PCO2 in, 10 hematogenous, 149 in HIV-infected patients, 153... on mechanical ventilation, 101 in metabolic alkalosis, 66 Hypovolemia, 64 in endocrine problems, 179 in environmental injury, 250 in hyponatremia, 60 Hypovolemic shock, 76 Hypoxemia, 68, 87, 89, 105 , 110, 121, 129, 151, 184 in air embolism syndrome, 94 ARDS associated with, 93 in asthma, 287 life-threatening, 215 on mechanical ventilation, 99, 102 and PaO2, 109 PEEP for, 104 in pneumonia, 137 in pregnancy, . J Med 2000;67:497. [PMID: 109 02239] 280 Current Essentials of Critical Care 5065_e19_p27 7-2 82 8/17/04 10: 16 AM Page 280 Superior Vena Cava (SVC) Syndrome ■ Essentials of Diagnosis • Compression,. 11512502] 290 Current Essentials of Critical Care 5065_e20_p28 3-2 92 8/17/04 10: 14 AM Page 290 Septic Abortion ■ Essentials of Diagnosis • Sepsis syndrome following recent spontaneous or induced preg- nancy. Summary of the NHLBI working group on research on hy- pertension during pregnancy. Hypertension 2003;41;437. [PMID: 12623940] 288 Current Essentials of Critical Care 5065_e20_p28 3-2 92 8/17/04 10: 14