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TUMOR LYSIS SYNDROME1,2

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  • Definition: Potentially life-threatening clinical syndrome that results in electrolyte derangements secondary to significant tumor cell death and impairment in the kidney's ability to maintain homeostasis

    • Most commonly occurs in patients with tumors with high cell turnover (acute leukemia, Burkitt's lymphoma) with initiation of therapy, but can occur in any malignancy, even without chemotherapy

    • Can lead to renal failure

  • Common electrolyte derangements include:

    • Hyperkalemia (typically the first to develop and most life threatening)

    • Hyperuricemia

    • Hypocalcemia

    • Hyperphosphatemia

  • Therapy:

    • Aggressive hydration: 1.5 to 2 times maintenance IV fluids (without potassium or phosphorus)

    • Prevention of hyperuricemia: allopurinol (first-line), rasburicase

    • Dialysis: Reserved for severe kidney injury with electrolyte disturbances and/or fluid overload

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HYPERLEUKOCYTOSIS AND LEUKOSTASIS3

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  • Definition: Hyperleukocytosis is defined as a white blood cell (WBC) count >100,000/μL, most commonly seen in children with acute lymphocytic leukemia (ALL). As WBC count increases, the viscosity of blood is increased, which can lead to aggregation of leukocytes and obstruction of blood vessels. Leukostasis causes local hypoxia and invasion of the blood vessels by leukemic cells.

    • Children with hyperleukocytosis have higher rates of morbidity and mortality:

      • Neurologic complications: Intracranial hemorrhage, ischemia (can present with headache, mental status changes, seizures, or visual disturbances)

      • Pulmonary leukostasis: Presenting with respiratory distress, hypoxemia

      • Tumor lysis syndrome

  • Therapeutic approach: Supportive care

    • Avoid diuretics and blood transfusions (may increase blood viscosity further)

    • Prevent bleeding complications by correcting coagulopathy

    • Treat/prevent tumor lysis syndrome

    • Consider exchange transfusion or leukapheresis-limited evidence of efficacy

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MEDIASTINAL MASS4

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  • Definition: Presence of a mass in the mediastinum can be seen in benign or malignant disease and should be considered when widened mediastinum is seen on chest radiograph.

    • Most commonly occurs in patients with lymphoma or neuroblastoma

    • Patients may report respiratory distress or orthopnea

  • Therapeutic considerations:

    • Masses in anterosuperior or middle mediastinum can compress the tracheobronchial tree, heart, and great vessels with a high risk of airway or vascular compromise, especially when lying flat

    • Sedation/anesthesia is high risk; complications vary from hypotension to complete cardiopulmonary collapse and occur in 9% to 20% of patients with mediastinal mass undergoing anesthesia

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FEVER AND NEUTROPENIA5

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  • Definition: Temperature of >38.5°C (or multiple temperatures >38°C) in a patient with an absolute neutrophil count (ANC) of <1,000

    • ANC = WBC count * % neutrophils * 1000

  • Workup:

    • Complete blood count (CBC) to confirm neutropenia and assess for anemia, thrombocytopenia

    • Blood (central and peripheral) and urine (noncatheterized) cultures

    • Remainder of workup depends on symptoms

      • Consider chest x-ray (CXR), respiratory polymerase chain reaction (PCR) if respiratory symptoms

      • Stool studies if gastrointestinal (GI) complaints

      • Cerebrospinal fluid (CSF) studies/central nervous system (CNS) imaging if neurologic changes

  • Therapeutic approach:

    • Follow sepsis guidelines: Fluid resuscitation, inotropic support, steroids if evidence of adrenal insufficiency, increased oxygen delivery, and decreased oxygen demand

  • Antibiotic therapy:

    • Gram-negative coverage: Including Pseudomonas (ceftazidime, cefepime, ...

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