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Tumour lysis syndrome, complex care planning, Pharmacological management,…
Tumour lysis syndrome
Management for optimal outcome
Management of intermediate and high-risk
Allopurinol-100mg-3 times/day
max800mg/day
3-7 days/ until resolves
Rasburicase 0.2mg/kg/day
consider first in high risk
Vigorous hydration
total fluid of 3L / m2 / day
urine output at least 100 ml/m2/hour
urine specific gravity ≤ 1.010g/cm3
low fixed dose Rasburicase-3-6 mg
reduced cost burden
potential improved access
Structured TLS prevention strategy
Disease debulking strategies
stepwise dose escalation (chemo)
eg. before high-risk therapy Ventoclax
Risk adapted prophylaxis
optimize fluid management
1.5-2L/day- 2days before treatment
24hours before & 48hours after
urinary output >100 mL/h
fluid overload and in-sufficient diuresis
consider Loop diuretics
Thiazide diuretics are contra-indicated
increases uric acid levels
prophylactic allopurinol
2-3 days prior chemotherapy
until signs of TLS absent
individualize risk stratification
based on
treatment related factors
cancer related factors
patient related factors
knowledge gaps in management
uncertain renal outcome
needs simplified risk classification
unequal access- appropriate rasburicase dose
Identification of deterioration
Diagnosis
based on
Cairo-bishop criteria
Laboratory TLS
Clinical TLS
serial electrolytes
cardiac monitoring
severity of ongoing TLS
degree of TLS risk
Risk stratification
based on
tumour burden
tumour type
treatment intensity and frequency
renal function and co-morbidity
Intermediate risk
every 8-12 hours
High risk
4-6 hours + intensive care
Low risk
once daily TLS
recognising TLS progression
Hyperuraecemia
cascade of homeostatic distruption
Monitor ECG for changes
continuous cardiac monitoring
electrolyte abnormalities
Serum k+ >6.5mmol/L
arrythmias, wide QRS complex,
lengthening PR interval
IV 10% Dextrose infusion
rapid acting insulin
IV calcium gluconate
while waiting for hemodialysis
Advanced ABCDE assessment
Respiratory and cardiovascular status
fluid overload
assess pulmonary edema/ renal dysfunction
strict urine output monitoring
careful fluid assessment
↓ urine output + ↑ creatinine
worsen renal function
trends AKI
aim >3L/day
Advanced nursing assessment
Hyperphosphataemia
prophylactic ICU admission
IV hydration
oral non-calcium phosphate binders
no response to
conventional therapies
severe metabolic abnormalities
early consideration of RRT
Refractory AKI
rapidly worsening metabolic complications
evaluate for dialysis treatment
chemotherapy temporarily delayed
MDT escalation
Hematology + Oncology + Nephrology + ICU
Timely chemotherapy treatment decision-making
individualized assessment
Nursing considerations
initial laboratory evaluation
early detection of G6PD deficiency
using rasburicase anticipated
hemolytic reactions
African, Middle Eastern, or Mediterranean ancestry
Pathophysiology
risk factors
novel or targeted therapies
combination with other chemotherapies
high tumour burden
chemo sensitive malignancies
high-grade lymphoma
some solid tumors
leukemias
↑ LDH (>2 × ULN)
bulky disease > 10cm
12 to 72 hours post chemotherapy
Age ≥60 years
high proliferation rate
spontaneous
treatment related
Pre-existing renal impairment or dehydration
leads to
release of intracellular contents
↑ phosphate → hyperphosphataemia →binds with calcium
Urate and calcium crystal nephropathy
Tubular obstruction
nucleic acid breakdown → uric acid ↑
cascade of homeostatic disruption
↑ pottasium → Hyperkalaemia →arrythmias
hypocalcaemia
worsens electrolyte clearances
renal consequences
metabolic imbalances + cytokine releases
life- threatening complications
neuromuscular irritability or seizures
AKI or uric acid nephropathy
multiorgan failure
fluid overload or pulmonary oedema
cardiac arrthmias
Early recognition and escalation
escalate deterioration promptly
initiate urgent MDT review
standardized measuring and reporting tools
interdisciplinary collaboration
complex care planning
known CKD
electrolytes derangements
baseline comparision
individualised assessment
plus
age > 60 years
hypovolaemia
obstruction of urinary tract
ICU + cardiology, and Nephrology
Pharmacological management
Hypocalcaemia
symptomatic- low dose oral calcium
Asymptomatic- resolves if phosphate corrected
in ICU
Hyperuraeecemia
Allopurinol
↓ new uric acid formation
Rasburicase
converts existing uricacid to allantoin
Advanced nursing assessment
vital signs and ECG monitoring
nausea, vomiting or diarrhea
to ascertain risk of dehydration
anorexia, weakness, lethargy, or tetany
check for edema
related to AKI or cardiac compromise
glucose 6 phosphate dehydrogenase
alone or
rapid tumour lysis
due to
anticipate
Nursing implications
and
plus
Liaise with
complex care planning
IV hydration
oral
aim
Pharmacological management of low risk TLS
Low risk
maintain
corticosteroids or alternative therapy
↓ severity of TLS
Liaise with ICU + cardiology, and Nephrology
develops
presence of
changes in lab values
worsening symptoms
to address
as
high risk
