CURRENT Essentials of Critical Care.pdf

Chapter 19 Oncology/Oncologic Emergencies 279■■■Leukemia, AcuteEssentials of Diagnosis• Pancytopenia: weakness, fatigue from anemia; bleeding (gingival,epistaxis) from thrombocytopenia; infection from ineffectiveleukocytes• No characteristic examination findings; fever; pallor, petechiae,retinal hemorrhages, gingival hypertrophy (monocytic subtypes),lymphadenopathy and splenomegaly (acute lymphoblasticleukemia, evolution from chronic myelogenous leukemia);rarely extramedullary leukemic involvement (chloroma)• Peripheral blood smear may have no, little, or marked increasein white blood cells; thrombocytopenia; 30% blasts in bonemarrow• Distinguish acute myelogenous leukemia (AML) from acutelymphoblastic leukemia (ALL) by Auer rods (AML), histochemicalmarkers; cytogenetics may have prognostic importance• AML has 7 subtypes; acute promyelocytic leukemia (APL,AML-M3) associated with disseminated intravascular coagulopathy(DIC), spontaneous hemorrhageDifferential Diagnosis• Aplastic anemia • Leukemoid reaction• Bone marrow infiltration with tumor, microorganismsTreatment• High-dose chemotherapy based on cell type followed by prolongedpancytopenia requiring aggressive transfusions of redcells, 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, allopurinol• APL may respond to all-trans retinoic acid (ATRA) and chemotherapy• Selected patients may benefit from bone marrow transplantation■ PearlATRA treatment of APL may be complicated by retinoic acid syndromein 6–27%, with fever, weight gain, hypotension, renal failure, pulmonaryedema, and pleural and pericardial effusions.ReferenceMassion PB et al: Prognosis of hematologic malignancies does not predict intensivecare unit mortality. Crit Care Med 2002;30:2260. [PMID: 12394954]