Page 217 - Critical Care Notes

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death if severe or untreated →↑ K levels → severe hyperkalemia → severe car-
diac dysfunction. An ↑ in purines (converted in the liver to uric acid) released
into bloodstream → hyperuricemia → precipitation of these crystals in the
kidney → sludge in the tubules → blockage → acute renal failure. TLS is most
often seen in patients receiving chemotherapy or radiation for cancers highly
responsive to this treatment, including leukemia (acute lymphocytic leukemia,
acute myelogenous leukemia), lymphoma (non-Hodgkin’s lymphoma, Burkitt’s
lymphoma), small cell lung carcinoma, germ cell tumors, inflammatory breast
cancer, melanoma, and multiple myeloma. This oncological emergency is a
positive sign the treatment is working.
Clinical Presentation
TLS is diagnosed if one or more of these three conditions arise:
■ Cardiac arrhythmias
■ Arthralgias from gout flare-up
■ Signs and symptoms of increased phosphorus, K , Ca 2 + , and uric acid
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Diagnostic Tests
■ CMP including uric acid level
■ CBC
■ Urinary uric acid/creatinine ratio
■ ECG
■ Ultrasound scan of kidneys
Management
■ Monitor fluid and electrolyte balance including intake and output.
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■ Provide IV hydration, which ↓ serum K level and ↑ kidney filtration rate.
■ Instruct patient to drink at least 3–5 L of fluid the day before, the day of,
and 3 days after treatment (especially in patients with tumors highly sensi-
tive to treatment, as mentioned earlier).
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■ Ensure that some fluids are alkaline (Na ).
■ Health teach importance of consistent fluid intake over 24 hr (help patient
draw up a schedule).
■ Health teach importance of taking antiemetics after treatment to prevent
nausea and vomiting, which would hinder fluid intake.
■ Administer diuretics, especially osmotic types, to increase urine flow. Use
with caution because diuretics may cause dehydration.
■ Administer medications that increase secretion of purines: allopurinol
(Zyloprim), rasburicase (Elitek).
■ Administer medications to decrease hyperkalemia: sodium polystyrene
sulfonate (Kayexalate), either orally or rectally by enema.
■ Administer IV infusion containing dextrose and insulin if hyperglycemic.
■ Initiate hemodialysis or CRRT as needed.
HEMA/
ONCO