Hematology and Oncology: PICU Handbook
Acute chest syndrome
- Rib infarct causing splinting & atelectasis
- Pulmonary fat embolism
- Infection (mycoplasma, chlamydia, viral)
- Pleuritic chest pain
- Worsening anemia, elevated HBSS%
- Infiltrate on CXR
- IV hydration (~1.5 x maintenance)
- Supplemental O2 (sats > 92%)
- Incentive spirometry
- Consider early BiPAP
- Antibiotics for presumed infection
- Pain meds
- RBC transfusion
- Simple transfusion (Hgb > 10)
- Exchange transfusion- multiple lobes involved, rapidly progressing, or worsening hypoxemia
Superior vena cava syndrome
- Results from compression or obstruction of the SVC
- Etiology: Lymphomas, Extrinsic compression,
- Intravascular thrombosis, Histoplasmosis
- Sx: Facial engorgement, headache, plethora, cyanotic facies, cough, dyspnea, orthopnea, wheezes. May also see pleural or pericardial effusions.
- Pts do not tolerate supine position!
- Do not sedate patients with suspected mediastinal mass without anesthesia involvement!!! Pts are at risk of sudden cardiorespiratory collapse from tracheal obstruction.
- Triad of hepatomegaly, weight gain, jaundice
- Usually occurs 7-20 days post transplant
- Findings: Fluid retention, hyperbilirubinemia, portal hypertension, clotting abnormalities
- Ultrasound usually for diagnosis, consider liver biopsy
- Tx: Ursodiol and Lovenox. Other considerations are prostaglandins and defibrotide
Tumor lysis syndrome
- Rapid destruction of tumor cells overwhelming usual metabolic pathways
- Seen after chemotherapy, steroids, hormones, radiation
- Hyperuricemia, hyperkalemia, hyperphosphatemia.
- Symptomatic hypocalcemia. (precipitant of Ca phos)
- Risk factors for ARF are primary tumor infiltrates, obstruction of urine flow, pre-existing renal pathology, & dehydration.
- Risk factors for TLS are Burkitt's lymphoma / leukemia, acute leukemias, non-Hodgkin’s lymphoma, tumors w/ rapid growth rate and large tumor burdens.
- Tx: D5 ¼ NS + 50-100 meq/L
- Na Bicarb @ 2X maint
- Keep urine pH 7 – 7.5
- Rasburicase or Allopurinol (Discuss w/ Heme-onc)
Respiratory failure post transplant
Early recovery period – Bacterial / fungal infections, sepsis, mucositis and upper airway obstruction, acute pulmonary edema, pulmonary vascular disease (diffuse alveolar hemorrhage), idiopathic pulmonary syndrome
Mid recovery – Cytomegalovirus pneumonitis (primary or reactivation), opportunistic infections (PCP), Interstitial pneumonitis
Late recovery – Common infections, CMV reactivation, Adenovirus, Chronic graft-versus-host, Bronchiolitis obliterans