Chapter 180. Management of Emergencies in Patients with Hematologic Malignancies

A 30-year-old Caucasian man developed lethargy and nausea. He recently started chemotherapy for Burkitt lymphoma. He was mildly tachycardic, afebrile, and had a large, easily palpable abdominal mass. In addition to anemia and thrombocytopenia, the blood work was notable for potassium of 5.8 mmol/L and creatinine of 3.9 mg/dL (350 umol/L). The nurse reported that he had produced only 200 mL of urine in the previous 8 hours. What other blood tests should be ordered? What measures can be taken to prevent permanent renal failure?

The serum uric acid was 15.6 mg/dL (925 mmol/L), the phosphate is 7.9 mg/dL (2.57 mmol/L), and the calcium was 7.88 mg/dL (1.97 mmol/L). Urinalysis showed marked uric acid crystals. The electrocardiogram was essentially normal. Glucose, insulin and Kayexalate for the hyperkalemia, normal saline 200 mL/h, aluminum hydroxide 60 mL four time a day, and rasburicase 0.2 mg/kg intravenously was administered. A Foley catheter was inserted and the patient was monitored closely for signs of fluid overload. Serum electrolytes and renal function were checked every four hours overnight, and the covering physician alerted the nephrologist and the patient's treating hematologist to the situation.

A 56-year-old woman presented to the emergency room for five days of progressive shortness of breath and headache, for which she took aspirin. Her oxygen saturation was 87% on room air, and she was tachycardic, mildly hypotensive, and febrile. Her examiners noted a palpable spleen 4 cm below the costal margin, lower extremities covered in petechia, and engored retinal veins. They did not identify focal neurologic deficits.

Her white count was 135 × 109/L with large, monocytic-appearing blasts on the peripheral blood film, hematocrit 22%, and platelet count 18 × 109/L. Her chemistry profile revealed hyperkalemia, a creatinine double her baseline, a uric acid level of 17 mg/dL, and an INR of 1.5. Her chest X-ray showed diffuse bilateral infiltrates.

Physician orders includec hydroxyurea 3 g orally stat, then 2 g every 8 hours, a platelet transfusion, normal saline at 125 mL/hour (2 L/m2/day), continuously monitoring O2 saturation, treatment of the hyperkalemia, and ceftazidime and rasburicase. Unfortunately, while her physicians were arranging transfer to a tertiary care hospital, the patient's level of consciousness deteriorated. A stat brain CT showed a large parietal hemorrhage with midline shift and herniation. The patient was immediately intubated, but the neurosurgeon concluded that surgical intervention would be futile. Two days later, her family elected to withdraw ventilator support and she passed away in the intensive care unit.