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Running head: CASE STUDY 94
Case Study 94
Julianne Shimer
University of New Hampshire
CASE STUDY 94
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Case Study 94
H.J is 46-year-old man who, 4 months ago, was unfortunately diagnosed with
Burkitts lymphoma, a high grade non-Hopkins lymphoma. Burkitts is treatable, however
is associated with higher relapses and higher treatment related mortality rates (Choi,
2009). He has received three of six chemotherapy courses and was seen today at his
physician’s office with a complaint of malaise and fever. He was found to have
splenomegaly on examination. Chest X-ray demonstrates patchy infiltrates in bilateral
lower lobes, right greater than left. He was sent for a CT of the abdomen, which showed
metastatic disease in the liver, spleen, and pancreas. He is admitted to the hospital with
progressive disease.
On top of H.J.’s Burkitts lymphoma diagnosis he is now diagnosed with acute
tumor lysis syndrome (TLS), which it is an oncologic emergency from extreme tumor
cell lysis with release of large amount of potassium, phosphate and nucleic acids into the
circulation. The high number of neoplastic cells are released so quickly that they are
releasing intracellular ions and metabolic byproducts. It occurs from initiation of cancer
treatment of bulky responsive tumors. Catabolism of nucleic acids to uric acid leads to
hyperurecemia which increases uric acid excretion which leads to uric acid in the renal
tubules, which then leads to vasoconstriction, altered auto regulation, decreased renal
blood flow, and inflammation and kidney injury (Larson, 2013). TLS can happen
spontaneously, but it is usually caused secondary to chemotherapy treatment, which is the
case for H.J. (Rajendran, 2012). TLS can happen to any age group, however older adults
may be at a greater risk if they have poor renal function to begin with, setting them up for
a decreased ability to get rid of the byproducts from tumor lysis. Of all types of
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lymphomas, especially non-Hodgkin’s types are the highest risk for developing TLS. “In
studies of frequency in patients with intermediate-grade or high-grade non-Hodgkin
lymphomas, laboratory evidence of tumor lysis syndrome (42%) occurred much more
frequently than the symptomatic clinical syndrome (6%)” (Ikeda, 2012). Unfortunately,
mortality rate of spontaneous tumor lysis syndrome is up 70% (Choi, 2009).
A lot of H.J’s labs are not within normal limits, but there are certain labs confirm
his diagnosis of TLS. These labs include high uric acid, high phosphate, potassium at the
higher end of normal, high creatinine and low calcium. If a nurse were to assess H.J. or a
patient with TLS common findings would include nausea, diarrhea, anorexia, lethargy,
hematuria, heart failure, cardiac dysrhythmias, seizures, muscle cramps, tetany, syncope,
flank pain, edema, hypocalemia, hypophosphatemia, and hyperkalemia (Larson, 2013).
However, TLS is asymptomatic at the beginning, and clinical manifestations do not
typically present until 12-72 hours after initiation of chemotherapy (Rajendran, 2012).
This is why it is crucial to identify those who are at risk for TLS, including those with
non-Hodgkin’s lymphomas, especially Burkitts.
Tumor lysis syndrome is a medical emergency and certain medications need to be
administered quickly. His medications will include IV 0.9% saline at 150ml/hr, 100 mEg
sodium bicarbonate added to the first liter of IV fluid, Allopurinol (aloprim) 500 mg
orally twice daily, Furosemide (Lasix) 40 mg IV now then every 6 hours, Sodium
polystyrene (kayexalate) 15 mg orally every 6 hours, and Aluminum hydroxide
(amphojel) two caps orally with meals. The IV saline is for hydration, as well as keeping
urine output up which increases renal flow and dilutes some of the harmful levels of
electrolytes. The sodium bicarbonate is for treatment of metabolic acidosis to alkalize the
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urine, protecting kidneys and the urinary tract. Alkalization is controversial, because for
as many pros there is also cons, including, the possibility of aggravating hypocalcaemia,
obstruction of the urinary tract from possible intratubular precipitation of calcium and
phosphate, and crystallization of uric acid precursors. You will often see alkalization used
when Rasburicase is no within financial constraints (Rajendran, 2012). The allopurinol is
a hypoxanthine, which competitively inhibits xanthine oxidase, blocking metabolism of
hypoxanthine and xanthine to uric acid, in turn decreasing uric acid. The furosemide is
used to maintain urinary output and increase renal blood flow. Kayexalate is for treatment
of hyperkalemia, it is considered the antidote to hyperkalemia. It is a cation exchange
resin that has sodium ions partially release and replaced by potassium, to lower potassium
in the blood stream. Lastly, amphojel is for treatment of the hypophosphatemia, it binds
with phosphate in gastrointestinal tract to form insoluble complexes and decrease
phosphate absorption. Another drug commonly used is Rasburicase. Although H.J. did
not receive it, the drug is an oncologic enzyme used to treat hyperuricemia caused by
TLS. It starts the oxidation of uric acid into a soluble metabolite of uric acid called
allantoin. Patients may not receive this medication due to its high cost (Chubb, 2010). A
recent studied found that “chemotherapy combined with continuous venovenous
hemofiltration (CVVH) might be effective and safe in patients with advanced Burkitt
lymphoma and leukemia at a high risk of developing TLS” (Choi, 2009).
Having tumor lysis syndrome puts patients at risk for other complications or
emergencies. They may be at risk for seizures or cardiac dysrhythmias due to electrolyte
imbalance. They may also be at risk for acute renal failure, since the kidneys clear the
body of potassium, phosphate and uric acid, and patients with TLS all have elevated
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levels, aggravating the kidneys. Problems with the kidneys also increase the patient’s risk
of metabolic acidosis as well as uremia. These complications and risks are reasons that
medical treatment must be initiated immediately and TLS is treated as an emergency
(Larson, 2014). Other things a nurse could do for patients with TLS is restrict food with
high levels of potassium like dark leafy green, potatoes, dried apricots, avocadoes and
bananas, restrict foods high in phosphorus like certain cheeses, nuts, beans, seeds, salmon
and pork and restrict foods high in uric acid like many kinds of meat and seafood, as well
as spinach, cauliflower, beans and alcohol. A nurse should also encourage hydration,
monitor heart sounds, manage pain, recheck labs frequently, and teach patient signs and
symptoms to be aware of and report to their doctor, including nausea, vomiting, diarrhea,
lethargy and muscle weakness. Hyperkalemia (>7 mEq/L) can cause electrocardiogram
changes, “including peaked T waves and QRS complex widening, which, when
untreated, may result in ventricular dysrhythmia and death” (Rajendran, 2012). So getting
orders for and electrocardiogram is a good idea as well.
Once a patient like H.J. stabilizes, chemotherapy is usually initiated again to focus
on getting rid of the lymphoma. Patients who are at risk for TLS may often be put on
chemotherapeutic drugs in a phased manner to prevent rapid tumor lysis (Rajendran,
2012). Because of the risk of a possible repeat episode of TLS nurses should be cautious
and use continuous cardiac monitoring, closely monitor the patients intake and output,
and frequently measure their labs and electrolytes, especially creatinine, BUN, uric acid,
potassium, and phosphorus at least every 6 hour. When preparing and administering the
patients new round of chemotherapy, there are also certain precautions the nurse needs to
take to keep herself safe. Usually the chemotherapy medications are prepared in a
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properly ventilated room to avoid splatter and breathing in of droplets. The pharmacist
usually prepares the chemotherapy drug. The nurse should always wear surgical gloves
and a disposable long sleeve gown to protect her skin incase of a spill. The nurse should
place an absorbent plastic-backed pad on work area, wear goggles when preparing an
intravenous infusion to protect eyes, and dispose of all waste in special biohazard
containers to protect herself and others. If other health workers are unfamiliar caring for
patients who are being treated with chemotherapy, certain instructions should be provided
to lesson their chances of injuring themselves. Some suggestions include being careful
handling body fluids like urine, stools, saliva, and emesis. Wear proper personnel
protective equipment when handling body fluids, and have patients flush the toilet twice.
They should also wash the patients sheets separately and avoid prolonged close contact
with the patient. All of these safety precautions are put into place because chemotherapy
can be harmful to healthy people. “Chemotherapy can cause abnormal changes in DNA.
They may be able to alter development of a fetus or embryo, leading to birth defects
(teratogenic). They may be able to cause another type of cancer. Some may cause skin
irritation or damage” (Safety precautions, 2013). So it is important for loved ones and
health care professionals to be aware of the dangers and take proper precautions.
After the round of chemotherapy, it is important to check labs again to see if TLS
is starting again and how the patient is responding to treatment. Once labs are back for
H.J. there is good news for him. His uric acid is now low, his potassium is lowered, and
his phosphorus is within normal limits. His glucose is now high, calcium is still low, and
white blood cells are reduced but still high. These results show that his TLS has subsided
and does not seem to be returning.
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H.J.’s labs also show he has low platelets, hemoglobin and hematocrit. Red blood
cells and platelets are produced from bone marrow; bone marrow cells are constantly
dividing and producing. Chemotherapy drugs work to target and get rid of fast diving
cells like tumor cells. This unfortunately means that RBCs and platelets will be targeted
as well. It is common for patients on chemotherapy to require transfusions. H.J,’s low lab
results require that he gets blood product support including leukocyte-poor pheresed
platelets and leukocyte-reduced packed red blood cells. He will also be given Tylenol and
Benadryl for premedication. Nurses need to be aware of different types of transfusion
reactions and what the general treatment should be. There are many different types of
transfusions reactions. Febrile reactions are usually cause by the recipients antibodies
reacting with antigens from the donors white blood cells. Allergic reactions happen when
allergens in the plasma activate the recipients IgE antibodies, then histamine is released
by mast cells and basophils, the reaction my be mild or as severe as anaphylactic.
Intravascular hemolytic reactions occur due to ABO blood incompatibility, like A blood
being given to type O by accident. Extravascular hemolytic reactions occur in patients
who have developed antibodies from previous transfusion or pregnancy but are not
considered a major problem, some RBC are lost and may be replaced with another
transfusion. Too much fluid being pumped into a patient over too short a period of time
causes hypervolemia. Acute lung injury reactions are associated with the presence of
antibodies in the donor plasma reactive to recipient leukocyte antigens. Lastly, bacterial
sepsis is usually caused by error in hygiene; some pathogen was transmitted while taking
the blood, delivering the blood, or during storage of the blood. All types of reactions
require different interventions, but in general, a nurse should stop the transfusion
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immediately, and usually start a line of normal saline. If a hypervolemic reaction a
diuretic may be ordered instead. If the patient is having an anaphylactic reaction
epinephrine is often given. With bacterial sepsis antibiotics will be given (7 Adverse
reactions to transfusion, 2009).
Overall, the take home message is to be aware of clients who are at risk for TLS.
If you know those at risk you can prepare ahead of time and carry out certain precautions
to prevent it, like used phased chemotherapy treatment, hyper-hydration, and managing
specific electrolyte imbalances. If TLS occurs it is important to recognize it through labs,
as symptoms may take days to arise. As for H.J, his chemotherapy should be continued
but he should be recognized as a patient in a high-risk category for developing TLS.
Using prophylactic measures, hopefully a repeat of TLS can be avoided.
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References
Choi, K., Lee, J., Kim, Y., Kim, D., Kim, K., Ko, Y., Oh, H., Kim, W., Huh, W. (2009).
Efficacy of continuous venovenous hemofiltration with chemotherapy in patients
with Burkitt lymphoma and leukemia at high risk of tumor lysis syndrome.
Springer. 88:639-645. Doi: 10.1007/s00277-008-0642-1
Chubb, E. A., Maloney, D., Farley-Hills, E. (2010). Tumor lysis syndrome: an unusual
presentation. Anesthesia, Journal of the Association of Anesthsia of Great Britain
and Ireland. 65, pages 1031–1033.doi: 10/1111/j.1365-2044.2010.06414.x
Ikeda, A., Harris, J. Jaishankar, D., Krishnan, K. (2012). Tumor lysis syndrome.
Medscape.
Larson, R., Pui, C., Drews, R., Freedman, A., Poplack, D., Savarese, D. (2013). Tumor
lysis syndrome: prevention and treatment. Uptodate.
Rajendran, A., Bansal, D., Marwaha, R., Singh, S. (2012). Tumor lysis syndrome.
Symposium on Pigmer Management Protocols on Oncological Emergencies.
80(1):50-54. DOI: 10.1007/s12098-012-0824-7
Safety precautions. (2013). American Cancer Society.
7 Adverse reactions to transfusion. (2009).
http://www.pathology.med.umich.edu/bloodbank/manual/bbch_7/