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AnaLYSIS of the Nurse’s Role in Assessment and Treatment of Tumour Lysis Syndrome (TLS) Presented by: Adrianna DeCastro BScN, RN - Stronach Regional Health Centre
AnaLYSIS of the Nurse’s Role in Assessment and Treatment of Tumour Lysis Syndrome (TLS)
Presented by:Adrianna DeCastro BScN, RN - Stronach Regional Health Centre
Disclosures
• I have received an honorarium for this presentation• Medical Oncology Outpatient Clinic• Some slide credits to clinicaloptions.com
Objectives
• Define Tumour Lysis Syndrome (TLS)• Who is at Risk?• Signs and Symptoms of TLS• Nursing Management
What is TLS?
• Oncologic emergency• Rapid breakdown of cancer cells results in intracellular release
Ø Uric Acid Ø Phosphorus Ø Potassium
What is TLS?
• Rapid breakdown = buildup in the blood stream• Causes metabolic abnormalities • TLS has two phases • The oncology RN plays a pivotal role in recognizing TLS and promptly
intervenes • Early intervention = better patient outcomes!
Categories of TLS
Laboratory TLS
Clinical TLS
Lysis of tumour cells
clinicaloptions.com
Risk Factors for TLSBulky Tumours• Large tumour mass• Organ infiltration• Bone marrow involvement
(leukemia's are bulky)
Highly Proliferative Tumours• LDH is a marker• Chemosensitive tumours• Burkitt lymphoma• Lymphoblastic lymphoma• Acute leukemia
Howard S, et al. Leuk Lymph. 2006;47:782-785.
https://www.cancernetwork.com/sites/default/files/cn_import/1837774.png
Cardiac Symptoms
• Hypertension• Dysrhythmias• Cardiac arrest
de Souza Institute
Neurological Symptoms
• Fatigue/lethargy• Weakness• Memory loss• Altered mental status• Muscle cramps• Tetany• Seizures• Paresthesias (numbness and tingling)
de Souza Institute
GI Symptoms
• Anorexia• Nausea & vomiting• Abdominal cramps• Diarrhea
de Souza Institute
GU Symptoms
• Flank pain• Oliguria• Anuria• Renal failure• Acidic urine
de Souza Institute
Signs & Symptoms of TLS
PUCK
Signs & Symptoms of TLS
PUCKHyperPhosphatemia
Signs & Symptoms of TLS
Held-warmkessel, J. (2012, August 27). A Patient With Tumor Lysis Syndrome. Retrieved January 29, 2020, from https://www.cancernetwork.com/oncology-nursing/patient-tumor-lysis-syndrome
Signs & Symptoms of TLS
PUCK
HyperUricemia
Signs & Symptoms of TLS
Held-warmkessel, J. (2012, August 27). A Patient With Tumor Lysis Syndrome. Retrieved January 29, 2020, from https://www.cancernetwork.com/oncology-nursing/patient-tumor-lysis-syndrome
Signs & Symptoms of TLS
PUCK
HypoCalcemia
Signs & Symptoms of TLS
Held-warmkessel, J. (2012, August 27). A Patient With Tumor Lysis Syndrome. Retrieved January 29, 2020, from https://www.cancernetwork.com/oncology-nursing/patient-tumor-lysis-syndrome
Signs & Symptoms of TLS
PUCKHyperKalemia
Signs & Symptoms of TLS
Held-warmkessel, J. (2012, August 27). A Patient With Tumor Lysis Syndrome. Retrieved January 29, 2020, from https://www.cancernetwork.com/oncology-nursing/patient-tumor-lysis-syndrome
Signs & Symptoms of TLS
PUCKHyperPhosphatemia
HyperUricemia HypoCalcemia
HyperKalemia
Hyperkalemia:release of intracellular
potassium
Hyperphosphatemia:release of intracellular
phosphates
Cardiac arrhythmia
PO3-
Ca2+
4
PO3-
Ca2+Uric acid crystals
Acute renal failure
Release of DNA(nucleic acids)
Hypoxanthine
Xanthine
Xanthine oxidase
Calcium phosphateprecipitates
4
2. Cammalleri L, Malaguarnera M. Rasburicase represents a new tool for hyperuricemia in tumor lysis syndrome and in gout. Int J Med Sci. 2007;4:83-93.
Management of TLS
• Allopurinol • One to two days prior to starting therapy and up to seven days post-
chemo • Hydrate, Hydrate, Hydrate!• Two to three litres of water per day• Cardiac monitoring and dialysis for patients severe clinical TLS
TLS ManagementMinimal Risk Low Risk Intermediate Risk High Risk Clinical TLS
No prophylaxis indicated
Prophylaxis:hydration ±allopurinol
Daily lab tests
Prophylaxis:hydration + allopurinol; consider rasburicase
Lab tests every 8-12 hrs
Prophylaxis:hydration +rasburicase
Lab tests every 6-8 hrs
Cardiac monitoring
Prophylaxis:hydration +rasburicase
Lab tests every 4-6 hrs
Cardiac monitoring in ICU
Howard SC, et al. N Engl J Med. 2011;364:1844-1854. clinicaloptions.com
Case Study• Mr. R is to be treated with Venetoclax 20mg OD x 7 DAYS• Starting labs WBC=44.9Cr=116Lymph=30.9• Returned 6 hours later for repeat labs• Allopurinol 300mg OD started 5 days prior
Case Study Cont’d• Labs @ 16:00 WBC=36.3 (4.0-11.0)Uric Acid= 279 (170-460)Phos=1.27 (0.83-1.48)Cr=112 (46-92)K+=4.9 (3.5-4.2)Calcium=2.28• Mr. R was hydrating orally 1.5-2 litres daily
Case Study Cont’d24 hours later• Cr= 117 (46-92)• Uric Acid= 320 (170-460)• WBC= 34 (4.0-11.0)• K+=4.9 (3.5-4.2)• Phos=1.17 (0.83-1.48)• Calcium=2.28• Returned 48 hours later with stable labs
Ramp-Up Dosing Schedule: Venetoclax
Cancer Care Ontario Requires TLS Prophylaxis based on Tumour Burden
Cancer Care Ontario Requires TLS Prophylaxis based on Tumour Burden
Cancer Care Ontario Requires TLS Prophylaxis based on Tumour Burden
Summary
• Define tumour lysis • Detecting signs and symptoms• Management • Venetoclax case study
