1. Tumor Lysis Syndrome Carol S. Viele RN, MS Clinical Nurse Specialist
Hematology-Oncology-Bone Marrow Transplant

2. Definition
Potentially fatal metabolic complication that occurs in some patients with cancer
Can result in potentially life threatening metabolic and electrolyte abnormalities

3. Pathophysiology
Involves a complex series of events related to the liberation of intracellular contents from tumor cells and inability of the kidneys to excrete and maintain normal serum composition

4. Manifestations
Usually occurs within hours after initiation of chemotherapy and may persist for 5-7 days post therapy
May occur as early as 6 hours post chemotherapy administration

6. Tumor Types Non-Hodgkins lymphoma Acute Leukemia’s
Burkitt’s
High grade T-cell
Acute Leukemia’s
Acute Promyelocytic leukemia
Acute lymphoblastic leukemia
Chronic Lymphoblastic leukemia
Solid tumors
Small cell lung cancer
Breast cancer

8. Symptoms Cardiac: Presence of S3 Bradycardia Heart Block
Cardiac Arrest

9. Symptoms Neuromuscular: Weakness Lethargy Cramping Tetany
Chvostek’s sign
Trousseau’s sign
Convulsions

10. Symptoms Renal: Oliguria Renal Insufficiency Flank pain Weight gain
Edema
Renal failure

11. Symptoms
Gastrointestinal:
Nausea
Vomiting
Diarrhea
Constipation

12. Hyperuricemia Results from tumor cell destruction
Most common signs and symptoms:
Nausea and vomiting
Azotemia
Oliguria
Anuria
Decreased urine pH
Uric acid crystals found in urinalysis

13. Hyperkalemia Results from rapid destruction of cells
Most common signs and symptoms
EKG changes
Peaked t waves
Flat p waves
Wide QRS complexes
Bradycardia
Ventricular tachycardia
Ventricular fibrillation
Asystole
Pulseless electrical activity

14. Hyperkalemia Results from rapid destruction of cells
Most common signs and symptoms
Weakness
Twitching
Increased bowel sounds
Nausea
Diarrhea

15. Hyperphosphatemia Most common signs and symptoms Hypocalcemia
Renal failure
Azotemia
Ologuria
Anuria
Hypertension
Edema

16. Hypocalcemia
Results from hyperphosphatemia and the inverse relationship between calcium and phosphorous
Most common signs and symptoms
EKG changes
Prolonged QT
Inverted T waves
Ventricular dysrhythmias
Heart block
Cardiac arrest

17. Hypocalcemia Neuromuscular signs and symptoms GI Symptoms Tetany
Twitching
Paresthesias
Seizures
GI Symptoms
Diarrhea

18. Diagnostic Tests Chvostek
Tapping the cheek below the temple where the facial nerve emerges

19. Diagnostic Tests Trousseau Sign
Occluding the arterial blood flow in the arm with the blood pressure cuff for one to five minutes, if the thumb adducts and the phalangeal joints extend the test is positive

20. Prevention Identify patients at risk
Monitor for all electrolyte abnormalities
Administer allopurinol,
Decrease uric acid levels by interfering with purine metabolism through the inhibition of the enzyme xanthine oxidase that is essential for the conversion of nucleic acids to uric acid
Alkalinization of the urine
Prevent as much as possible renal damage
Sodium bicarbonate solution
Decreases the risk of renal obstruction, however urinary alkalinization should be used cautiously because of risk of precipitation in the kidneys of calcium-phosphorous binding and the risk of hypocalcemic induced neuromuscular irritability

21. Prevention Rasburicase- recombinant urate oxidase-
Reduces the uric acid pool
Reduces existing uric acid
Prevents the accumulation of xanthines and hypoxanthine
Does not require alkalinization
Facilitates phosphorous excretion
Dosing:
IV over 30 minutes
0.2 mg/kg IV QD or BID

22. Management Hydration 3 Liters daily
Aggressive hydration starting 1-2 days prior to chemotherapy and continuing for a few days post chemotherapy

23. Management Diuretics: Renal dose Dopamine- 2-4 mcg/kg Prevents:
Furosemide
Renal dose Dopamine- 2-4 mcg/kg
Prevents:
Fluid overload
Electrolyte imbalance
Complications of uric acid buildup

24. Management Hyperkalemia Kayexalate with sorbitol Calcium GluconatePO
Rectal
Calcium Gluconate
Sodium bicarbonate
Hypertonic dextrose and regular insulin
Albuterol (Ventolin) or another beta stimulant

25. Management Dialysis: Hemodialysis/CVVH/CRRT( Requires ICU Care)
Used for patients unresponsive to preventive measures and electrolyte corrections
Used to remove uric acid
Used in patients with:
Serum potassium >6 mEq/L
Uric acid >10 mg/dl
Phosphorous > 10 mg/dl
Symptomatic hypocalcemia
Presence of volume overload

26. Medication Management
Avoid nephrotoxic medications
Avoid agents which block tubular reabsorption of uric acid
Aspirin
Probencid
Thiazide diuretics
Radiographic contrast containing iodine

27. Nursing Interventions
Symptom management
Maintenance of fluid status
Review of systems
Cardiac via EKG
Neurologic
Neuromuscular
Gastrointestinal
Renal

28. Nursing Interventions
Monitor weights at least daily
Daily EKG’s
Monitor for altered level of consciousness
Strict I&O
Check pH of urine with each void, goal is to keep pH >7.0
Monitor for signs and symptoms of nausea and vomiting, administer antiemetics as ordered

29. References
Jeha,S., Pui, C. ‘Recombinant Urate Oxidase (Rasburicase) in the Prophylaxis and Treatment of Tumor Lysis Syndrome, Ronco,R. Rodeghiero, F. (eds) Hyperuricemic Syndrome: Pathophysiology and Therapy, Contrib Nephrol, Basel,Karger,2005,Vol 147,pp69-79

30. References
Reid-Finlay,M. Kaplow, R. ‘Leukemia and Bone Marrow Transplantation’, Schell,H., Puntillo, K., Critical Care Nursing Secrets, Hanley and Belfus, Inc, Philadelphia 2001,p
Zobec,A., ‘Tumor Lysis Syndrome’, Oncology Nursing Secrets, Hanley and Belfus, 2008, p