Tumour lysis syndrome developing during an operation

Spontaneous tumor lysis syndrome (STLS) during biopsy for burkitt lymphoma: a case report

BACKGROUND

Tumor lysis syndrome (TLS) is a hematologic oncological emergency characterized by metabolic and electrolyte imbalances. On breakdown of tumor cells, enormous amounts of potassium, phosphate, and nucleic acids are released into systemic circulation. TLS mainly occurs during chemotherapy. However, there are rare incidences of spontaneous tumor lysis syndrome (STLS) prior to commencement of therapy.

CASE PRESENTATION

In the case being reported, the child had just undergone a biopsy. As the incision was being closed, there was a sudden onset of high fever, arrhythmia, severe hyperkalemia, hypocalcemia, and acidosis. Following timely symptomatic treatment and continuous renal replacement therapy(CRRT), the child's laboratory results improved, and organ function was restored to normal. The final pathological diagnosis confirmed Burkitt lymphoma. The boy is currently on maintenance chemotherapy.

CONCLUSIONS

TLS is a potentially life-threatening complication in hematologic oncology. Several important conclusions can be drawn from this case, reminding clinicians to: (1) be fully aware of the risk factors of TLS and evaluate the level of risk; (2) pay attention to the possibility of STLS during operation, if surgical procedures are necessary and operate with minimal trauma and in the shortest time possibly; (3) take preoperative prophylaxis actively for high-risk TLS patients, including aggressive fluid management and rational use of diuretics and uric-acid-lowering drugs. In addition, this case confirms the effectiveness of CRRT for severe STLS.

Retrospective evaluation of acute hyperkalemia of unknown origin during general anesthesia in dogs

OBJECTIVE

To report and characterize cases of acute hyperkalemia of unknown origin in dogs under anesthesia.

STUDY DESIGN

Multicentric retrospective clinical study.

ANIMALS

Medical records of 19 client-owned dogs that developed acute hyperkalemia during anesthesia.

METHODS

Anesthetic records of dogs developing acute hyperkalemia from January 2015 to December 2022 were evaluated. Data collected included demographics, duration of anesthesia until the episode, electrolytes and blood gas measurements, electrocardiogram (ECG) abnormalities, drugs used as part of the anesthetic protocol, hyperkalemia treatment and outcome.

RESULTS

A total of 13 cases met the inclusion criteria with documented acute hyperkalemia with no apparent underlying cause during anesthesia. Dogs were [mean ± standard deviation (range)] 6.5 ± 5.0 (3-10) years old and weighed 18.0 ± 14.3 (5.1-40.0) kg. All dogs were administered dexmedetomidine and an opioid as part of the premedication. All dogs had inhalation anesthesia of >60 minutes' duration. The first clinical sign was bradycardia that was minimally responsive to anticholinergic administration and was often accompanied by moderate/severe hypotension. These signs were rapidly followed by ECG changes compatible with hyperkalemia and/or cardiac arrest. Rapid identification and treatment for hyperkalemia, with or without dexmedetomidine reversal, resulted in survival of 12 dogs and one fatality.

CONCLUSIONS AND CLINICAL RELEVANCE

Unknown origin hyperkalemia is a life-threatening complication that can occur during general anesthesia. In healthy dogs, preanesthetic administration of dexmedetomidine in association with an opioid and followed by inhalation anesthesia of more than 1 hour duration may predispose to this complication. A sudden decrease in heart rate >90 minutes after dexmedetomidine administration, or ECG changes, may warrant measurement of blood potassium concentrations.

A Case of Spontaneous Tumor Lysis After Pathologic Femur Fracture in Squamous Cell Lung Cancer

Tumor lysis syndrome (TLS) occurs when large numbers of tumor cells lyse and release their contents, causing electrolyte derangements and renal injury. It is an uncommon complication of solid tumors and occurs most commonly after cytotoxic therapy rather than spontaneously. In this article, we describe a case of spontaneous TLS in a patient with squamous cell carcinoma of the lung. We also present a literature review of spontaneous TLS occurrence in solid tumors.

Guideline for Children With Cancer Receiving General Anesthesia for Procedures and Imaging

Children with cancer and those undergoing hematopoietic stem cell transplantation frequently require anesthesia for imaging as well as diagnostic and therapeutic procedures from diagnosis through follow-up. Due to their underlying disease and side effects of chemotherapy and radiation, they are at risk for complications during this time, yet no published guideline exists for preanesthesia preparation. A comprehensive literature review served as the basis for discussions among our multidisciplinary panel of oncologists, anesthesiologists, nurse practitioners, clinical pharmacists, pediatric psychologists, surgeons and child life specialists at the Children's Hospital of Philadelphia. Due to limited literature available, this panel created an expert consensus guideline addressing anesthesia preparation for this population.

Anesthesia for children with anterior mediastinal masses

Children with an anterior mediastinal mass may have cardiopulmonary compromise that can be exacerbated under general anesthesia. Signs and symptoms such as cough, shortness of breath, stridor, orthopnea, accessory muscle use, a history of respiratory arrest, and the presence of a pleural effusion and upper body edema are predictive of perioperative complications. A larger mediastinal mass on imaging is predictive of perioperative complications. Risk stratification of patients, together with an individualized plan, will best guide operative management for patients with an anterior mediastinal mass. General anesthesia (GA) should be avoided if possible, but a spontaneous breathing technique is recommended if GA is required.

Pediatric abdominal non-Hodgkin's lymphoma: diagnosis through surgical and non-surgical procedures

OBJECTIVE

To describe the success rate and the complications after procedures to diagnose abdominal non-Hodgkin's lymphoma in children and adolescents.

METHODS

A retrospective cross-sectional study was conducted with a population consisting of children and adolescents with abdominal non-Hodgkin's lymphoma diagnosed between September 1994 and December 2012. The sample comprised of 100 patients who underwent 113 diagnostic procedures, including urgent surgery (n=21), elective surgery (n=36), and non-surgical diagnosis (n=56).

RESULTS

The most frequent procedures were laparotomy (46.9%) and ultrasound-guided core biopsy (25.6%). The rate of diagnostic success was 95.2% for urgent surgeries; 100% for elective surgeries and 82.1% for non-surgical procedures (p<0.05). The rates of complication during the three diagnosis procedures considered were significant (p<0.001; 95.2% of the urgent surgeries, 83.8% of the elective surgeries, and 10.7% of the non-surgical procedures). The length of time before resuming a full diet and starting chemotherapy was significantly reduced for patients who underwent non-surgical procedures when compared with the other procedures (p<0.001).

CONCLUSION

Non-surgical procedures for the diagnosis of pediatric abdominal non-Hodgkin's lymphoma are an effective option with low morbidity rate, allowing an earlier resumption of a full diet and chemotherapy initiation. Furthermore, non-surgical procedures should also be considered for obtaining tumor samples from patients with extensive disease.

Tumor Lysis Syndrome: A Unique Solute Disturbance

Tumor lysis syndrome (TLS) is a life-threatening disorder that is an oncologic emergency. Risk factors for TLS are well-known, but the current literature shows case descriptions of unexpected acute TLS. Solid tumors and untreated hematologic tumors can lyse under various circumstances in children and adults. International guidelines and recommendations, including the early involvement of the critical care team, have been put forward to help clinicians properly manage the syndrome. Advanced practice nurses may be in the position of triaging and initiating treatment of patients with TLS, and need a thorough understanding of the syndrome and its treatment.

Tumor lysis syndrome: a systematic review of case series and case reports

Tumor lysis syndrome (TLS) is a clinical condition that is caused by a massive lysis of tumor cells that accumulate very rapidly and disturb hemodynamics. This oncologic emergency requires immediate intervention. Tumor lysis syndrome was first described in the 19th century. Since then, it has become a well-known disease with improved management measures. Tumor lysis syndrome can occur after any type of neoplasm. It is highly associated with rapidly proliferating tumors compared with those that are well demarcated, such as acute lymphoblastic leukemia and high-grade non-Hodgkin lymphoma. Initiation of chemotherapy, radiotherapy, or steroid treatment may trigger TLS, or it may develop spontaneously. The release of massive quantities of intracellular contents may produce hyperkalemia, hyperphosphatemia, secondary hypocalcemia, hyperuricemia, and acute renal failure. Prevention and treatment measures include intravenous hydration, use of allopurinol and rasburicase, management of TLS-associated electrolyte abnormalities, and renal replacement therapy; the use of urine alkalinization remains controversial. In this article, we summarize the findings of case series and case reports published over the past 6 years in an effort to help familiarize clinicians better recognize and manage TLS.

Tumor lysis syndrome developing intraoperatively

Tumor lysis syndrome is a potentially life threatening condition which is most commonly encountered in patients being treated with chemotherapy. We report a case of spontaneous tumor lysis syndrome that developed intraoperatively in a patient with undiagnosed Burkitt's lymphoma. Characteristic electrolyte disturbances and white emulsion like urine following laparotomy and tumor handling intraoperatively suggested the diagnosis. This is a rare perioperative complication and the report emphasizes the importance of being vigilant in recognizing the same.

Diagnosis in childhood abdominal Burkitt's lymphoma

BACKGROUND

The role of surgery has changed substantially over the years in abdominal Burkitt's lymphoma. Laparotomy without total excision of the tumor does not have a positive effect on survival, might cause complications, and delays initiation of chemotherapy. Here we present our diagnostic management of patients with abdominal Burkitt's lymphoma.

MATERIALS AND METHODS

The diagnostic methods of abdominal Burkitt's lymphoma cases treated between January 1999 and December 2009 were evaluated retrospectively.

RESULTS

Of the 48 abdominal Burkitt's lymphoma patients, 13 also had extra-abdominal site involvement. Diagnosis was made with ultrasound-guided tru-cut needle biopsy of the abdominal mass (n = 11), fluid cytology (n = 7), extra-abdominal site biopsy (n = 4), bone marrow aspiration (n = 2), gastroscopy (n = 1), and laparotomy (n = 23). In patients diagnosed with laparotomy, chemotherapy was started in 4-22 days (median 7) compared with patients diagnosed with other diagnostic interventions in 2-4 days (median 2) (P < .001).

CONCLUSION

Although the most frequently used technique is laparotomy and open biopsy in our series, other methods provided quicker initiation of chemotherapy and less surgical morbidity. Especially in patients with high stages, cytological evaluation and tru-cut needle biopsy with radiological guidance is a better alternative of laparotomy.

Anesthetic considerations for the pediatric oncology patient--part 2: systems-based approach to anesthesia

One of the prices paid for chemo- and radiotherapy of cancer in children is damage to the vulnerable and developing healthy tissues of the body. Such damage can exist clinically or subclinically and can become apparent during active antineoplastic treatment or during remission decades later. Furthermore, effects of the tumor itself can significantly impact the physiologic state of the child. The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should understand what effects cancer and its therapy can have on various organ systems. In part two of this three-part review, we review the anesthetic issues associated with childhood cancer. Specifically, this review presents a systems-based approach to the impact from both tumor and its treatment in children, followed by a discussion of the relevant anesthetic considerations.

Anesthesia for children with hyperleukocytosis a retrospective review

BACKGROUND

Hyperleukocytosis (a white cell count in peripheral blood >100 x 10(9) l(-1)) is a well-recognized medical emergency. Rates of morbidity associated with anesthesia in hyperleukocytotic patients have not been previously described. This retrospective study describes the perioperative morbidity and mortality of children who present acutely with hyperleukocytosis.

METHODS

All patients under 17 years of age with leukemia complicated by hyperleukocytosis and who received general anesthesia as part of their acute care at the Children's Hospital in Westmead from July 1999 to June 2008 were included. Data describing perioperative adverse events within 48 h of anesthesia were collected using a systematic chart review.

RESULTS

Over the 8- year period, 60 children were admitted with hyperleukocytosis related to a new diagnosis of leukemia. Fifty-two children had general anesthesia within 48 h of their admission. Eleven children required two separate general anesthetics within this same time frame. Two deaths were recorded within 48 h of anesthesia; one child died from neurological complications of her disease, and the second died from multi-organ failure. Three children had serious respiratory adverse events requiring postanesthesia intensive care. Thirteen children had notable but less serious adverse events. These were typically respiratory in nature and required supplemental oxygen for more than 2 h after anesthesia.

CONCLUSION

Children with leukemia-related hyperleukocytosis often require general anesthesia at the time of presentation and are at significant perioperative risk. Respiratory adverse events are very common and mandate close postanesthesia care.

Management of pediatric tumor lysis syndrome in the emergency department

Tumor lysis syndrome is most often seen after the treatment of blood and solid malignancies. The resultant hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia can lead to life threatening complications. Expeditious evaluation and therapy are paramount in preventing the most serious sequelae of acute renal failure and fatal dysrhythmias.

Tumor lysis under anesthesia in a child

Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency characterized by metabolic derangements caused by massive lysis and release of cellular components. TLS has been reported to occur under various circumstances. There have however, been only two reports of precipitation of TLS by anesthesia in the current medical literature. We report on the development of TLS in a 7-year-old child with a pelvic neuroectodermal tumor following induction of anesthesia and discuss the peri-operative concerns while dealing with patients with high tumor burdens.

Tumor lysis associated with dexamethasone use in a child with leukemia

Postoperative nausea and vomiting (PONV) occurs in every third patient undergoing general anesthesia without PONV prophylaxis. Antiemetic prophylaxis with dexamethasone is commonly used in patients at moderate risk. We present a case in which PONV prophylaxis with a single dose of dexamethasone led to tumor lysis in a patient with acute leukemia. In case of a cancer patient at moderate risk for PONV, the anesthesiologist should contact the oncologist first, or use other antiemetic drugs such as antiserotoninergic agents for PONV prophylaxis.