Oncological Emergencies: Recognize and Respond
- In this course we will learn about oncological emergencies, and why it is important for nurses to be informed on the signs, symptoms, and available treatment options.
- You’ll also learn the basics of tumor lysis syndrome, malignant pericardial effusion, and many more common oncological emergencies.
- You’ll leave this course with a broader understanding of the Oncology Nursing Society resources and how they can assist you in oncological emergencies!
Contact Hours Awarded: 2
RN, BSN, CEn, CDE
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The following course content
Oncology patients can present significant challenges for both healthcare providers and caregivers. Modern-day chemotherapies may cause potentially life-threatening oncological emergencies. Nurses working with oncology patients must recognize signs and symptoms of these oncological emergencies and be knowledgeable in treatment therapies aimed at reducing these risks (1).
Overview of Oncological Emergencies
The lifespan of cancer survivors has increased over the years in direct response to advancements in both cancer diagnosis and treatment options. The risk for associated oncologic complications has also increased, demanding that oncologic healthcare providers develop a strong knowledge base for identifying potential complications and oncological emergencies and take actions to minimize such issues.
Nurses working with oncology patients are in a unique position to educate patients and their caregivers about the risk factors of oncological emergencies. Oncology nurses are not only delivering patient care but also participating in clinical trials and advancing cancer research. They are able to educate on preventive strategies, early symptom recognition, and available treatment options, all pivotal areas in enhancing both quantity (of life years) and quality of life. It is vital that the oncology nurse be aware of the various oncological emergencies that can arise.
Tumor Lysis Syndrome
Tumor Lysis Syndrome (TLS) is one of the most common oncological emergencies and is a condition that occurs when massive tumor cell lysis (or breakdown) releases large amounts of potassium, phosphate, and nuclide cells into the patient’s systemic circulation (2,3). A large number of cancer cells are dying within a very short period of time and releasing their content into the bloodstream, resulting in the sudden onset of hyperkalemia, hyperphosphatemia, secondary hypocalcemia, and acute kidney injury.
Patients with a large “tumor burden” (number of cancer cells, the size of a tumor, or the amount of cancer in the body) of cancer cells and/or tumors that typically have rapidly dividing cells, such as acute leukemia or high-grade lymphoma, as well as tumors that are highly responsive to therapy, are at greatest risk of developing TLS. The condition can also occur in patients receiving steroids, hormonal therapy, targeted therapy, or radiation therapy. Patients who are dehydrated and those with existing kidney dysfunction are at higher risk of developing TLS; kidney failure can occur if left untreated (4).
In TLS, clinical signs and symptoms may develop prior to the initiation of chemotherapy or, more commonly, within 72 hours after administration of cytotoxic therapy. These symptoms often appear very vague initially; some symptoms are initially thought to be related to the chemotherapy agents rather than as a possible complication.
Symptoms may include the following (4):
- Nausea with or without vomiting
- Lack of appetite and fatigue
- Dark urine reduced urine output, or flank pain
- Numbness, seizures, or hallucinations
- Muscle cramps and spasms
- Heart palpitations
Treatment for TLS consists of serial blood testing to monitor electrolyte imbalances. Additionally, intravenous fluids and ICU monitoring to ensure kidney function; temporary hemodialysis may be warranted in the acute treatment phase. Strict intake/output monitoring is important to treat not only decreases in urine output but also the threat of fluid overload. Medications such as allopurinol and rasburicase have been used to reduce serum uric acid levels. A renal diet, low in potassium and phosphorus) may be prescribed.
Oncology patients at high risk for TLS should have blood testing and monitoring done both before and during therapy to ensure an early diagnosis and treatment intervention.
Patient and caregiver education should include dietary instructions (avoiding foods high in potassium and phosphorus, such as bananas, oranges, tomatoes, and certain prepared/processed foods), home monitoring for adequate fluid intake and output, and signs/symptom recognition (5).
- Describe clinical symptoms, suggestive of TLS, that may begin to occur within 72 hours after chemotherapy infusion.
- How are these early symptoms mistaken for side effects of chemotherapy and not TLS?
- Are you familiar with any other types of oncological emergencies?
Febrile neutropenia is the development of fever, often with other signs of infection; in a patient with neutropenia, an abnormally low number of neutrophil granulocytes (a type of white blood cell) in the blood. Febrile neutropenia is not only the most common life-threatening complication of cancer therapy; its treatment is one of the most urgent oncological emergencies (6).
In many oncology cases, the actual cause of this condition is unable to be determined and gets marked as a fever of unknown origin (FUO). The actual definition of FUO is neutropenic cases with a fever greater than 38.3 C (100.9F), without any clinically or microbiologically defined infection. Documented infections only comprise approximately 30% of cases.
Infection is the primary cause of morbidity and mortality in patients with cancer who present with fever and neutropenia. The majority of infections are bacterial, but viral or fungal etiology is possible. Common bacterial pathogens include gram-positive bacterial infections such as Staphylococcus, Streptococcus, and Enterococcus species. In a cancer-related immunocompromised state, patients have a weakened immune to fend off infections. The GI tract or sinuses’ mucosal lining may be damaged, leading the host open to invasion from an infectious pathogen.
Symptoms that indicate febrile neutropenia may include the following (7):
- Fever, tachycardia, and hypotension
- History of recent chemotherapy
- History of prior episodes of neutropenia after chemotherapy
- A fever, which is a temperature of 100.5°F (38°C) or higher
- Chills or sweating
- Sore throat, sores in the mouth, or a toothache
- Abdominal pain
- Pain or burning when urinating, or urinating often
- A cough or shortness of breath
- Any redness, swelling, or pain (especially around a cut, wound, or catheter)
- pretreatment hemoglobin <12 g/dL (7)
Risk factors for febrile neutropenia include preexisting bone marrow problems, autoimmune diseases, poor nutrition, preexisting organ dysfunction (heart, liver, kidney disease), and certain medications (blood pressure medications, certain epilepsy medications, and some antibiotics).
Neutropenia is confirmed with a blood test (neutrophil level). A normal result of the absolute neutrophil count (ANC) is between 2,500 and 6,000 (8). The range of neutrophil numbers in mild neutropenia is 1,000-1,500; the number in moderate neutropenia is 500-1,000, and the count in severe neutropenia is less than 500.
For patients with a diagnosis of febrile neutropenia, the most important determining factor of patient outcomes is the timing of administrating IV antibiotics. Early administration of antibiotics has been shown to reduce mortality and the hospital length of these patients. Although antibiotics will not affect the actual neutrophil counts, they will treat the suspected underlying infection (9).
Oncology patient education on febrile neutropenia should include the following:
- Avoid exposure to persons with respiratory infections; avoid crowded places.
- Taking temperature daily, especially if they develop symptoms such as chills, sweats, or feeling feverish.
- Proper oral hygiene, including daily brushing and flossing to decrease the risk of dental inflammation/ infection.
In a hospital setting, neutropenic precautions may be instituted. The goal of such isolation is to prevent contaminates/ infectious potential from entering the patient room. Staff should wear PPE when entering the room; fresh fruits and vegetables should not be included in patient meals, and flowers of any kind should not be brought into the room. Handwashing is paramount prior to entering a neutropenic isolation room (10, 11).
Discuss the preexisting risk factors (unrelated to cancer) for the development of febrile neutropenia.
Describe the critical differences between neutropenic precautions and contact isolation procedures.
Superior Vena Cava Syndrome
The superior vena cava is a major vein in your upper body; it carries blood from your head, neck, upper chest, and arms to the heart. Superior vena cava syndrome (SVCS) happens when the superior vena cava is partially blocked or compressed. Cancer (specifically lung cancer and non-Hodgkin’s lymphoma) is usually the main cause of SVCS. Such tumors in the chest cavity can press on/ block the superior vena cave, block lymph nodes in the area, or cause blood clots in the chest cavity veins. Lung cancer accounts for nearly 80 percent of SVCS occurrences (12).
Symptoms of SVCS can cause serious breathing problems; it is considered one of the most dangerious oncological emergencies, however, most patients do well with treatment if recognized quickly.
Common symptoms of SVCS include:
- Swelling of the face, neck, upper body, and arms
- Trouble breathing or shortness of breath, coughing
- A hoarse voice, difficulty speaking, or trouble swallowing
- Swollen veins in your chest and neck, or swollen arms
- Coughing up blood, chest pain
- Horners syndrome (a condition where a nerve pathway may be disrupted by a tumor, resulting in a decreased pupil size, a drooping eyelid and decreased sweating on the affected side of your face. Treatment for SVCS may alleviate the symptoms)
SVCS is diagnosed by x-ray of the chest, CT (computer tomography) scan or MRI studies (magnetic resonance imaging), and ultrasound studies of venous blood blow to the affected area. Surgical interventions such as a stent placement for blocked blood flow may be necessary. Corticosteroids are used to reduce inflammation of the area, and diuretics may be ordered if there is evidence of fluid retention/ overload (13).
Patient education regarding SVCS should include temperature monitoring at home, reporting any signs and symptoms of infection, difficulty breathing, coughing up blood, changes in voice, and signs of Horner syndrome (14).
What types of cancer are at high risk for SVCS?
Describe signs and symptoms related to Horners Syndrome.
Malignant Pericardial Effusion
Malignant pericardial effusions (MPEs) are most often caused by lung cancer, breast cancer, melanoma, lymphoma, and leukemia. Lymph vessels may become blocked, which causes inflammation and possible infection. The extra fluid may then cause pressure on the heart, which keeps it from pumping blood normally (15).
The diagnosis of cancer as the cause of pericarditis requires imaging (e.g. a CT scan or cardiac magnetic resonance [CMR] imaging), cytology of pericardial fluid, and ultimately biopsies confirming malignant infiltration within the pericardial tissue (16). Malignant cancer cells can travel into nearby structures, as well spread throughout the bloodstream. Radiation and chemotherapy further increase the risk of viral or bacterial infections. Malignant cardiac involvement is thought to occur in approximately 10% of patients with known cancer.
Symptoms may occur slowly or rapidly, depending on fluid accumulation rate, and may include the following:
- Chest pain
- Palpitations and orthopnea
- Anxiety and confusion
Dependent on the severity of the effusion, the patient may experience tachycardia, decreased heart sounds, neck vein distension, peripheral edema, and pericardial friction. If the effusion worsens into cardiac tamponade, the patient may show signs of low-output shock. Symptoms of cardiac tamponade may include severe shortness of breath, weakness, lightheadedness, and cough. Beck’s triad, the three strongly diagnostic indicators associated with cardiac tamponade, include muffled or distant heart sounds, fast heart rate, and low blood pressure (17).
The treatment of malignant pericardial effusions must be individualized with consideration to the patient’s condition, tumor type, and the success rates and risks of various treatment options.
The initial relief of symptoms is achieved with a percutaneous pericardiocentesis. After drainage of the pericardial effusion, local sclerotherapy and/or chemotherapy usually alleviated the effusion without recurrence in most cases. Recurrent pericardial effusions may be treated with serial pericardiocentesis, sclerosing agents, and a percutaneous balloon pericardiotomy (18).
Nursing education for patients at risk of an MPE includes contacting their healthcare provider for any issues of breathing difficulties, unusual weakness or fatigue, and palpitations/ irregular heartbeats. As with many oncological emergencies, many symptoms can also be attributed to the side effects of ongoing chemotherapy and radiation, so it is important to keep providers appraised of any new symptom development.
- Discuss treatment options that are available to treat a pericardial effusion.
- What are the three clinical indicators for the condition known as Beck’s triad?
Syndrome of Inappropriate Antidiuretic Hormone
Syndrome of inappropriate antidiuretic hormone (SIADH) is a group of symptoms that develops when there is too much antidiuretic hormone (ADH) in the body (19). Increased levels of ADH lead to water retention, electrolyte imbalances, and a low level of sodium in the blood (called hyponatremia or water intoxication) (19).
The following cancers have been shown to be at high risk for the development of SIADH (19):
- Small cell lung cancer/ non–small cell lung cancer
- Primary brain tumors, head and neck cancers
- Stomach cancer, duodenum cancer, pancreatic cancer
- Bladder cancer, prostate cancer
- Uterine cancer (19)
In addition, some cancer treatments can also heighten the risk for SIADH; these treatments include chemotherapy drugs such as cyclophosphamide, ifosfamide, and vincristine. Finally, some pain medications associated with cancer care, including opiate pain medicines such as morphine, can also lead to SIADH. Suffice to say, SIADH is considered one of the high-priority oncological emergencies.
Symptoms of SIADH (often mild at first and worsening as the sodium level continues to decrease) can differ. There are both early and late symptoms.
- Nausea and vomiting
- Muscle cramps
- Worsening mental status
- Extreme weakness and irritability
- Agitation and confusion
- Hallucinations and poor balance
Administration of high-dose cyclophosphamide (a chemotherapy medication often used to treat types of leukemias and lymphomas) may actually be problematic in patients at risk for SIADH. Aggressive hydration is used to prevent hemorrhagic cystitis, creating the potential for water retention and severe hyponatremia. Combination chemotherapy often includes cisplatin administration, which usually is administered with large volumes of fluids to prevent nephrotoxicity. In addition, chemotherapy-induced nausea can stimulate the release of ADH.
Diagnostic lab work done to confirm SIADH may include serum levels of potassium, sodium chloride, osmolality, and urine-specific gravity. Hyponatremia is considered the hallmark lab test for SIADH. The normal range is 136-145 mEq/L. Levels below 136 may indicate the presence of SIADH.
Treatment for SIADH includes appropriate fluid replacement (which may actually include fluid restrictions (generally <500 mL/day in severe cases and 800 to 1000 mL/day in moderate cases).
There should also be ongoing cardiac monitoring and serial laboratory testing to assess for possible electrolyte imbalances.
Patient education should include the recognition of early symptoms, including fatigue, headache, and nausea/vomiting. Fluid intake and output and daily body weight should be monitored at home, with the healthcare provider being notified for extreme variances in these areas. As many chemotherapy medications (and their premedication precautions) can cause SIADH, further treatment may need to be adjusted for the patient’s safety and well-being (20).
Verbalize the critical differences between early and late symptoms of SIADH.
What is the blood work done to confirm hyponatremia?
Describe treatment interventions used to treat SIADH.
Disseminated Intravascular Coagulation
Disseminated intravascular coagulation (DIC) is the occurrence of abnormal clumps of thickened blood (clots) forming inside blood vessels. These abnormal clots use up the blood’s clotting factors, which can lead to massive bleeding in other places. Causes include inflammation, infection, and cancer.
The treatment goal is to address the underlying cause and provide supportive care through intravenous fluids and blood transfusions.
In some cases of DIC, small blood clots form in the blood vessels and prevent the normal blood supply to organs such as the liver, brain, or kidneys (33). In other cases of DIC, the clotting proteins in your blood are consumed. When this happens, there is a high risk of serious bleeding, even from a minor injury or without injury (21, 22).
Bleeding, often from multiple locations on the body, is one of the more common symptoms of DIC. Bleeding from the mucosal tissue (in the mouth and nose) and other external areas may occur in addition to internal bleeding (34). Other symptoms may include decreased blood pressure, easy bruising, and the presence of petechiae (tiny round brown-purple spots due to bleeding under the skin).
Risk factors for DIC may include the following (22,22):
- Blood transfusion reaction
- Cancer, especially certain types of leukemia
- Inflammation of the pancreas (pancreatitis)
- Infection in the blood, especially by bacteria or fungus
- Liver disease
- Pregnancy complications (such as placenta that is left behind after delivery)
- Recent surgery or anesthesia
- Severe tissue injury (as in burns and head injury)
There is no specific treatment for DIC. The goals of treatment are to determine the underlying cause and treat it appropriately. Currently, DIC is treated with plasma transfusions to replace blood clotting factors and anticoagulants to prevent further blood clotting (23).
Acute DIC can develop over a few hours or days and leads to serious bleeding. Conversely, chronic DIC may develop over weeks or months and usually presents with the formation of blood clots more so than excessive bleeding. Blood clots forming and traveling to the lungs will have the patient present as a possible pulmonary embolus, with shortness of breath, cyanosis, and severe chest pain.
Simple nursing procedures such as a venipuncture or IV insertion may cause severe external bleeding; thus, pressure to puncture sites may be longer than usual. Stool softeners are often prescribed to lessen straining during bowel movements. Bleeding precautions should be initiated, including no razors, soft toothbrushes, limited needle sticks, and blood pressure readings.
Laboratory tests confirm the presence of DIC. Platelet counts are decreased, while PT/PTT and D-dimer levels are increased. Heparin is the drug of choice for chronic DIC when clotting is the issue. Excessive blood loss may require transfusions, and antibiotics are prescribed when infection or sepsis are also present.
Patient education for DIC includes the reporting of any unusual bruising or bleeding, as well as the onset of weakness, dizziness, or fatigue. Preventive bleeding precautions should also be encouraged, with the use of electric razors, soft bristle toothbrushes, and the regular use of stool softeners.
What types of cancers put a patient at risk for DIC?
Describe the differences between acute and chronic DIC.
Hypercalcemia of Malignancy
Hypercalcemia of malignancy (HCM) is the most common life-threatening metabolic disorder associated with cancer.
There are two main mechanisms by which cancer can lead to hypercalcemia. The first and most common is local action on bone, as may be seen in multiple myeloma or carcinomas (e.g., breast or prostate) that metastasize to bone. The second mechanism is tumors that secrete humoral factors that stimulate bone resorption (24).
Squamous carcinomas are the most common malignancies that cause HCM, including squamous cell cancers of the lung, head and neck, and esophagus, breast cancer, renal cell carcinoma, lymphomas, and multiple myeloma.
Patients experiencing hypercalcemia often complain of generalized/nonspecific symptoms, such as muscle weakness and fatigue. Others may complain of kidney stones, a direct result of high levels of calcium.
Up to 30 percent of patients with cancer develop hypercalcemia. Approximately 50% of these patients will die within 30 days of a hypercalcemia diagnosis, even if the hypercalcemia is corrected, which suggests that hypercalcemia is a sign of hormonally advanced cancer (25).
- Normal serum levels of calcium: 8.6-10.3 mg/dl
- Levels of hypercalcemia:
- Mild 10.5-11.9 mg/dl
- Moderate 12-13.9 mg/dl
- Severe >14 mg/dl
Treatment of hypercalcemia includes IV hydration and loop diuretics. Normal saline IV fluid at 200-500 ml/hr increases the glomerular filtration rate and filtered amount of calcium. Loop diuretics blocks calcium resorption in the loop of Henle. The patient is also advised to discontinue any medications that affect serum calcium, including vitamin supplements, thiazides, and calcium antacids (26).
After or often in conjunction with aggressive hydration, IV bisphosphonate treatment should be started to treat HCM. Bisphosphonates are very well studied in this population of patients and are considered to be quite safe and effective. Bisphosphonates act by inhibiting bone resorption. They bind to the bone and reduce or prevent osteoclast activity, which as discussed above, is a major factor in the development of HCM (27).
Malignant hypercalcemia is preventable. The condition can often be effectively treated. However, it often occurs as a late complication of cancer and indicates widespread disease, so successful treatment effects are likely to be short-lived. This makes its management a combination of providing compassionate end-of-life care and the correct treatment.
Patient education should focus on the identification (and notification of the healthcare provider) of the early symptoms of hypercalcemia: fatigue, muscle weakness, anorexia, and constipation. Left untreated, these symptoms could worsen to include confusion, nausea, and vomiting, resulting in dehydration, renal failure, cardiac arrhythmia, and eventual coma.
- Malignant hypercalcemia is thought to be a late-stage complication of cancer. What concerns do you have as a nurse, regarding compassionate end-of-life care, in this emergent situation?
- Is malignant hypercalcemia considered one of the most life-threatening oncological emergencies?
Extravasation of Chemotherapy
Chemotherapy extravasation remains an accidental complication of chemotherapy administration and may result in serious damage to patients. It is defined as the accidental infiltration of chemotherapy into the subcutaneous or sub-dermal tissue at the injection site and can result in tissue necrosis. The exact incidence of chemotherapy extravasation varies greatly due to the general lack of reporting and absence of a centralized registry of chemotherapy extravasation events (28). Chemotherapy extravasation is one of the most preventable oncological emergencies.
Chemotherapy extravasation has a prevalence range from 0.1% to 6% when administered through peripheral intravenous access and from 0.26% to 4.7% when administered through a central venous access device (CVAD).
Intravenously administered drugs can be classified into five categories according to their damage potential: Vesicant, Exfoliants, Irritants, Inflammitants, and Neutrals. The drug damage from extravasation can range from skin erythema to soft tissue necrosis:
- Vesicants can result in tissue necrosis or the formation of blisters when accidentally infused into tissue surrounding a vein.
- Exfoliants can cause inflammation and shedding (peeling off) of skin without causing underlying tissue death.
- Irritants can cause inflammation, pain, or irritation at the extravasation site without any blister formation.
- Inflammitants can cause mild to moderate inflammation, painless skin erythema and elevation (flare reaction) at the extravasation site.
- Neutral are drugs that neither causes inflammation nor damage upon extravasation.
Risk factors are related to the chemotherapeutic agent infused, as well as patient factors.
- Chemotherapeutic agent-associated risk factors include the drug’s vesicant properties, its concentration, volume, and duration in which the infusion extravasated.
- Risk factors related to patients that increase the risk of chemotherapy extravasation include small and/or fragile veins, preexisting patient lymphedema, obesity, impaired level of consciousness, and having had multiple previous venipunctures.
Iatrogenic causes (effects inadvertently produced by the healthcare provider) include any of the following scenarios:
- Lack of training of nurses
- Poor cannula size selection and IV poor location selection
- Accidental puncturing of the vein
- Accidental movement of the cannula (due to patient movement or IV site being improperly secured)
- Prolonged peripheral line infusions of vesicants
Education and training for nurses and physicians remain the mainstay of safe chemotherapy administration and emphasizes the importance of being preemptive instead of reactive to extravasation. Extravasation prevention includes ensuring knowledge of risk factors, signs and symptoms, guidelines for prevention and management.
Consideration of the appropriate vascular access is crucial for the prevention of chemotherapy extravasation:
- Chemotherapy should be infused only through central venous access or an adequate peripheral vein.
- Veins that are small/fragile should be avoided as they might not withstand the required flow and rate of infusion.
- IV insertion sites to avoid include the dorsum of the hand, the antecubital fossa, and the radial and ulnar aspects of the forearm.
- Patients should be assessed for possible risk factors, including preexisting diabetes, steroid usage, previous lymph node dissection, previous venipunctures, and current level of consciousness (for the purpose of assuring immobility and compliance during catheter insertion), prior to IV insertion and chemotherapy infusion.
Patient education should include instructions to report any discomfort, pain, redness, or swelling at infusion sites. Patients should also be aware of the class of drugs and options of venous access and understand the higher risk of extravasation associated with it.
- Discuss patient risk factors for the occurrence of an IV extravasation.
- What can nurses do to lower the risk of extravasation prior to and during the administration of chemotherapy?
- Why is chemotherapy extravasation one of the most preventable oncological emergencies?
Infusion Reactions (Hypersensitivity and Anaphylactic)
Chemotherapy drugs are aimed at improving the quality of life and life expectancy of patients, but an increasing number of reactions, including anaphylaxis, precludes their use in targeted populations. Drug allergic reactions are unexpected, can be severe, including anaphylaxis, and prevent the use of first-line therapies, with consequent impact in patient’s survival and quality of life (29).
Drug reactions can range from mild pruritus and hives to life-threatening anaphylaxis with hypotension, oxygen desaturation and cardiovascular collapse, and deaths have been reported after re-exposure to allergic drugs. Patients presenting with delayed cutaneous reactions are a great concern for Stevens-Johnson syndrome and toxic epidermal necrolysis, two life-threatening conditions that can lead to permanent disability, blindness, and a dramatic decrease in the quality of life for survivors. Drug hypersensitivity is an increasing health hazard, compromising the quality of life and the life expectancy of cancer patients.
Stevens-Johnson syndrome (SJS) is a rare, serious disorder of the skin and mucous membranes, often due to a medication reaction (30). Symptoms may include a painful rash with blister formation, fever or malaise, mouth ulcers, and difficulty swallowing. As the disorder worsens, the extensive skin damage predisposes a person to a severe loss of body fluids and exposure to bacterial infections. Shock and multisystem organ failure can occur, making SJS/TCN a life-threatening disease. Toxic epidermal necrolysis is the more severe end of the SJS spectrum, fatal in up to 50 percent of such cases.
Hypersensitivity reactions (HSRs) once prevented patients from receiving first-line therapies. Rapid desensitization protocols have been developed in many cases, allowing patients to now receive first line therapies safely, (despite previous documented reactions) while under close physician observation (31).
Adverse reactions to chemotherapeutic agents can range from mild to anaphylactic. Symptoms vary person to person, and may include changes in blood pressure and heart rate to chest tightness, back pain, and fever. Although severe reactions occur in less than 5% of oncology patients, isolated deaths have been reported.
Severe infusion reactions should be discontinued immediately and be treated appropriately. Repeated infusion reactions that occur, despite pre-medication and slowed infusion rates, leave few alternate treatment options. While some oncologists advocate discontinuation of the chemotherapy agent, others may attempt a trial of specific drug desensitization. The decision to pursue either treatment is based on many factors, including the severity of the reaction, the disease process itself, and the availability of comparable treatment options.
Infusion reactions (IRs) tend to occur with various anticancer medications. Symptoms range from mild flushing to severe anaphylaxis-type symptoms. Most IRs occur either within the first hour of the first or second administration. Continuous monitoring during infusion initiation is encouraged for early identification and treatment of any potential IRs (32). The more rapidly a reaction develops, the more severe it is likely to be.
Patient education for infusion reactions includes reporting all unusual symptoms (no matter how mild they appear initially) to healthcare providers throughout an infusion. Patients should be informed that they will be closely monitored throughout the infusion process (serial blood pressures and pulse checks). Discharge instructions may include routine temperature checks at home and indicators when to seek emergency care (difficulty breathing, chest pain, facial swelling (lips, tongue, and throat).
In conclusion, oncology nurses must be knowledgeable in all aspects of patient care, including possible oncological emergencies. Early identification and prompt treatment afford the patient the best outcomes. Modern advances in the treatment of cancer have prolonged the lives of many oncology patients. However, some treatments remain aggressive and have deleterious effects. Thus, the ongoing management of a cancer patient is a delicate balance of compassionate end-of-life care and correct treatment. Ongoing cancer care education, thus, is paramount in enabling nurses to truly provide holistic patient care.
- Which of these oncological emergencies have you seen or treated in the past?
- Do you feel better prepared to recognize and respond to these oncological emergencies?
Case Study on Oncological Emergencies
You are working in an outpatient infusion center. Your patient arrives for her first chemotherapy infusion. Mary, age 39, is diagnosed with breast cancer and is six weeks post-operative from a bilateral mastectomy. She expresses mild anxiety, with concern over possible side effects from the chemotherapy. Her vital signs are all within normal range. As you begin to look for a good IV insertion site, Mary states, “good luck; they had a hard time getting blood from me in the hospital.” You are able to secure an IV site in her left forearm, with confirmed blood return.
Given your patient medical history, what assessment should be done prior to obtaining a peripheral IV site (to lower the risk of extravasation)?
Does this patient have any contraindications for a peripheral IV site?
What other options are available, both short and long-term, for IV access?
Mary tolerates her first infusion without incident. She asks you if there are any special instructions she needs to follow until her next appointment. She is observed after the infusion is complete; vital signs remain normal, and she is anxious to go home.
What discharge instructions should Mary be given?
What instructions should she receive, regarding monitoring for signs and symptoms of oncological emergencies?
When should she notify her medical provider?
Are there any specific instructions regarding food and fluid intake?
Six days later, Mary calls the outpatient infusion center, complaining of a fever of 101F, with complaints of a poor appetite and decreased urine output. She is advised to go to the local emergency room and is eventually admitted to the hospital with a diagnosis of FUO- fever of unknown origin. Blood tests confirm an additional diagnosis of febrile neutropenia.
Describe laboratory testing to support a diagnosis of FUO. What blood tests confirm neutropenia?
Discuss special isolation procedures (neutropenic precautions) that should be initiated for this patient. How to they differ from contact isolation?
The patient’s condition improves, and she is discharged home after three days. She asks you what she can do to lower her risk of infection while she is home.
What are some risk factors in the development of febrile neutropenia?
Describe the importance of early IV antibiotic intervention when treating a neutropenic oncology patient.
What are some personal care behaviors this patient can do at home to lower the risk of infection and other oncological emergencies?
When should this patient be instructed to contact her medical provider (regarding symptom onset)?
Oncology Nursing Society and Oncology Nursing Certification
The ONS is a professional association of more than 35,000 members committed to promoting excellence in oncology nursing and the transformation of cancer care. Membership includes ongoing education, national conference, networking opportunities, and subscriptions to various nursing resources and journals.
125 Enterprise Drive
Pittsburgh, PA 15275
Oncology Nursing Certification Information
125 Enterprise Drive
Pittsburgh, PA 15275
(US and Canada only)
ONCC is the premier provider of nationally accredited certification for nurses in oncology and related specialties. ONCC administered the first Oncology Certified Nurse (OCN®) examination in 1986. Today, ONCC offers eight credential programs and has nearly 40,000 currently certified nurses.
ONCC offers the following certifications:
- Oncology Certified Nurse (OCN)
- Certified Pediatric Hematology Oncology Nurse (CPHON)
- Certified Breast Care Nurse (CBCN)
- Blood & Marrow Transplant Certified Nurse (BMTCN)
- Advanced Oncology Certified Nurse Practitioner (AOCNP)
- Advanced Oncology Certified Clinical Nurse Specialist (AOCNS)
- Certified Pediatric Oncology Nurse (CPON)
- Advanced Oncology Certified Nurse (AOCN)
References + Disclaimer
- Oncology Nursing Society. (2018, October 2). Oncology Nurses’ Role in Recognizing and Addressing Oncologic Emergencies. ONS Voice. https://voice.ons.org/news-and-views/oncology-nurses-role-in-recognizing-and-addressing-oncologic-emergencies
- Larson, R. A., & Pui, C. (2021, February 17). Tumor lysis syndrome: Definition, pathogenesis, clinical manifestations, etiology and risk factors. Https://Www.Uptodate.Com/. https://www.uptodate.com/contents/tumor-lysis-syndrome-definition-pathogenesis-clinical-manifestations-etiology-and-risk-factors
- Gupta, A. (2018, June 1). Tumor Lysis Syndrome. Hematology | JAMA Oncology | JAMA Network. https://jamanetwork.com/journals/jamaoncology/fullarticle/2680750
- Ikeda, A. K. (2020, December 31). Tumor Lysis Syndrome Clinical Presentation: History, Physical Examination. Https://Emedicine.Medscape.Com/. https://emedicine.medscape.com/article/282171-clinical#:%7E:text=Presence%20of%20abdominal%20pain%20and,Such%20as%20weakness%20and%20paralysis
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