Cancer Emergencies

  1. Leukostasis occurs with WBC count greater than 50,000 with symptoms (usually 100,000), predominantly pulmonary and neurologic symptoms.80% of patients will have fever, so treat for infection concurrently. Chemotherapy is the only treatment that decreases mortality, but if not available, leukopheresis is the next step.
  2. Neutropenic fever is defined as a single oral temperature greater than 38.3 oC or temperature >38.0 oC for one hour, with absolute neutrophil count (ANC) of < 1500 cells/microL, with severe defined as an ANC less than 500 cells/microL or an expected drop to < 500 over 48 hours. 30% of fevers are due to infection, with gram positives accounting for 60% of infections. Broad coverage targeting gram positives and pseudomonas is needed.
  3. Venous Thromboembolism (VTE) (DVT, Pulmonary Embolism (PE))is common in cancer, with 15% of patients with malignancy experiencing DVT/PE. Khorana score is validated for VTE risk stratification in this patient population. CT PE and DVT US are the best tests. Anticoagulation with heparin has the best literature support for treatment.

When your child (> 6 months) is burning up…

  • “Fever is not a disease. It is merely the child’s immune system APPROPRIATELY responding to an infectious process which is viral the majority of the time.”
  • “We treat fever with anti-pyretics because it makes the child feel bad, not because fever in and of itself is bad.”
  • “The “number” on the thermometer is not nearly as important as how the child looks (interactivity, energy, hydration).”
  • “Length of the fever is actually more concerning than height in most cases. If the fever lasts for more than 5 days, the child should at least have a repeat physical exam by a clinician.”
  • “Come back if you are worried about the child.”

The evidence behind treating fever in children

  • Antipyretics don’t appear to lengthen duration of fever in ill children
  • Antipyretics an be combined for effect, but to what end?
  • Antipyretics don’t appear to decrease risk of febrile seizure recurrence
  • Fever:  Not your enemy!