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The Paper Chase: Acute Cancer Emergencies

Sanjay Arora, MD and Mel Herbert, MD MBBS FAAEM
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EM:RAP October 2013 Written Summary 2 MB - PDF

Sanjay and Mel discuss a new article from the journal "Blood". I find it odd that most of the subscribers are from Transylvania? Maybe just a coincidence.

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Vince DiGiulio -

You don't sound 100% sold on this title still, so how about The Paper Cut (if it hasn't already been suggested)?

Aaron G. -

A non-zero number of our febrile neutropenics get sent home on oral Cipro/Clavulin. This is not a decision we as ED docs are making independently though, it's in discussion with oncology.

Mitchell L. -

I'll sum up my comment/question in one sentence because I ended up being quite verbose ... Regarding leukostasis in blast crises: instead of leukopheresis if it is unavailable, would exchange transfusion be a reasonable alternative (or adjunct) to prayer?

For perspective, I am at Rob Roger's and Amal Mattu's shop in Maryland. This is on the forefront of my mind because we recently had an m&m on this subject when a patient who was admitted to the medicine service (as our cancer services were full) developed an initially unrecognized blast crisis overnight and eventually died. Even had the crisis been recognized overnight, it turns out that leukapheresis (or any pheresis) for that matter, is virtually impossible to initiate overnight for political reasons that are above my pay grade. The heme/onc attending simply stated "it's a problem". A month prior to that, I was doing night float at the VA MICU (which is connected by a bridge to the University Hospital) when we had a patient with a major GI bleed (I believe he was essentially defecating units of packed red blood cells - we probably could have used a cell saver) with coags off the chart whose initial ddx included ttp which would have required plasmapheresis. There are no pheresis services at the VA, so a lengthy transfer process must take place to send the patient to University, at which point, it would likely be night again and pheresis services would again be delayed until the following morning. The point? Pheresis services seem to be in high demand emergently and in low supply.

Thankfully in TTP, we can temporize with FFP to replace the missing ADAM TS13. In blast crisis or leukostasis, the problem is too many leukocytes floating around with the solution being remove them selectively followed by urgent induction chemotherapy as Dr. Arora points out. But why not just remove them non-selectively, ie. through exchange transfusion? I don't know what the process is for exchange transfusion in the ED (I'm sure it's a project if its ever done), but it seems at least intuitive that much less fancy equipment is needed and that as long as we can get a couple of good lines in, that we can take bad blood out, and put fresh blood components in. I did a quick pubmed search and only found one retrospective single center study with all of four patients (peds) who underwent either leukapheresis or exchange transfusion. Half of them had exchange transfusions - in both groups, a marked reduction in leukocytes and related symptoms were found with no adverse events. Not a lot of data, but makes intuitive sense, and if your only alternative is praying... why not? Study citation below for reference.

Klin Padiatr. 2009 Nov-Dec;221(6):374-8. doi: 10.1055/s-0029-1239533. Epub 2009 Nov 4.
Leukapheresis and exchange transfusion in children with acute leukemia and hyperleukocytosis. A single center experience.
Haase R, Merkel N, Diwan O, Elsner K, Kramm CM.

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Episode 145 Full episode audio for MD edition 218:18 min - 103 MB - M4AEM:RAP Resumen October 2013 Español 97:28 min - 67 MB - MP3EM:RAP 2013 October MP3 266 MB - ZIPEM:RAP October 2013 Written Summary 2 MB - PDFEM:RAP October 2013 Board Review Questions 641 KB - PDFEM:RAP October 2013 Board Review Answers 658 KB - PDF

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