Care of the oncology patient in the picu

There are numerous malignant conditions that place the pediatric patient at great risk requiring the need of critical care services. Therefore, it is essential that the pediatric critical care provider possess a sound understanding of these conditions such that they may be anticipated, recognized and treated effectively. Of these conditions, perhaps none requires the prompt, well conceived care of a pediatric intensivist as much as a malignant mediastinal mass. A definitive diagnosis must be established balancing the likelihood of a definitive result with the risk of the diagnostic procedure and the associated sedation. A clear understanding of the findings that suggest a patient is at high risk for airway compromise is essential. Hyperleukocytosis is another malignant condition associated with significant morbidity and mortality as a result of leukostasis. Leukostasis is a clinical condition characterized by progressive and potentially severe neurologic or respiratory disease attributable to small vessel infiltration and occlusion by leukemic blasts. Hypercalcemia is another disorder that may be associated with a variety of malignant processes. Although relatively rare in children, it may result in a number of life-threatening conditions including cardiac dysrhythmias, neurologic impairment, and renal failure. Additionally, it is well-established that varying degrees of coagulopathy are present in most patients with advanced malignancy. Perhaps most notable, acute promyelocytic leukemia is associated with such a high incidence of death near the time of presentation secondary to intracranial and pulmonary hemorrhages that it is viewed as a medical emergency. Other forms of leukemia may be associated with other pathophysiological consequences that may also be life-threatening. For example, lactic acidosis resulting from a high rate of glycolysis is a very rare, but life-threatening complication of hematologic malignancies. A heightened sense of alertness for these rare conditions may result in earlier detection, more effective therapy, and better outcomes for these children.

Duke Scholars

Author Jennifer Ann Rothman Pediatrics, Hematology-Oncology