Patients with cancer can face a number of complications as they undergo treatment. Assessment can be difficult because some crises emerge because of the cancer or cancer treatment, whereas others arise unrelated to either cancer or treatment. Moreover, some patients may not look as sick as they are because of the progressive decline in their condition, and long-term abnormalities can diminish symptoms. Although these emergencies are common, Brenda Shelton, RN, MS, and Cynthia Chernecky, PhD, RN, CNS, argued, at the 41st Annual ONS Congress, that many of these complications could be avoided with diligent monitoring and early intervention.
Many emergencies can occur related to different types of malignancies. Solid tumors, for example, can invade soft tissues and vessels with infection and bleeding, can interfere with organ function, can cause long-term chronic illness despite multiple metastatic sites, and can cause hypercoagulability. Hematologic malignancies diffuse body-wide disease at onset and can cause generalized multi-system failure. Shelton and Chernecky explained current considerations when classifying oncologic emergencies. Providers should consider the mechanism of injury when an emergency presents, such as hematologic complications, organ toxicity, structural abnormalities, issues unrelated to the cancer or the treatment, and metabolic abnormalities. The timing of the emergencies can also help classify them—whether the issues present at diagnosis, during treatment, with progression of the disease, or late effects of therapy. TABLE 1 shows how these elements help classify oncologic emergencies.
Shelton and Chernecky offered a framework for considering complications in patients with cancer. Bearing in mind the nature of the critical illness, providers should evaluate
- Cancer involvement of body structures
- Toxicity of therapy
- Interaction of comorbidities and cancer or treatment
- Incidental critical illness.
Caregivers can then make a decision to treat based on the reversibility of the event or cancer, the projected life expectancy of the patient, recovery potential, or other factors. Additionally, crises that emerge unrelated to the cancer or cancer treatment can be assessed by considering how reversible is the problem without cancer, how does cancer affect the ability to treat this complication, and what is the patient’s current physical condition and ability to recover from treatment. Asking these questions can help establish a clearer treatment path for better outcomes.
One such critical oncologic emergency is sepsis, which is the 10th leading cause of death in the United States, the most common cause of nonmalignant death in oncology, and occurring in 14% off patients with cancer. There are 750,000 cases per year, resulting in 250,000 deaths each year. “Early recognition saves lives,” said Shelton. “Nurses, as the bedside practitioners are often the first to recognize the onset of sepsis.” Careful observation and interventional strategies can assist in helping patients survive sepsis. For example, in the first three hours, providers can
- Screen for sepsis first encounter/defined intervals
- Examine blood cultures and lactate if the screening is positive
- Assess organ function
- Administer the first antimicrobial dose within 60 minutes of triage
- Give oxygen if oxygen saturation is less than 90%
- Administer initial fluid bolus of at least 30 ml/kg if the patient is hypotensive.
There are, Shelton and Chernecky argued barriers in implementing interventional strategies to address sepsis. To start, evaluating sepsis can be difficult because it is often excluded from clinical studies and quality measurement organizations vary in how to identify and address sepsis. Moreover, they said, patients do not receive the same care in all setting. Timeliness can be a factor because many interventions are time sensitive and prompt sepsis management activation systems are not consistently available. Other variables can affect the timely use of critical antimicrobials, such a misdiagnosis, waiting for cultures to be obtained, or patients being cared for by non-emergency department physicians. The delay in time is problematic, because “every hour delay beyond the first 60 minutes increases mortality about 7.6%,” they said.
Diligent assessment and early, proactive interventional strategies can assist in other critical oncology emergencies as well, including dysrhythmias, hemorrhagic cystitis, and pancreatitis. A collaborative, clear, and well-established protocol for screening cancers with cancer for medical crisis and a clear interventional plan tailored to patient needs is essential in promoting positive outcomes for patients in these critical moments.