UNM Internal Medicine Residency – ALBUQUERQUE, NEW …



Created by APN Marissa Pettit and Dr. Ala Ebaid of the Heme/Onc Department.??OCD Tip Sheet for Heme/Onc PatientsNeutropenic Fever?new fever in neutropenic patient: ?38 degrees Celsius sustained for one hour or single reading of 38.3 degrees Celsius?-blood cultures x 3 (one from central line, two from periphery)-urine culture (neutropenic patients may not mount neutrophil response needed in UA culture if indicated)-chest PA/lat-start broad spectrum ABX with gram negative coverage (zosyn or cefepime)-CT chest if persistently febrile > 48 hours?persistent fever in neutropenic patient:-consider adding gram positive ABX coverage with vancomycin if patient has been on gram negative coverage for at least 24 hours, hemodynamically unstable, MRSA positive or if mucositis present-please be sure to order blood cultures Q24 hours with persistent fevers?May order Demerol 25mg IV x1 for rigors with fever if deemed safe with patient’s medication profile.?Please use acetaminophen only for fever. Avoid NSAIDs please.?AM labs and Transfusion Parameters?Heme Onc patients: need daily CBC, diff, CMP (please order if RN calls)Med Onc patients: some will need daily CBC and CMP (please order if RN calls), patients inpatient for radiation may not need daily labs?Parameters:-transfuse 1 unit PRBCs for hemoglobin < 7-transfuse 1 unit platelets for platelets < 10-transfuse 1 unit platelets for platelets < 20 if patient febrile-transfuse 1 unit platelets for platelets < 50 if actively bleeding-transfuse 1 unit platelets for platelets < 100 with CNS bleeding?Please order irradiated blood products for all Heme Onc patients. Med Onc patients are okay with non-irradiated blood products.?Tumor Lysis Monitoring?For patients with high tumor burden, expect to see tumor lysis labs ordered Q8hr with initiation of chemotherapy. Labs will be CMP, uric acid and LDH. If these labs are not ordered for a patient meeting these criteria, please feel free to add them.?If rising potassium or phosphorus or increase in creatinine, increase IV fluids as appropriate per patient’s other comorbidities.?If uric acid above 9, call the Heme onc fellow?Please verify patient also on allopurinol at maximum dose of 300mg PO daily.?Cardiac monitoring is also appropriate for this patient population.?Chemo-therapy?Patient on Ifosphamide/Cyclophosphamide:-continuous mesna infusion during hospital stay-urine heme checks with each void-if POC urine positive for heme- collect UA-if UA has ?> 4 RBCs, notify on call Heme Onc fellow. plan to likely hold chemotherapy.?Patient on Methotrexate:-urine pH checks with each void-goal to keep urine pH > 7 until methotrexate < 0.10-if POC urine pH < 7, increase sodium bicarbonate infusion?Patient on Cytarabine:-neuro checks Q12 to asses for cerebellar toxicity-if abnormal exam, hold chemo and notify on call Heme Onc fellowHypercalcemiaEvaluate serum calcium corrected for albumin. Order re-check within 6 hours if elevated.?Initiate IVF with NS at 150-200mL/hr as appropriate for patient’s health history. Consider Lasix if appropriate.?Consider starting bisphosphonates with pamidronate or zometa.?May also start calcitonin.Miscellaneous TopicsIf DVT to extremity with PICC line, start anticoagulation and defer to day team for decisions regarding discontinuation of PICC line unless life threatening ischemia present. ................
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