MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

SAKINAH MOHD SALEH1090041MOHD AZIZUL MOHD ATAN1090042ABDULLAH ZAHID AZHARI1090043NUR AMALINA ZULKEPRE1090044NURMARZURA ABDUL LATIF1090045AHMAD ZULKHAIRI RESALI1090046NURUL ASMAT ABDUL RAHMAN1090048

MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

GROUP 3: ONCOLOGYDiscuss the aetiologies, clinical presentations, problems related to dental management and general management of patients with this medical problem.IntroductionCancer is a complex illness that requires clinical care by a physician or other health care professional.Survival rate for childhood cancers : 72%, adult cancers: 60%.

What is cancer?Cancer is an abnormal growth of cells. Cancer cells rapidly reproduce despite restriction of space, nutrients shared by other cells or signals sent from the body to stop reproduction. Cancer cells are often shaped differently than healthy cells, they do not function properly and they can spread to many areas of the body. Oncology is the study of cancer and tumors.ONCOLOGYAETIOLOGYThe factors involved may be genetic, environmental or constitutional characteristics of the individual.Lifestyle factors :-smoking, high-fat diet and working with toxic chemicalsGenetics:genetic mutation, exposure to chemicals near a family's residence, a combination of these factors or simply coincidence.genetic disorders (i.e., Wiskott-Aldrich and Beckwith-Wiedemann syndrome)Exposure:-viruses such as the Epstein-Barr virus (EBV) and human immunodeficiency virus (HIV).- environmental such as pesticides, fertilizers, and powerONCOLOGYCLINICAL PRESENTATIONClinical presentations: Incidence150 new cases per I million US children

2nd leading cause of deathClinical presentationsIncidence of childhood cancerCancerIncidenceleukemia30.2Central nervous system21.7lymphoma10.9neuroblastoma8.2Soft tissue sarcoma7.0Renal tumor6.3Bone tumor4.7others11.0Recent trends in childhood cancer incidence and mortality in the United States. J Nati Cancer Inst 1999;91:1051-8Clinical presentationsCancer diagnosis in children is often delayedbecause the presenting symptoms tend to benonspecific and resemble those of benignconditions.Oncologic EmergenciesRefer to oncologistTumor Lysis Syndrome (TLS)Lysis of tumor cells releases electrolytes & urea cycle products resulting in hyperuricemia, hyperkalemia,hyperphosphatemia & resultant hypocalcemiaSevere TLS seen with large tumor burden including (but not limited to):Burkitts LymphomaAcute Lymphoblastic Leukemia with WBC count >100,000/mm3AMLNeuroblastomaTLS Labs: minimum daily up to every 6hrs as resources allowUrea & ElectrolytesCalciumMagnesiumPhosphateUric AcidMaintain urine output at > 2.5 ml/kg/hrHemodialysis reserved for severe TLS, prevention of severe disease will obviate requiring this invasive & expensive intervention

Specific ManagementHyperuricemia ManagementHydration with 3000 ml/m2/day with fluids not containing potassium (e.g. D5 1/2NS)Consider adding 40 mEq NaHCO3/L to aid in uric acid excretionNeed to monitor calcium & phosphate several times daily if adding NaCO3,where this is not feasible,do not add NaHCO3to fluidsAllopurinol 100 mg/m2/dose PO given three times dailyMax dose 600 mg/day for age 10 yrsRasburicase: currently not available in the resource-limited settingHyperkalemiaECG: T wave elevation (peaked T wave), loss of P wave, widened QRS complexAvoid potassium in fluids to help prevent this complicationStop any potassium supplementation if presentDextrose 0.5 g/kg with 0.3 units insulin/gm dextrose, infuse over 2 hoursKayexalate 1 g/kg/dose PO four times daily1 g/kg lowers potassium by 1 mEqHyperphosphatemia/HypocalcemiaRemove NaHCO3 from fluids if Ca x PO4>60Where calcium & phosphate levels cannot be checked several times daily, do not add NaHCO3 to fluidsHyperphosphatemia -treat with aluminum hydroxide 25 mg/kg/dose four times daily & avoid foods containing large amounts of phosphateHypocalcemia: 10% calcium gluconate 500 mg/kg IV infusion through a central lineMaximum dose 2000 mg/doseMonitor calcium level closely including ionized calcium where availableHyperleukocytosisDefined as WBC > 100,000/mm3High risk for pulmonary & CNS complications due to viscosity & stasisIV fluid rate 3600 ml/m2/dayMonitor WBC counts along with TLS labsMonitor pulse oximetry for evidence of pulmonary complications, continuous monitoring where possibleDo not transfuse above Hg 8.5 g/dL as pRBC or whole blood may increase viscosityMay transfuse platelets for active bleeding or platelets