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Hematology/Oncology 22. Approach to a Child with Anemia Sources: WHO, Pocket book of hospital care for children, 2013; Eddleston et al, Oxford handbook of tropical medicine, 2008; Bugando Medical Centre, Paediatrics management guidelines, 2011. Definition WHO for children 3 hours), FBPºº Management: Inpatient with urgent urologic consultation if available * Blood transfusion (ideal goal is Hb ≥ 10) * Pain control * IV hydration * 30mg or 60mg pseudoephedrine at night to prevent recurrent priapism 82 Hematology/Oncology • Strokeºº Diagnosis: History and physical exam, FBP, type and cross, head CT (but do not delay treatment to obtain)ºº Management: Inpatient * Blood transfusion (ideal goal is Hb ≥ 10) * IV hydration * *Manual exchange transfusion ideal therapy * *Rehabilitation • Aplastic anemiaºº Diagnosis: History and physical exam, FBPºº Management: * Inpatient management for transfusions/hypoxemia management * Blood transfusion if necessary * Oxygen therapy if necessary • Splenic sequestrationºº Diagnosis: History and physical exam (enlarged, tender spleen), FBP, thrombocytopeniaºº Management: * Inpatient management initially until hemoglobin stabilizes * Frequent evaluations, can quickly develop hypovolemic shock * Likely will need blood transfusion. Do not transfuse more than 5ml/kg aliquots at a time as spleen can release sequestered blood. Repeat Hb with each transfusion. * IV hydration • Gallstonesºº Diagnosis: History and physical exam, FBP, *abdominal ultrasoundºº Management: Surgical (cholecystectomy) if severe General Management • Folic acid 5mg PO daily • Prophylaxis—penicillin V 125mg PO daily if 5 or 6 y.o. due to high risk of infections • Mentzer index = MCV/RBCºº If index 13, more likely iron deficiency anemia 25. Leukemia/Lymphoma Sources: The Harriet Lane handbook, 19th ed., 2012; Bugando Medical Centre , Paediatrics management guidelines, 2011; UpToDate, Epidemiology, clinical manifestations, pathologic features, and diagnosis of Burkitt lymphoma , 25. Leukemia/Lymphoma 85 General Clinical Manifestations • Unexplained fevers • Night sweats (older kids) • Failure to thrive/weight loss • Poor feeding • Bone pain • Limping/refusal to walk • Easy bruising • Petechiae • Nosebleeds • Gum bleeding • Hematochezia • Melena • Abdominal mass • Unexplained head, neck, chest, extremity mass • Hepatomegaly • Splenomegaly • Large lymph nodes • Difficulty breathing • Pallor • CNS changes (incontinence, seizures, headaches, lower extremity weakness, paralysis, etc) Investigations • History and physical exam • FBP (and peripheral smear)—may see pancytopenia or impressive leukocytosis • CXR to rule out mediastinal mass/metastases (PA and lateral ideally) • Abdominal ultrasound • HIV testing • *Electrolytes, including renal and liver function tests for baseline • *ESR 86 Hematology/Oncology • *Serum uric acid and LDH • If bleeding, should check *PT/PTT • Fine needle aspiration or biopsy of mass or lymph node, bone marrow biopsy and CSF for cytology (limited locations capable of performing, will need referral to capable facility) Management • Referral to capable specialty hospital with ability to provide chemotherapy • If febrile, start ceftriaxone 50mg/kg/day IV • Blood transfusion as needed for hematologic stability • Start IV fluids for elevated WBC count or high tumor burden. Do not use RL or any other solution that contains potassium, as there is high risk for tumor lysis syndrome. Common Chemotherapy Agents and Their Common or Dangerous Side Effects Chemotherapy Agents (potentially available) Side Effects Cyclophosphamide Hemorrhagic cystitis, myelosuppression, SIADH, vomiting Doxorubicin Mucositis, cardiotoxicity, liver toxicity, vesication, vomiting Methotrexate Renal failure, mucositis, liver toxicity, myelosuppression, vomiting Prednisone/dexamethasone Hyperglycemia, hypertension, mood swings Vincristine Peripheral neuropathy, constipation, vesication Complications • Heart failure/respiratory distressºº From significant anemia or tumor invasion itself or chemotherapy complicationsºº Start specific cancer treatment; may start steroids alone while in transfer to hospital with chemotherapyºº May need Lasix or steroids as appropriate 25. Leukemia/Lymphoma 87 • Tumor lysis syndrome—hyperkalemia, hyperphosphatemia, hyperuricemia , acute renal failureºº Prevent or treat with allopurinol 10mg/kg/day PO divided every 8 hours and IV hydration (ideally 2× maintenance if appropriate supportive care to monitor for fluid overload complications) • Spinal cord compression (often seen with Burkitt lymphoma)ºº Dexamethasone 1mg/kg IV q4–6hºº Urgent referral to hospital center with ability for chemotherapy • Increased intracranial pressureºº Fluid restrict to ¾ maintenance rateºº Dexamethasone 1mg/kg IV q4–6hºº Acetazolamide 5mg/kg q6hºº Mannitol 0.25–1g/kg IV • Mediastinal mass/upper airway lesion—high risk for airway compromise; avoid sedation without appropriate staff/airway protection available; can give steroids while en route to higher-­ level care • Infections—very high risk for serious infections; requires ceftriaxone immediately while other investigations occurringºº Add gentamicin for pseudomonal coverageºº Add metronidazole for oral lesions Leukemia • Pancytopenia or leukocytosis on FBP • May see myeloblasts or lymphoblasts on peripheral smear • Often with bone pain/leg pain due to bone marrow expansion Burkitt Lymphoma • B-­ cell type of non-­ Hodgkin lymphoma • Neoplastic proliferation of lymphoid tissue that is rapidly growing • Associated with EBV infection and repeated malaria infections 88 Hematology/Oncology...


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