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Melissa, I agree with you on the needing a refresher from my inpatient TLS days. I truly have not had to give Rasburicase in the outpatient setting. But is that because our patients are waiting too long and ending up inpatient?
I agree we need a smart phrase for our AVS for patient education. I remember seeing TLS on 15 James that happened so quickly it was shocking. In 6 years outpatient I really can’t think of 1 incident were TLS was a concern. I am sure it has been but I have not been part of it.Stephanie & Harms, the things you 2 do and see in CTU is amazing. And it is so refreshing to see the “proactive” treatments that go on their. I remember the pt coming back for lysis labs & complaining about having to come back in for labs until it was explained to them what the labs were for & how it would better them to get the labs & not be home sick or in their local ED. Your nursing worklists are so complex & thorough, I wonder what happens to certain “steps” in a protocol once they leave CTU, like the 24-48hr labs.
Holly you bring up a good point. How far do we screen for TLS in outpatient setting. I was in the CTU the other day and a good bit of their patient were being screened (unsure of the med) but not so much for 5th floor chemo. Sometimes I get so used to looking for the hold parameters labs that maybe my practice should include looking at the uric acid levels more in the outpatient setting.
1. What was the knowledge gained from the article? I learned from these articles that is important to complete thorough assessments when evaluating for risk of TLS. Although TLS can occur in hematologic malignancies like lymphomas, it is also found to happen in solid tumors.
2. Will the research/information change or influence your practice? I feel that I will be looking at patients with comorbidities like renal insufficiency and dehydration closer for potential TLS. Catching this early is key to their treatment and recovery so I will change my practice to think about this diagnosis in the solid tumor patients I care for. We do have some physicians that draw an LDH which I assume it look at their tumor burden level and I will pay more attention to this on lab draw to identify those at risk.
3. What other questions does this article raise? I wonder how much physicians in solid tumors address TLS and what the incidence is in our facility. If they are checking LDH for this reason, are they following up on this potential for TLS and pre treating with allopurinol? I haven’t heard of this but don’t work in clinic setting either.
Michelle, I too wonder how often this is happening at home and if we are catching and treating it? I do too think that a lab draw 72 hours after would be a good idea with patients that has a risk for TLS.
Megan Burk
Melissa- I think that the pre hydration is quite interesting as well. What an easy way to educate and hopefully prevent the TLS. Educating that patient on the potential dangers for TLS I believe is important and I hope when these patients get chemo education that is one of the main points that is hit during education. It could help and save a lot.
Megan Burk
I really enjoyed reading both articles.
1. What was the knowledge gained from the article? For me, the articles provided an excellent explanation of TLS, – a condition I saw as a floor rn but do not expect to see in the GI and GU oncology surveillance clinics where I currently work. From the articles, I got a better understanding of the pathophysiology involved. In addition, I was not aware of G6PD as a risk factor for TLS
2. Will the research/information in this article change or influence your practice? If so, how? I do not expect to see current chemo patients in my practice, however, I will be paying more attention to the identification of patients at high risk of TLS development among those with disease progression who require referral for further chemotherapy.
3. What other questions does the article raise about current practice? I agree with others over the concern of recognizing TLS outpatient.conrad.369 I re-read the case studies several times focusing on the rasburicase induced methemoglobinemia.That was new information for me. I applaud you to taking the time to share the information with your inpatient nurse friends.
smith.10494 These articles helped me see that I needed some additional education on this topic too, even though I am not directly involved in chemo administration at this time. There is a learning unit on tumor lysis syndrome available on buckeye learn that was brief to complete. There is also an oncological emergency lecture by Scott Rowley that I plan to listen to when I have some time.
Wine.40 I didn’t realize there was a CBL for TLS. Going to look for it today. I think TLS is complex in general but to monitor for it in outpatient setting seems complicated. Michelle you bring up a good point. CTU has very rigorous scheduling that allows monitoring for such issues but what sticks after the drugs and regimens are approved?
1. What was the knowledge gained from the article?
While an inpatient nurse I only remember the STAT team mentioning methemoglobinemia a couple of times and I had no idea it was caused by rasburicase. We did not routinely give pre-treatment rasburicase with our patients either. Everyone was started on allopurinol pre-treatment, but rasburicase was reserved for TLS that did not respond to other interventions.
2. Will the research/information in this article change or influence your practice? If so how?
TLS is seen with much greater frequency in the inpatient population, since AML is treated there. But I probably should keep a better eye out for it in the outpatient world as well, especially with heme patients. With the relative lack of use of rasburicase, I don’t think it would be worth pre-screening each patient at risk for G6PD deficiency. One of the challenging aspects of TLS for outpatient nurses is the fact that 48–72 hours after treatment. Typically the patient is at home during this time. By the time we would see them again in a week or more they could be very sick.
3. What other questions does the article raise about current practice?
Do we need to screen for methemogloinemia routinely in our clincs? I don’t think so. Should we routinely screen for TLS? I think we really should. We routinely check bloodwork but don’t have a TLS specific assessment or assessment tools. I think these articles argue that we should.Burke.109- You bring up a good point about solid tumors. I do not see routine use of allopurinol or routinely drawing uric acid, LDH levels, etc in the solid tumor population. In everyone’s comments it sounds like we all agree there is no institutional standard for TLS but there should be. It sounds like it is clinic specific and even provider specific.
Michelle,
I also remember seeing things like TLS and flash pulmonary edema on 15E and it was always considered an emergency. I really hope someone experiencing those symptoms at home would dial 911. The only clinic that sees patients several days in a row is radiation oncology, and I’ve never heard of TLS from radiation. The greatest frequency I see in outpatient infusion is weekly, and that would be too late for TLS. I think patient and family member education would be key in these situations.
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