When I first started working in oncology, I had never heard of tumor lysis syndrome. It was one of the first things I researched to understand better. I found it fascinating: tumor shrapnel clogging up the kidneys.
Tumor lysis syndrome is actually a complicated group of metabolic disturbances that occurs when bulky tumors that are treatment-responsive die quickly and shed metabolic byproducts into the circulation. It is most commonly associated with leukemias and lymphomas but can occur with solid tumor diseases as well.
As with many oncologic emergencies, being proactive is key. Often high-risk patients begin allopurinol prior to initiation of chemotherapy. Since volume depletion is a significant risk factor, aggressive IV hydration may be done. If supportive measures, as well as correcting electrolyte imbalances with medications, are ineffective, sometimes patients require dialysis.
The first time I actually saw tumor lysis syndrome in practice, it was a patient with lymphoma who hadn't even been diagnosed, let alone treated. The lymphoma grew so quickly the tumor's vasculature couldn't keep up with the demand, and it began to die all on its own. The patient presented in acute distress, requiring intubation and dialysis. So naturally, once the metabolic disturbances were reversed and chemotherapy began, we had to anticipate a recurrence of tumor lysis syndrome.
I could launch into a really lengthy pathophysiology on tumor lysis syndrome, but let's face it: what nurses really want to know and are most likely to remember is care of the patient. Besides, we have lots and lots of textbooks that more than abundantly explain the pathophysiology.
As someone relatively new to oncology, what continues to amaze me is how the basic principles of good nursing care are the keys to managing any patient. Of course, there are differences in the various specialties, but good nursing skills give you a leg up in any specialty.
For instance, an oncology nurse knows specifically that a patient with non-Hodgkin's lymphoma who started chemotherapy 48 hours ago is at high risk for tumor lysis syndrome. However, any nurse in the hospital knows generally that a patient receiving continuous IV fluids and having his electrolytes closely monitored needs to have his intake and output accurately measured. Something as simple as oliguria reported to the oncologist can help stop tumor lysis syndrome in its tracks.
Nurses who float to oncology units can use good judgment in assessment and reporting. Even though they may not truly understand tumor lysis syndrome, they can still use their nursing skills to identify a problem early. Common and reportable symptoms a nurse might identify include:
- Flank pain
- Abdominal pain and distention
- Itchy skin
- Metallic taste in the mouth
- Restless legs
Additionally, the hallmark symptoms of hypocalcemia and hyperkalemia should be part of a nurse's knowledge base, whether or not she works in oncology.
On the other hand, the less than observant nurse who doesn't measure urine output because "it isn't ordered" may miss key symptoms such as oliguria.
When nurses do not design and implement quality care plans that address patient needs, we become automatons instead of autonomous. Something as simple as an intake and output measurement can make a big impact on patient outcomes, and nurses shouldn't wait on a physician to tell them to implement good nursing interventions.
Certainly not every incidence of tumor lysis syndrome is preventable, but prevention and early detection play a big role in successfully managing this oncologic emergency.