Anticoagulation and bleeding in the cancer patient.

Cancer patients have an increased risk of bleeding compared to non-cancer patients with anticoagulant therapy. A bleeding risk assessment before initiation of anticoagulation is recommended. Currently low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) are the mainstays of treatment for cancer-associated venous thromboembolism (VTE). Since DOACs are administered orally, they offer some convenience and ease of administration; however, LMWH may be preferred in certain cancers. Given the prevalence of anticoagulant therapies in cancer patients, clinical providers must be able to recognize potentially critical bleeding sites and modalities to reverse major hemorrhage. Reversal agents or antidotes to bleeding may be required when bleeding is persistent or life-threatening. These include vitamin K, fresh frozen plasma (FFP), protamine, prothrombin complex concentrate (PCC) or andexanet alfa, and idarucizumab. Inferior vena cava (IVC) filter insertion can be also considered in those with major bleeding. Evidence for timing and need for re-initiation of anticoagulant therapy after a major bleeding remains sparse, but a multi-disciplinary approach and shared decision-making can be implemented in the interim.

Assessing Compliance With Established Pneumonia Core Measures at a Comprehensive Cancer Center.

Healthcare organizations use Pneumonia Core Measures (PCMs) to ensure delivery of high-quality care. In this study, a multidisciplinary team was organized to optimize care and enhance compliance in a comprehensive cancer emergency center. We performed a four-phase study, three of which were interventional: intense education regarding PCM; microbiologic analysis of the pathogens responsible for the pneumonias; development and implementation of an institutional pneumonia algorithm and order set. In phase 4, we analyzed five PCMs. The percentage of pneumonia patients from whom blood cultures were obtained increased from 73% to 91% after intervention (p < .001); sputum cultures increased from baseline 24.6% to 51% (p = .004) post order-set implementation, and order-set utilization increased from 40% to 77%. We achieved the benchmark for only one PCM, PN 3a. More than 80% of patients met clinical and microbiological criteria for healthcare-associated pneumonia. We identified a gap between our patient population and some PCMs that relates to antibiotics selection. The treatment of cancer patients and pneumonia falls outside established guidelines for treating community-acquired pneumonia. Although the algorithm and order set implemented optimized care and minimized variation, national benchmarks for four of the PCMs were not met. Our findings provide information for policymakers considering pneumonia measurements for antibiotic selection in a cancer care setting.

Etomidate use for Cushing's syndrome caused by an ectopic adrenocorticotropic hormone-producing tumor.

OBJECTIVE: To report the preparation and use of etomidate in a patient with Cushing's syndrome caused by an ectopic adrenocorticotropic hormone (ACTH)-producing tumor. CASE SUMMARY: A 73-year-old man with a 5 year history of prostate cancer was admitted for symptoms consistent with Cushing's syndrome. He was started on oral metyrapone for elevated serum cortisol, ACTH, and 24 hour urinary unbound cortisol levels. Shortly after starting metyrapone, he was transferred to the medical intensive care unit for new-onset atrial fibrillation, neutropenic fever, and respiratory failure. A nasogastric tube could not be inserted to administer metyrapone. Intravenous etomidate 4 mg/h (0.06 mg/kg/h) was initiated to decrease cortisol production and provide sedation for mechanical ventilation. Despite supportive treatment, the patient died from multiple organ dysfunction. DISCUSSION: For patients exhibiting signs and symptoms of Cushing's syndrome who have no enteral access, administering etomidate intravenously may be a viable alternative treatment route. Although several articles report the use of etomidate to control cortisol overproduction, the intravenous preparation and stability are discussed only vaguely. In our patient, etomidate was infused via a 30 mL syringe, 2 mg/mL undiluted through a central venous catheter; syringe use was limited to 24 hours. Etomidate should be infused only with continuous monitoring of hemodynamics and periodic assessment of adrenal function. CONCLUSIONS: When oral or enteral medications cannot be administered and sedation is required in critically ill patients, etomidate is an appropriate intravenous agent for hypercortisolemia. There were no obvious problems with stability when undiluted etomidate 2 mg/mL was infused through a dedicated central venous catheter lumen.