Tumor Lysis Syndrome Clinical Pathway — Inpatient, ICU | Children's Hospital of Philadelphia

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

New Diagnosis or Relapse of a Hematological Malignancy
or Bulky Solid Tumor at Risk for Tumor Lysis Syndrome (TLS)

Team Assessment

History and Physical, VS, MS
Review labs
- CBC, BMP (K, Ca, creatinine), Phos, Uric acid, LDH, G6PD
- Blood gas, lactate if poor perfusion or respiratory distress
Consider CXR
Consider 12-lead ECG
- Electrolyte derangement or dysrhythmia
- Symptomatic with palpitations/dizziness
- Other clinical concerns

TLS Definition
Goals of Therapy
Classic electrolyte derangements
- Hyperphosphatemia
- Hyperuricemia
- Hyperkalemia
- Hypocalcemia
Novel Agents associated with increased risk of TLS

Assess for Emergent TLS Signs/Symptoms

Laryngospasm, bronchospasm
Hypotension, heart failure due to decreased calcium
Seizures
Neuromuscular irritability, sensory disturbance
Urine output
- Oliguria: < 0.5 ml/kg/hr x 6 hrs

No emergent
TLS signs/symptoms

Emergent
TLS signs/symptoms

Assess for Laboratory or Clinical TLS

Signs/Symptoms of TLS
Labs for electrolyte derangements

Emergent TLS Signs/Symptoms

Admit/transfer to ICU
Consult Nephrology
- Consider Renal Replacement Therapy

No concerning
labs or symptoms

Concerning
labs or symptoms

Possible Comorbidities

Pre-existing renal conditions
Dehydration
Acidosis
Nephrotoxins
Mediastinal mass

Assess Risk for TLS

Assess Tumor Burden
Review risk assignment with Oncology Fellow/Attending

Low
Tumor Burden

Intermediate
Tumor Burden

High
Tumor Burden

Assess
Comorbidities

Not
Present

Present

Not
Present

Present

	Low Risk of TLS	Intermediate Risk of TLS	High Risk of TLS or Laboratory/Clinical TLS	Severe TLS
Hydration: D5NS No K, No Phos Do not alkalinize	Maintenance IVF	1.5x MIVF	2x MIVF	2x MIVF
Monitoring	Labs Daily VS q4hr I&O q4hr Weight daily	Labs q8-12hr VS q4hr I&O q4hr Weight daily	Labs q6-8hr VS q4hr ECG if not previously obtained Continuous CR monitor if abnormal ECG I&O q4hr Weight daily	Labs q4-6hr VS per ICU standards ECG and initiate supplemental arrhythmia monitoring I&O q4hr Weight daily
Prophylaxis Medications		Allopurinol	Allopurinol Add rasburicase if uric acid ≥ 8 mg/dL	Allopurinol Add rasburicase if uric acid ≥ 8 mg/dL

Contraindications to Hyperhydration

Suspected metabolic disease
Hypoglycemia
Liver failure
Adrenal insufficiency
Abnormal renal function
Heart failure
Neurosurgical patients
SIADH
Nephrotic syndrome
Diabetes insipidus

Correct Laboratory Abnormalities

Assess Treatment Response

TLS resolution
- Normalized electrolytes, BUN, creatinine
- No evidence of fluid overload
- Normalized BP, UOP
- No cardiac arrhythmias
- Clinical symptoms resolved

Resolved TLS

Ongoing TLS

Uncontrolled TLS

Discontinue hyper-hydration
Decrease lab monitoring
- Reduce to next lower
  risk frequency
- Reassess every 24 hrs
- Off monitoring after 72 hrs
Discontinue medications
- Allopurinol when uric
  acid normalizes
- Phosphate binders when phosphate normalizes

Escalate treatment and monitoring to next level of risk

Consult Nephrology
- Consider Renal Replacement Therapy
- Reassess vascular access as needed
Admit/transfer to ICU

Posted: May 2021
Last Revised: March 2024

Authors:
- A. Reilly, MD;
- H. Rhodes, CRNP;
- V. Batra, MD;
- C. Croy, PharmD;
- J. Freedman, MD;
- B. Laskin, MD;
- K. Takasaki, MD

Editors: Clinical Pathways Team

Evidence

CHOP Programs

Cancer Center

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

Inpatient and ICU Clinical Pathway for Evaluation and Treatmentof Oncology Patients at Risk for Tumor Lysis Syndrome (TLS)

Evidence

CHOP Programs

Inpatient and ICU Clinical Pathway for Evaluation and Treatment
of Oncology Patients at Risk for Tumor Lysis Syndrome (TLS)