Lactic acidosis in patients with cancer.

Lactic acidosis is the most common metabolic acidosis in hospitalized patients-the result from an underlying pathogenic process. To successfully manage lactic acid production, its cause needs to be eliminated. Patients with cancer have many risk factors for developing lactic acidosis, including the cancer diagnosis itself. Patients with lactic acidosis are critically ill, requiring an intense level of nursing care with accompanying frequent cardiopulmonary and renal assessments. The mortality rate from lactic acidosis is high. Therefore, appropriate nursing interventions may include end-of-life and palliative care.

Gemcitabine-associated thrombotic thrombocytopenic purpura and hemolytic uremic syndrome.

A patient being treated for metastatic adenocarcinoma of the pancreas presents to the clinic for a routine appointment. A complete blood count reveals hemoglobin of 6.5 g/dl and a platelet count of 30,000 K/mm3 thought to be from the last of many doses of gemcitabine. On assessment, the only complaint was fatigue with no evidence of bleeding or other abnormal physical findings other than pallor. Past medical history includes hypertension managed with three antihypertensive agents. Additional laboratory tests reveal elevated blood urea nitrogen (69 mg/dl), creatinine (2.76 mg/dl), and lactic dehydrogenase (LDH), was well as indirect bilirubin (2.1 mg/dl). The patient is admitted and transfused with packed red blood cells (pRBCs). The next day, the platelet count drops to 9,000 K/mm3 and the hemoglobin increases, appropriately, to 8.9 g/dl. Urinalysis is positive for hemoglobin (+ 3). The peripheral blood smear is positive for schistocytes (fragmented RBCs). A pheresis catheter is placed after the patient was evaluated by a hematologist and a nephrologist. A presumptive diagnosis of thrombotic thrombocytopenic purpura (TTP) with hemolytic uremic syndrome (HUS) was made.

Care of the open abdomen after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies.

A patient with a mucinous appendiceal cancer presents to the surgeon complaining of abdominal discomfort and nausea. Having undergone a prior right hemicolectomy, the patient has been disease free and on surveillance with clinical and carcinogenic antigen (CEA) monitoring. The CEA was noted to be elevated and a computed tomography scan revealed peritoneal nodules throughout the abdomen with a presumptive diagnosis of pseudomyxoma peritonei (progressive peritoneal implants from a mucinous primary). Several therapeutic options were offered and the patient selected to undergo cytoreductive surgery (CRS) with the potential to receive hyperthermic interoperative chemotherapy (HIPEC). Extensive resection was performed, including removal of the entire greater omentum, partial gastrectomy, and total pelvic exenteration with end colostomy and ileal conduit. Reassessment of the peritoneal cavity after the resections revealed almost complete cytoreduction. HIPEC was performed with mitomycin C and, after drainage and abdominal washing, the intestinal segments were anastomosed and the abdominal wall closed. Seven days postoperatively, an acute abdomen with septic shock developed as a result of a leak from the ileocolonic anastomosis. The patient returned to the operating room and an exploratory laparotomy, a small bowel resection, a resection of the ileocolonic anastomosis, and an abdominal washout were performed. Edema of the bowel caused by peritonitis resulting from the anastomotic leak necessitated delayed closure of the abdominal wall. A temporary abdominal closure using the ABThera™ Open Abdomen Negative Pressure Therapy system was applied and the abdomen was eventually closed.