癌癥兒童的急癥處理鄭兆能國立成功大學醫學院附設醫院小兒部癌癥兒童的急癥處理鄭兆能國立成功大學醫學院附設醫院1癌癥兒童的急癥產生的原因腫瘤壓迫重要器官代謝產物血球減少–出血、發燒癌癥兒童的急癥產生的原因2癌癥兒童的急癥依照系統來區分有胸腔內腹腔泌尿系統神經系統代謝方面癌癥兒童的急癥依照系統來區分有3胸腔內的急癥前縱膈腔上腔靜脈癥候群(SVCsyndrome)上縱膈腔癥候群(Superiormediastinalsyndrome)中縱膈腔心臟內腫瘤心包填塞心肌炎及心肌病變後縱膈腔Spinalcordcompression肺部胸腔內的急癥前縱膈腔4SVCsyndrome(1)上腔靜脈被壓迫甚至阻塞如果氣管也被壓迫則為上縱膈腔癥候群(SMS)發生原因：靜脈管壁較薄，易被壓扁小孩氣管軟骨易被壓扁且管脛較小上腔靜脈的周圍是淋巴結及胸腺淋巴瘤最常見，其次是ALL及固態腫瘤SVCsyndrome(1)上腔靜脈被壓迫甚至阻塞5SVCsyndrome(2)IncidenceofmediastinalmassandSVCsyndromeDiagnosis No.ofpatient MediastinalmassSVCsyndromeALL 1464 130(8.4%)6(4.6%)AML 392 9(2.3%) 0Hodgkin’s 333 102(30.6%) 2(2.0%)NHL 330 230(69.7%) 8(3.4%)Neuroblastoma332 69(20.8%) 3(4.3%)Germcelltumor114 10(8.8%) 2(20%)Sarcoma 696 26(3.7%) 3(11%)St.JudeMedPedOncol1990;18:476SVCsyndrome(2)Incidenceofm6SVCsyndrome(3)臨床癥狀呼吸窘迫、咳嗽、胸痛、吞嚥困難、聲音沙啞、躺平時癥狀更嚴重上肢及臉水腫、充血、頸靜脈擴大、結膜充血、呼吸有喘鳴聲、有時會有肋膜及心包膜積水SVCsyndrome(3)臨床癥狀7SVCsyndrome(4)照顧時注意事項可採取趴躺較舒服嚴禁麻醉、鎮靜劑除非不得已，獲得腫瘤組織切片後再治療SVCsyndrome(4)照顧時注意事項8SVCsyndrome(5)SVCS/SMSCXRMassCBC;OtherstudiesDiagnosticTreatNon-DiagnosticDDXAssessriskLowriskbiopsyTreatHighriskTreatReassessSVCsyndrome(5)SVCS/SMSCXRM9SVCsyndrome(6)緊急治療放射治療化學治療手術治療如果是血栓塞住SVC則要用抗凝劑未獲得診斷前緊急放射治療的壞處只是經驗療法，可能沒效癌細胞可能在幾天內就死光了，而無法獲得正確的診斷前幾天可能因edema而更嚴重SVCsyndrome(6)緊急治療10SVCsyndrome(7)一般而言，Lymphoma對R/T很有效ALL用chemotherapy，同時對mass及hyperleukocytosis都有效，除非有acuterenalfailure才使用R/T對於teratoma,large-celllymphoma,neuroblastoma,germcelltumororbenigntumor，大概都要用手術才有效SVCsyndrome(7)一般而言，Lymphoma11PleuralandPericardialeffusion(1)分成transudates及exudates區別方法：protein、比重、pH、WBCExudates：infection或malignancyTransudates：可能是fluidoverload、heartfailure、hypoproteinemia,sympatheticresponsetotumor也可能是ChylouseffusionPleuralandPericardialeffusi12PleuralandPericardialeffusion(2)癥狀：dyspnea,orthopnea,chestpain,cough要抽嗎？抽的適應癥：呼吸窘迫心臟壓迫為了診斷清除以免藥物毒性，例如MTXPleuralandPericardialeffusi13PleuralandPericardialeffusion(3)治療：治療癌癥本身重複抽放置catheter打入硬化劑(肋膜硬化術)(Pleurodesis)手術切除肋膜或是心包膜PleuralandPericardialeffusi14Hemoptysis可能原因：流鼻血嗆入咳出PulmonaryaspergillosisPneumonia(S.aureus,Klebsiella,Pseudomonas)凝血功能異常腫瘤吃到肺部血管(小孩少見)Hemoptysis可能原因：15PneumothoraxorPneumomediastinum可能原因：

肺炎或縱膈腔發炎因化療吐太厲害造成破裂食道穿孔腫瘤侵犯肺纖維化(R/Torbleomycin)PulmonaryhistiocytosisPneumothoraxorPneumomediasti16RetinoicAcidSyndrome發生於APL的病人吃All-trans-retinoidacid(ATRA)，常合併hyperleukocytosis癥狀：發燒，呼吸窘迫，體重增加，fluidretention，肋膜或心包膜積水，血壓降低，腎衰竭治療：DexamethasoneRetinoicAcidSyndrome發生於APL17癌癥病人腹腔急癥(1)腸胃道出血腸胃道阻塞腸胃道破裂腸胃道發炎及感染肛門周圍膿瘍膽管炎及膽道阻塞Veno-occlusiondisease(VOD)Massivehepatomegalyinneuroblastoma出血性胰臟炎癌癥病人腹腔急癥(1)腸胃道出血18癌癥病人腹腔急癥(2)最主要的癥狀是‘痛’即使有很嚴重的infection也不一定會發燒每天很仔細的physicalexamination及配合laboratoryanddiagnosticstudies癌癥病人腹腔急癥(2)最主要的癥狀是‘痛’19腸胃道出血食道靜脈瘤出血肝腫瘤肝炎及肝硬化上腸胃道出血類固醇嘔吐造成Mallory-Weisstear壓力性潰瘍下腸胃道出血Infection(typhlitis)腸套疊痔瘡及肛門裂傷腸胃道出血食道靜脈瘤出血20腸胃道阻塞藥物造成：Oncovin，Morphine腸子沾黏或狹窄腸套疊腫瘤壓迫阻塞：Burkitt’s淋巴瘤，sarcoma，GIcarcinoma，presacralteratoma腸胃道阻塞藥物造成：Oncovin，Morphine21腸胃道破裂Ulcerorgastritis太厲害Obstruction沒解決InfectionTumorerosionTherapyresponse腸胃道破裂Ulcerorgastritis太厲害22Typhlitis盲腸附近的壞死性腸炎右下腹痛(很像闌尾炎)通常在化學治療後血球很低時必須給予廣效抗生素開刀的適應癥：持續性腸胃道出血腸胃道破裂無法控制的敗血癥(如血壓不穩….)SymptomsnormallyrequireanoperationTyphlitis盲腸附近的壞死性腸炎23PseudomembranousColitisClostridiumdifficileinfection因為使用抗生素造成Oralmetronidazole(5mg/kgq6h)OralVancomycin(125mgq6h,50mgq6hforBW<30kg)PseudomembranousColitisClostr24Veno-OcclusionDisease發生在肝靜脈，右上腹痛，肝腫大，體重增加5%，腹水，黃疸通常發生在BMT的病人6-TG也會(forALL)Oncovin+Dactinomycin也會(forWilmsandRhabdomyosarcoma)主要是靠支持性療法Veno-OcclusionDisease發生在肝靜脈，右25肛門周圍膿瘍肛門周圍疼痛，壓痛，解便痛肛門周圍水腫(woodyedema)，像蜂窩組織炎因血球很低，可能沒有膿通常是混合感染(嗜氧、厭氧、黴菌)給予廣效抗生素及坐浴(Sitzbath)手術切開引流可能形成瘻管肛門周圍膿瘍肛門周圍疼痛，壓痛，解便痛26HugeHepatomegalyinNB神經母細胞瘤stage4S有呼吸窘迫時才處理肝臟腫大ChemotherapyIrradiation(150cGYx3days)手術擴大腹壁(Silasticpouch)HugeHepatomegalyinNB神經母細胞瘤27出血性胰臟炎L-asparaginaseandcorticosteroid主要癥狀是嘔吐及上腹痛NPO,NGdecompressionImipenem+SandostatinIVFhydrationSurgicaldrainageforpancreaticabscessorpseudocyst出血性胰臟炎L-asparaginaseandcorti28癌癥病人的泌尿道急癥OliguriaandAnuriaHypertension出血性膀胱炎癌癥病人的泌尿道急癥OliguriaandAnuria29OliguriaandAnuria分成腎前性、腎性、腎後性、神經性腎前性：敗血性休克或脫水腎性：化學藥物，抗生素，抗黴菌藥腎後性：Tumorlysissyndrome，腫瘤壓迫輸尿管或膀胱神經性：主要是脊髓神經或骨盆腔神經叢受侵犯或藥物影響如Narcotics、Oncovin、herpeszosterOliguriaandAnuria分成腎前性、腎性、30Hypertension腎素(Renin)分泌增加腎血管性腫瘤分泌如Wilms’tumor，神經母細胞瘤，Pheochromocytoma腦壓上升腦瘤，中樞神經白血病，腦膜腦炎藥物造成類固醇，Cyclosporin，AmphotericinBHypertension腎素(Renin)分泌增加31出血性膀胱炎(1)癥狀：頻尿、小便困難、小便疼痛造成原因：感染、放射治療、化學藥物感染：Adenovirus,CMV,polyomavirusBK(BKvirus)化學藥物：CyclophosphamideandIfosfamideMayoccurhourstomonths出血性膀胱炎(1)癥狀：頻尿、小便困難、小便疼痛32出血性膀胱炎(2)治療：Hydration矯正凝血功能異常Onfoley膀胱灌洗Ditropan,Baclofen,Belladonna,opioidEndoscopyandelectrocoagulationInstillationofformalin,alum,PGE2出血性膀胱炎(2)治療：33癌癥病人的神經急癥意識不清中風(CVA)SeizureIT藥物注射錯誤SpinalcordcompressionHyperleukocytosis癌癥病人的神經急癥意識不清34癌癥病人意識不清(1)TumorInfectionCVASeizureDICTherapy-relatedLeukoencephalopathyMetabolicPost-R/TsomnolenceSyndromeHypotensionHypertensionDehydrationHypoxiaAnemiaLiverfailureDepression癌癥病人意識不清(1)TumorMetabolic35癌癥病人意識不清(2)詢問病史時的注意事項StatusofmalignancyRecentillnessFeverMedicationChemotherapyandradiotherapySeizureactivityorsimilarepisode癌癥病人意識不清(2)詢問病史時的注意事項36癌癥病人意識不清(3)身體檢查時的注意事項Consciousnesslevel(comascales)BreathingpatternPupilsizeandreactivityAbnormalextraocularmovementRostrocaudalorcentralherniationUncalherniation癌癥病人意識不清(3)身體檢查時的注意事項37癌癥病人意識不清(4)實驗室檢查及評估CBC,glucose,electrolytes,ammonia,hepaticandrenalfunction,bloodculture,coagulationprofilesEmergentCTorMRIscanLumbarpunctureshouldnotbeperformeduntilmasslesionbeR/O癌癥病人意識不清(4)實驗室檢查及評估38治療導致的意識不清(1)頭部放射治療類固醇:personalitychange,hallucinationandpsychosisHD-Ara-C:cerebellardysfunction,seizure,coma,deathHD-MTX:encephalopathy,seizureIfosfamide:acutesomnolence,neurologicdeterioration,coma治療導致的意識不清(1)頭部放射治療39治療導致的意識不清(2)動脈注射BCNU,cisplatin:acuteneurologicdeterioration,seizure,stroke,encephalopathy遺傳性缺乏dihydropyrimidinedehydrogenasewith5-FUHD-thiotepa,BCNU:encephalopathyATRA:pseudotumorcerebri治療導致的意識不清(2)動脈注射BCNU,cisplati40治療導致的意識不清(3)HD-narcotics:sedation,withdrawalsymptomsBenzodiazepine:dysphoriaHD-IL2:disorientation,confusion,paranoia,combativeness,somnolence,coma干擾素:subacutesomnolence,alteredcognition,psychiatricsymptoms,conceptualdisorganization,focalneurologicdeficit,corticalblindness,coma,death治療導致的意識不清(3)HD-narcotics:seda41意識不清---治療(1)IICP:Decadron,mannitol,hyperventilation感染的可能:Broad-spectrumantibioticsNeurosurgicalinterventionifindicationSpecificantidoteforifosfamideencephalopathyismethyleneblueSteroidsamelioratetheIL-2CNSeffect意識不清---治療(1)IICP:Decadron,42意識不清---治療(2)LeucovorinorcarboxypeptidaseforMTXHyperbaricoxygenationandanticoagulationforR/TvasculitisNaloxonefornarcoticsFlumazepineformidazolam意識不清---治療(2)Leucovorinorc43中風(CVA)依照發生的時間原因可能不同剛診斷癌癥時:disease-relatedcoagulationabnormalities在治療中:chemotherapy-relatedorinfection末期癌癥:sepsis,DIC,CNSinfection,progressivetumorMonthstoyearspostR/Tvasculitis中風(CVA)依照發生的時間原因可能不同44SeizureTumorBraintumorCNSleukemiaHyperleukocytosisCNSinfectionCVATherapy-relatedHD-MTX,HD-Ara-CIT(Ara-C,MTX)L-asparaginaseR/TMetabolicabnormalityHypoxiaSeizureTumorTherapy-related45IT藥物注射錯誤(1)ITMTX<100mg：可能沒事或頭痛ITMTX>500mg：seizure,coma,deathITAra-C200mg：dilatedpupilsITEpirubicin：delayedonset,deathIToncovin：ascendingparalysis,coma,death(幾乎必死無疑)IT藥物注射錯誤(1)ITMTX<100mg：可能46IT藥物注射錯誤(2)一發現時馬上的動作CSF

drain-outCSFexchangewithL-RandFFPVentricularcatheterplacementforventriculolumbarperfusionIT藥物注射錯誤(2)一發現時馬上的動作47IT藥物注射錯誤(3)IT-MTXoverdoseIT-carboxypeptidaseG2(CPDG2)SystemicleucovorinIVdexamethasonePyroxidineandGlutamicacidITleucovirinworseningneurotoxicityITcorticosteroidcontraindicationbecauseCSFmustbedrainedandexchangedIT藥物注射錯誤(3)IT-MTXoverdose48SpinalCordCompression(1)癥狀最早大概都是背痛ProgressiveweaknessSensoryabnormalitiesParesis,paraplegia,quadriplegiaUrinaryandfecalincontinenceSpinalCordCompression(1)癥狀49SpinalCordCompression(2)IncidenceofSCCinchildrenwithsolidtumorsEwingsarcoma 30(17.9%) 168Neuroblastoma 32(7.9%) 402Osteogenicsarcoma 16(6.5%) 243Rhabdomyoarcoma 14(4.9%) 287Hodgkindisease 8(2.0%) 404Softtissuesarcoma 4(3.9%) 102Germcelltumor 5(3.5%) 130Wilmstumor 2(0.7%) 290Total 113(5.0%) 2259Pathology Noofcases TotalcasesHepatoma 1(1.4%) 69Other 0 164St.JudeJNeurosurg1991;74:70SpinalCordCompression(2)Inc50SpinalCordCompression(3)任何懷疑或是癌癥的小朋友，只要有backpain都要考慮spinalcordcompression的可能如果有weakness甚至不能走路，馬上排MRI檢查如果沒有MRI，則排CTmyelographySpinalCordCompression(3)任何懷51SpinalCordCompression(4)如果history或NE有懷疑，先打dexamethasone再排MRI如果證實有mass，則除了Dexamethasone外，要馬上decompressionDecompression有localR/T，chemotherapy，以及surgicaldecompression可用如果診斷確定，而且又是radiosensitive，R/T通常是treatmentchoice如果是leukemia，lymphoma，neuroblastoma可用C/T如果R/TorC/T癥狀仍持續，手術無可避免SpinalCordCompression(4)如果52Hyperleukocytosis(1)定義：周邊白血球>100000/mL通常AML>200000/mL，ALL及CML>300000/mL比較會有癥狀造成癥狀的原因是increasebloodviscosity，AML又比ALL的血球更大更黏Hyperleukocytosis(1)定義：周邊白血球53Hyperleukocytosis(2)大部分沒癥狀，有些會有CNS、Pulmonary等癥狀，包括有：意識障礙、頭痛、視力模糊、seizure、coma、中風的癥狀、papilledemaandretinalvesseldistentionDyspnea、hypoxia、acidosisandcyanosisHyperleukocytosis(2)大部分沒癥狀，有些54Hyperleukocytosis(3)ComplicationinpatientswithhyperleukocytosisCNShemorrhage 2 9 <0.001K↑ 16 2 Ca↓,P↑ 15 3 Lunghemorrhage 2 3Acuterenalfailure 5 4 Respiratory 0 6 <0.001Complications ALL(n=161) AML(n=73) pvalueDeath 8 17 <0.001St.JudeJClinOncol1985;2:1590Hyperleukocytosis(3)Complicat55Hyperleukocytosis(4)治療：Hydration，maintenance的二到四倍AlkalinizationAllopurinolKeepPlatelet>20000沒有癥狀不要輸pRBC及FFPExchangetransfusion及leukapheresis(一次大概降50~60%)儘快化學治療有人預防性頭部放射性治療，預防腦出血Hyperleukocytosis(4)治療：56TumorLysisSyndrome(1)因癌細胞死後內涵物釋放至血液循環中典型表現：K↑、P↑、Uricacid↑當Ca×P>60calciumphosphate沉積secondaryCa↓Uricacid及calciumphosphate沉積會導致腎衰竭通常在開始治療後12~72小時發生常發生在Burkitt’slymphoma、lymphoblasticlymphoma、T-cellALLwithhyperleukocytosisTumorLysisSyndrome(1)因癌細胞死後內57TumorLysisSyndrome(2)癥狀：

腹痛、腹脹、背痛、嘔吐、腹瀉、脫水、食慾不振、cramps、spasms、tetany、seizure、意識不清TumorLysisSyndrome(2)癥狀：58TumorLysisSyndrome(3)評估：BP,HR,heartrhythm(EKG),CxR(mediastinalmassorpleuraleffusion)CBC,Na,K,Cl,HCO3,Ca(ionizedCaandalbumin),P,uricacid,BUN,Cre,U/AUSorCTtoR/Oobstructiverenalfailure(catheterization,exacerbatedbyhydration)TumorLysisSyndrome(3)評估：59TumorLysisSyndrome(4)Hydration:2~4倍,urineoutput100ml/m2/hrAlkalinization:urinepH7.0~7.5Uricacid:AllopurinolorUrateoxidaseK↑:Kayexalate,Calciumgluconate,RI+glucoseP↑:AluminumhydroxideCa↓:CalciumgluconateifsymptomaticTumorLysisSyndrome(4)Hydrati60TumorLysisSyndrome(5)Dialysisindications:Volumeoverload:plerualandpericardialeffusionsRenalfailureHyperkalemiaHyperphosphatemiaHyperuricemiaSymptomatichypocalcemiaTumorLysisSyndrome(5)Dialysi61Hypercalcemia(1)定義：Ca>12mg/dL兒童癌癥很少見，ALL和橫紋肌肉瘤Defectinrenalexcretion，increaseinboneresorption分成三種：humoral，osteolytic，calcitriol-mediatedEctopicparathyroid-likehormoneHypercalcemia(1)定義：Ca>12mg62Hypercalcemia(2)癥狀腸胃方面：食慾不振、噁心、嘔吐、便秘、Ileus心臟血管方面：心跳減慢、心律不整、毛地黃中毒神經肌肉方面：嗜睡、面無表情、憂鬱、疲倦、Hypotonia、Stupor、昏迷腎臟方面：多尿、夜尿Hypercalcemia(2)癥狀63Hypercalcemia(3)評估:CheckCa,P,BUN,Cre,Uricacid,ionizedCaCheckparathyroidhormone,parathyroidhormonerelatedpeptide,25-(OH)vitaminDand1,25-(OH)2vitaminDEKG(PRprolongedandbroadTwave)BonescanorskeletalsurveyHypercalcemia(3)評估:64Hypercalcemia(4)治療策略：

Hydration增加腎臟排出減少從骨頭的吸收治療本身癌癥Hypercalcemia(4)治療策略：65Hypercalcemia(5)一般治療Hydration+Lasix治療當中也要密切追蹤K,MgPamidronate(Aredia)---最常用Bisphosphonates如果是osteoclastorcalcitriol-mediatedPrednisoneSalmoncalcitoninMithramycinHypercalcemia(5)一般治療66謝謝謝謝67癌癥兒童的急癥處理課件68癌癥兒童的急癥處理鄭兆能國立成功大學醫學院附設醫院小兒部癌癥兒童的急癥處理鄭兆能國立成功大學醫學院附設醫院69癌癥兒童的急癥產生的原因腫瘤壓迫重要器官代謝產物血球減少–出血、發燒癌癥兒童的急癥產生的原因70癌癥兒童的急癥依照系統來區分有胸腔內腹腔泌尿系統神經系統代謝方面癌癥兒童的急癥依照系統來區分有71胸腔內的急癥前縱膈腔上腔靜脈癥候群(SVCsyndrome)上縱膈腔癥候群(Superiormediastinalsyndrome)中縱膈腔心臟內腫瘤心包填塞心肌炎及心肌病變後縱膈腔Spinalcordcompression肺部胸腔內的急癥前縱膈腔72SVCsyndrome(1)上腔靜脈被壓迫甚至阻塞如果氣管也被壓迫則為上縱膈腔癥候群(SMS)發生原因：靜脈管壁較薄，易被壓扁小孩氣管軟骨易被壓扁且管脛較小上腔靜脈的周圍是淋巴結及胸腺淋巴瘤最常見，其次是ALL及固態腫瘤SVCsyndrome(1)上腔靜脈被壓迫甚至阻塞73SVCsyndrome(2)IncidenceofmediastinalmassandSVCsyndromeDiagnosis No.ofpatient MediastinalmassSVCsyndromeALL 1464 130(8.4%)6(4.6%)AML 392 9(2.3%) 0Hodgkin’s 333 102(30.6%) 2(2.0%)NHL 330 230(69.7%) 8(3.4%)Neuroblastoma332 69(20.8%) 3(4.3%)Germcelltumor114 10(8.8%) 2(20%)Sarcoma 696 26(3.7%) 3(11%)St.JudeMedPedOncol1990;18:476SVCsyndrome(2)Incidenceofm74SVCsyndrome(3)臨床癥狀呼吸窘迫、咳嗽、胸痛、吞嚥困難、聲音沙啞、躺平時癥狀更嚴重上肢及臉水腫、充血、頸靜脈擴大、結膜充血、呼吸有喘鳴聲、有時會有肋膜及心包膜積水SVCsyndrome(3)臨床癥狀75SVCsyndrome(4)照顧時注意事項可採取趴躺較舒服嚴禁麻醉、鎮靜劑除非不得已，獲得腫瘤組織切片後再治療SVCsyndrome(4)照顧時注意事項76SVCsyndrome(5)SVCS/SMSCXRMassCBC;OtherstudiesDiagnosticTreatNon-DiagnosticDDXAssessriskLowriskbiopsyTreatHighriskTreatReassessSVCsyndrome(5)SVCS/SMSCXRM77SVCsyndrome(6)緊急治療放射治療化學治療手術治療如果是血栓塞住SVC則要用抗凝劑未獲得診斷前緊急放射治療的壞處只是經驗療法，可能沒效癌細胞可能在幾天內就死光了，而無法獲得正確的診斷前幾天可能因edema而更嚴重SVCsyndrome(6)緊急治療78SVCsyndrome(7)一般而言，Lymphoma對R/T很有效ALL用chemotherapy，同時對mass及hyperleukocytosis都有效，除非有acuterenalfailure才使用R/T對於teratoma,large-celllymphoma,neuroblastoma,germcelltumororbenigntumor，大概都要用手術才有效SVCsyndrome(7)一般而言，Lymphoma79PleuralandPericardialeffusion(1)分成transudates及exudates區別方法：protein、比重、pH、WBCExudates：infection或malignancyTransudates：可能是fluidoverload、heartfailure、hypoproteinemia,sympatheticresponsetotumor也可能是ChylouseffusionPleuralandPericardialeffusi80PleuralandPericardialeffusion(2)癥狀：dyspnea,orthopnea,chestpain,cough要抽嗎？抽的適應癥：呼吸窘迫心臟壓迫為了診斷清除以免藥物毒性，例如MTXPleuralandPericardialeffusi81PleuralandPericardialeffusion(3)治療：治療癌癥本身重複抽放置catheter打入硬化劑(肋膜硬化術)(Pleurodesis)手術切除肋膜或是心包膜PleuralandPericardialeffusi82Hemoptysis可能原因：流鼻血嗆入咳出PulmonaryaspergillosisPneumonia(S.aureus,Klebsiella,Pseudomonas)凝血功能異常腫瘤吃到肺部血管(小孩少見)Hemoptysis可能原因：83PneumothoraxorPneumomediastinum可能原因：

肺炎或縱膈腔發炎因化療吐太厲害造成破裂食道穿孔腫瘤侵犯肺纖維化(R/Torbleomycin)PulmonaryhistiocytosisPneumothoraxorPneumomediasti84RetinoicAcidSyndrome發生於APL的病人吃All-trans-retinoidacid(ATRA)，常合併hyperleukocytosis癥狀：發燒，呼吸窘迫，體重增加，fluidretention，肋膜或心包膜積水，血壓降低，腎衰竭治療：DexamethasoneRetinoicAcidSyndrome發生於APL85癌癥病人腹腔急癥(1)腸胃道出血腸胃道阻塞腸胃道破裂腸胃道發炎及感染肛門周圍膿瘍膽管炎及膽道阻塞Veno-occlusiondisease(VOD)Massivehepatomegalyinneuroblastoma出血性胰臟炎癌癥病人腹腔急癥(1)腸胃道出血86癌癥病人腹腔急癥(2)最主要的癥狀是‘痛’即使有很嚴重的infection也不一定會發燒每天很仔細的physicalexamination及配合laboratoryanddiagnosticstudies癌癥病人腹腔急癥(2)最主要的癥狀是‘痛’87腸胃道出血食道靜脈瘤出血肝腫瘤肝炎及肝硬化上腸胃道出血類固醇嘔吐造成Mallory-Weisstear壓力性潰瘍下腸胃道出血Infection(typhlitis)腸套疊痔瘡及肛門裂傷腸胃道出血食道靜脈瘤出血88腸胃道阻塞藥物造成：Oncovin，Morphine腸子沾黏或狹窄腸套疊腫瘤壓迫阻塞：Burkitt’s淋巴瘤，sarcoma，GIcarcinoma，presacralteratoma腸胃道阻塞藥物造成：Oncovin，Morphine89腸胃道破裂Ulcerorgastritis太厲害Obstruction沒解決InfectionTumorerosionTherapyresponse腸胃道破裂Ulcerorgastritis太厲害90Typhlitis盲腸附近的壞死性腸炎右下腹痛(很像闌尾炎)通常在化學治療後血球很低時必須給予廣效抗生素開刀的適應癥：持續性腸胃道出血腸胃道破裂無法控制的敗血癥(如血壓不穩….)SymptomsnormallyrequireanoperationTyphlitis盲腸附近的壞死性腸炎91PseudomembranousColitisClostridiumdifficileinfection因為使用抗生素造成Oralmetronidazole(5mg/kgq6h)OralVancomycin(125mgq6h,50mgq6hforBW<30kg)PseudomembranousColitisClostr92Veno-OcclusionDisease發生在肝靜脈，右上腹痛，肝腫大，體重增加5%，腹水，黃疸通常發生在BMT的病人6-TG也會(forALL)Oncovin+Dactinomycin也會(forWilmsandRhabdomyosarcoma)主要是靠支持性療法Veno-OcclusionDisease發生在肝靜脈，右93肛門周圍膿瘍肛門周圍疼痛，壓痛，解便痛肛門周圍水腫(woodyedema)，像蜂窩組織炎因血球很低，可能沒有膿通常是混合感染(嗜氧、厭氧、黴菌)給予廣效抗生素及坐浴(Sitzbath)手術切開引流可能形成瘻管肛門周圍膿瘍肛門周圍疼痛，壓痛，解便痛94HugeHepatomegalyinNB神經母細胞瘤stage4S有呼吸窘迫時才處理肝臟腫大ChemotherapyIrradiation(150cGYx3days)手術擴大腹壁(Silasticpouch)HugeHepatomegalyinNB神經母細胞瘤95出血性胰臟炎L-asparaginaseandcorticosteroid主要癥狀是嘔吐及上腹痛NPO,NGdecompressionImipenem+SandostatinIVFhydrationSurgicaldrainageforpancreaticabscessorpseudocyst出血性胰臟炎L-asparaginaseandcorti96癌癥病人的泌尿道急癥OliguriaandAnuriaHypertension出血性膀胱炎癌癥病人的泌尿道急癥OliguriaandAnuria97OliguriaandAnuria分成腎前性、腎性、腎後性、神經性腎前性：敗血性休克或脫水腎性：化學藥物，抗生素，抗黴菌藥腎後性：Tumorlysissyndrome，腫瘤壓迫輸尿管或膀胱神經性：主要是脊髓神經或骨盆腔神經叢受侵犯或藥物影響如Narcotics、Oncovin、herpeszosterOliguriaandAnuria分成腎前性、腎性、98Hypertension腎素(Renin)分泌增加腎血管性腫瘤分泌如Wilms’tumor，神經母細胞瘤，Pheochromocytoma腦壓上升腦瘤，中樞神經白血病，腦膜腦炎藥物造成類固醇，Cyclosporin，AmphotericinBHypertension腎素(Renin)分泌增加99出血性膀胱炎(1)癥狀：頻尿、小便困難、小便疼痛造成原因：感染、放射治療、化學藥物感染：Adenovirus,CMV,polyomavirusBK(BKvirus)化學藥物：CyclophosphamideandIfosfamideMayoccurhourstomonths出血性膀胱炎(1)癥狀：頻尿、小便困難、小便疼痛100出血性膀胱炎(2)治療：Hydration矯正凝血功能異常Onfoley膀胱灌洗Ditropan,Baclofen,Belladonna,opioidEndoscopyandelectrocoagulationInstillationofformalin,alum,PGE2出血性膀胱炎(2)治療：101癌癥病人的神經急癥意識不清中風(CVA)SeizureIT藥物注射錯誤SpinalcordcompressionHyperleukocytosis癌癥病人的神經急癥意識不清102癌癥病人意識不清(1)TumorInfectionCVASeizureDICTherapy-relatedLeukoencephalopathyMetabolicPost-R/TsomnolenceSyndromeHypotensionHypertensionDehydrationHypoxiaAnemiaLiverfailureDepression癌癥病人意識不清(1)TumorMetabolic103癌癥病人意識不清(2)詢問病史時的注意事項StatusofmalignancyRecentillnessFeverMedicationChemotherapyandradiotherapySeizureactivityorsimilarepisode癌癥病人意識不清(2)詢問病史時的注意事項104癌癥病人意識不清(3)身體檢查時的注意事項Consciousnesslevel(comascales)BreathingpatternPupilsizeandreactivityAbnormalextraocularmovementRostrocaudalorcentralherniationUncalherniation癌癥病人意識不清(3)身體檢查時的注意事項105癌癥病人意識不清(4)實驗室檢查及評估CBC,glucose,electrolytes,ammonia,hepaticandrenalfunction,bloodculture,coagulationprofilesEmergentCTorMRIscanLumbarpunctureshouldnotbeperformeduntilmasslesionbeR/O癌癥病人意識不清(4)實驗室檢查及評估106治療導致的意識不清(1)頭部放射治療類固醇:personalitychange,hallucinationandpsychosisHD-Ara-C:cerebellardysfunction,seizure,coma,deathHD-MTX:encephalopathy,seizureIfosfamide:acutesomnolence,neurologicdeterioration,coma治療導致的意識不清(1)頭部放射治療107治療導致的意識不清(2)動脈注射BCNU,cisplatin:acuteneurologicdeterioration,seizure,stroke,encephalopathy遺傳性缺乏dihydropyrimidinedehydrogenasewith5-FUHD-thiotepa,BCNU:encephalopathyATRA:pseudotumorcerebri治療導致的意識不清(2)動脈注射BCNU,cisplati108治療導致的意識不清(3)HD-narcotics:sedation,withdrawalsymptomsBenzodiazepine:dysphoriaHD-IL2:disorientation,confusion,paranoia,combativeness,somnolence,coma干擾素:subacutesomnolence,alteredcognition,psychiatricsymptoms,conceptualdisorganization,focalneurologicdeficit,corticalblindness,coma,death治療導致的意識不清(3)HD-narcotics:seda109意識不清---治療(1)IICP:Decadron,mannitol,hyperventilation感染的可能:Broad-spectrumantibioticsNeurosurgicalinterventionifindicationSpecificantidoteforifosfamideencephalopathyismethyleneblueSteroidsamelioratetheIL-2CNSeffect意識不清---治療(1)IICP:Decadron,110意識不清---治療(2)LeucovorinorcarboxypeptidaseforMTXHyperbaricoxygenationandanticoagulationforR/TvasculitisNaloxonefornarcoticsFlumazepineformidazolam意識不清---治療(2)Leucovorinorc111中風(CVA)依照發生的時間原因可能不同剛診斷癌癥時:disease-relatedcoagulationabnormalities在治療中:chemotherapy-relatedorinfection末期癌癥:sepsis,DIC,CNSinfection,progressivetumorMonthstoyearspostR/Tvasculitis中風(CVA)依照發生的時間原因可能不同112SeizureTumorBraintumorCNSleukemiaHyperleukocytosisCNSinfectionCVATherapy-relatedHD-MTX,HD-Ara-CIT(Ara-C,MTX)L-asparaginaseR/TMetabolicabnormalityHypoxiaSeizureTumorTherapy-related113IT藥物注射錯誤(1)ITMTX<100mg：可能沒事或頭痛ITMTX>500mg：seizure,coma,deathITAra-C200mg：dilatedpupilsITEpirubicin：delayedonset,deathIToncovin：ascendingparalysis,coma,death(幾乎必死無疑)IT藥物注射錯誤(1)ITMTX<100mg：可能114IT藥物注射錯誤(2)一發現時馬上的動作CSF

drain-outCSFexchangewithL-RandFFPVentricularcatheterplacementforventriculolumbarperfusionIT藥物注射錯誤(2)一發現時馬上的動作115IT藥物注射錯誤(3)IT-MTXoverdoseIT-carboxypeptidaseG2(CPDG2)SystemicleucovorinIVdexamethasonePyroxidineandGlutamicacidITleucovirinworseningneurotoxicityITcorticosteroidcontraindicationbecauseCSFmustbedrainedandexchangedIT藥物注射錯誤(3)IT-MTXoverdose116SpinalCordCompression(1)癥狀最早大概都是背痛ProgressiveweaknessSensoryabnormalitiesParesis,paraplegia,quadriplegiaUrinaryandfecalincontinenceSpinalCordCompression(1)癥狀117SpinalCordCompression(2)IncidenceofSCCinchildrenwithsolidtumorsEwingsarcoma 30(17.9%) 168Neuroblastoma 32(7.9%) 402Osteogenicsarcoma 16(6.5%) 243Rhabdomyoarcoma 14(4.9%) 287Hodgkindisease 8(2.0%) 404Softtissuesarcoma 4(3.9%) 102Germcelltumor 5(3.5%) 130Wilmstumor 2(0.7%) 290Total 113(5.0%) 2259Pathology Noofcases TotalcasesHepatoma 1(1.4%) 69Other 0 164St.JudeJNeurosurg1991;74:70SpinalCordCompression(2)Inc118SpinalCordCompression(3)任何懷疑或是癌癥的小朋友，只要有backpain都要考慮spinalcordcompression的可能如果有weakness甚至不能走路，馬上排MRI檢查如果沒有MRI，則排CTmyelographySpinalCordCompression(3)任何懷119SpinalCordCompression(4)如果history或NE有懷疑，先打dexamethasone再排MRI如果證實有mass，則除了Dexamethasone外，要馬上decompressionDecompression有localR/T，chemotherapy，以及surgicaldecompression可用如果診斷確定，而且又是radiosensitive，R/T通常是treatmentchoice如果是leukemia，lymphoma，neuroblastoma可用C/T如果R/TorC/T癥狀仍持續，手術無可避免SpinalCordCompression(4)如果120Hyperleukocytosis(1)定義：周邊白血球>100000/mL通常AML>200000/mL，ALL及CML>300000/mL比較會有癥狀造成癥狀的原因是increasebloodviscosity，AML又比ALL的血球更大更黏Hyperleukocytosis(1)定義：周邊白血球121Hyperleukocytosis(2)大部分沒癥狀，有些會有CNS、Pulmonary等癥狀，包括有：意識障礙、頭痛、視力模糊、seizure、coma、中風的癥狀、papilledemaandretinalvesseldistentionDyspnea、hypoxia、acidosisandcyanosisHyperleukocytosis(2)大部分沒癥狀，有些122Hyperleukocytosis(3)ComplicationinpatientswithhyperleukocytosisCNShemorrhage 2 9 <0.001K↑ 16 2 Ca↓,P↑ 15 3 Lunghemorrhage 2 3Ac