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Management
Patients who present with signs of CRS may be indistinguishable from patients with
sepsis and concurrent treatment for presumed sepsis including administration of
broad-spectrum antibiotics is important. For mild symptoms, supportive care may be
sufficient. For patients with severe symptoms, evidence of organ dysfunction, or
life-threatening illness, the addition of glucocorticoids and/or tocilizumab (an anti–
IL-6 monoclonal antibody) may be indicated, in consultation with an oncologist. All
of these patients should be admitted and many will require a critical care setting.

METABOLIC COMPLICATIONS OF CANCER TREATMENT
Complications affecting metabolic balance and the endocrinologic system are
common in children with cancer. These may be because of the neoplastic disease
itself, as has been addressed in the sections on newly diagnosed cancer, or due to
complications from cancer therapy.
TLS is probably the most noteworthy example of metabolic derangement in the
setting of cancer (see “Leukemia” section). TLS can be present at the time of
diagnosis or develop as chemotherapy is initiated and tumor cells begin to die in
response. Prevention of tumor lysis relies on protecting the function of the kidneys
while preventing severe metabolic derangements ( Table 98.3 ). Hyperhydration
should be initiated to achieve brisk, dilute urine output. In addition to IV hydration,
all patients should receive therapy with either allopurinol (10 mg/kg/day with
maximum dose 300 mg) or rasburicase. Allopurinol is a xanthine oxidase inhibitor
that impairs the production of uric acid. Rasburicase, a recombinant urate-oxidase
enzyme, causes direct lysis of uric acid and leads to a rapid drop in uric acid levels.
The usual starting dose is 0.2 mg/kg IV. Rasburicase is indicated in patients who are
at higher risk of TLS complications such as patients with compromised renal
function or an extremely elevated uric acid level, who have advanced Burkitt
lymphoma, who cannot tolerate hydration (e.g., CNS hemorrhage or pre-existing
cardiac dysfunction), or whose uric acid is rising despite allopurinol. Rasburicase is
contraindicated in patients with glucose-6-phosphate dehydrogenase (G6PD)
deficiency as it can result in oxidative stress and hemolysis. Use of alkalinized

intravenous fluids is becoming less common as its efficacy is uncertain. If using
rasburicase, hydration with alkalinization is unnecessary.
Of note, not all electrolyte abnormalities in the setting of TLS should be corrected
( Table 98.3 ). Hyperphosphatemia can be treated using aluminum hydroxide as
frequently as every 2 to 4 hours. Hypophosphatemia should not be corrected unless
it is in a critically low range (less than 1 mEq/L). Serum potassium levels must be
aggressively monitored. Hyperkalemia in the setting of TLS should be managed as it
would be in other disease states (see Chapter 100 Renal and Electrolyte Emergencies
) with Kayexalate, insulin and glucose, and dialysis, if needed. Hypokalemia should