Twelve hours after initiation of induction chemotherapy in a patient with B-acute lymphoblastic leukaemia and a presenting WBC of 120,000/uL, labs show potassium 6.4 mEq/L, phosphate 8.5 mg/dL, calcium 6.8 mg/dL, uric acid 14 mg/dL, and creatinine rising from 0.9 to 1.9 mg/dL. The patient is oliguric with peaked T waves on ECG. What is the correct set of immediate interventions?
- A Allopurinol orally, normal saline, and routine monitoring only
- B Cardiac monitoring with calcium gluconate, insulin-dextrose, rasburicase, aggressive hydration, and dialysis evaluation ✓
- C Furosemide infusion to force diuresis and sodium bicarbonate to alkalinise urine
- D Hold further chemotherapy permanently and give single-agent hydroxyurea
Explanation
This is established laboratory tumour lysis syndrome with clinical consequences: life-threatening hyperkalemia with ECG changes, hyperphosphatemia with hypocalcemia, severe hyperuricemia, and acute kidney injury. Management demands continuous cardiac monitoring, calcium gluconate for myocardial stabilisation, insulin-dextrose for potassium shifting, rasburicase for uric acid breakdown, and volume expansion, with renal replacement therapy when oliguria or refractory electrolyte derangement persists. Allopurinol is prophylactic only, urine alkalinisation promotes calcium phosphate deposition, and stopping curative chemotherapy is unwarranted.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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