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- Many patients, especially children and younger adults, can be cured of acute leukemia with the use of intensive chemotherapy and skillful supportive care.
- The prognosis for the leukemia patient depends on the specific type of leukemia, defined by cytogenetics and immunophenotype, its stage, prior therapy, and coexisting chronic medical problems.
- Infection and bleeding are due to the severe pancytopenia caused by either the leukemia itself or its myelosuppressive treatment; these problems resolve as the normal bone marrow recovers.
- The success of chemotherapy for acute leukemia depends not only on the drug susceptibility of the individual patient's leukemia but also on the ability of that patient to survive the toxicity of treatment.
- Blood transfusions should be used to maintain a hematocrit greater than 30% and a platelet count greater than 10,000/μL.
- Hyperleukocytosis with malignant myeloblasts must be treated as a medical emergency with leukapheresis and chemotherapy.
- Central nervous system (CNS) leukemia can be treated successfully with radiotherapy, intrathecal chemotherapy, and high-dose systemic chemotherapy.
- Tumor cell lysis, aminoglycoside antibiotics, disseminated intravascular coagulation, elevated lysozyme levels, hyperuricemia, and direct infiltration by leukemia cells can lead to acute renal failure, which is often reversible with proper care.
- Necrotizing enterocolitis requires aggressive medical management with antibiotics, blood transfusions, nasogastric suction, bowel rest, and maintenance of normal serum proteins and electrolytes.
- Hyperuricemia is proportional in severity to the leukemia tumor burden, and it responds to effective chemotherapy together with administration of fluids, bicarbonate, rasburicase, and allopurinol.
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Acute leukemia is a malignant proliferation of bone marrow or lymphoid cells that is uniformly fatal when left untreated. However, with the use of intensive chemotherapy and skillful supportive care, many patients, particularly children and younger adults, can be cured of this devastating disease. Not uncommonly, use of the medical ICU is necessary during the treatment of acute leukemia to manage either the complications of the disease itself or the complications of intensive cytotoxic therapy (Table 71-1). Such newly diagnosed patients deserve maximum aggressive supportive care in the medical ICU because most of the acute complications of leukemia resolve as a complete remission (CR) is achieved. The successful treatment of patients with acute leukemia requires a multidisciplinary approach with close collaboration among intensive care physicians, hematologic oncologists, infectious disease specialists, and the blood bank. Twenty-four-hour physician coverage is necessary to respond to emergencies that otherwise could lead to rapid deterioration of a patient in the midst of treatment.
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Appropriate decision making requires an understanding of the pathophysiology and clinical history of the leukemic disorders. The likelihood of a successful outcome from intensive care management depends in part on the specific type of leukemia and its stage; i.e., the prognosis depends on whether ...