•Observations: Vital signs (pulse, blood pressure, respiration rate, temperature), ECG, daily weight

•Measure input and output continuously

•Laboratory investigations every 2–4 h

•Symptoms of disturbed microcirculation: hypoxia, infarction, hemorrhagia

18.1.3 Treatment

•Avoid potassium

•Avoid calcium except in the case of hypocalcemic tetanus (clinical investigation: Chvostek sign, Trousseau sign)

•Intravenous line, central line optimal, otherwise peripheral intravenous line

•Hydration (3–5 l/m2 body surface area) output every 4 h; if output is less than 60% of input, give furosemide 0.5–1.0 mg/kg i.v.

•Alkalinization of urine: goal is for urine pH to be 6.5–7.5 (start with sodium bicarbonate 8.4% (50 mEq)/l fluid). Urine pH after each void should be 6.5–7.5

•Allopurinol 400 mg/m2/day or 10–20 mg/kg/day orally, or i.v. in three or four doses/day (dose limit 400 mg/day), or recombinant uratoxidase enzyme (0.20 mg/ kg/day, once daily as an infusion over 30 min). Rasburicase, if renal insufficiency, severe hyperuricemia, severe hyperleukocytosis

•Discuss necessity for hemodialysis with nephrologist if signs and symptoms show progression

•Severe symptomatic hyperleukocytosis: leukapheresis

18.2Fever and Netropenia

18.2.1 General

•Fever

•Severe neutropenia (absolute neutrophil count, ANC <0.5 × 109/l)

•Risk of septic toxic shock within short time period

•Attempts to differentiate between lowand high-risk patients according to presenting symptoms and laboratory results have been undertaken

•ANC “trigger” has been discussed to be <0.5 × 109/l

18.2.2 Diagnosis

•History and physical examination

•CBC and blood smear in case of fever and neutropenia: blood cultures from peripheral blood and central venous accesses