Pediatric emergency medicine trisk 2744 2744
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cultures of the blood and urine are pending. While gram-negative organisms have
historically been of primary concern, gram-positive bacteria have more recently
become more threatening, particularly with the emergence of MRSA in some
regions. Antibiotic regimens need to broadly cover gram-positive and gram-negative
bacteria (e.g., piperacillin/tazobactam and gentamicin) as well as MRSA when
relevant.
Rarely seen as a complication of stem cell transplant, thrombotic
thrombocytopenic purpura (TTP) can present with the classic pentad of fever,
neurologic symptoms, hemolytic anemia, thrombocytopenia, and renal compromise
( Table 98.11 ). The disorder seems to be associated with immunosuppression with
cyclosporine or FK506 in the posttransplant period. In some patients, TTP may
evolve into a more chronic picture with renal dysfunction and a clinical picture more
consistent with HUS.
An experimental, promising new treatment for leukemia involves chimeric
antigen receptor modified T cells (CART). See Complications of CAR-T Cell
Therapy section above. In this specialized therapy, a patient’s T cells are harvested
and engineered to express a receptor that allows them to seek out and destroy
leukemic blasts. These cells are then reinfused into the patient in an inpatient setting.
Importantly for emergency clinicians, steroids are contraindicated for any patients
being treated with CART therapy since steroids are lymphotoxic and likely to be
detrimental to this type of therapy.
CARE OF PATIENTS WITH ADVANCED CANCER
Pediatric palliative care has seen major changes in recent decades and these
developments clearly impact care for children with cancer. Children with incurable
cancer may still receive treatment that may be life prolonging and options for
managing symptoms related to advanced disease have expanded. Also noteworthy is
the increased decision-making role for the patient and family members in the setting
of advanced disease. Options for patients to receive care outside of the hospital,
either in hospice or at home, have greatly evolved.
