Fatal peri‐operative acute tumour lysis syndrome precipitated by dexamethasone

Abstract

A 3-year-old patient presented for elective adenotonsillectomy to treat symptomatic obstructive sleep apnoea. The patient had not been assessed at a pre-operative anaesthesia clinic but had undergone uneventful general anaesthesia twice in the previous two years. An uneventful operative course was complicated by the development of clinical instability over the first 6 h postoperatively culminating in cardiorespiratory arrest. Subsequent investigation demonstrated the acute development of tumour lysis syndrome in the setting of a new onset, undiagnosed acute leukaemia. The patient died on the third postoperative day. The use of dexamethasone for prophylaxis against postoperative nausea and vomiting was the likely aetiology of the acute tumour lysis syndrome in this case. This is the first documented peri-operative death due to tumour lysis syndrome after adminstration of dexamethasone. We discuss the various problems encountered with this case and review the recent literature and case reports on tumour lysis syndrome in the operating theatre.

Perineural versus Intravenous Dexamethasone for Prolongation of Multiple Nerve Blocks for Pain Relief after Total Knee Arthroplasty

“…A case report of perioperative death after a single dose of DXM causing this syndrome in a three-year-old during tonsillectomy was published [64]. Rapid lysis of lymphocytes with following rapid acute hyperpotassemia, hyperphosphatemia, lactic acidosis and acute renal failure may occur [65].…”

Safety of perioperative dexamethasone administration in children: time for reflection?

“…23 Le second cas traitait d'un garçon de trois ans en retard de développement ayant une microdélétion du chromosome Xq28. 24 On savait qu'il souffrait d'anémie microcytique hypochromique accompagnée d'une splénomégalie, mais aucune numération plaquettaire préopératoire récente n'avait été réalisée avant son adéno-amygdalectomie. Six heures après l'opération, l'enfant a subi un arrêt cardiorespiratoire, et après avoir été réanimé, on a découvert qu'il souffrait d'une leucémie aiguë lymphoblastique non diagnostiquée ainsi que d'un présumé SLT induit par la dexaméthasone.…”

“…23 The second case involved a developmentally delayed three-year-old male with Xq28 microdeletion. 24 He was known to have hypochromic microcytic anemia with splenomegaly, but he had no recent preoperative blood count before his adenotonsillectomy. On the sixth postoperative hour, the child suffered a cardiorespiratory arrest, and following resuscitation, he was found to have undiagnosed acute lymphoblastic leukemia and presumed dexamethasoneinduced TLS.…”

Onco-Nephrology

“…TLS most commonly follows treatment of hematologic malignancies, such as acute lymphocytic or lymphoblastic leukemia, acute myeloid leukemia, and Burkitt lymphoma, but also occurs after treatment of other bulky or rapidly growing tumors, particularly if highly sensitive to the effects of cytotoxic chemotherapy (2)(3)(4). TLS has been reported after treatment with conventional chemotherapy, dexamethasone (5), and newer agents such as bortezomib (6,7), thalidomide (8,9), and rituximab (10); radiation therapy of radio-sensitive solid tumors (11); and total-body irradiation (12).…”