Management of Adverse Events and Clinical Situations in Cancer and Non-Malignant Hematology
Grade before you act
Use CTCAE grading and distinguish expected toxicity from urgent complications. Core emergencies: febrile neutropenia, tumor lysis syndrome, extravasation, anaphylaxis, cytokine release syndrome, immune-related adverse events (irAEs), cardiac toxicity, and thrombotic events. In nonmalignant hematology, know anticoagulation for VTE, ITP therapy, sickle cell acute chest, and transfusion thresholds.
Concepts to master
Neutropenic fever: obtain cultures and give empiric antipseudomonal beta-lactam within 60 minutes; add coverage for instability or specific risks. irAEs: hold checkpoint inhibitor for grade 2-3, start corticosteroids promptly for high-grade events, and use infliximab for steroid-refractory colitis. Extravasation: stop infusion, aspirate if appropriate, apply cold/heat per agent, and use antidote when evidence-based. Hypersensitivity: stop drug, assess severity, premedicate only for future mild reactions under protocol.
Traps
Do not treat all infusion reactions as anaphylaxis; do not delay steroids for biopsy in grade 3-4 irAE; do not give G-CSF routinely for afebrile neutropenia; do not use warfarin without checking interactions; do not ignore cumulative cardiotoxicity. Distinguish tumor lysis prevention from treatment.
Worked example
Grade 3 immune colitis: hold immunotherapy, start IV/oral steroids (e.g., prednisone 1-2 mg/kg/day), monitor, and escalate to infliximab if no improvement in 2-3 days.
Rule of thumb: grade, stabilize, treat, then decide whether to hold, reduce, or resume-and document the reasoning.