Thorough nursing assessment and follow-up lead to escalation of care.
- Acute myeloid leukemia (AML) leads to symptoms associated with bone marrow failure, including pancytopenia.
- Patients with AML are at a high risk of developing active infections due to neutropenia, resulting in altered mental status, lethargy, and confusion.
- Tumor lysis syndrome, which can occur spontaneously or as a result of treatment, raises serum levels of uric acid, potassium, and phosphate, ultimately leading to life-threatening complications.
James Solari*, an 80-year-old man, recently received a diagnosis of acute myeloid leukemia (AML). He’s been hospitalized for a month, including an ICU stay before transferring to the inpatient oncology unit. He received chemotherapy during the first few days of hospitalization. Mr. Solari has a history of hypertension, type 2 diabetes, prostate cancer, and coronary artery disease.
History and assessment
During his ICU stay, Mr. Solari received mechanical ventilation due to acute hypoxic respiratory failure. He also developed an acute kidney injury secondary to tumor lysis syndrome (TLS), for which he required continuous renal replacement therapy and now needs intermittent hemodialysis.
At 8:00 am, Mr. Solari’s nurse, Amber, notices that he appears confused and lethargic. He follows simple commands, but his speech is incomprehensible and he can’t answer simple questions.
Acute myeloid leukemia in older patients: 6 questions asked and answered
Mr. Solari’s vital signs include temperature 100.8° F (38.2° C), HR 114 bpm in sinus tachycardia, RR 18 breaths per minute, BP 95/57 mmHg, and SpO2 96% on 2L of O2 by nasal cannula. His previous lab results show a WBC of 1,400 cells/µl, absolute neutrophil 500 cells/µl, platelets 15,000 cells/µl, and serum lactate 2.3 mmol/L.
Taking action
Amber notifies the oncologist and obtains orders for blood cultures, cooling compress, acetaminophen, cefepime, and vancomycin.
At 9:45 am, Amber notes the patient’s worsening vital signs: temperature 100.9° F (38.3° C), HR 109 bpm, RR 19 breaths per minute, BP 84/52 mm Hg, and SpO2 92% on 4L O2 by nasal cannula. She calls the provider to examine the patient.
The provider orders a 500 mL bolus of I.V. electrolytes and an O2 increase to 6L, which improves the SpO2 to 94%. Despite fluid resuscitation, the patient remains hypotensive with a MAP of 57 mmHg.
Outcome
Amber calls a rapid response. The team immediately begins a norepinephrine infusion and transfers Mr. Solari to the ICU. He’s intubated due to worsening hypoxia and possible septic shock.
Education and follow up
AML, a hematological disorder of the WBCs, can lead to life-threatening complications, such as bleeding and infections. More than two-thirds of AML cases occur in patients over age 50; it has a 21% average 5-year survival rate.
Chemotherapy used to treat AML attacks rapidly growing and dividing leukemia cells in the bone marrow, which, after treatment, can result in pancytopenia that increases the risk for bleeding, sepsis, disseminated intravascular coagulation, and TLS. (See AML and treatment complications)
AML and complications
An acute myeloid leukemia (AML) diagnosis requires a bone marrow biopsy showing more than 20% blasts. Further genetic and molecular testing guides AML classification and treatment selection. For patients younger than 60 with favorable- or intermediate-risk, treatment includes introductory chemotherapy with cytarabine or an anthracycline drug such as daunorubicin.
Patients with AML present with symptoms related to bone marrow failure resulting from the body’s inability to produce white blood cells, red blood cells, and platelets. Symptoms of AML include lethargy, fever, infection, ecchymosis, bleeding, and anemia, which result from the cancerous blasts invading the bone marrow.
AML also may result in disseminated intravascular coagulation, which activates the clotting pathway and results in the formation of thrombi by fibrin and platelets, while simultaneous bleeding occurs. For complications related to cytopenia, patients should receive blood products as appropriate. For anemia, patients should receive packed red blood cell transfusions, and those with thrombocytopenia will require platelet transfusions.
Tumor lysis syndrome
Tumor lysis syndrome (TLS) may occur spontaneously or in response to treatment when myeloid blasts break down. TLS releases large amounts of potassium, phosphate, and uric acid into systemic circulation, which requires frequent monitoring of serum levels and prophylactic therapy (such as I.V. hydration and allopurinol) to mitigate renal complications from increased uric acid levels. To break down serum uric acid, providers should consider rasburicase for patients with active TLS. If medical management proves ineffective, patients may require dialysis.
Neutropenia
Neutropenia can occur as a result of AML or as an adverse effect of treatment. Febrile neutropenia presents a medical emergency as patients with AML have a high risk for sepsis. Because these patients struggle to produce a normal inflammatory response to an infectious agent, providers should prescribe prophylactic antimicrobials. For patients with clinical signs and symptoms of systemic inflammatory response syndrome or sepsis (heart rate >90 bpm, body temperature >38° C or <36° C, systolic blood pressure <90 mmHg, MAP <70 mmHg, and respiratory rate >20 breaths per minute), nurses must immediately report the deterioration to the provider.
Amber’s prompt recognition of symptoms and quick action ensured that Mr. Solari received appropriate treatment.
*Name is fictitious.
Jae Chung is an education specialist at The Mount Sinai Hospital in New York City, New York.
American Nurse Journal. 2025; 20(5). Doi: 10.51256/ANJ05246
References
American Cancer Society. Chemotherapy for acute myeloid leukemia (AML). June 5, 2024. Accessed December 26, 2024. https://www.cancer.org/cancer/types/acute-myeloid-leukemia/treating/chemotherapy.html
Luo XL, Zhang YL, Chen QR. Nursing care plan and management of patients with acute leukemia. Altern Ther Health Med. 2022;28(1):80-85.
Stubbins RJ, Francis A, Kuchenbauer F, Sanford D. Management of acute myeloid leukemia: A review for general practitioners in oncology. Curr Oncol. 2022;29:6245-6259. doi:10.3390/curroncol29090491
Tavakoli A, Carannante A. Nursing care of oncology patients with sepsis. Semin Oncol Nurs. 2021;37(2):151130. doi:10.1016/j.soncn.2021.151130
Key words: AML, acute myeloid leukemia, oncology
