Inpatient and ICU Clinical Pathway for Evaluation and Treatment
of Oncology Patients at Risk for Tumor Lysis Syndrome (TLS)

Team Assessment
  • History and Physical, VS, MS
  • Review labs
    • CBC, BMP (K, Ca, creatinine), Phos, Uric acid, LDH, G6PD
    • Blood gas, lactate if poor perfusion or respiratory distress
  • Consider CXR
  • Consider 12-lead ECG
    • Electrolyte derangement or dysrhythmia
    • Symptomatic with palpitations/dizziness
    • Other clinical concerns
Assess for Emergent TLS Signs/Symptoms
  • Laryngospasm, bronchospasm
  • Hypotension, heart failure due to decreased calcium
  • Seizures
  • Neuromuscular irritability, sensory disturbance
  • Urine output
    • Oliguria: < 0.5 ml/kg/hr x 6 hrs
No emergent
TLS signs/symptoms
TLS signs/symptoms
Assess for Laboratory or Clinical TLS
Emergent TLS Signs/Symptoms
No concerning
labs or symptoms
labs or symptoms
Possible Comorbidities
  • Pre-existing renal conditions
  • Dehydration
  • Acidosis
  • Nephrotoxins
  • Mediastinal mass
Assess Risk for TLS
  Low Risk of TLS Intermediate
Risk of TLS
High Risk of TLS or
Laboratory/Clinical TLS
Severe TLS
Hydration: D5NS
  • No K, No Phos
    Do not alkalinize
Maintenance IVF 1.5x MIVF 2x MIVF 2x MIVF
Monitoring Labs Daily
VS q4hr
I&O q4hr
Weight daily
Labs q8-12hr
VS q4hr
I&O q4hr
Weight daily
Labs q6-8hr
VS q4hr
ECG if not previously obtained
Continuous CR monitor if abnormal ECG
I&O q4hr
Weight daily
Labs q4-6hr
VS per ICU standards
ECG and initiate supplemental arrhythmia monitoring
I&O q4hr
Weight daily
Prophylaxis Medications   Allopurinol Allopurinol
Add rasburicase if uric acid ≥ 8 mg/dL
Add rasburicase if uric acid ≥ 8 mg/dL
Contraindications to Hyperhydration
  • Suspected metabolic disease
  • Hypoglycemia
  • Liver failure
  • Adrenal insufficiency
  • Abnormal renal function
  • Heart failure
  • Neurosurgical patients
  • Nephrotic syndrome
  • Diabetes insipidus
Assess Treatment Response
  • TLS resolution
    • Normalized electrolytes, BUN, creatinine
    • No evidence of fluid overload
    • Normalized BP, UOP
    • No cardiac arrhythmias
    • Clinical symptoms resolved
Resolved TLS
Ongoing TLS
Uncontrolled TLS
  • Discontinue hyper-hydration
  • Decrease lab monitoring
    • Reduce to next lower
      risk frequency
    • Reassess every 24 hrs
    • Off monitoring after 72 hrs
  • Discontinue medications
    • Allopurinol when uric
      acid normalizes
    • Phosphate binders when phosphate normalizes
  • Escalate treatment and monitoring to next level of risk