# A nurse is caring for a patient with acute lymphoblastic leukemia who develops tumor lysis syndrome. The patient's laboratory results show: potassium 6.8 mEq/L, phosphorus 8.2 mg/dL, calcium 7.1 mg/dL, and uric acid 12.5 mg/dL. Which nursing intervention should be the priority?

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## 문제

A nurse is caring for a patient with acute lymphoblastic leukemia who develops tumor lysis syndrome. The patient's laboratory results show: potassium 6.8 mEq/L, phosphorus 8.2 mg/dL, calcium 7.1 mg/dL, and uric acid 12.5 mg/dL. Which nursing intervention should be the priority?

## 보기

1. Administer calcium gluconate 1 gram IV push immediately
2. Prepare for emergency hemodialysis and notify the nephrologist **✔ 정답**
3. Increase IV fluid rate to 200 mL/hour with normal saline
4. Administer allopurinol 300 mg orally as prescribed

**정답: 2**

## 해설

Tumor lysis syndrome with severe hyperkalemia (6.8 mEq/L), hyperphosphatemia, hypocalcemia, and hyperuricemia requires immediate hemodialysis to prevent life-threatening cardiac arrhythmias and acute kidney injury. Other options address specific imbalances but do not correct all simultaneously.

## 심화 해설

Understanding the Clinical Scenario

The patient has acute lymphoblastic leukemia and has developed tumor lysis syndrome (TLS). The laboratory values indicate severe metabolic derangements: a critically high potassium level of 6.8 mEq/L, hyperphosphatemia at 8.2 mg/dL, hypocalcemia at 7.1 mg/dL, and severe hyperuricemia at 12.5 mg/dL. These findings represent a life-threatening oncologic emergency.

Priority Nursing Intervention and Rationale

The correct answer is to prepare for emergency hemodialysis and notify the nephrologist. The priority in TLS management is determined by the immediate threat to life. The serum potassium of 6.8 mEq/L places this patient at extreme risk for a fatal cardiac arrhythmia. While all the listed interventions are components of TLS management, the severity and combination of electrolyte disturbances, particularly the hyperkalemia, make hemodialysis the definitive and most urgent treatment to rapidly correct these abnormalities. As noted in the simulation case by Soliman et al., prompt recognition and treatment of hyperkalemia-induced arrhythmias in TLS is vital, as these can be life-threatening, potentially leading to renal failure, arrhythmias, or multi-organ failure [1].

Analysis of the Intervention Options

- Administer calcium gluconate IV push: This is a temporizing measure that stabilizes the cardiac membrane against the effects of hyperkalemia but does not lower the serum potassium level. It is an important step, but it is not the definitive priority over arranging for definitive potassium removal in a patient with multi-electrolyte disturbances from TLS.

- Prepare for emergency hemodialysis: This is the priority. Hemodialysis is the most rapid and effective method for removing potassium, phosphorus, and uric acid from the blood, while also correcting acidosis. The presence of severe hyperkalemia, hyperphosphatemia, and hyperuricemia that is refractory to medical management or causing acute kidney injury makes this the definitive, life-saving intervention.

- Increase IV fluid rate: Aggressive IV hydration is a cornerstone of TLS prevention and management, primarily to promote renal excretion of uric acid and phosphorus. However, in the setting of established severe hyperkalemia and potential renal dysfunction, this intervention is too slow and insufficient to address the immediate cardiac threat.

- Administer allopurinol: Allopurinol reduces the production of new uric acid by inhibiting xanthine oxidase. It is a preventative measure and does not treat pre-existing hyperuricemia or the other life-threatening electrolyte imbalances already present. Its effect is not immediate and does not address the critical hyperkalemia.

Clinical Integration and System-Level Evidence

The urgency of this scenario is supported by real-world data on hyperkalemia management. A large retrospective study by Lyu et al. demonstrated that a standardized hyperkalemia management system significantly improved rates of diagnosis, treatment, and review . This underscores that hyperkalemia is a critical finding requiring a systematic and rapid response. The study found that in routine care, treatment rates were only 58.29%, highlighting a dangerous gap in care that a standardized, protocol-driven approach—like the one a nurse initiates by preparing for emergency hemodialysis—is designed to close . The nurse’s priority action of recognizing the severity and mobilizing the definitive therapy (hemodialysis) is the clinical application of this system-level principle, ensuring the patient receives the highest level of timely intervention to prevent a cardiac arrest.References (research sources)

- [1]Recognition and Management of Hyperkalemia-Induced Tachyarrhythmia in Pediatric Spontaneous Tumor Lysis Syndrome: A Simulation Case.Research articleSoliman YH, Kochhar M, Petrone G, Wing R, Sojar SH. (2026) · DOI: 10.7759/cureus.107494

## 임상 시나리오

TLS with Severe Hyperkalemia: Emergency DialysisRecognizing when temporizing measures are insufficient
In tumor lysis syndrome, a serum potassium level above 6.5 mEq/L or a rapidly rising level constitutes a life-threatening emergency due to the risk of fatal cardiac arrhythmia. The definitive priority intervention is emergency hemodialysis to rapidly and effectively remove potassium and correct other metabolic derangements.

While calcium gluconate is administered first to stabilize the cardiac membrane, its effect is temporary and does not lower potassium. It is a bridge to definitive therapy, not the primary treatment. Aggressive IV hydration and allopurinol are core components of TLS management but are not the priority when severe, established hyperkalemia is present.

CautionNever delay preparing for dialysis to administer temporizing agents alone. The nurse must immediately notify the nephrologist and prepare the patient and equipment for emergency hemodialysis while other interventions are initiated concurrently.

## 핵심 개념

- **Tumor Lysis Syndrome (TLS)** — An oncologic emergency caused by the rapid release of intracellular contents (potassium, phosphate, uric acid) from dying cancer cells, leading to hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia.
- **Hyperkalemia (K+ > 6.5 mEq/L)** — A critically high serum potassium level that places the patient at extreme risk for life-threatening cardiac arrhythmias and cardiac arrest, requiring immediate definitive treatment like hemodialysis.
- **Hemodialysis in TLS** — The definitive, most rapid method to correct severe electrolyte imbalances and remove uric acid in TLS, indicated for refractory hyperkalemia, hyperphosphatemia, or hyperuricemia.
- **Calcium Gluconate** — A medication that antagonizes the cardiotoxic effects of hyperkalemia by stabilizing the cardiac cell membrane; it does not lower serum potassium levels and is a temporizing measure only.

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