What is the plan of care for a patient with ovarian cancer on chemotherapy (cisplatin and carboplatin) who is experiencing convulsions and has been diagnosed with metabolic encephalopathy?

Plan of Care for Ovarian Cancer Patient with Metabolic Encephalopathy and Seizures

Immediate Management Priorities

The primary focus should be on stabilizing the metabolic encephalopathy, managing seizures, and determining whether chemotherapy can be safely continued or should be temporarily held. 1

Neurological Assessment and Seizure Management

• Identify and correct the underlying metabolic derangement causing the encephalopathy, which may include electrolyte abnormalities (particularly hyponatremia, hypocalcemia, hypomagnesemia), renal dysfunction, or hepatic toxicity from platinum-based chemotherapy 1
• Monitor for platinum-induced neurotoxicity, as cisplatin can cause encephalopathy with seizures, confusion, and visual disturbances, though this is rare at cumulative doses below 400 mg/m² 2, 3
• Initiate or continue anti-epileptic therapy for seizure control while investigating the underlying cause 2
• Perform daily neurological examinations to assess for improvement in sensorium, command-following ability, and any focal deficits 3

Respiratory Management

• Continue T-piece weaning at 40% FiO2 as tolerated, monitoring for signs of respiratory fatigue or deterioration 1
• Assess readiness for decannulation once mental status improves sufficiently to protect the airway and handle secretions 1
• Monitor for aspiration risk given the fluctuating level of consciousness 2

Chemotherapy Decision-Making

Hold cisplatin and carboplatin temporarily until the encephalopathy resolves and the underlying cause is identified 1, 2, 3. The key considerations are:

• If metabolic encephalopathy is due to electrolyte imbalances or renal dysfunction, chemotherapy can be resumed once these are corrected, with appropriate dose modifications based on renal function 1
• If cisplatin-induced encephalopathy is suspected (particularly with cumulative doses >300 mg/m²), consider switching to carboplatin alone or alternative regimens, as carboplatin causes significantly less neurotoxicity 4, 1
• Carboplatin/paclitaxel does not typically cause encephalopathy and is generally safe for the CNS, making it the preferred platinum agent if resuming treatment 5, 6

Metabolic and Organ Function Monitoring

• Check daily comprehensive metabolic panel including electrolytes, renal function (creatinine, BUN), hepatic function (AST, ALT, bilirubin), and magnesium 1
• Monitor for myelosuppression with complete blood counts, particularly platelet counts if carboplatin is being used 1, 6
• Assess for cumulative platinum neurotoxicity through neurological examination, as this may contribute to altered mental status 1

Multidisciplinary Care Plan

Oncology Team

• Reassess chemotherapy regimen once encephalopathy resolves, considering carboplatin as the preferred platinum agent over cisplatin due to lower neurotoxicity 4, 1
• Calculate cumulative cisplatin dose to determine if neurotoxicity threshold has been reached (typically >300-400 mg/m²) 2
• Consider dose modifications of 25-50% if renal function is impaired (creatinine clearance <60 mL/min) 1

Neurology Consultation

• Obtain EEG to evaluate for subclinical seizure activity or periodic lateralized epileptiform discharges, which can occur with platinum-induced encephalopathy 3
• Consider brain MRI to rule out metastatic disease, posterior reversible encephalopathy syndrome (PRES), or platinum-induced leukoencephalopathy 3
• Optimize anti-epileptic medication based on seizure type and frequency 1

Critical Care Team

• Continue supportive ICU care with close monitoring of vital signs, neurological status, and respiratory function 1
• Implement aspiration precautions until mental status fully recovers 2
• Provide adequate hydration to prevent further renal toxicity, particularly if resuming platinum therapy 1

Palliative Care Integration

• Involve palliative care early to address symptom management, quality of life concerns, and goals of care discussions, particularly given the serious nature of this complication 7
• Screen for distress using validated tools and address physical, psychosocial, and spiritual needs 7
• Engage family caregivers in care planning and provide support for their needs 7

Plan Modifications Based on Clinical Course

If Encephalopathy Resolves Within 7-10 Days

• Resume chemotherapy with carboplatin/paclitaxel (avoiding cisplatin) once metabolic parameters normalize 1, 6, 4
• Continue with standard 6-cycle regimen unless cumulative toxicity necessitates early discontinuation 1
• Monitor closely for recurrent neurotoxicity with each subsequent cycle 1

If Encephalopathy Persists or Worsens

• Consider discontinuing platinum-based chemotherapy and transitioning to alternative regimens such as pegylated liposomal doxorubicin, gemcitabine, or topotecan 1
• Reassess goals of care with patient and family, considering whether continued aggressive treatment aligns with patient values and quality of life priorities 1, 7
• If progressive disease is documented, options include clinical trials, alternative chemotherapy, or transition to comfort-focused care 1

If Platinum-Refractory Disease is Suspected

• Recognize poor prognosis with median survival <12 months in platinum-refractory disease 1
• Avoid interval cytoreductive surgery as it is unlikely to benefit patients with primary platinum-refractory disease 1
• Prioritize quality of life over aggressive disease-directed therapy 1, 7

Critical Pitfalls to Avoid

• Do not resume cisplatin if encephalopathy is suspected to be drug-related, as recurrence is likely and potentially more severe 2, 3
• Do not overlook electrolyte monitoring, particularly magnesium and calcium, which are commonly depleted with platinum therapy and can cause seizures 1
• Do not delay palliative care referral in critically ill patients with advanced cancer, as early integration improves outcomes 7
• Do not continue chemotherapy without adequate renal function (creatinine clearance >60 mL/min for full-dose platinum) 1