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A Review On Hematology and Oncology Emergencies
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A Review On Hematology and Oncology Emergencies


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Slides on the discussion points during Intensive Course for Final MMed (Emergency Medicine) 2010

Slides on the discussion points during Intensive Course for Final MMed (Emergency Medicine) 2010

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  • 1. Hematology Emergencies Intensive Course Final Year MMED Candidates 2009-2010 Chew Keng Sheng School of Medical Sciences UNIVERSITI SAINS MALAYSIA
  • 2. Whole Blood
    • Rarely used today (individual blood components provided separately)
    • Indications
      • Autologous transfusion
      • Exchange transfusion (ie, sickle cell anemia)
    • Comments
    • Risk of transfusion reaction is >2 times than with packed red blood cells (PRBCs)
    • Risk of allergic reaction is 1%
  • 3. Packed Red Blood Cells
    • Preparation
    • Plasma removed from whole blood and remaining RBC mass is washed
    • Washing RBCs removes leukocytes, platelets, proteins, and other antigenic components of whole blood
    • Type and cross-match
    • ABO blood group antigen system and Rhesus system
  • 4.
    • Production of anti-D antibody occurs in Rh– individuals who have exposure to small amounts of D antigen
    • A) Maternal-fetal mixing (Rh– mother and Rh+ fetus)
    • B) Anti-D immunoglobulin required in Rh– mothers with exposure to D antigen within 72 hours of exposure
    Packed Red Blood Cells (2)
  • 5.
    • Indications
    • Generally, transfusion is rarely indicated when Hb >10 g/dL and is almost always indicated in when Hb level < 6 g/dL
    • The determination of transfusion in patients whose Hb is 6-10 g/dL should be based on any ongoing indication of organ ischemia, the rate and magnitude of any potential or actual bleeding and the patient’s intravascular volume status.
    Packed Red Blood Cells (3)
  • 6.
    • Indications
    • Transfusion for Hb >6 g/dL in healthy nonsurgical patients is generally not indicated because oxygen delivery in healthy adults is maintained even with Hb as low as 6-7 g/dL.
    • Transfusion usually recommended prior to major surgery when hemoglobin levels are <10 g/dL
    Packed Red Blood Cells (4)
  • 7.
    • Indications
    • In acute hemorrhage, up to 40% of the blood volume in a bleeding, otherwise healthy young adult can be replaced with crystalloid without the need for red cell transfusion.
    Packed Red Blood Cells (5)
  • 8.
    • Comments
    • Each unit of PRBCs has approximate volume of 250 mL
    • In adults, 1 unit of PRBCs increases Hb level by ~1 g/dL and hematocrit by ~ 3%
    • In children, PRBCs increase the hematocrit by 1% for each mL/kg transfused
    Packed Red Blood Cells (6)
  • 9. Fresh Frozen Plasma
    • Frozen fluid product of centrifuged and separated whole blood
    • FFP is frozen at -18C or colder within 6-8h of collection
    • Contains normal plasma levels of stable clotting factors, albumin and immunoglobulin, but variably reduced levels of Factor V and Factor VIII
  • 10.
    • Before use, should be thawed in warm water which between 30°C to 37°C.
    • Higher temperatures will destroy clotting factors and proteins.
    • Once thawed, to be infused immediately (best within 6hr) or re-stored at 1-6C for up to 24 hours, which will be relabeled as Thawed Plasma, and to be used as a source of stable coagulation factors for up to 5 days
    Fresh Frozen Plasma (2)
  • 11.
    • Indications
    • Clotting factor deficiencies
      • Hemophilia A
      • Hemophilia B
      • von Willebrand disease
    • Cirrhosis (lack factors II, VII, IX, and X)
    • Massive blood transfusion – may transfuse 1 unit of FFP for every 5 to 6 units of PRBCs
    • Coagulopathy secondary to super-therapeutic warfarin
      • Transfusion of 5 to 10 mL/kg of FFP will reverse the effects of supertherapeutic warfarin
    Fresh Frozen Plasma (3)
  • 12.
    • Requires ABO-compatibility; but not crossmatched
    • Amount to transfuse: 3 to 10 mL/kg or as needed
    • Each unit of FFP has a volume of ~200 to 250 mL
    • Each unit of FFP increases coagulation factor levels by 2% to 3%
    Fresh Frozen Plasma (4)
  • 13. Cryoprecipitate
    • Cryoprecipitate prepared from precipitants of slowly thawed FFP between 1-6C. The cold insoluble precipitant then collected and refrozen within 1 hour.
    • Contains factor VIII, factor XIII, vWF, fibrinogen, and fibronectin
  • 14.
    • Indications
    • Hypofibrinogenemia (congenital, DIC, cancer,
    • Cirrhosis
    • Reversal of tissue plasminogen activator
    • Coagulopathy from massive transfusion
    Cryoprecipitate (2)
  • 15.
    • It is preferable to use cryoprecipitate that is ABO-compatible with the recipient’s red cells, but not crossmatched.
    • Infuse within 6 hours of thawing
    • Each bag of cryoprecipitate contains 10 to 25 mL of fluid
    Cryoprecipitate (3)
  • 16. Platelets
    • Obtained from centrifuged whole blood
    • Indications
    • Thrombocytopenia <10,000 cells/mm3 in asymptomatic patients
    • Thrombocytopenia <20,000 cells/mm3 with active hemorrhage
    • Thrombocytopenia <50,000 cells/mm3 undergoing invasive procedure
    • Dilutional thrombocytopenia (with massive blood transfusions)
  • 17.
    • Not indicated in diseases with ongoing consumption of platelets: ITP, TTP, untreated DIC & thrombocytopenia associated with septicaemia, until Rx has commenced or in cases of hypersplenism.
    Platelets (2)
  • 18.
    • Thienopyridine platelet ADP receptor inhibitors and direct glycoprotein IIb/IIIa inhibitors impair platelet function.
    • Platelets should not be transfused prophylactically without thrombocytopenia, but high dose therapeutic transfusion may be required for life threatening hemorrhage in patients on these drugs.
    Platelets (3)
  • 19.
    • Amount to transfuse: 1 unit per 10 kg body weight (6 to 10 units of platelets for the average adult)
    • Cross-matching is unnecessary, but all transfused platelets should be ABO and Rh compatible
    • 1 unit increases the platelet count by 5000 to 10,000 cells/mm3
    Platelets (4)
  • 21. Massive Transfusion
    • Definition
    • No strict definition but commonly referred as the replacement of entire body blood volume within 24 hours, or >10 units of PRBC transfusions within a few hours
  • 22.
    • Complications
    • Metabolic alkalosis and hypocalcemia secondary to citrated blood
    • Hyperkalemia or hypokalemia
    • Hypothermia
    • Dilutional coagulopathy
    • Thrombocytopenia
    • Acute respiratory distress syndrome (ARDS)
    Massive Transfusion (2)
  • 23.
    • Administer via blood warmer (no microwave)
    • Calcium gluconate (if ECG changes occur)
    Massive Transfusion (3)
  • 24. Hemolytic Crisis (Acute Transfusion Reaction)
    • Most commonly caused by ABO incompatibility
    • May result in activation of coagulation cascade (DIC)
    • Symptoms and signs
      • Headache, back pain, joint pain, anxiety, fever, tachycardia, hypotension, wheezing, pulmonary edema, and renal failure
      • Delayed reactions occur in extravascular space, most commonly spleen, liver, or bone marrow
      • Pink serum or urine
  • 25.
    • Management
    • Stop transfusion
    • IV fluids
      • Maintain urine output at 30 to 100 cc/h
    Hemolytic Crisis (Acute Transfusion Reaction) (2)
  • 26. Other Complications
    • Febrile transfusion reaction
    • Etiology: recipient antibody response to donor leukocytes, and release of cytokines that are produced in storage
    • Difficult to differentiate from hemolytic reaction
    • Management: stop transfusion until hemolytic reaction excluded
  • 28. Aspirin
    • Mechanism
    • Irreversibly blocks conversion of arachidonic acid into thromboxane A2 (platelet aggregation agent) by inhibiting cyclooxygenase (COX)
    • Effect on platelets irreversible, lasts for entire platelet life span (~7 to 10 days)
  • 29.
    • Mechanism
    • Irreversibly blocks ADP receptor on platelets
    • Deforms the fibrinogen receptor on platelet, that renders the platelet unable to aggregate via the GP IIb and GP IIIa pathway
    Clopidogrel and Ticlopidine
  • 30. Clopidogrel and Ticlopidine (2)
    • Complications
    • Dyspepsia, rash, diarrhea
    • Ticlopidine is associated with hematologic effects
      • Neutropenia
      • ITP
      • TTP
    • Reversal
    • Platelet transfusion
  • 31. Heparin
    • Mechanism
    • Reduced thrombin and fibrin formation by binding and activating antithrombin III (potentiate activities of antithrombin III)
    • Unfractionated Heparin
        • Derived from bovine lung tissue
        • Inhibits factors Xa and IIa in roughly equal proportions
        • Requires frequent monitoring of aPTT (target generally between 1.5 and 2.5 times baseline)
  • 32. Heparin
    • Low Molecular Weight Heparin
    • Derived from porcine intestinal mucosa
    • Higher ratio of antifactor Xa to antifactor Iia activity than unfractionated heparin
    • Activity onset within 3 to 5 hours
  • 33.
    • Complications
    • HIT
    • Reversal
    • Reversed with protamine sulfate (derived from fish sperm; beware hypotension and anaphylaxis)
  • 34. Heparin Induced Thrombocytoenia
    • HIT is a syndrome of antibody-mediated thrombocytopenia that paradoxically is often associated with thrombosis [thrombotic risk is more than 30 times that in control populations]
  • 35.
    • Platelet factor 4, a small peptide stored within the alpha granules of platelets, binds to heparin and is released into the blood during treatment with heparin.
    • These complexes then activate platelets [contributes to the thrombotic complications of heparin-induced thrombocytopenia]
    Heparin Induced Thrombocytoenia
  • 36.
    • Typically, HIT begins with the appearance of thrombocytopenia about a week after the start of heparin therapy.
    • Patients who have HIT should not be treated with low-molecular-weight heparins, since these have high cross-reactivity with circulating PF4–heparin antibodies.
    Heparin Induced Thrombocytoenia
  • 37. HIT Type 1 and 2
  • 38. Warfarin
    • Mechanism
    • I nhibits synthesis of vitamin K-dependent coagulation factors (factors II, VII, IX, and X)
    • Also inhibits the anticoagulants protein C and protein S
    • Ingredient in many rodenticides or “superwarfarins”
  • 39. Warfarin (2)
    • Reversal
    • Reversed with FFP or prothrombin complex concentrate
    • May be reversed with vitamin K
      • Oral route preferred, unless rapid reversal required (may administer intravenously)
      • Delay (up to 24 hours) in onset
  • 40. GP IIb and GP IIIa Receptor Inhibitors
    • Examples: abciximab, eptifibatide, tirofiban
    • Mechanism
        • Inhibit platelet aggregation and activation by preventing activated fibrinogen binding to GP IIb/IIIa receptors
    • Effects typically last 24 to 48 hours
    • Complications
        • Thrombocytopenia, Hemorrhage
    • Reversal
        • Platelet transfusion, Desmopressin (may be beneficial)
  • 42. Neutropenic Fever
    • Definition
    • Single oral temperature of ≥38.3°C (101°F)
    • or sustained temperature elevation of 38°C (100.4°F) for 1 hour and
    • Polymorphonuclear leukocyte count <500 to 1000 cells/mm3
  • 43.
    • Diagnosis
    • All neutropenic patients with fever should be managed as if they have a serious bacterial infection
    • Cultures (blood, urine, and other areas as indicated)
    • Radiographic imaging as indicated (eg, chest radiographs, CT sinuses, etc.)
    Neutropenic Fever (2)
  • 44.
    • Management
    • Admission, Start prophylactic empiric antibiotic therapy
      • Monotherapy
          • Imipenem and cilastatin
          • Ceftazidime
          • Cefipime
      • Combination therapy
        • Ceftazidime or cefepime or imipenem/ cilastatin and vancomycin
          • For suspected MRSA (recent hospitalizations) or with indwelling catheter
    Neutropenic Fever (3)
  • 45.
    • Complications
    • Untreated neutropenic fever associated with 20% mortality rate compared to <2% if treated promptly
      • Infections are the number one cause of cancer death
      • Remember: Although fever may result from the malignancy itself, 55% to 70% of fevers in this patient population will have an infectious etiology
    Neutropenic Fever
  • 46. Tumor Lysis Syndrome
    • Definition
      • Electrolyte abnormalities that result from the breakdown products of dying cancer cells
    • Etiology
      • Typically following chemotherapy of Leukemias and lymphomas (especially Burkitt lymphoma)
      • Small cell lung carcinoma
      • Following steroid administrations
  • 47.
    • Symptoms and signs
    • Occurs most commonly within 1 to 5 days of initiating chemotherapy or radiation therapy for rapidly growing tumors
    • Reflect the presenting electrolyte abnormality
    Tumor Lysis Syndrome (2)
  • 48.
    • Diagnosis (constellation of the following metabolic disturbances)
    • Hyperuricemia (>7 or 8 mg/dL)
      • Secondary to DNA degradation
      • Acute renal failure
    • Hyperkalemia
      • Susceptible to arrhythmias
      • Exacerbated by renal failure
    Tumor Lysis Syndrome
  • 49.
    • Diagnosis (constellation of the following metabolic disturbances)
    • Hyperphosphatemia
      • Secondary to protein degradation
      • Precipitation with calcium in heart and kidney
    • Hypocalcemia
      • Secondary to hyperphosphatemia
      • Muscle weakness and cramps
    Tumor Lysis Syndrome