Hematology Requirements for Flight Surgeons and Airmen
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Hematology Requirements for Flight Surgeons and Airmen
- 1. Hematology For flight surgeon
- 2. For airman
- 3. Hematologic requirements “blood must carry sufficient oxygen to satisfy metabolic requirements at rest, during exertion and anxiety, both at ground level and at altitude.” Hb < 10.5 - 11 g/L should be considered as unfit. Hemoglobinopathic trait or thalassemia minor is genera%y acceptable. Manual of cicil aviation medicine. 3rd ed. ICAO. 2012.
- 4. Common condition G-6-PD deficiency Hemoglobinopathy Polycythemia vera Acute leukemia Chronic leukemia Lymphoma Bleeding diathesis Manual of cicil aviation medicine. 3rd ed. ICAO. 2012.
- 5. Common condition G-6-PD deficiency Hemoglobinopathy Polycythemia vera Acute leukemia Chronic leukemia Lymphoma Bleeding diathesis Manual of cicil aviation medicine. 3rd ed. ICAO. 2012.
- 6. How to diagnose Anemia Male: Hb < 13 g/dL Female: Hb < 12 g/dL
- 7. Approach to anemia History Family history of anemia On set: acute vs chronic Physical exam Pa%or Liver and spleen
- 8. Key point Family Hx su'ests congenital disease e.g. thalassemia Acute onset su'ests blood loss or hemolysis e.g. G-6-PD deficiency, AIHA, UGIB Chronic onset usua%y causes no symptom and more likely due to decrease production Liver and spleen also su'est thalassemia or hereditary spherocytosis
- 9. Screening LAB Hb 13.2 g/dL WBC 8,000/mcL Hct 39% PMN 60% MCV 84 fL Lymphocyte 20% MCH 32 g/dL Mono 5% MCHC 31 g/dL Platelet 230,000/mcL RDW 12 MPV 7.2 fL
- 10. Screening LAB Hb 13.2 g/dL WBC 8,000/mcL Hct 39% PMN 60% MCV 84 fL Lymphocyte 20% MCH 32 g/dL Mono 5% MCHC 31 g/dL Platelet 230,000/mcL RDW 12 MPV 7.2 fL
- 11. Key point Hct > Hb x 3 : su'ests hemoglobin H disease MVC < 80 : su'ests iron def. of thalassemia RDW > 12 : su'ests anisocytosis Normal RDW could be thalassemia trait of ACD MCHC > 34 g/dL su'ests hereditary spherocytosis PMN predomination reflects normal marrow function
- 12. G-6-PD deficiency X-linked recessive inherited Send for G-6-PD level to make diagnosis May considered as fit to fly if can avoid food or medication that cause hemolysis Fava Sulfa Manual of cicil aviation medicine. 3rd ed. ICAO. 2012.
- 13. Polycythemia vera Hb > 18.5 g/dL in male or > 16.5 g/dL in female Presence of JAK2V617F or Jak2 exon 12 mutation Panmyelosis marrow with prominent erythroid, granulocytic and megakaryocytic proliferation Low EPO level Endogenous erythroid colony formation in vitro Swerdlow SH, et al, ed. WHO classification of tumours of haematopoietic and lymphoid tissues. 4th ed. 2008.
- 14. Polycythemia vera Genera%y considered as unfit due to risk of thromboembolic episode May considered a restricted certification if we% control by blood letting, aspirin, and hydroxyurea Manual of cicil aviation medicine. 3rd ed. ICAO. 2012.
- 15. Acute leukemia Why do you ask? Event cured case sti% has a risk of late complication of chemotherapy and radiation Cataract Pulmonary fibrosis Manual of cicil aviation medicine. 3rd ed. ICAO. 2012.
- 16. Chronic leukemia CML may be considered restricted certification CLL may be assessed as fit as long as they remain asymptomatic Manual of cicil aviation medicine. 3rd ed. ICAO. 2012.
- 17. Lymphoma If cured, restricted certification may be issued a*er two years a*er treatment Hodgkin lymphoma, diffuse large B-ce% lymphoma, etc. Manual of cicil aviation medicine. 3rd ed. ICAO. 2012.
- 18. Bleeding disorder Platelets < 75,000/mcL is disqualified ITP in remission a*er 6 months of treatment is acceptable Moderate to severe hemophilia or other congenital bleeding disorder is disqualified Manual of cicil aviation medicine. 3rd ed. ICAO. 2012.
- 19. Thromboembolism Pulmonary embolism required 6 months of treatment before reconsideration as fit Recurrent pulmonary embolism is considered as unfit History of deep vein thrombosis require fu% investigation for underlying cause before consideration Manual of cicil aviation medicine. 3rd ed. ICAO. 2012.
- 20. Anticoagulant & antiplatelet W arfarin or coumarin use is incompatible with certification Low dose low molecular weight heparin may be acceptable (e.g. enoxaparin 40 mg OD) Aspirin in low dose is acceptable but clopidogrel or other more potent antiplatelet a bar to flying Manual of cicil aviation medicine. 3rd ed. ICAO. 2012.
- 21. Hemoglobinopathy A% trait is acceptable for certification Sickle ce% disease in any form is disqualified Thalassemia disease is usua%y disqualified due to low hemoglobin level Manual of cicil aviation medicine. 3rd ed. ICAO. 2012.
- 23. Hematologic physiology G Y LO TO R!! A E EM PT H A N O CH Davis JR, ed. Fundamentals of aerospace medicine 4th ed. LippincottWi%iams&Wilkins. 2008.
- 24. Hemoglobin & hypoxia Oxygen-carrying capacity(mL O2/100 mL) = (1.34 x Hb x SaO2) + (PaO2 x 0.0031) Norma%y 20 ml O2/100 ml blood Davis JR, ed. Fundamentals of aerospace medicine 4th ed. LippincottWi%iams&Wilkins. 2008.
- 25. Hemoglobin & hypoxia O2 carrying capacity(mL O2/100 mL) = (1.34 x Hb x SaO2) + (PaO2 x 0.0031) Norma%y 20 ml O2/100 ml blood (at Hb 15 g/dL) If Hb 7 g/dL O2 carrying capacity is only 9.8 ml O2/100 ml blood Davis JR, ed. Fundamentals of aerospace medicine 4th ed. LippincottWi%iams&Wilkins. 2008.
- 26. What can we do?? Raise Hb level Raise PaO2 level Davis JR, ed. Fundamentals of aerospace medicine 4th ed. LippincottWi%iams&Wilkins. 2008.
- 27. Preparing Hb < 7 g/dL should be contraindicated to fly Transfusion to keep Hb > 10 g/dL before flight If transfusion is not available altitude restriction is mandatory O2 supplement to keep O2Sat > 90% is helpful in most patients with mild anemia or cardiac disease Davis JR, ed. Fundamentals of aerospace medicine 4th ed. LippincottWi%iams&Wilkins. 2008.
- 28. Sickle cell disease Sickle ce% crisis occur at desaturation Threshold is PaO2 < 60 mmHg (alt. 10,000 feet) Most commercial flights are pressurized to 8,000 feet But if patient with underlying pulmonary disease may desaturate at 4000 feet Genera%y O2 supplement is recommended for a% patients Davis JR, ed. Fundamentals of aerospace medicine 4th ed. LippincottWi%iams&Wilkins. 2008.
- 29. Bleeding diathesis Aspirin usua%y does not cause bleeding problem Platelet below 50,000/mcL should be transfused before flight Coagulogram more than 1.5 time of control should be corrected before flight
- 30. In flight DVT prevention avoidance of constrictive clothing around the lower extremities or waist maintenance of adequate hydration .equent calf muscle contraction Hirsh j, et al. ACCP evidence-based clinical practice guidelines 8th ed. Chest 2008;133;71-109.
- 31. Thromboembolism Hx of DVT or high risk of DVT should be prophylaxis with below-knee graduated compression stocking or low molecular weight heparin during a long-haul flight* Un.actionated heparin can be used to treat thromboembolism patient with monitoring before and during flight Protamine can be used to neutralized heparin if bleeding *Hirsh j, et al. ACCP evidence-based clinical practice guidelines 8th ed. Chest 2008;133;71-109.
- 32. Dose of protamine Protamine 1 mg for 100 units of accumulated heparin Accumulated heparin = 2 x rate Anaphylactic reaction can occur with protamine
- 33. Conclusion
- 34. For airman Acceptable Hb is not less than 10 - 15 g/dL Most hematologic diseases are disqualified Hemoglobinopathy trait is not a disease Only low dose aspirin is acceptable
- 35. For evacuation Keep Hb > 10 g/dL, Plt > 50,000/mcL, coagulogram < 1.5 times of normal range O2 supplement for mild anemia or high risk for ischemia Altitude restriction if transfusion is unavailable DVT prophylaxis measure for long-haul flight
- 36. Fin
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