14.13 (8.3) Anemia, Cytopenias, And Thrombosis In PC

Question 1

List four causes of anemia in pt with advanced illness

Answer 1

Microcytic anemia:
TAILS - nutritional deficiencies

Normocytic anemia:
Poor production (low to normal retic) - anemia of chronic disease, bone marrow infiltration, myelosuppression from chemo
High production (high retic) - acute blood loss, hemolysis

Macrocytic anemia:
B12/folic acid deficiency
Liver impairment

Question 2

Pathophysiology of anemia of chronic disease?

Answer 2

IMMUNOLOGICAL reaction secondary to inflammation and malignancy leading to release of cytokines causing:

1) uptake and storage of iron in macrophages and monocytes -> iron-deficient erythropoiesis occurring in bone marrow replete with iron

2) suppress kidney ability to produce erythropoietin

Question 3

How does anemia of chronic disease show up in bloodwork? How to differentiate from iron def anemia?

Answer 3

Normocytic (can be microcytic)
Low retic count
Low iron, normal/high Fe (reflective of total body iron storage) and low TIBC (reflective of transferrin)

Iron def anemia: microcytic anemia, low iron, low Fe and high TIBC

Question 4

List three side effects of oral iron

Answer 4

Nausea
Heartburn, abdo pain
Constipation
Diarrhea

Question 5

When to give oral versus parenteral iron

Answer 5

Oral iron:
Generally preferred as less SEs

Parenteral iron:
- Intolerant of oral iron
- Intestinal malabsorption
- Losing iron more quickly than can be replaced with oral iron

Question 6

A pt with small bowel resection develops macrocytic anemia with normal b12 levels. What are they likely deficient in?

Answer 6

Folic acid

Question 7

You order a peripheral blood smear for a pt with anemia. It comes back showing nucleated rbcs, myeloid white cell precursors, and tear drop rbcs. What process does this represent? What test can you order to confirm diagnosis?

What three solid tumors are most likely to cause this?

Answer 7

Bone marrow infiltration
Bone marrow biopsy

Breast
Lung
Prostate

Question 8

Patients with ANC (absolute neutrophil count) < or = to 100 cells/microlitre for >7 days should be considered for?

Answer 8

Fluoroquinolone prophylaxis (levo or cipro) to prevent febrile neutropenia

Cover pseudomonas

Question 9

What antibiotic to use with febrile neutropenia?

How long to treat?

Answer 9

Anti-pseudomonal beta lactam (e.g. piptazo, meropenem) +/- Vanco

Treat until ANC recovery (> or = to 500 cells/microliter) plus duration appropriate for site of infection and organism

Question 10

What is DIC (disseminated intravascular coagulopathy)?

What does it lead to?

Answer 10

OVERPRODUCTION of PROCOAGULANTS (overwhelms anticoagulant mechanism) leading to:

1) systemic generation of intravascular microthrombi (clotting) –> ischemic organ failure (e.g. liver, renal, intestinal, respiratory)

2) consumption of plts, fibrinogens -> bleeding

Question 11

List three risk factors for DIC in patients with cancer

Answer 11

Advanced stage of cancer
Chemotherapy
Anti estrogen therapy
Advanced age

Question 12

List 3 triggers of DIC

Answer 12

Sepsis
Immobilization
Liver mets

Question 13

Indicate whether the following lab indices increase or decrease in DIC
Platelets
Fibrinogen
aPTT
INR

Answer 13

Platelets - decrease
Fibrinogen-decrease
aPTT- increase
INR- increase

Question 14

Treatment of DIC

Answer 14

Cardiovascular support
Replacement of coagulation factors by blood products (fibronogen, factor VIII, fresh frozen plasma)

Can consider: plt transfusion, anticoagulants carefully if main issue is clotting

FS - UpToDate:
1. Treat underlying cause
2. Supportive management - hemodynamic, ventilatory, hydration
3. Transfusions as needed - RBC, platelets, fresh frozen plasma
4. Anticoagulant if indicated

Question 15

When to transfuse Hb?

When to transfuse plt?

Answer 15

Hb less than 70-80, or
Hb <100 + symptomatic + palliative

Plts less than 10, or
Active bleeding

UpToDate for plt transfusions:
< 10 (risk of spontaneous bleeding)
< 20+infection
<50+bleeding
<100+CNS bleeding

Question 16

List five types of transfusion rxn (2 common rxns and then 3 less common)

Answer 16

Most common:
Fever
Mild allergy

Other types:
Sepsis
Anaphylaxis
Acute intravascular hemolytic
Acute extravascular hemolytic
Transfusion associated circulatory overload (TACO)
Transfusion related acute lung injury (TRALI)

Question 17

EPO works by? Traditionally used for?

Answer 17

GROWTH FACTOR for red cell progenitors in bone marrow

Advanced renal disease and cancer Tx related anemia (hb < 100)

Question 18

Indication of EPO in cancer patient?

Answer 18

Patients using myelosuppressive chemo with Hb <100g/L

Question 19

How does cancer increase risk of VTE

Answer 19

Virchow’s triad:
- Venous stasis - tumors causing compression, paralysis from SCC, hospitalizations
- Endothelial injury of blood vessels - chemo, surgery, central venous access
- Hypercoagulability - cancer causing procoagulant changes

Question 20

What are four targets of VTE tx in the initial phase

Answer 20

Improve symptoms (pain, chest pain, SOB)
Prevent clot extension
Preventing embolic events
Prevent early recurrence
Decreasing upfront mortality

Question 21

Preferred anti-coagulants in cancer associated thrombosis

Answer 21

LMWH (e.g. dalteparin) - effective and safer
DOACs (e.g. rivaroxaban)

Question 22

What is the only acceptable indication for IVC filter? Why?

Answer 22

Patients with acute lower extremity DVT and absolute contraindication to anticoagulation

IVC filter is costly and has complications:
- Recurrent DVT
- Filter fracture and migration
- Vessel and organ penetration