Haematology Flashcards
1
Q
3 classic Sx of anaemia?
A
fatigue, dyspnoea, faintness
2
Q
When is anaemia severe? name 2 signs ?
A
< 8g/dL
Tachycardia
Flow murmur
Cardiac enlargement
Increased cardiac output
3
Q
what transports iron?
A
transferrin
4
Q
where is iron stored
A
ferritin, haemosiderin
5
Q
Name 3 things on presentation with Fe deficiency anaemia
A
Pallor
Nail changes - Koilonychia (spoon), brittleness
Hair loss
Mouth changes - Angular stomatitis, atrophic glossitis
Classic 3
Fatigue
Faintness
Dyspnoea
6
Q
What are the general causes of iron deficiency
A
Inadequate intake
Poor absorption
Excessive loss
Excessive iron requirement
7
Q
Name 3 Ix in Iron deficiency anaemia and 2 things seen on bloods
A
Hb <13g/dL (men), <12g/dL (women)
MCV - microcytic
Peripheral blood smear
Iron studies - Low iron / ferritin
Ix for cause
Coeliac (malabsorption), H. pylori (basically eats iron), endoscopy (bleed or Malab)
8
Q
Why might ferritin be unexpectedly high in iron deficiency
A
It is an acute phase protein so will increase if inflammation, infection and malignancy
9
Q
2 key DDx for iron deficiency anaemia
A
chronic disease
sideroblastic anaemia (bone marrow produces sideroblasts rather than normal erythrocytes)
10
Q
mx of iron deficiency
A
oral replacement - ferrous sulphate
consider transfusion
11
Q
SE of ferrous sulphate
A
constipation, black stools, vomit
12
Q
When would you think this pt has sideroblastic anaemia
A
microcytic hypochromic anaemia NOT responding to iron
13
Q
Pathology and What causes sideroblastic anaemia
A
Ineffective erythropoesis - cant incorporate iron into Hb
Congenital - inherited XLSA (x-linked)
Acquired - MDS (myelodysplastic syndrome), myeloma, PRV, pyridoxine (B6) deficiency
14
Q
name 3 Ix in sideroblastic anaemia. Make sure you know the last one
A
Hb - low
MCV - microcytic
Peripheral blood smear
Iron studies - Iron / ferritin high
Marrow aspirate - Perinuclear ring of iron granules with Prussian Blue
15
Q
Mx of sideroblastic
A
iron chelation (gets rid of excess iron in body) - desferrioxamine
Avoid alcohol / vit c (increase iron absorption)
16
Q
What happens in b thalassaemia
A
Inherited microcytic anaemia caused by mutation in beta-globin gene
-ineffective erythropoesis
Erythroid hyperplasia
17
Q
2 Effects of erythroid hyperplasia in b thalassaemia?
A
Bony changes - skull bossing, vertebral….
hepatosplenomegaly
18
Q
Name 3 Ix in b thalassaemia
A
FBC
Peripheral blood smear
Hb anaylsis
LFT
Xray skull for skull bossing
Abdo USS for hepatosplenomegaly
19
Q
b thal mx points
A
genetic councelling
transfusion
Iron chelation
splenectomy
Bone marrow transplant
20
Q
name 3 complications of thalassaemia
A
thrombotic
iron overload - heart arrhythmia, pituitary, pancreas
transfusion reactions
transfusion infections
splenectomy comps
21
Q
Reticuloendothelial causes of haemolysis
A
Macrophages of liver
Spleen
Accelerated red cell destruction due to immune targeting by antibodies
22
Q
Name 3 hereditary causes of haemolytic anaemia
A
Glucose 6 phosphate dehydrogenase deficiency
Hereditary spherocytosis,
Sickle cell anaemia, thalassaemia
23
Q
Test for immune mediated haemolytic anaemia
A
direct antiglobulin +ve (Coombs’ positive)
24
Q
Name 3 causes of non immune mediated haemolytic anaemia
A
Infection (e.g. malaria), trauma,
microangiopathic haemolytic anaemia (DIC, TTP, HUS, HELLP)
hypersplenism, liver disease
Paroxysmal nocturnal haemoglobinuria
trauma - eg mechanical heart valve
complement mediated lysis
25
Dx of Paroxysmal nocturnal haemoglobinuria
urinary haemosiderin
People with this condition have paroxysmal episodes of haemolytic due to things like infection
26
3 Ix in haemolytic anaemia
FBC - low Hb
Unconjugated bilirubin
Urinanalysis - haemaglobinuria
Peripheral blood film
Direct coombs test = test antibodies ON red blood cells
27
In haemolytic anaemia there is increased breakdown - what do you see in blood (and one other place) as a result of this?
Increased bilirubin, increased urobilinogen [not blood obvs], increased LDH
28
In haemolytic anaemia there is increased production - what do you see as a result of this?
Increased MCV as there are increased reticulocytes (bigger)
marrow hyperplasia
29
How might you differentiate between Extravascular or intravascular haemolytic anaemia
Intravascular - increased free plasma Hb and decreased haptoglobin, increased haemoglobinuria (no blood cells)
Extravascular - splenomegaly
30
What supplement is usually given in haemolytic anaemia
folic acid
31
How does G6PDD present? Triggers?
Presents with prolonged neonatal jaundice
In older:
Jaundice
Pallor
Dark urine (suggests intravascular haemolysis)
Nausea, vomiting, dehydration, AKI (haemoglobin precip)
Infection
Broad beans
Certain drugs (causing oxidative stress) e.g. sulphonamides, *cephalosporins
32
mx of G6PDD
Fluid intake
folic acid
blood transfusion if severe anaemia
renal support if needed
33
what is anaemia of chronic disease
Anaemia and evidence of immune system activation
- decreased RBC production + decreased survival
34
Whats seen on lab studies of anaemia of chronic disease?
Normocytic normochromic/microcytic hypochromic
Low reticulocyte count
Low serum iron
Low TIBC
Low transferrin saturation
Elevated ferritin
35
1 test that can differentiate anaemia of chronic disease and iron deficiency
ferritin - increased in ACD
36
How does aplastic anaemia present?
What is it?
Autoimmune destruction of RBCs.
Neutropenia - infections
Anaemia - fatigue, pallor, dyspnoea, faintness
Thrombocytopenia - bleeding, bruising
37
Name 2 associations with aplastic anaemia
pregnancy, coeliac, SLE, paroxysmal nocturnal haemoglobinuria
38
Seen on bone marrow biopsy of aplastic anaemia
Hypocellular marrow with no abnormal cell population
39
2 parts of Non pharma mx of aplastic anaemia
MASSC risk assessment if NP< 0.5
[risk of febrile neutropenia]
Full barrier nursing
Avoid IM injections
Look for infection
Check bloods and cultures
Vitals 4 hourly
40
Medical Mx of aplastic
allogeneic BM transplant
+ RBC and Pt transfusion
+ ABX
41
2 issues with crescent shaped Hb in sickle cell
Disrupt blood flow and break (haemolysis)
- Painful crises
-Organ damage
-Increased vulnerability to infection
Cause varying degrees anaemia
42
what triggers sickle cell crisis?
CHIDS:
Cold
Hypoxia (extreme exercise)
Infection
Dehydration
Stress
43
3 areas affected in exam land by sickle cell crisis?
Acute chest syndrome: pneumonia like syndrome (due to sickling in pulmonary vasculature) - chest pain, fever, dyspnoea, tachypnoea
Bone infarction and avascular necrosis femoral head
Acute abdomen - mesenteric ischaemia
44
When is sickle cell usually Dx? Mx at this point?
newborn screening - blood spot
pneumococcal vaccine and penicillin prophylactically
genetic counselling
parental education
45
mx of sickle cell crisis
cross match
analgesia
O2
IV vluids
Abx -broad
Blood if needed
46
Chronic Mx of sickle cell
Supportive
-Pain
-Pneumococcal vaccination and penicillin prophylaxis
-Trigger avoidance
-Folic acid if severe haemolysis
Hydroxyurea - Increases fetal Hb production
Repeat transfusions if Hb <10g/dL
47
Name 3 comps of sickle cell
crisis
anaemia
liver - jaundice / gallstones
iron overload from transfusion
leg ulcers
48
What causes megaloblastic anaemia?
B12/folate deficiency + drugs (hydroxyurea)
This causes defective DNA synthesis which also leads to leukopenia and thrombocytopenia
49
Where is folate found naturally
green veg
nuts
liver
50
4 causes of folate deficiency
Poor diet - eg alcoholic , poverty
Increased demand - eg pregnancy renal disease
Malabsorption - coeliac/ tropical spure
Drugs, alcohol and methotrexate
51
signs of folate deficiency
Headache - hallmark of megaloblastic
Anaemia
Pallor, fatigue, dyspnoea, faintness, tachycardia, heart murmur
Gi
Loss of appetite/wt loss
Skin
glossitis, exfoliative dermatitis
52
Mx of folate deficiency
oral folic acid
53
What do you get with b12 deficiency
macrocytic anaemia with peripheral neuropathy and neuropsych complaints
54
foods rich in b12
meat, fish, dairy
[vegans always lacking]
55
which cell and what do they produce is needed for b12 absorption
parietal - intrinsic factor
56
neuro sx of b12 deficiency
Subacute degeneration of spinal cord
[peripheral neuropathy, demetia, ataxia, paraethesia]
57
triad of signs Subacute degeneration of SC?
Upgoing plantars
Loss knee jerk
Loss ankle jerk
58
mouth signs b12 deficiency
Glossitis (painful), angular cheilitis
59
mx of b12 deficiency if severe (pancytopenia + anaemia + neurological)
IM hydroxycobalamin (cobalamin = b12)
oral folic acid
blood transfusion
admit neuro / haem
60
Mx of b12 deficiency if no neuro o
IM hydroxycobalamin
61
What is pernicious anaemia
Autoimmune atrophic gastritis -> Atrophy of gastric mucosa with failure of IF and acid production due to autoantibodies to IF
62
Association wit pernicious anaemia? increased risk of ?
AI diseases - thyroid, DM, vitiligo....
Gastric Ca
63
Specific Ix for pernicious
IF antibody
antiparietal antibody
Schilling test (radio b12)
64
What is leukaemia
Excess of abnormal white cells in peripheral blood - myeloid or lymphoid
65
Acute leukaemia 3 Sx categories?
Tumour related:
Bone pain, fever, lethargy, night sweats, wt loss
BM sx
Anaemia
thrombocytopenia
neutropenia
Circulating cell sx
headache, lyphadenopathy, hepatosplenomegally
66
Dx of AML
Bone marrow blasts > 20% or peripheral blood
[may be complication of chemotherapy]
[?most common in old age]
67
Ix in AML name 3
FBC - leukocytosis, neutropenia
Peripheral blood film - blasts + auer rods
Bone marrow biopsy - blasts >20%
CXR - pulm infiltrates
Coagulation
UE, LFT, Coagulation
68
name 2 DDx of AML
ALL
myelodysplastic syndrome
aplastic anaemia
69
What is tumour lysis syndrome? electrolytes?
Electrolyte and metabolic disturbance due to breakdown of large number leukaemic cells
(hyperuricaemia, hyperphosphataemia, hyperkalaemia, hypocalcaemia, renal impairment)
70
Mx of tumour lysis syndrome?
IV fluids
allopurinol
[haemodyalysis if needed]
71
Drug for leukoreduction in AML?
Hydroxycarbamide
72
2 parts Mx AML ?
Chemo - [Cytarabine and daunorubicin (don't think need to know)]
Allogenic transplant at first remission
73
Dx of ALL
Bone marrow blasts > 20%, blood smear leukaemic lymphoblasts
74
Chromosomal association with ALL
Philadelphia chromosome - translocation (9,22
75
ALL affects CNS. How present?
CNS infiltration by leukaemoid cells presents as papilloedema, nuchal rigidity and meningismus
May also have a focal neurology (CN 3, 4, 6, 7)
76
ALL ix
FBC -
peripheral blood film
coagulation pannel
bone marrow biopsy
CXR , LP
UE, LFT, renal
77
seen on CXR of ALL
Mediastinal widening
78
Name 3 Comps of ALL
Tumour lysis syndrome
Neutropenic sepsis
Pancytopenia
Chemotherapy side effects
79
Name 3 parts of acute Mx for ALL
Supportive care:
-Hydration - [electrolyte abnormalities]
-Allopurinol - [for acute tumour lysis syndrome (increased urate)]
-Prophylactic antimicrobials -Think bacterial/viral/fungal (aciclovir + fluconazole + ciprofloxacin)
Transfusions - RBC + platelets (if pt<10 x 10^9)
Induction chemotherapy (kill leukaemic cells) +- tyrosine kinase inhibitor (imatinib)
Intrathecal methotrexate (for CNS disease)
80
CML genetics
Philadelphia chromosome/
BCR-ABL fusion gene
Confirms Dx
81
mx of CML
Tyrosine kinase inhibitor (imatinib / dasatinib)
allogeneic haematopoeitic stem cell transplant
high-dose induction chemotherapy
82
Cell in CLL? what happens?
B lymphocytes avoid apoptosis -> invade liver spleen and bone marrow
->
Lymphadenopathy, hepatosplenomegaly, BM suppression
83
most common leukaemia of old age? trigger?
CLL
Pneumonia
84
Sx of CLL
Anaemia
SOB / fatigue...
Infiltration -
Lymphadenopathy , splenomegaly
B sx
Fever
Night sweats
Weight loss
[Fatigue, Chills]
85
name 3 Ix in CLL
FBC - lymphocytosis , low hB, low pt
Peripheral blood film - smudged cells (damage to lymphocytes in prep)
Flow cytometry
CD5, CD19, CD23 positive
CT
Hepatosplenomegaly, retroperitoneal, mediastinal lymph nodes
86
Mx of CLL
chemotherapy: [rituximab + cyclophosphamide + fludarabide]
+/-stem cell transplant
87
2 comps and their Mx in CLL
Hypogammaglobulinaemia
- cant produce antibodies
-> give monthly IVIg
Autoimmune haemolytic anaemia
-> pred
88
Difference between lymphomas and leukaemia
Lymphomas are solid, leukaemias are circulating
89
Most common type of non-hodgkins ? what can it produce?
is diffuse large B-cell lymphoma (mainly from B cell lines)
May produce immunoglobulins. [T cells can travel to extranodal sites e.g. skin and CNS]
90
Associations with NHL
AI disorders (Sjogren’s, RA, SLE, coeliac),
immunodeficiency
91
How does NHL present?
Lymphadenopathy
Dry cough - mediastinal mass / pneumonia
Bone marrow
spenomegaly
GI
B Sx
Night sweats
Fever
Weight loss
92
3 Ix in NHL
FBC - Thrombocytopenia (liver or BM), or pancytopenia (BM)
Lymph node biopsy - (for flow cytometry - tumour surface markers and cytogenetics)
LDH - high
CT/MRI - staging
93
NHL how might you provide
CNS prophylaxis?
Antimicrobial?
intrathecal methotrexate
ciprofloxacin + aciclovir + fluconazole
94
HL from what cells?
most common presentation?
what cells are seen?
Arises from mature B cells
Most commonly presents with cervical or supraclavicular lymphadenopathy (painless)
-B symptoms in 30% of patients
Presence of Reed-Sternberg cells (large, multinucleated
95
HL aetiology?
Immunodeficiency
EBV
AI - SLE
96
Often get mediastinal adenopathy in HL -> name 3 sx?
Dry cough
Dyspnoea
Chest pain
Superior vena cava syndrome (facial and upper limb oedema, dilated vessels)
97
What is multiple myeloma? how is it therefore diagnoses?
Clonal proliferation of plasma cells in the bone marrow associated with monoclonal element (Ig or Ig fragment) in serum or urine
-> Diagnosis by serum and urine protein electrophoresis
98
Most common presentation of MM
Bone pain (esp back pain!)
Anaemia
[Fatigue
Infections
Hypercalcaemia
Renal impairment]
99
Key protein in MM
M-protein - monoclonal component
100
Which organs / features involved in MM
CRAB
Calcium elevation
Renal insufficiency
Anaemia (Hb < 10g/dL
Bone disease - lytic or osteopenic
101
2 Ix you should do in all over 50 with back pain?
serum protein electrophoresis
ESR
102
Sx groups in MM
Osteolytic lesions (backache / fractures)
Anaemia, neutropenia, thrombocytopenia from BM infiltration
Recurrent infections
Renal impairment
103
What causes renal impairment in MM
Deposition of Tamm-Horsfall protein in loop of henle
104
gold standard Ix in MM
Serum/urine electrophoresis
105
bar Serum/urine electrophoresis, what other Ix might you do MM? name 3
Skeletal survey
BM aspiriate
Blood film
FBC, ESR, UE, Ca
106
MM mx of comps...
Bone disease?
anaemia?
spinal cord compression?
hyperviscosity -> reduced cognition / blurred vision?
AKI?
Infection?
Bone disease: Hypercalcaemia + pain - bisphosphonates + analgesics
Anaemia - blood transfusion/EPO
Spinal cord compression - dexamethasone
Hyperviscosity (reduced cognition/blurred vision) - plasmapheresis
AKI - rehydration/ preserve good hydration
Infection - antibiotics + pneumonia/flu vaccine
107
What is polycythaemia? 2 cause categories
increased proportion of haemoglobin in the blood
Relative - decreased plasma volume
e.g dehydration, smoking, obesity
Absolute - increased RBC
Eg polycythaemia vera, altitude, chronic lung disease
108
PRV -> More RBCs (also WBC and pt a bit). What comps?
Hyperviscosity -> thrombosis, haemorrhage
progress -> myelofibrosis and acute leukaemia
109
genetics of PRV
JAK2
110
Sx categories of PRV
Hyper-viscous
- headache, visual change, dizzy, red/full apperance
Thrombosis /bleeding
Bath
Pruritus after hot bath, erythromelalgia (pain) + redness of fingers, palms, heels toes
111
3 key Ix in PRV
FBC Raised haemoglobin, raised haematocrit, raised WBC, raised Pt
JAK2 gene mutation screen (e.g. PCR)
BM biopsy
112
in Polycythaemia Vera treatment aims to keep a low haematocrit and reduce the risk of thrombosis...
What drug?
what other mx?
hydroxycarbamide [Reduces number of blood cells produced by bone marrow - So also used in CML]
(+aspirin)
Management of CV risk factors (DM, hyperlipidaemia, HTN, smoking)
113
Differentiate PV and CML
PV has no philadelphia chromosome
Neutrophil alkaline phosphatase is raised in PV but decreased in CML
114
3 characteristics of myelodysplastic syndrome?
dysplastic changes in one or more cell lineages
ineffective hematopoiesis
likely to develop AML
115
How does Myelodysplastic syndrome present
anaemia
neutropenia
thrombocytopenia
116
Name 3 Ix in Myelodysplastic syndrome
FBC
Blood film - diamorphic blood cells
Ferritin, B12, renal function, LFT,
CXR
ECG
BM biopsy
117
What anaemia described ...
[Congenital dysmorphic features (what?)
Pancytopenic bone marrow failure
Susceptibility to cancer ]
Age?
faconi
[Sounds Italian - think of darker skin, italian hand shape which has a weird thuumb and in shape of triangle and could be a odd shaped heart - DIS SHIT TENUOUS]
Triangular faces
Cafe au lait + hyperpigmented skin
Cardiac and renal malformations
Abnormal thumbs
<7 - similar to aplastic/AML/Myelodysplastic
118
what regulated production of patelets?
thrombopoeitin
(from liver)
119
When does ITP usually occur?
children with a preceding viral illness
120
3 Ix in ITP
FBC
Peripheral smear - Rule out other cause
BM biopsy
121
how can ITP be differentiated from
Thrombocytopenia due to liver disease?
TTP?
DIC?
Thrombocytopenia due to liver disease or alcohol - raised GGT, alk phos
TTP - may have neurological changes or fever + anaemia
DIC - prologed PT and aPTT
122
Mx of severe bleeding in itp
IVIG
Pred
pt transfusion
123
Mx of chronic ITP
rituximab + splenectomy
124
Thrombotic thrombocytopenic purpura is a medical emergency (95% fatal) What are the pentad of Sx ?
[Fuck Renal HTN]
Fever
Renal failure
Haemolytic anaemia
Thrombocytopenia
Neurological change
125
What causes TTP
Absence of VWF cleaving protein (ADAMTS-13)
[platelet aggregation in microvasculature (brain, kidney, heart)
+Haemolysis]
126
seen on peripheral blood smear of TTP
Microangiopathic blood film with schistocytes (RBC fragments)
127
Mx of TTP ? what not?
Urgent plasma exchange + prednisolone + aspirin
DO NOT GIVE PLATELETS
128
Which drug commonly used to target antibpdy production
rituximab
129
Pres of DIC
Symptoms/signs of systemic collapse: oliguria, hypotension, tachycardia
Bleeding: bruising, purupura
130
2 things you transfuse in DIC
Platelet transfusion
FFP - replace coagulation factors
131
can girls get haemophilia? Where is bleeding commonly \/ age of presentation?
no - x linked recessive-
muscles and joints
toddlers
132
When does WVD present? how?
teens
Bleed into mucus membranes and skin
133
Haemophilia Avs B
A = F8 deficient
B = F9 deficient
134
What should you avoid with haemophilia
IM injections, aspirin and NSAIDS
135
What can be given in mild haem A ?
desmopressin (IV) -> stimulates endogenous release F8 + VWF
136
genetic VWD
AD chromosome 12
Presentation - menorrhagia, telangiectasia, bruising and bleeding, gum bleeding
137
mx VWD
IV demopressin
severe - + F8
138
HHT is? other name?
hereditary haemorrhagic telangiectasia
Osler-Weber-Rendu
139
Vit K needed for synthesis of what factors
1972
140
What is prolonged in liver disease
PT time
141
What happens in the coagulation cascade
Series of proteolytic enzymes that circulate in inactive state which are sequentially activated
Generate thrombin that cleaves fibrinogen creating fibrin = clot
142
In endothelium damage what do platelets adhere to?
collagen and VWF and GP1b
143
2 drugs affecting platelet function ?
2 for coagulation
Aspirin and clopidogrel affect platelet function
Heparin and warfarin affect coagulation cascade
144
Aspirin mech?
Irreversibly inhibits COX1
145
Clopidogrel mech?
Irreversible P2Y12 antagonist
146
warfarin Mech
a vitamin K antagonist - prolongs PT
147
Eg of noac and mech?
FXa inhibitors - apixaban, rivaroxiban
148
Name some RFs of DVT
Antiphospholipid syndrome
Cancer
Slow flow - sickle cell, PRV
Nephrotic syndrome
Obesity
Pregnancy
Sedentry
Protein C/S deficiency
149
what 2 Ix before transfusion
Group and screen
Cross match
150
Name 3 comps of transfusion
infection
Acute
Acute haemolytic reaction
Febrile, non-haemolytic reaction
Allergic/anaphylactic reactio
Delayed
Iron overload
Delayed haemolytic reaction
Transfusion-associated graft vs host disease
151
2 main comps of splenectomy
thrombocytosis - platelets peak at 7-10 days - could give aspirin prophylactic
infection
152
What prophylax in splenectomy
ABx
phenoxymethylpenicillin + or macrolides (azithromycin/clarithromycin
Pneumococcal vaccine and influenza vaccine
153
blood test to differentiate ALL and AML
nuclear staining for TdT - only in Lymphoblasts
[not in lymphocytes or myleoblasts]
myeloperoxidase in myeloblasts
[seen as auer rods]
154
Key features of subtype monoblast AML
infiltrates gums
often no myeloperoxidase
155
Key features of megakaryoblast AML
often no myeloperoxidase
associated with downs
156
What is myelodysplastic syndrome ? usual cause of death?
blast buildup in bone marrow but not >20%
->can progress to AML
Cytopenia -> infection + bleeding
157
Key difference in cells between acute and chronic leukemia
Chronic - partial maturation
acute - no maturation
158
Seen on blood smear of CML vs CLL
For Dx?
CML - increased granulocytes and monocytes
CLL - smudge cells - due to immature B cells being damaged
Dx:
phildelphia chromosome = CML
Chromosomal defects in CLL
159
How long for effects of change / initiation in warfarin?
What should you co prescribe when initiating warfarin?
3 days
[If initiating give 3 days of LMWH]
160
What is beriplex also called
prothrombin complex concentrate
161
Staging tool for lymphoma
Ann Arbor scale
162
Sickle cell crises
Veno-occlusive - Eg Long bones, GI, priaprism
Acute chest
Aplastic - preceded by parvovirus b19
Sequestration - massive spleen, decreased Hb, Hypovolaemic shock
163
HL Vs NHL in age ?
HL - younger - 20-34
50% EBV positive
164
Key associations with CML ?
Gout - purine breakdown
Abdo distension
165
If you were going to give 1 drug for CML what would it be?
Imatinib
166
Which leukaemia has rule of 3rds?
CLL
167
DKA 5 aspects of Mx
fluids
insulin
detrose
LMWH
Kcl if needed
