Hematology abn

Question 1

Hb drop

Answer 1

- Hx + PE (PR)
>>>> Hb <8
>>>> Hb drop 1-2 within 1D
>>>> post-op Hb drop 2
- Bld x CBC, txs
- Bld x B12, folate, Fe profile, retic count, Hb pattern (if not done in past 3/12)

Acute bleeding (BP low): IV gelosfusine 500mL FR x1, direct pressure
- Reverse coagulation abn
> PLT <10 if afebrile/ <20 if febrile
> INR H + symptomatic

Source identified
> UGIB: PO pantoloc 40mg q24H +- OGD
> LGIB: IV transamine 500mg q8H +- colonoscopy
> rectal bleed: adrenaline gauze + IV transamine 500mg q8H +- colonoscopy
> hemoptysis: IV transamine 500mg q8H +- bronchoscopy
> hematuria: foley + bladder irrigation x1/7 +- cystoscopy (transamine cause clot retention + AROU)
> hip pain: psoas hematoma

Transfusion if Hb <8

• transfuse ___ U (1U = 1Hb) of packed cell (FR, q1H, q2H if active bleed/emergent; q4H if nonurgent/renal/CHF)
• lasix ___ mg post-packed cell, W/H if SBP <=110 (10-20mg; 40-60mg if renal)
• renal: CAPD 4.25% 2L q2H when transfusion / HD session transfuse
• CBC, RFT

Question 2

Polycythemia

Answer 2

(usu COPD)

• thrombosis: + aspirin 80mg PO daily
• BM exam if normal

Question 3

Neutropenic

Answer 3

(usu post-CT D7-10)

• fever
• ANC <0.5 / <1 but predictable fall to <0.5

Mx:
NO FEVER
- reverse isolation
- septic workup
 > bld x C/S + hickman C/S x 2set
 > sputum C/S
 > MSU multistix, C/S
 > CXR

• PO levofloxacin 500mg daily
• PO fluconazole 200mg daily
• PO acyclovir 400mg BD

FEVER
- reverse isolation
- septic workup
- IV tazocin 4.5g q6H, check response in 2days
> no response in 2days
&raquo_space;> consider + IV gentamycin 3.6mg/kg q24H
&raquo_space;> C/S gram-: IV meropenem 500mg q8H
&raquo_space;> C/S gram+: IV cloxacillin 500mg q6H for SA, IV vancomycin 500mg q6H for MRSA
> no response in 5days
»> +amphotericin B 0.5-1mg/kg/day (caution hypoK) + PO amiloride 10mg daily + IV hydrocortisone 100mg q24H premed + IV piriton 10mg q24H premed
- IVF, consult ICU if septic shock
- (MO give) SC GCSF 30millionU q24H, 1days post-chemo

Question 4

Leukocytosis

Answer 4

• consider sepsis, inflammatory, leukemia, (leukemoid reaction)

Mx:
- septic workup if fever
 > Bld x c/s
 > Sputum x c/s
 > MSU x c/s
 > CXR
- antibiotics

Question 5

PLT low

Answer 5

• consider clumping, post-chema, ITP, DIC, TTP, CLL immno-phenomenon

Mx:

• transfuse when PLT <10 afebrile, <20 febrile/ symptomatic (bleeding tendency, epistaxis, hemoptysis, hematuria)
• transfuse PLT __ U FR
• consult hemat prn

post-transfuse if fever
- PO Panadol 500mg q4H prn

post-transfuse if allergic

• PO piriton 4mg tds prn/ IV piriton 10mg q8H prn (if PMH of allergic reaction)
• IV hydrocortisone 100mg q8H prn (if PMH of allergic reaction)

Mx for ITP/ CLL:

• Pulse steroid PO dexamethasone 40mg daily x4 days
• or IVIG 0.4g/kg/day (consult hemat)

Mx for DIC

• Transfuse if need
• Treat underlying cause

Question 6

Elevated PLT

Answer 6

(usu no treat)

• PO aspirin 80mg dialy if thrombosis
• Consult hemat prn

Question 7

Elevated INR

Answer 7

• check warfarin, DIC, TCM

Mx:

• Daily INR
• W/H warfarin
• urine x toxicology
• INR <5: observe
• INR 5-9: PO VitK1 5-10mg (for TCM toxicity; usu not for warfarin, diff to titrate)
• INR 9/>9 + bleeding tendency: transfuse FFP FR prn/ IV VitK1 10mg
• pre-procedure (tapping, IR procedure): transfuse 4-6U FFP FR on call to procedure

When INR normalize

• restart PO warfarin 3mg x1day, then PO warfarin 2mg daily
• titrate up: + 0.5mg alt day (e.g. 2mg/2.5mg alt day)
• titrate down: - 0.5mg alt day

Question 8

Prolong APTT (unfinished)

Answer 8

• consider cause of heparin, contamination