Heme-Onc Flashcards
Sickle Cell Emergencies
Review Evernote
How to supplement Iron
Iron supplementation: 50 mg elemental Fe QHS with 500 mg vitamin C. Avoid taking with tea. Better taken with bloody red meat. More is not better unless severely deficient.
Ferrous gluconate 300 mg = 35 mg elemental Fe
Ferrous sulfate 300 mg = 60 mg elemental Fe
Ferrous fumarate 300 mg = 100 mg elemental Fe
FeraMAX 150 mg = 150 mg elemental Fe
PERC Rule
- Pretest probability of PE
2.
Hormone use (estrogen)
Age > 50
DVT/PE Hx
Coughing blood
Leg swelling
O2 sat
Tachycardia > 100 BPM
Surgery/Trauma (within 4 weeks)
Explain the prothrombotic effect of Warfarin at initiation of therapy
- protein C has short half-life (7 hours)
- 10, 9, 7, 2 have longer half-lives (up to 60 hours)
- thus, on balance, the initial effect for the first 24-36 h is prothrombotic (hence bridging with LMWH)
Drugs that increase/decrease INR
- Drugs that increase INR
- NSAIDS
- TMP-SMX
- macrolides (but not azithro)
- quinolones
- Drugs that decrease INR
- anticonvulsants
- antipsychotics
- sedatives (haldol, trazodone)
Warfarin Reversal and nomogram
- Life-threatening bleeding
- Vitamin K 5-10 mg slow IV bolus
- Octaplex IV
- INR > 6: 50 units/kg (max 5000)
- INR 4-6: 35 units/kg (max 3500)
- INR <4: 25 units/kg (max 2500)
- FFP (instead of PCC)
- 10-15 mL/kg IV
- restores INR to 1.7-1.8
- rFVIIa (instead of FFP/PCC)
- 80 mcg/kg slow IV bolus
- Minor/no bleeding, INR > 10
- Vitamin K 2 mg PO
- hold 1-2 doses
- Minor/no bleeding, INR 4.5-10
- Vitamin K 2 mg PO if high risk
- hold 1-2 doses
- Minor/no bleeding, INR 3-4.5
- lower dose by 15% or omit 1 dose if high risk
Dabigatran
Class
Reversal
- direct thrombin inhibitor
- reversal
- hemodialysis
- aPCC > rFVIIa > PCC may work
- idarucizumab
Rivaroxaban, Apixaban
Class
Reversal
- FXa inhibitors
- reversal
- dialysis not effective
- FFP, PCC, rFVIIa
- reversal
UFH Reversal, side-effects of reversal
- protamine
- 0.2% incidence anaphylaxis
HIT (read through)
- normal for plt to fall 10-20%
- (no lower than 100 k) 2-3 d after starting tx, recover within 4 days
- check plt 24h after starting UFH + Q2-3 days
- HIT is IgG/IgM aggainst heparin + platelet factor 4
- low plts + thrombosis
- usually 5-10 days after starting treatment
- may be immediate if received heparin before
- plt fall of > 50%
- tx
- stop all heparin
- give fonda or bivalirudin if strongly suspicious
- platelets recover within 4-6 days
LMWH Reversal
- protamine (partial)
ASA
- effect duration
- treatment of bleeding
- lasts ~7 d
- treatment (may need to repeat daily)
- platelet transfusion to increase count by 50 k +
- desmopressin
Plavix, Ticagrelor, Prasugrel
Class
Treatment of bleeding
- Adenosine Diphosphate Receptor Agents
- supportive +- platelet transfusion +- desmopressin
Febrile Neutropenia Definition
- ANC < 500 or ANC < 1000 with predicted decline
- nadir 5-10 days post-chemo
- single oral T >=38.3 or miltiple >= 38.0 separated by > 1h
ITP (read through)
- immune thrombocytopenia (ITP)
- 80% self-limited, resolve within 6 mo.
- incidence life-threatening bleeding <0.5%
- > 3 mo. is persistent, >12 mo. is chronic
- usually isolated thrombocytopenia, bruising, after viral illness
- speak with heme
- sometimes prednisone (only if leukemia excluded), anti-Rh (D), IVIG
- admit if bleeding, IV meds, or plt < 20 k
- transfuse only if life-threatening bleeding
Afebrile Neutropenia
- ANC < 1.5 sometimes normal in infants and also blacks/middle easterners
- ANC < 1.0 always abnormal
- Fx + ANC < 1.5, always Abx even if not on chemo
- if higher counts and looks well or no fever/infection then outpatient peds
Definition of Massive Transfusion
- > 6 units PRBC in 4h
- rapid blood loss (>1500 mL)
Labs to send in Massive Transfusion
-
Initial
- Cross-match
- CBC
- INR
- aPTT
- fibrinogen
- ROTEM (if trauma patient)
- lytes, Cr
- ionized calcium
- VBG, lactate
-
Subsequent
- ABG/VBG, ionized calcium, lytes Q 15-30 min
- CBC, INR, aPTT, fibrinogen Q1h
1st Round Massive Transfusion
- 6 units PRBC (x-matched, or grouped, or Group O)
- 4 units FFP (grouped or AB if unknown)
Massive Transfusion Targets
- FFP to INR < 1.5 and/or aPTT < 1.5x normal
- cryo to fibrinogen > 1.5 g/L
- plt to > 50k during bleeding or > 100k if CNS bleeding/TBI
- RBC to Hb > 80
Spherocytosis vs. schistocytosis
- spherocytosis: extravascular hemolysis (spleen takes bite out of RBC membrane, making it more spherical)
- schistocytosis: intravascular hemolysis
TTP Pentad
pentad (present in 5% of patients)
- fever
- CNS problems (sz/CVA/LOC)
- renal failure
- MAHA
- thrombocytopenia (often < 20k)
Aquired Hemolytic Anemias
Read Through
Warfarin Management
Review Evernote
Febrile Neutropenia Definition & Management
- ANC < 1.0 + T > 38.3 (100.9F) on one occasion or > 38 (100.4) > 1h
- severe neutropenia is ANC < 0.5
- nadir is 5-10d post-chemo, recovers within 5d afterwards
-
labs
- CBC, eGBCL, LFT’s
- BC x 2 + 1 for each cath site
- wound/sputum cultures if applicable
- CXR
- no DRE until after IV abx (if necessary)
-
dispo
- MASCC score
- > 21 is generally safe for outpatient treatment
- < 21 should be admitted
-
tx
- treat ANC < 0.5, or < 1 and falling/concerned/evidence of infection
- median duration of fever after starting empiric abx is 2 days in low-risk patients and 5-7 days in high-risk patients
- therefore wait 2-4 days before adjusting therapy unless clinical deterioration
- continue until infection resolved or ANC > 0.5
- outpatient: cipro/levo + clavulin
- daily medical assessments for initial 3d
- inpatient: cefepime 2g IV Q8h or pip-tazo 4.5 g IV Q6h, add vanco if HD instability, catheter infection, pneumonia; add Flagyl if abdominal symptoms present
Hyperviscosity Syndrome
- most often from Waldenstrom’s or IgA myeloma or leukemia
- fatigue, AP, HA, altered LOC, thrombosis/bleeding
- lab measurement of plasma/serum viscosity will not identify hyperviscosity from polycythemia/leukemia
- rouleaux bodies on smear
- tx: IVF, 1L phlebotomy with 2-3L NS replacement if coma (discuss with heme)
Tumor Lysis Syndrome
- usually heme malignancy, usually after treatment
- AKI (precipitation of uric acid and CaPO4 in tubules, sz, arrhythmias
- hyperuricemia, hyperK+, hyperPO4, hypoCa2+
-
tx
- aggressive IVF
- HD
- careful with Ca in hyperK as may cause worse AKI from precipitation (only use if unstable/ECG changes)
Hypercalcemia of Malignancy
- rarely needs tx if asymptomatic and total serum Ca < 3.5
-
tx
- tend to be intravasc deplete because of calcium related diuresis, 1-2 L NS bolus –> 250 mL/h
- lasix if CHF/renal insufficiency to help with volume
Hemophilia
Review Evernote (Bleeding Disorders)
Selection of anticoagulants in renal impairment
See Evernote “Antithrombotics”
Multiple Myeloma
Review Evernote
