Heme-Onc

Question 1

Sickle Cell Emergencies

Answer 1

Review Evernote

Question 2

How to supplement Iron

Answer 2

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

Question 3

PERC Rule

Answer 3

1. 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)

Question 4

Explain the prothrombotic effect of Warfarin at initiation of therapy

Answer 4

• 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)

Question 5

Drugs that increase/decrease INR

Answer 5

• Drugs that increase INR
  
  • NSAIDS
  • TMP-SMX
  • macrolides (but not azithro)
  • quinolones
• Drugs that decrease INR
  
  • anticonvulsants
  • antipsychotics
  • sedatives (haldol, trazodone)

Question 6

Warfarin Reversal and nomogram

Answer 6

• 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

Question 7

Dabigatran

Class

Reversal

Answer 7

• direct thrombin inhibitor
• reversal
  
  • hemodialysis
  • aPCC > rFVIIa > PCC may work
  • idarucizumab

Question 8

Rivaroxaban, Apixaban

Class

Reversal

Answer 8

• FXa inhibitors
  
  • reversal
    
    • dialysis not effective
    • FFP, PCC, rFVIIa

Question 9

UFH Reversal, side-effects of reversal

Answer 9

• protamine
• 0.2% incidence anaphylaxis

Question 10

HIT (read through)

Answer 10

• 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

Question 11

LMWH Reversal

Answer 11

• protamine (partial)

Question 12

ASA

• effect duration
• treatment of bleeding

Answer 12

• lasts ~7 d
• treatment (may need to repeat daily)
  
  • platelet transfusion to increase count by 50 k +
  • desmopressin

Question 13

Plavix, Ticagrelor, Prasugrel

Class

Treatment of bleeding

Answer 13

• Adenosine Diphosphate Receptor Agents
• supportive +- platelet transfusion +- desmopressin

Question 14

Febrile Neutropenia Definition

Answer 14

• 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

Question 15

ITP (read through)

Answer 15

• 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

Question 16

Afebrile Neutropenia

Answer 16

• 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

Question 17

Definition of Massive Transfusion

Answer 17

• > 6 units PRBC in 4h
• rapid blood loss (>1500 mL)

Question 18

Labs to send in Massive Transfusion

Answer 18

• 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

Question 19

1st Round Massive Transfusion

Answer 19

• 6 units PRBC (x-matched, or grouped, or Group O)
• 4 units FFP (grouped or AB if unknown)

Question 20

Massive Transfusion Targets

Answer 20

• 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

Question 21

Spherocytosis vs. schistocytosis

Answer 21

• spherocytosis: extravascular hemolysis (spleen takes bite out of RBC membrane, making it more spherical)
• schistocytosis: intravascular hemolysis

Question 22

TTP Pentad

Answer 22

pentad (present in 5% of patients)

• fever
• CNS problems (sz/CVA/LOC)
• renal failure
• MAHA
• thrombocytopenia (often < 20k)

Question 23

Aquired Hemolytic Anemias

Answer 23

Read Through

Question 24

Warfarin Management

Answer 24

Review Evernote

Question 25

Febrile Neutropenia Definition & Management

Answer 25

• 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

Question 26

Hyperviscosity Syndrome

Answer 26

• 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)

Question 27

Tumor Lysis Syndrome

Answer 27

• 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)

Question 28

Hypercalcemia of Malignancy

Answer 28

• 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

Question 29

Hemophilia

Answer 29

Review Evernote (Bleeding Disorders)

Question 30

Selection of anticoagulants in renal impairment

Answer 30

See Evernote “Antithrombotics”

Question 31

Multiple Myeloma

Answer 31

Review Evernote