Module 6: Hematologic Problems-Blood Component Therapy Flashcards

1
Q

Anemia

A

A deficiency in
 Number of erythrocytes (RBCs)
 Quantity or quality of hemoglobin (Hgb)
 Volume of packed RBCs (hematocrit)

Diagnosed based on
 Complete blood count (CBC)
 Reticulocyte count
 Peripheral blood smear

Classified according to
 Morphology
* Cellular characteristic
* RBC size and color
 Etiology
* Cause
* Clinical condition causing anemia

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2
Q

RBC Function

A

Transport oxygen (O2) from lungs to systemic tissues
 Carry carbon dioxide from tissues to lungs

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3
Q

Anemia Skin Manifestations

A

Pallor
 Decreased Hgb
 Decreased blood flow to the skin
Jaundice
 Increased concentration of serum bilirubin
Itching
 Increased serum and skin bile salt concentrations

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4
Q

Anemia
Cardiopulmonary Manifestations

A

Result from heart and lungs trying to provide
adequate O2 to tissues
 Cardiac output maintained by increasing heart
rate and stroke volume
 Low blood viscosity contributes to systolic
murmurs and bruits
 Angina, MI, and heart failure may occur

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5
Q

Anemia
Clinical Problems

A

 Fatigue
 Nutritionally compromised
 Inadequate tissue perfusion

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6
Q

Anemia Interventions

A

Acute interventions may include blood transfusions,
drug therapy (e.g., iron supplements), and O2 therapy

Patients with fatigue
 Alternate rest and activity
 Prioritize activities
* Accommodate energy levels
* Maximize O2 supply for vital functions
 Aid to minimize risk of injury from falls
 Monitor cardiorespiratory response
 Evaluate nutrition needs

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7
Q

Anemia
Gerontologic Considerations

A

Anemia is not normal
 Healthy older adults have a modest decline in Hgb of
about 1 g/dL after age 70
 Often related to an underlying cause
* Iron deficiency, bleeding, chronic disease, renal problems
 Signs and symptoms may be overlooked
 Other health issues
 May be mistaken for normal aging

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8
Q

Anemia
Decreased RBC Production

A

RBC production (erythropoiesis) is in equilibrium
with RBC destruction/ loss
 Balance ensures that adequate number of RBCs
is always available

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9
Q

RBC Production

A

Life span of an RBC is 120 days
-3 problems that lead to decreased RBC production:
 Decreased Hgb synthesis
 Defective DNA synthesis in RBCs
 Diminished availability of RBC precursors

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10
Q

Iron-Deficiency Anemia

A

Most common nutrition disorder in the world
**Most susceptible
 Very young
 Poor diet
 Women in reproductive years

Inadequate diet intake
 Normally diet intake is enough
 Need more with menstruation, pregnancy
Malabsorption
 Iron absorption occurs in the duodenum
 Diseases or surgery that alter, destroy, or remove
absorption surface of this area of intestine cause
anemia

Blood loss
 Major cause of iron deficiency in adults
 Chronic blood loss most commonly through GI and
GU systems
* GI bleeding often not apparent
* May take time to identify
 Postmenopausal bleeding, chronic kidney disease,
and dialysis may contribute

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11
Q

Iron-Deficiency Anemia Clinical Manifestations

A

General manifestations of anemia
 Pallor is most common
 Glossitis is second
* Inflammation of tongue
 Cheilitis is also found
* Inflammation of lips
 Headache, paresthesias

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12
Q

Diagnosing Iron-Deficiency Anemia

A

Laboratory findings
 Hgb, Hct, MCV, MCH, MCHC, reticulocytes, serum
iron, TIBC, bilirubin, platelets
 Stool occult blood test
 Endoscopy and colonoscopy
 Bone marrow biopsy

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13
Q

Iron-Deficiency Anemia Drug Therapy

A

Oral iron
 Inexpensive
 Convenient
 Factors to consider
* Enteric-coated or sustained-release capsules are
counterproductive
* Daily dose is 100 to 200 mg

Factors to consider
* Best absorbed in an acidic environment
 Vitamin C or orange juice
* Undiluted liquid iron may stain teeth
 Should be diluted and drank through a straw
* Side effects
 Heartburn, constipation, diarrhea

Parenteral iron
Indicated for malabsorption, oral iron intolerance,
need for iron beyond normal limits, poor patient
compliance
 Can be given IM or IV
* Give IV test dose and observe for anaphylaxis
 IM may stain skin
* Z-track

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14
Q

Thalassemia
Etiology

A

A group of diseases involving inadequate production
of normal Hgb
 Results in decreased RBC production
 Due to absent or reduced globulin protein
 Abnormal Hgb synthesis
 Hemolysis occurs

Autosomal recessive genetic basis
 1 thalassemic gene
 Thalassemia minor
 2 thalassemic genes
 Thalassemia minor
 Thalassemia major

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15
Q

Thalassemia Clinical Manifestations

A

Thalassemia minor (Thalassemia trait)
 Often asymptomatic
 Mild to moderate anemia
* Microcytosis (RBCs are smaller than normal), hypochromia (RBCs have less hemoglobin than normal and are paler under microscope)
* Mild splenomegaly (slight enlargement of the spleen), bronzed skin color, and bone
marrow hyperplasia (increased production of bone marrow cells, reactive to anemia)
 Body adapts to reduction of Hgb—thus no treatment
is indicated

Thalassemia major
 Life-threatening disease
 Growth and developmental deficits
 Jaundice is prominent
 Splenomegaly (enlarged spleen), hepatomegaly (enlarged liver), cardiomyopathy (group of diseases that make it harder for heart to pump blood, can lead to heart failure)
 Symptoms develop in childhood
 Bone marrow responds to the reduced O2-carrying
capacity of the blood by increasing RBC production
 Marrow becomes packed with immature erythroid
precursors that die
 Chronic bone marrow hyperplasia
 Cardiac complications from iron overload, lung
disease, HTN
 Endocrine problems, thrombosis (blood clot)

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16
Q

Thalassemia Care

A

Thalassemia major
 Blood transfusions or exchange transfusions with
chelating agents that bind to iron to reduce iron
overloading

luspatercept-aamt (Reblozyl), may be given
subcutaneously every 21 days.
* Improves hemoglobin levels and reduces transfusion needs.
* Blocks inhibitors of late-stage RBC production
 Splenectomy
 Hematopoietic stem cell transplantation (HSCT) is the
only cure

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17
Q

Megaloblastic Anemias

A

Characterized by abnormally large RBCs
(megaloblasts)
 caused by impaired DNA synthesis, resulting in
defective RBC maturation
 Majority result from deficiency in
-Cobalamin (vitamin B12)
-Folic acid

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18
Q

Cobalamin Deficiency
Etiology

A

Cobalamin deficiency, also known as vitamin B12 deficiency, can lead to a range of hematological and neurological disorders. One of the most common causes of cobalamin deficiency is pernicious anemia, which is an autoimmune condition characterized by the following features:

Caused by Absence of Intrinsic Factor (IF)
-body’s inability to produce intrinsic factor (IF), a protein secreted by the stomach lining. Intrinsic factor is essential for the absorption of vitamin B12 (cobalamin) in the small intestine. Without intrinsic factor, vitamin B12 cannot be effectively absorbed, leading to deficiency

-Insidious onset - gradual, therefore tougher to diagnose

-begins in middle age or later

-Predominant in Scandinavians and Blacks

Cobalamin deficiency can result from a variety of factors other than pernicious anemia, including dietary insufficiency (common in strict vegetarians and vegans since B12 is primarily found in animal products), gastrointestinal surgeries, certain medications, and gastrointestinal disorders that affect B12 absorption. Regardless of the cause, cobalamin deficiency can lead to significant hematological abnormalities, such as megaloblastic anemia, and neurological complications, including neuropathy and cognitive disturbances.

Can also occur:
 Surgery or chronic diseases of the GI tract
 Excess alcohol or hot tea intake
 Smoking
 Long-term users of H2 histamine receptor blockers
and proton pump inhibitors
 Strict vegetarians
 Familial predisposition

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19
Q

Cobalamin Deficiency
Clinical Manifestations

A

General manifestations of anemia develop slowly
due to tissue hypoxia
 GI problems:
* Sore, red, beefy, and shiny tongue, anorexia, nausea,
vomiting, and abdominal pain
 Neuromuscular problems:
* Weakness, paresthesias of feet and hands, decreased
vibratory and position senses, ataxia, muscle
weakness, and impaired cognition

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20
Q

Cobalamin Deficiency
Diagnostic Studies

A

Macrocytic RBCs have abnormal shapes and
fragile cell membranes
 Serum cobalamin levels are low
 Normal serum folate levels and low cobalamin
levels suggest megaloblastic anemia is due to
cobalamin deficiency
 Upper GI endoscopy with biopsy of gastric
mucosa to rule out gastric cancer

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21
Q

Cobalamin Deficiency Treatment

A

Parenteral or intranasal administration of cobalamin
is treatment of choice
 Patients will die in 1 to 3 years without treatment
 Anemia can be reversed with ongoing treatment but
long-standing neuromuscular complications may not
be reversible

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22
Q

Megaloblastic Anemia
Folic Acid Deficiency

A

Causes megaloblastic anemia
 Folic acid is needed for DNA synthesis
 RBC formation and maturation
 Manifestations are similar to cobalamin deficiency,
but if neurologic symptoms present, may be caused
by thiamine deficiency

Common causes include
 Diet deficiency, malabsorption syndromes
 Alcohol use and anorexia
 Loss during hemodialysis

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23
Q

Folic Acid Deficiency

A

Serum folate level is low
 Normal is 5 to 25 ng/mL (11 to 57 nmol/L)
 Serum cobalamin level is normal
 Treated with replacement therapy
 Usual dose is 1-5 mg/day by mouth
 Encourage patient to eat foods with large amounts
of folic acid

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24
Q

Anemia of Inflammation

A

Can be caused by
 Cancer
 Autoimmune and infectious disorders
* HIV, hepatitis, malaria
 Chronic inflammation
 Heart failure
 Bleeding episodes

Associated with
 Underproduction of RBCs
 Mild shortening of RBC survival
* Normocytic, normochromic, and hypoproliferative RBCs
 Usually develops after 1 to 2 months of disease
activity
 Can become more severe if the underlying disorder
is not treated

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25
Anemia of Chronic Disease
Anemia of chronic disease findings  High serum ferritin  Increased iron stores  Normal folate and cobalamin levels Treating underlying cause is best  Blood transfusions for severe cases  Limited use of erythropoietin therapy
26
Aplastic Anemia
A disorder in which the bone marrow fails to produce sufficient amounts of blood cells. Pancytopenia  Decrease in all blood cell types * Red blood cells (RBCs) * White blood cells (WBCs) * Platelets  Hypocellular bone marrow (Hypocellular bone marrow refers to a condition where the bone marrow has a lower than normal cellularity, meaning it contains fewer hematopoietic (blood-forming) cells than expected for the individual's age)  Ranges from moderate to very severe  Potentially fatal Rare  Annual rate of 2 to 5 new cases/million/year  About 70% due to autoimmune activity by autoreactive T-lymphocytes  May be acquired  Toxic injury to bone marrow stem cells  Inherited stem cell defec
27
Aplastic Anemia Clinical Manifestations
Abrupt or insidious development  Symptoms caused by suppression of any or all bone marrow elements  General manifestations of anemia  Fatigue, dyspnea  Cardiovascular and cerebral responses  Neutropenia (abnormally low number of neutrophils, which are a type of WBC), thrombocytopenia (abnormally low number of platelets, which play a crucial role in blood clotting and wound healing)
28
Aplastic Anemia Diagnostic Studies
Diagnosis confirmed by laboratory studies  Decreased Hgb, WBC, and platelet values  Decreased reticulocyte count  Elevated serum iron and TIBC  Hypocellular bone marrow with increased yellow marrow (fat content)
29
Aplastic Anemia Care
Identify and remove causative agent (when possible)  Provide supportive care until pancytopenia resolves  Prevent complications from infection and hemorrhage Prognosis of severe untreated aplastic anemia is poor  Advances in treatment options have significantly improved outcomes  Immunosuppressive therapy and HSCT transplantation can be curative
30
Anemia Caused by Blood Loss Acute and Chronic
Anemia from blood loss may be caused by either acute or chronic problems  Acute blood loss occurs because of sudden bleeding * Trauma, complications of surgery, problems that disrupt vascular integrity  2 clinical concerns: * Hypovolemic shock * Compensatory increased plasma volume with diminished O2 -carrying RBCs
31
Acute Blood Loss Clinical Manifestations
Caused by body’s attempts to maintain adequate blood volume and meet oxygen requirements  Clinical signs and symptoms are more important than laboratory values Pain  Internal bleeding * Tissue distention, organ displacement, nerve compression  Retroperitoneal bleeding * Numbness * Pain in lower extremities  Shock is major complication
32
Acute Blood Loss Diagnostic Studies
With sudden blood volume loss, values may seem normal or high for 2 to 3 days  Once plasma volume is replaced, low RBC concentrations become evident  Low RBC, Hgb, and Hct levels reflect actual blood loss Replace blood volume to prevent shock  Promote coagulation to prevent further bleeding  Find source of bleeding and stop blood loss  Correct RBC loss  Provide supplemental iron
33
Chronic Blood Loss
Sources of chronic blood loss:  Bleeding ulcer  Hemorrhoids  Menstrual and postmenopausal blood loss Management involves  Identifying the source and stop bleeding  Providing supplemental iron as needed
34
Hemolytic Anemia
Destruction or hemolysis of RBCs at a rate that exceeds production  Caused by problems intrinsic or extrinsic to the RBCs * Intrinsic forms are usually hereditary and result from defects in RBCs themselves * RBCs are normal in acquired forms, but damage is caused by external factors. General manifestations of anemia  Specific manifestations including -Jaundice -Enlargement of the spleen and liver  Maintenance of renal function is a major focus of treatment
35
Sickle Cell Disease
Group of inherited, autosomal recessive disorders  An abnormal form of Hgb in RBC  Genetic disorder usually found during routine neonatal screening  Incurable, significantly affects quality of life Abnormal Hgb, Hgb S, causes the RBC to stiffen and elongate  Substitution of valine for glutamic acid on the β-globin chain of Hgb  Erythrocytes take on a sickle shape in response to decreased O2 levels
36
Types of Sickle Cell Disease
Types of SCD  Sickle cell anemia * Most severe * Homozygous for hemoglobin S (Hgb SS)  Sickle cell thalassemia  Sickle cell Hgb C disease  Sickle cell trait (Hgb AS)
37
Sickle Cell Disease Sickling Episodes
The major pathophysiologic event of this disease  Triggered by low O2 tension in blood  Infection is most common precipitating factor  At first, sickling is reversible with re-oxygenation
38
Sickle Cell Crisis
Severe, painful, acute exacerbation of RBC sickling causes a vaso-occlusive crisis  Severe capillary hypoxia eventually leads to tissue necrosis  Life-threatening shock is a possible result of severe O2 depletion of the tissues and a reduction of the circulating fluid volume
39
Sickle Cell Clinical Manifestations
Typical patient is anemic but asymptomatic except during sickling episodes -Symptoms may include  Pain from tissue hypoxia and damage  Pallor of mucous membranes  Jaundice from hemolysis  Prone to gallstones (cholelithiasis)
40
Sickle Cell Disease Complications
Infection is a major cause of mortality  Function of spleen becomes compromised from sickled RBCs * Autosplenectomy is a result of scarring  Pneumococcal pneumonia most common  Severe infections can cause aplastic and hemolytic crisis and gallstones * Can lead to shutdown of RBC production Acute chest syndrome  Pulmonary complications include pneumonia, tissue infarction, and fat embolism  Characterized by fever, chest pain, cough, lung infiltrates, and dyspnea  Pulmonary infarctions may cause pulmonary hypertension, MI, and cor pulmonale, HF, retinal detachment and blindness, renal failure, stroke
41
Sickle Cell Disease Diagnostic Studies
Peripheral blood smear  Hemoglobin electrophoresis  Skeletal x-rays  Magnetic resonance imaging (MRI)  Doppler studies  Chest x-ray Hospitalized patients in sickle cell crisis  O2 therapy treats hypoxia and controls sickling  Assess for changes in respiratory status  Rest with VTE prophylaxis  Pain medication and fluids  Transfusion therapy * Chelation therapy with repeated transfusion
42
Sickle Cell Disease Treatment
Treat infections  Give folic acid  Various drugs can reduce sickling episodes  Hydroxyurea (Hydrea)  Adakveo (crizanlizumab -tmca)  Voxelotor (Oxbryta) -HSCT is only available cure (Hematopoietic Stem Cell Transplantation (HSCT) for sickle cell disease (SCD) is a treatment option that aims to replace the patient's bone marrow, which produces the abnormal sickle-shaped red blood cells characteristic of the disease, with healthy bone marrow from a compatible donor. This process involves the transplantation of hematopoietic stem cells, which are the blood-forming cells found in the bone marrow, capable of giving rise to all types of blood cells, including red blood cells, white blood cells, and platelets)
43
Acquired Hemolytic Anemia
Results from hemolysis of RBCs from extrinsic factors  Physical destruction  Antibody reactions  Infectious agents and toxins Physical destruction of RBCs results from exertion of extreme force on cells  Hemodialysis  Extracorporeal circulation used in cardiopulmonary bypass  Prosthetic heart valves  Abnormal vessels RBCs can be fragmented and destroyed as they try to pass through abnormal arterial or venous microcirculation  Excessive platelet aggregation and/or fibrin polymer formation * Seen in thrombotic thrombocytopenic purpura (TTP) and disseminated intravascular coagulopathy (DIC) Antibodies may destroy RBCs by mechanisms involved in antigen-antibody reactions  Blood transfusion reaction  Autoimmune antibody reactions
44
Acquired Hemolytic Anemia Infectious Agents
Cause hemolysis in three ways:  Invade the RBC and destroy its contents * Parasites, such as in malaria  Release hemolytic substances * Clostridium perfringens  Generate an antigen-antibody reaction * Mycoplasma pneumonia
45
Acquired Hemolytic Anemia Treatment and Management
Supportive care until the causative agent can be eliminated or made less injurious  Emergency preparedness is essential for potential hemolytic crises * Aggressive hydration and electrolyte replacement, corticosteroids, blood products, splenectomy  Folate replacement and immunosuppressive agents for chronic conditions  Plasma exchange and eculizumab (Soliris), a monoclonal antibody
46
Hemochromatosis
Iron overload disorder  Genetic defect most common cause  May occur with other diseases Genetic link  Increased intestinal iron absorption  Increased tissue and organ iron deposition
47
Thrombocytopenia
In Normal Hemostasis  Involves the vascular endothelium, platelets, and coagulation factors  Function together to stop hemorrhage and repair vascular injury  Disruption of any component may result in bleeding or thrombotic disorders Reduction of platelets below 150,000/μL (150 × 109/L)  Results in abnormal hemostasis  Prolonged or spontaneous bleeding Primarily an acquired disorder  Commonly from ingestion of certain drugs Inherited or Acquired  Immune thrombocytopenia purpura (ITP)  Thrombotic thrombocytopenia purpura (TTP)  Heparin-induced thrombocytopenia (HIT
48
Immune Thrombocytopenia (ITP)
Most common acquired thrombocytopenia  Syndrome of abnormal destruction of circulating platelets  Acquired autoimmune disorder  Generally, presents as an acute condition in children and a chronic condition in adults
49
Thrombotic Thrombocytopenia Purpura (TTP)
An uncommon syndrome with a variety of features that are not always present  Called TTP-HUS as it is almost always associated with hemolytic-uremic syndrome  Associated with enhanced aggregation of platelets that form into microthrombi  Characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia, neurologic changes, fever (in the absence of infection), and renal problems  Caused by plasma enzyme deficiency  Primarily in previously healthy adults  May be idiopathic or from drug toxicities  Medical emergency  Bleeding and clotting occur at the same time
50
Heparin-Induced Thrombocytopenia
Associated with use of heparin  Life-threatening  2 major responses to an immune-mediated response to heparin:  Platelet destruction  Vascular endothelial injury Develops 5 to 14 days after heparin therapy is started  Platelet count drops by more than 50%  VTE is major clinical problem  Arterial thrombosis can also develop  DVT and PE often result Other complications  Arterial vascular infarcts, causing skin necrosis, stroke, and end-organ damage (e.g., kidneys)
51
Thrombocytopenia Clinical Manifestations
Clinical manifestations  Patients are often asymptomatic  Most common symptom is mucosal or cutaneous bleeding * Petechiae—microhemorrhages * Purpura—bruise from numerous petechiae * Ecchymoses—larger lesions from hemorrhage Hemorrhage may be insidious or acute * Internal bleeding may manifest as weakness, fainting, dizziness, tachycardia, abdominal pain, or hypotension * Prolonged bleeding after routine procedures * Vascular ischemic problems Diagnostic studies  Decreased Platelet count< 150,000/μL * Prolonged bleeding < 50,000/μL * Hemorrhage decreased 20,000/μL  Patient history and assessment  Lab parameter comparisons Lab tests for hemostasis and coagulation can be normal  Specific assays can assist  Bone marrow exam can rule out production problems as the cause Removal or treatment of underlying cause or disorder may be sufficient  Avoid aspirin and other drugs that affect platelet function or production
52
Immune Thrombocytopenia Purpura (ITP)
Interprofessional care  Therapy initiated if platelets ↓ 30,000/μL  Corticosteroids * Suppress phagocytic response of splenic macrophages resulting in increased life span of the platelets * Depress antibody formation * Reduce capillary leakage Interprofessional care  High doses of IV immunoglobulin (IVIG) and anti- Rho(D) * Compete with antiplatelet antibodies for macrophage receptors in the spleen  Rituximab (Rituxan) * Lyses activated B cells * Reduces immune recognition of platelets Interprofessional care  Immunosuppressive therapy * Used in refractory cases * azathioprine, cyclosporine A Splenectomy * May be needed if patient does not respond to treatment * 2/3 of patients achieve sustained remission Effectiveness of splenectomy based on 4 factors * Spleen has an abundance of macrophages that sequester and destroy platelets * Structural features enhance interaction of antibody -coated platelets and macrophages * Some antibody synthesis occurs in spleen , so antiplatelet antibodies decrease after splenectomy * Spleen normally sequesters around 1/3 of the platelets, so its removal increases number of platelets in circulation Interprofessional care  First treat underlying disorder or remove cause  Untreated TTP usually results in irreversible renal failure and death  Plasmapheresis can aggressively reverse platelet consumption * Continued daily until platelet counts normalize and hemolysis has ceased * Corticosteroids are used with this treatment Rituximab * Given to those who do not respond to plasma exchange * Decreases level of inhibitory ADAMTS13 IgG antibodies  Caplacizumab * anti-VWF antibody, blocks VWF binding to platelets * Can reduce platelet aggregation and thrombosis  Other immunosuppressants may be used  Splenectomy may be considered
53
Heparin-Induced Thrombocytopenia Care
Interprofessional care  Stop all heparin including heparin flushes * Note clearly on medical record  Start patient on * Argatroban (a direct thrombin inhibitor) * fondaparinux (Arixtra), a factor Xa inhibitor (indirect thrombin inhibitor) * bivalirudin (a synthetic thrombin inhibitor)  Start warfarin (Coumadin) only when platelet count reaches 150,000/μL For severe clotting: * Plasmapheresis to clear platelet-aggregating IgG from the blood * Thrombolytic agents to treat thromboembolic events * Surgery to remove clots
54
Thrombocytopenia From Decreased Platelet Production
Interprofessional care  Management is based on identifying cause and treating disease or removing the causative agent  May try immune therapies if a cause is unknown  Platelet transfusions for life-threatening bleeding Often caused by another underlying condition or therapy used to treat another problem * In acute leukemia, all blood cell types may be depressed * Chemotherapeutic drugs can cause bone marrow suppression * Thrombocytopenia will resolve if patient is adequately supported during treatment
55
Nursing Management Thrombocytopenia
The main clinical problem is impaired tissue perfusion
56
Hemophilia and von Willebrand Disease
Hemophilia is X-linked recessive genetic disorder caused by defective or deficient coagulation factor  Two major types  Hemophilia A  Hemophilia B Von Willebrand disease is a related disorder involving deficiency of von Willebrand coagulation factor (Factor VIII)  Made in the liver Clinical manifestations/complications  Slow, persistent, prolonged bleeding  Delayed bleeding after minor injuries  Uncontrollable bleeding after dental extractions or irritation with toothbrush  Nosebleeds, especially after a blow to the face  GI bleeding from ulcers and gastritis Hematuria and potential renal failure  Splenic rupture from falls or abdominal trauma  Bruising and subcutaneous hematomas  Compartment syndrome  Neurologic signs, such as pain, anesthesia, and paralysis  Hemarthrosis Diagnostic studies  Factor deficiency within the intrinsic system (factor VIII, IX, XI, XII , vWF)  Interprofessional care  Preventive care  Replacement therapy  Treatment of complications
57
Disseminated Intravascular Coagulation
Serious bleeding and thrombotic disorder  Results from abnormally initiated and accelerated clotting  Decreases in clotting factors and platelets ensue  May lead to uncontrollable bleeding Always caused by an underlying disease or condition  Abnormal response to clotting cascade stimulated by a disease process or disorder * Acute, catastrophic condition * Subacute, or chronic level most often seen in patients with long-standing illnesses Clinical manifestations  Bleeding in the skin, respiratory and cardiovascular systems, GI and urinary tracts, neurologic and musculoskeletal systems  Thrombosis in the skin, respiratory and cardiovascular systems, GI tract, kidney Diagnostic studies  D-dimer is a specific marker for the degree of fibrinolysis  Decreased Platelets  Decreased Fibrinogen  Clotting times prolonged  Fragmented RBCs found in blood smear Control ongoing thrombosis and bleeding * If chronic DIC and not bleeding, no therapy needed * When patient with DIC is bleeding, blood products are given while treating underlying causes
58
Leukemia
A group of cancers affecting the blood and blood- forming tissues of  Bone marrow  Lymph system  Spleen Occurs in all age-groups  Accumulation of dysfunctional cells due to loss of regulation in cell division  Fatal if untreated  Accounts for 28% of all childhood cancers
59
Leukemia Etiology and Pathophysiology
No single cause  Combination of genetic and environmental influences * Oncogenes, or abnormal genes, can cause many types of cancers * Chemical agents, chemotherapy drugs, viruses, radiation, and immunologic increase the risk of leukemia
60
Leukemia Classification
Acute versus chronic Leukemia, a type of cancer that affects the blood and bone marrow, is classified based on the speed of progression (acute vs. chronic) and the type of blood cells involved (lymphoid vs. myeloid)  Cell maturity and nature of disease onset * Acute: Clonal proliferation of immature hematopoietic cells * Chronic: More mature forms of WBC and onset is more gradual
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Acute Leukemia
Acute Leukemia: Cell Maturity: Acute leukemia is characterized by the rapid accumulation of immature blood cells, often referred to as blasts, in the bone marrow and blood. These cells are poorly differentiated, meaning they have not developed into fully functioning blood cells. Nature of Disease Onset: Acute leukemia tends to develop quickly and can rapidly progress, leading to severe symptoms and complications if not treated urgently. Symptoms may include fatigue, easy bruising, frequent infections, and bleeding. Types: The main types of acute leukemia are Acute Lymphoblastic Leukemia (ALL), affecting lymphoid cells, and Acute Myeloid Leukemia (AML), affecting myeloid cells.
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Chronic Leukemia
Cell Maturity: In contrast to acute leukemia, chronic leukemia involves the clonal proliferation of more mature forms of white blood cells (WBCs). These cells can partially carry out their normal functions but are produced in excessive amounts and may crowd out normal cells in the bone marrow over time. Nature of Disease Onset: Chronic leukemia typically has a more gradual onset, and patients may be asymptomatic or have only mild symptoms for years before the disease is diagnosed. Often, chronic leukemia is discovered incidentally during routine blood tests. Types: The main types of chronic leukemia are Chronic Lymphocytic Leukemia (CLL), affecting lymphoid cells, and Chronic Myeloid Leukemia (CML), affecting myeloid cells.
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Leukemia Key Differences
Onset and Progression: Acute leukemias are fast-developing diseases requiring immediate treatment, whereas chronic leukemias usually progress more slowly and may not need immediate intervention. Affected Cell Types: Acute leukemias primarily involve immature blasts, whereas chronic leukemias involve more mature blood cells. Symptoms and Diagnosis: Acute leukemia often presents with sudden and severe symptoms, leading to a prompt diagnosis. Chronic leukemia may have a more indolent course, with symptoms developing slowly over time or being discovered incidentally. Based on type of WBC  Acute lymphocytic leukemia (ALL)  Acute myelogenous leukemia (AML)  Chronic myelogenous leukemia (CML)  Chronic lymphocytic leukemia (CLL
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Acute Myelogenous Leukemia (AML)
1/3 of all leukemias  80% of the acute leukemias in adults  Abrupt, dramatic onset  Serious infection or abnormal bleeding  Characterized by uncontrolled proliferation of myeloblasts  Hyperplasia of bone marrow
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Acute Lymphocytic Leukemia (ALL)
Most common type of leukemia in children  20% of acute leukemia in adults  Immature, small lymphocytes proliferate in the bone marrow  Most are of B-cell origin Signs and symptoms may appear  Abruptly * Fever at time of diagnosis * Bleeding  Insidiously * Progressive weakness, fatigue, bone and/or joint pain, bleeding tendencies  CNS manifestations are common
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Chronic Myelogenous Leukemia (CML)
Excessive development of neoplastic granulocytes in bone marrow  In all stages of development  Move into peripheral blood in massive numbers  Infiltrate liver and spleen Philadelphia chromosome  Genetic marker  Present in 98% or more CML patients  Chronic, stable phase  Followed by acute, aggressive (blastic) phase
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Chronic Lymphocytic Leukemia (CLL)
Most common leukemia in adults  Production and accumulation of functionally inactive but long-lived, mature-appearing lymphocytes  B cells usually involved  Lymphocytes infiltrate bone marrow, spleen, liver  Lymphadenopathy throughout body Complications are rare in early stage  May develop as disease advances  Pain, paralysis from pressure caused by enlarged lymph nodes  Mediastinal node enlargement leads to pulmonary symptoms  Many patients in early stages may require no treatment
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Other Leukemias
Subtype may be difficult to identify  May have lymphoid, myeloid, or mixed characteristics  Poor prognosis  Overlap with non-Hodgkin’s lymphoma  Both involve proliferation of lymphocytes or their precursors
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Leukemia Clinical Manifestations
Varied but usually related to  Bone marrow failure * Overcrowding by abnormal cells * Inadequate production of normal marrow elements  Formation of leukemic infiltrates Inadequate marrow elements predispose patient to  Anemia  Thrombocytopenia  Decreased number and function of WBCs As leukemia progresses, fewer normal blood cells are made  Abnormal WBCs continue to accumulate, do not go through normal cell cycle to death (apoptosis) Leukemic cells may cause  Splenomegaly  Hepatomegaly  Lymphadenopathy  Bone pain  Meningeal irritation  Oral lesions  Solid masses (chloromas Leukostasis  Life-threatening complication  Caused by a high leukemic WBC count in peripheral blood * Greater than 100,000 cells/μL  Blood thickens and blocks circulatory pathway
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Diagnosing Leukemia
To diagnose and classify types of leukemia  Peripheral blood evaluation  Bone marrow examination To identify cell types and stage  Morphologic, histochemical, immunologic, and cytogenetic methods To determine the presence of leukemic cells outside of blood and bone marrow  Lumbar puncture  PET/CT scan
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Leukemia Interprofessional Care
Initial goal is to attain remission  Complete, partial, or molecular * Prognosis is directly related to ability to maintain a remission  Minimal residual disease * Tumor cells cannot be detected by morphologic examination but can be identified by molecular testing.  Chemotherapy is the mainstay of treatment Stages of chemotherapy * Induction therapy * Postinduction or postremission (consolidation) * Maintenance
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Induction therapy
Attempt to induce remission  Seeks to destroy leukemic cells in tissues, peripheral blood, and bone marrow  Patient may become critically ill * Neutropenia, thrombocytopenia, anemia  70% of patients younger than 50 achieve complete remission
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Postinduction or postremission chemotherapy
Intensification therapy * High-dose therapy * May start immediately after induction therapy * Other drugs that target cell in a different way than those administered during induction may be added Consolidation therapy * Started after remission is achieved * 1 or 2 more courses of induction drugs * Eliminate remaining leukemic cells that may not be clinically or pathologically evident
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Maintenance Therapy
Maintenance therapy  Goal is to keep body free of leukemic cells  May also be used for acute leukemia
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Leukemia Drug Therapy Regimens
Combination chemotherapy  Mainstay of treatment  Three purposes * Decrease drug resistance * Minimize drug toxicity by using multiple drugs * Interrupt cell growth at multiple points in cell cycle  Corticosteroids  Radiation therapy -Total body radiation in preparation for bone marrow transplantation -Organ- or field-specific such as liver or spleen -Cranial radiation when CNS involved  Immunotherapy and targeted therapy
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Leukemia Hematopoietic Stem Cell Transplant
Goal of HSCT  Eliminate all leukemic cells using combinations of chemotherapy with or without total body irradiation  Eradicates patient’s hematopoietic stem cells
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Leukemia Stem Cell Transplantation
Replaced with those of an HLA-matched  Sibling  HLA-half-matched relative  Volunteer donor (allogenic)  Identical twin (syngeneic)
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Lymphomas
Cancers originating in bone marrow and lymphatic structures  Result in proliferation of lymphocyte Comprise 4% to 5% of all cancers in United States  Two major types  Hodgkin’s lymphoma  Non-Hodgkin’s lymphoma (NHL)
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Hodgkin’s Lymphoma
Known as Hodgkin’s disease  Makes up about 10% of all lymphomas  Cancerous condition with *Proliferation of abnormal giant, multinucleated cells * Reed-Sternberg cells * Proliferate in the lymph nodes Bimodal age-specific incidence  15 to 30 years of age  Above 55 years of age  About 8480 new cases each year  Long-term survival exceeds 85% for all stages
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Hodgkin’s Lymphoma Etiology and Pathophysiology
Cause remains unknown  Key factors  Infection with Epstein-Barr virus (EBV)  Genetic predisposition  Exposure to occupational toxins  Incidence increased in those with HIV infection Starts in a single location then spreads to adjacent lymphatics  Eventually infiltrates other organs  Disease above diaphragm stays confined to lymph nodes for variable time  Disease below diaphragm often spreads to extralymphoid sites, such as liver Usually gradual onset  Enlargement of cervical, axillary, or inguinal lymph nodes  Second most common location is a mediastinal node mass  Nodes are movable and nontender  Not painful unless nodes exert pressure on adjacent nerves Patient may notice  Weight loss  Fatigue and weakness  Fever and chills  Tachycardia  Night sweats Initial findings that correlate with a worse prognosis  Called B symptoms * Fever greater than 100.4° F (38° C) * Drenching night sweats * Weight loss exceeding 10% in 6 month Alcohol-induced pain at site of disease  Generalized itching without lesions  With mediastinal node involvement  Cough  Dyspnea  Stridor  Dysphagia Advanced cases  Hepatomegaly  Splenomegaly  Anemia  Other physical signs vary, depending on disease location
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Hodgkin’s Lymphoma Diagnostic Studies
Peripheral blood analysis  Increased ESR, high leukocyte alkaline phosphatase, hypercalcemia, hyperalbuminemia  Excisional lymph node biopsy  Bone marrow examination  Radiologic evaluation
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HL Combination Chemotherapy
Combination chemotherapy  Favorable early-stage disease, receive 2 to 4 cycles  Unfavorable early stage, receive 4 to 6 cycles  Advanced stage, receive 6 to 8 cycles Secondary cancers  May occur 10 years after treatment for Hodgkin’s lymphoma  Most common secondary cancers * Lung cancer * Breast cancer
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Non-Hodgkin’s Lymphomas
Broad group of cancers of immune system affecting all ages  Primarily B, T, or NK cells , histocytic and dendritic cells  Over 75 types Categorized by  Level of differentiation (maturity)  Cell of origin  Rate of cellular proliferation  Immunophenotype (cell surface markers)  Clinical features Most common subtypes  Diffuse large B-cell lymphoma  Follicular lymphoma  Marginal zone lymphoma  Mantle cell lymphoma  Peripheral T-cell lymphoma Unknown cause  May result from  Chromosomal translocations  Infections  Environmental factors  Immunodeficiency states
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Non-Hodgkin’s Lymphoma Etiology and Pathophysiology
Most common in people who have  Inherited immunodeficiency syndromes  Have used immunosuppressive agents  Received chemotherapy or radiation  No hallmark feature  All NHLs involve lymphocytes arrested in various stages of development Widespread disease usually present at time of diagnosis  Painless lymph node enlargement  Primary clinical manifestation  Lymphadenopathy can wax and wane  Other symptoms depending on where disease is present Patients with high-grade lymphomas  Lymphadenopathy  B symptoms * Fever * Night sweats * Weight loss
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Non-Hodgkin’s Lymphoma Diagnostic and Staging Studies
Resemble those used for Hodgkin’s lymphoma  Since NHL is more often extranodal  MRI  Lumbar puncture  Bone marrow biopsy  Barium enema or upper endoscopy Staging guides therapy  Precise histologic subtype through biopsy is extremely important  Classified based on morphologic, genetic, immunophenotypic, and clinical features  In early NHL, CBC may be normal Treatment guided by  Cell type  Cytogenetic studies  Clinical behavior * Indolent (low grade) * Aggressive (high grade) * Highly aggressive (very high grade)
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NHL Treatment
Treatment  Chemotherapy  Biotherapy  Radiation  Sometimes phototherapy and topical therapy More aggressive lymphomas (diffuse large B- cell) are generally more responsive to treatment  Indolent lymphomas are hard to effectively treat Hematopoietic stem cell transplant  Rituximab (Rituxan)  Monoclonal antibody against the CD20 antigen  Monitor for symptoms of severe hypersensitivity infusion reactions * Especially with first infusion  Ibritumomab tiuxetan (Zevalin).  Numerous chemotherapy combinations Complete remission is uncommon  However, improvement in symptoms is expected in the majority of patients
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Multiple Myeloma
Condition in which cancerous plasma cells proliferate in bone marrow and destroy bone  Accounts for 1.8% of all cancers  18% of all hematologic cancers  Occurs between ages of 65 and 74  About 10% of patients who undergo stem cell transplant may be cured. Cause unknown  Possible exposure to organic chemicals, herbicides, insecticides  Viral infections Involves excess production of plasma cells  Normal plasma cells are activated B cells, which make immunoglobulins to protect the body  In multiple myeloma, plasma cells make monoclonal antibodies that are ineffective and even harmful * Monoclonal proteins (called M proteins) * Bence Jones proteins are the light chain part of these monoclonal antibodies Develops slowly and insidiously  Skeletal pain is major manifestation  Pelvis, spine, and ribs  Diffuse osteoporosis develops  Osteolytic lesions seen in skull, vertebrae, long bones, ribs  Compression of spinal cord, pathologic fractures Calcium loss from bones causes hypercalcemia  May cause renal, GI, neurologic manifestations  Serum hyperviscosity syndrome leads to cerebral, lung, renal, and other organ dysfunction
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Multiple Myeloma Diagnostic Studies
Laboratory  M protein found in blood and urine  Pancytopenia  Hypercalcemia  Bence Jones protein in the urine  High serum creatinine -Radiologic  MRI, PET, and CT scans -Bone marrow examination
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