Heme/Onc
Disclaimer: the clinical information on this site is only meant to serve as a reference. Please consult with your team for individual diagnostic and treatment decisions.
Sickle Cell Vaso-Occlusive Pain Crisis
- Triggers: natural course of disease, running out of pain medication, weather, stress
- Complications: acute chest syndrome (chest pain with CXR infiltrate), bilirubin gallstones, pulmonary hypertension, renal failure, stroke
- Many sickle cell patients use hemoglobin < 6 as transfusion threshold
- Treatment: IV isotonic fluids (NS/LR) at 100-150cc/hr to flush out sickled cells, Tylenol (acetaminophen), Motrin (ibuprofen), Toradol (IV ketorolac), and opiates (some patients as high as Dilaudid 4mg every 2 hours IV)–med surg floor maximum is every 3-4 hours, if needs more frequently then use PCA. Usually give 2 days of IV opiates then on day 3 all home orals with lowered IV, day 4 all home orals with even lower IV, day 5 just home orals and discharge. Some patients are on hydroxyurea (requires hospitalist chemotherapy consent) or deferoxamine (iron chelator)
- If acute chest syndrome: ceftriaxone/azithromycin empiric treatment for pneumonia and monitor for worsening (could require intubation or exchange transfusion)
- Some patients have “superutilizer” plans (go to EPIC and on the left side click Medview, if a pain medication plan exists it will be highlighted in red at the top right)
- First look at MCV then at RDW. If MCV is low then microcytic anemia. If MCV is normal then could be normocytic anemia (normal RDW) or if RDW high the normocytic anemia could be a mix of microcytic and macrocytic cells. If MCV is high then is macrocytic anemia.
- Microcytic anemia: iron deficiency anemia (low transferrin saturation or low ferritin but doesn’t have anything to do with serum iron level, treat with IV iron sucrose 300mg daily x 3 days if normal kidneys/some CKD or 100mg on dialysis days x 10 days (total = 900-1000mg) or once/twice daily oral ferrous sulfate
- Normocytic anemia: anemia of chronic disease (high ferritin), acute blood loss anemia (very recently)
- Macrocytic anemia: alcohol, B12/folate deficiency (nutritional or from drugs such as Bactrim, methotrexate, valproic acid, phenytoin, methotrexate)
- Decreased production: sepsis, nutritional, liver disease (liver makes thrombopoietin), aplastic anemia, myelodysplastic syndrome, leukemia
- Increased sequestration: splenomegaly from portal hypertension
- Increased destruction: HIT (heparin-induced thrombocytopenia), ITP (idiopathic thrombotic thrombocytopenia), TTP (thrombotic thrombocytopenic purpura), DIC (disseminated intravascular coagulation)
- Option 1: heparin subcutaneous 5000 units every 8 hours (for those who could bleed and only want an every 8 hour drug onboard or CrCl < 30)
- Option 2: Lovenox (enoxaparin) subcutaneous 40mg daily (for those with normal kidneys and low likelihood to bleed)
- Option 3: mechanical prophylaxis (intermittent or sequential compression devices, for those who are bleeding)
- Option 4: nothing more because already on a treatment-dose anticoagulant
Pulmonary Embolism (PE) / Deep Vein Thrombosis (DVT)
- If have PE, do four extremity dopplers so if clot forms in the future you know if you failed anticoagulation or if the clot was already there
- If concern for submassive/massive PE that might need a PE response team consult for catheter-directed thrombolysis or mechanical thrombectomy, check BP (<90/60), troponin, proBNP, echocardiogram, and persistence of severe symptoms even after therapeutic anticoagulation for several days
- First provoked DVT/PE: 3 months anticoagulation
- First unprovoked DVT/PE: 6 months anticoagulation
- Cancer DVT/PE: treat as long as cancer is still active (could be lifelong)
- Massive PE, second DVT/PE, autoimmune or hereditary clotting disorder, lifelong immobility, common femoral (very proximal) DVT: discuss possibility of lifelong anticoagulation
- Heparin drip: good for any kidney function, any weight, and easily turned off for a procedure, check PTTs (“heparin chase”) every 6 hours until 2 are therapeutic then daily afterward (some floors have an RN-driven protocol), if PTTs persistently high they may be being drawn upstream of a heparin infusion IV. Reversal agent: protamine sulfate
- Lovenox (enoxaparin, low molecular weight heparin): use for creatinine clearance > 30, not good if you need to quickly turn off the activity, not studied in patients over 150kg, can give 1.5mg/kg daily or 1mg/kg twice daily (preferred for cancer patients). Reversal agent: protamine sulfate
- Coumadin (warfarin, vitamin K antagonist): requires frequent lab draws, affected by vitamin K leafy green vegetables in diet. Reversal agent: vitamin K, FFP
- Pradaxa (dabigatran, direct thrombin inhibitor): does not require blood work but requires 5 day bridge with heparin drip or Lovenox, long acting so not good if need to quickly turn off the activity. Reversal agent: Praxbind (idarucizumab)
- Xarelto (rivaroxaban, factor Xa inhibitor): requires 21 day load of 15mg BID then maintenance dose of 20mg daily. Reversal agent: Andexxa (andexanet alfa) or PCC (prothrombin complex concentrate)
- Eliquis (apixaban, factor Xa inhibitor): requires 7 day load of 10mg BID then 5mg daily, of all the non-warfarin oral choices this is most likely to be safe for head bleeding and renal failure/CKD. Reversal agent: Andexxa (andexanet alfa) or PCC (prothrombin complex concentrate)
GI Bleed: Exsanguination Protocol
- Blood bank: 215-662-3448 / 215-662-3449 at HUP, 215-662-8336 at PPMC
- First round: 10 units RBCs, 6 units FFP, 1 unit platelet of uncrossed blood
- For massive transfusions consider calcium gluconate after the 4th RBC to counteract hypocalcemia due to citrate in packed RBCs and also giving RBC:FFP:platelets in a 4:2:1 ratio (4:1:1 in surgical data) due to dilutional coagulopathy/thrombocytopenia
- Hemoglobin goal usually > 7 or higher if actively bleeding or hemodynamically unstable
- Consider hemoglobin goal > 6 for some sickle cell patients
- Consider hemoglobin goal > 8 for active cardiac ischemia
- Usually 1 unit RBCs raises hemoglobin by about 1.0 g/dL
- FFP goal usually < 2 for procedures
- Remember FFP has an INR of 1.6 itself so it will not lower the INR beyond this point
- Platelet goal usually > 10 in most patients, > 50 if active bleed or most procedures, > 100 if brain bleed or CSF-related procedure (LP)
- Usually 1 unit of platelets raises platelet count by 10-25k/microliter
- Goal fibrinogen usually > 100
- Transfuse 10 units of cryoprecipitate at a time
- Defined as temperature of 100.4F in a patient who has an ANC (absolute neutrophil count) of 500 or an ANC of 1000 expected to fall (ex: recent chemotherapy). Some sources use an ANC of 1500 as a cutoff.
- Patients form ulcers in areas of high cell turnover (oral/GI mucosa) and are more prone to Pseudomonas aeruginosa and also fungal infections
- Empiric antibiotics should include Pseudomonal coverage (cefepime/Zosyn)
- Treat for infection course or at least until counts reach ANC 500
- Order neutropenic diet and often single room
- UPHS Antibiotic Guidelines for Diagnosis and Treatment
- Definition: spinal cord compressed by tumor, fractured vertebral bone, or abscess leading to ischemia of the spinal cord nerves
- Detection: MRI of the spine
- Treatment: dexamethasone 10mg x 1 IV then 4mg every 6 hours with a taper, neurosurgery and radiation oncology STAT consult
- For first time detection (often incidental) of new small lung nodule (usually about <1cm) refer to Fleischner Society Guidelines for repeat imaging criteria
- For larger masses, discuss with radiology or pulmonology if the mass is best biopsied by CT-guided biopsy or bronchoscopic biopsy
- Remember lung masses can also be granulomas, hamartomas, Wegener’s granulomatosis, organizing pneumonia, abscess, or sarcoid
- Consider if hypocalcemia (3 calcium 2+ ions bind to every two phosphate PO4-3 molecules leading to a calcium relative deficiency), hyperkalemia, hyperphosphatemia, hyperuricemia +/- AKI
- Labs: TLS (BMP, calcium, phosphate, uric acid) and DIC (PT, PTT, D-dimer, fibrinogen)
- Treatment: fluids, allopurinol, rasburicase (need to meet strict criteria)
- Corrected calcium = serum calcium + (4 – serum albumin) x (0.8)
- Symptoms: depression, lethargy, abdominal pain, constipation, kidney stones
- Labs: Vit D, PTH, PTHrP, ionized calcium, serum calcium, albumin, phosphate
- Treatment: aggressive fluids with normal saline (has calciuretic effect that LR doesn’t), calcitonin, IV bisphosphonate (Zometa or zoledronic acid), denosumab