Haematology

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Haematology
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Help I need blood!
Both O negative and group specific are unsuitable
for patients with antibodies
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How well do you know your blood products?

• FFP
• How long does it take? 30mins
• Does it need to be XMed? . Yes
• What does it contain? . All CFs fibrinogen
  ..
• 
  BUT its large volumes and needs to be thawed
• When else to use? warfarin, factor
  deficiencies, TTP
• Cryo
• How long does it take? ..30mins
• Does it need to be XMed? ..preferable
• What does it contain? VIII, XIII, fibrinogen,
  vWF
• When else to use? .just in bleeding when
  fibrinogen lt1
• Platelets
• How long does it take? . 15-30mins
• Does it need to be XMed? .no
• When else to use? ..ITP, DIC, bleeding and
  more
• Prothrombinex

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• Picture from JehovahsWitness.net highly
  recommended source material

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What about factor VIIa?

• Trials have not identified clinically significant
  improval of outcome
• Increased mortality in blunt trauma
• 5 increased risk of VTE
• Indications?
• As last resort in
• generalised bleeding
• only if control of
• bleeding has been
• obtained

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Massive Transfusion

• Definition of massive transfusion?
• gt50 patients blood volume at once
• 100 patients blood volume over 24hrs
• Prognosis 45-65 survival rate

Name the movie
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Fill in the blanks
Remember ratio PRBC FFP plt cryo
5 5 1-2 1-2
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In Summary

• O neg
• 2iu PRBC 2iu FFP
• 4iu PRBC 4iu FFP 3iu cryo
• 4iu PRBC 4iu FFP 1iu plts
• Alternate the above
• Check bloods every 30mins
• Aim INR lt1.5, APTT lt40, fib gt1, plts gt75, Ca gt1

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DIC

• What is it?
• Acquired diffuse inappropriate intravascular
  coagulation with 2Y fibrinolysis or inhibition of
  fibrinolysis ? microvascular thrombi, consumptive
  coagulopathy ? ARF, ARDS, ALF, CCF, bleeding,
  purpura fulminans, gangrene

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Part II Pneumonic

• H Hepatic failure
• O Obstetric (eg amniotic fluid embolism,
  eclampsia,
• fetal death, placental abruption,
  septic abortion)
• T Trauma (eg. Fat embolism, rhabdo, HI, burns,
  
• envenomation, hypothermia)
• M Malignancy
• I Immune (eg. Rejection, tranfusion
• reaction, anaphylaxis)
• S Sepsis (esp G-ives)
• S Shock

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Management

• Remember this?

Give Vit K to all Give PRBC if needed May need
large volumes of FFP If not bleeding, can
tolerate platelets gt20 Give folate
supplementation consider APC, factor VIIa
heparin if organ survival is threatened by
thrombus
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Warfarin Overdose

• Remember basics
• Charcoal if lt1hr

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Summary before the test

• INR lt5 and stable
• If normal INR and no therapeutic need
• Give 10-20mg PO Vit K
• Discharge with repeat INR in 48hrs
• If INR lt5 and therapeutic need
• Omit dose
• Consider 10 dose reduction

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• INR gt5 and stable
• If no therapeutic need
• 10mg IV Vit K
• Consider discharge with follow up INR
• If therapeutic need
• Dont overshoot
• Consider 1-5mg PO Vit K
• Recheck INR at 6-12hrs and give repeat dose until
  INR lt5 then restart warfarin at lower dose
• Heparin if INR lt2 and at high risk

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• INR gt5 and stable but high risk
• Active peptic ulcer
• Recent OT in 2/52
• On aspirin
• Plt lt50
• INR gt9
• PO / IV Vitamin K
• Consider PTX (25-50iu/kg depending on INR)

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• INR gt5 and unstable / life threatening bleed
• ICH, spinal, intra-abdominal, intraocular
• Haematemesis, melaena, significant haemoptysis
• SBP lt90
• Oliguria
• Decr Hb gt20
• Or at risk of significant bleeding use common
  sense
• 1-2iu FFP
• 50iu/kg PTX
• 5-10mg IV Vit K

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Vit K can be given as slow IV push over
2-3mins IV Vit K onset of action 3-6hrs PO Vit K
onset of action 6-24hrs PTX onset of action
15mins After PTX completed (3ml/min, 500iu in
20ml therefore up to 140ml needed to give 50iu/kg
to 70kg male) can repeat INR after 15mins. Repeat
dose as necessary as per INR.
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Dabigatran

• Mechanism of action
• Direct thrombin inhibitor
• Duration of action
• 12-24hrs
• Longer if renal impairment
• Reversal agent
• There is none
• Treatment
• Treat as per any haemorrhagic episode
• Additional measures to reverse if significant
  bleeding and above not working
• There is no published data on dabigatran reversal

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What do coagulation tests mean in dabigatran???

• There is no linear correlation between blood
  tests and bleeding risk
• APTT
• Higher risk of bleeding if gt80, but lt80 may be
  acceptable moderate sensitivity
• PR / INR
• Higher risk if gt1.5 lower sensitivity
• dTCT
• Very sensitive levels gt80 seen in low or high
  dabigatran levels
• APTT and PR normal low risk
• APTT lt50 and PR lt1.5 levels probably low to
  moderate
• Can you do dabigatran levels?
• Yes
• Therapeutic 0.09mcg/ml (trough) to 0.18mcg/ml
  (peak)
• If level lt0.1mcg/ml and CrCl gt30, then levels
  will decrease over 12-24hrs
• Threshold for dialysis UNKNOWN

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Rever
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In Summary

• Stop dabigatran
• If OD consider charcoal
• Check bloods, inc TCT, and crossmatch
• Vit K tranexamic acid (easy to do)
• If bleeding fluids, RBC, FFP
• If plt lt80 or on anti-plt plts
• If bad bleeding / brain bleeding PTX factor
  VII
• If severe and renal failure haemodialysis

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Neutropenic Sepsis

• Febrile neutropenic patient has gt60 likelihood
  of being infected, and 37 chance of ive blood
  culture (usually G-ives)
• Whats the definition of neutropenic sepsis?
• T gt38.5 (or gt38 twice over 2hrs)
• Neutrophils lt 1.0 X 109/L
• Assessment
• 2x blood cultures
• Central and peripheral blood cultures if line
• Take down dressing and check site if recent
  aspirate / line

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Treatment of Low Risk Patient
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Treatment of High Risk Patient

• Whats a high risk patient? (hidden on
  haematology website)
• Neutrophils lt0.5
• Rapid decrease in neutrophils
• Protracted neutrophils lt0.5
• Other contributing factors eg.
  Immunocompromised, steroids, central line, GVHD
• BMT patient with impaired B and T cell function

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Treatment of High Risk Treatment
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