Download Preoperative evaluation in hematologic problem 2 SEP

Preoperative evaluation
and Management of
patient with
Hematologic Problems
Preoperative evaluation
1. Disease : severity
: curable
2. Surgery : emergency
: risk of bleeding
Hematologic problem
• Anemia
• Bleeding tendency
– Platelet : thrombocytopenia , dysfunction
–Coagulopathy
– anticoagulant
• Hematologic malignancy
Bleeding risk procedure
Low risk
Moderate risk
high risk
•
•
•
•
Nonvital organs
exposed site
limited degree dissection
Local hemostatic effective
• Vital organs
• deep or extensive dissection
• Local hemostatic ineffective
• local fibrinolysis
• CABG, brain injury, extensive
malignancy)
• Bleeding complications
compromise result
Anemia
Perioperative transfusion
European Journal Of Haematology July 2005
Preoperative transfusion in sickle cell disease: a survey of practice in England
Complication transfusion
1. independent predictor of postoperative infections
2.new transfusion hazards : West Nile virus and
variant Creutzfeld Jacob disease
3. iron overload
4. red cell alloimmunisation
• Review : transfusion not improve postoperative
complication
• No RCT : transfusion VS non transfusion
Vamvakas EC. Meta-analysis of randomized controlled trials investigating the risk of postoperative infection
in association with white blood cell containing allogeneic blood transfusion: the effects of the type of
transfused red blood cell product and surgical setting. Transfusion 2004;16: 304 314.
Perioperative transfusion
• preoperative Erythropoietin
• < 7 - 8 g/dL should be given
• Except : severe ill , >55 year , cardiac diseasae
Anemia
Iron deficiency anemia
• Elective surgery : postpone: Hct > 10 g/dL
• Emergency : Hct 8-10
Thalassemia
HCC syndrome
Hypertensive, Convulsion, Cerebral hemorrhage
• Risk : thalassemia major, Hct 9-20%
• Onset : during  2 week ( cmm< 2 days)
• Mortality 33%
• Etiology : volume overload  pressor
hyperresponsiveness, RAAS system, symphatetic
• Prevent : slow rate ,< 3 pack/d , interval 3
days, monitor BP,
• diuretic ,antihistamine before transfusion
• Rx : diuretic , antihypertensie, dexamethaxone
AIHA
Laparoscopic Splenectomy
AIHA
2. Transfusion :
most patients tolerate serologically incompatible
blood
2. corticosteroids
1. suppress HPA axis:
prednisolone ≥ 5 mg/day for
> 3 weeks 6 -12 months prior to surgery
or clinical Cushing's syndrome.
2. Impaired wound healing
3. Increased risk infections,
4. gastrointestinal hemorrhage
uiz
ผูป้ ่ วยหญิงไทยคู่ 35 ปี เป็ น SLE (DLE,
ANA,anti DsDNA,LN) on
prednisolone (5) 2*2
Dx MCA with abdominal injury
need Explor laparoscopic
CBC : Hct 21 , WBC 1,600 N 75
% L 20% Plt 600,000 )
Peripheral blood smear
uiz
• blood transfusion  Hct 25
• Steroid stress dose
uiz
ผูห้ ญิง 18 ปี CVT consult
preoperative mediastinal
mass พบ anemia
CBC : Hct 18 WBC 5,600
Plt 560,000
Thrombocytopenia
Thrombocytopenia
• surgical bleeding
low risk < 50,000/dL
moderate to high risk < 100,000 /dL
• standard dose : 0.1-0.2 u/Kg
• 5-8 units for prophylactic
• Single donor platelets = 6-10 units
• Maintain postoperative 1 week
2. Antifibrinolytic
1. Tranexamic acid
2. epsilon aminocaproic acid (EACA)
• areas increased fibrinolysis,
• required for 7- 14 days depend on amount of
tissue injury.
Plasminogen activator
plasminogen
Tranexamic acid
3. microfibrillar collagen, fibrin glue
• Two plasma proteins; fibrinogen and thrombin
• are being used to develop fibrin glue
Refractoriness to platelet transfusion
corrected platelet count increment (CCI),
CCI = increment platelet count 1 hr) x BSA [m(2)]
unit of platelets
• practical : 10,000/dL
• 6 units to BSA 2 m2
• 10,000= increment x2  platelet ~ 30,000/dL at 1 hr
6
• refractoriness = CCI < 5,000
~ absolute platelet count increment ≤2,000/dL /unit
American Society of Clinical Oncology
Refractoriness to platelet transfusion
Vancomycin , amphotaracin B
alloimmunization
1. HLA-matched platelets
2. Single donor crossmatch-compatible platelet with
patient's serum
3. +/- IVIG , plasmaphoresis
avoid transfusion
in 1. TTP/HUS
2. heparin-induced thrombocytopenia.
worsening neurologic symptoms and acute renal
failure,
ITP
•
•
1.
2.
Splenectomy
platelet count >50,000/ตL
Pulse methylprednisolone : resp 4.7 day
IVIG
1 gm/kg IV, repeated following day if platelet
remains <50,000/dL 60% resp in day 3
3. Anti Rh D
4. platelet
5. Emergency splenectomy : response in 24-48 hrs
postsplenectomy
Infection
• immunize 2 weeks prior :
 at time of diagnosis.
Alternatives
1. splenic irradiation
2. partial splenic embolization.
Platelet dysfunction
Agonist
Adhesion
1. Bernard-Soulier synd
2.vWF
2.1 congenital
2.2 acquired
1. Ab : AI, Lymphoproliferative
2.absorb vWF : Lymphoma,WM
Secretion
1.Acquire storage pool disease :
1.1 CABG, activate clot i.e. DIC
1.2 CLL, myeloproliferative
1.3 ; Cirrhosis , SLE
2.Drug : NSAID , dipyridamole
Aggregate 1. Glanzmann , antiPlt Ab: SLE, ITP
2. Dysproteinemia
3. Drug , plavix,fibinolytic
Mixed
Uremia
Plt
Fc VIII 2-3 day
dDAVP
Rx cause
Mild
Rx cause
Plt
dDAVP
PLt
Ab Novoseven
Rx underlying
Antiplatelet
Platelet transfusion prophylaxis???
2004 ACC/AHA task force
: not discontinue in CABG after STEMI
Antiplatelet
1. ASA: irrevesible
: 5-10 days
2. Dipyridamole.
: 2 days
3. ticlopidine and clopidogrel :irreversibly
: 7-10 days
4. NSAIDs
: 3 days
COX -2 ???
Uremia
both aggregation , adhesion.
1. Intrinsic factors : GP, ADP,
TXA2
2. Extrinsic factors
1. uremic toxins
( guanidinosuccinic acid and phenolic )
NO production (inh aggregation),
2. anemia,
3. impair vWF-Plt interaction
aggregation ,adhesion
Correlate ????
uremia
1. anemia Hct > 25- 30
2. Erythropoietin –increasing GPIIb/IIIa
and improving platelet calcium signaling
3.
effective 50% patients
improvement within 1 hour and lasts 4 -24 hrs.
• Repeat every 24 hrs
• tachyphylaxis due to depletion of
endothelial multimer stores. , limit 3 dose
4.Dialysis
5.Estrogen : due to decreased generation NO.
6. Cryoprecipitate –
10 units every 12 -24 hrs : effect = dDAVP
uiz
ชายไทย 34 ปี CKD จาก polycystic kidney disease
On regular hemodialysis 3 /สัปดาห์ นัดมาทา kidney
transplantation
• regular hemodialysis
• Hct >30
uiz
DM , HT , CKD Cr 2.5 มาด้วย acute febrile illness
Dx melioid sepsis , acute ontop chronic kidney
disease , severe metabolic acidosis , plan acute
peritoneal dialysis
• bleeding time < 7 min
• cryoprecipitate or dDAVP
Coagulopathy
•
•
•
•
•
•
•
FRESH FROZEN PLASMA
all coagulation factors
130%
unitsx: 250
40mL;
cc/kg= 12 cc/kg ~10-15cc/kg
1 cc = 1 % activity
15 cc/Kg
50 Kgactivity
= 750/250
= of
3 bag
hemostasis
whenx factors
~ 25 - 30 %
plasma volume(40 mL/kg,)
= FFP at 10-15 mL/kg,
Indications
multiple coagulation factors
DIC , warfarin overdose, vitamin K deficiency, liver
failure, massive transfusion
Every 6 hrs ( T1/2 factor VII 4-6 hrs)
CRYOPRECIPITATE
• factor VIII, XIII, fibrinogen, fibronectin, vWF
• volume of 10 - 15 mL.
• fibrinogen = 200 mg
• Factor VIII = 100 u (80-110 IU)
1.deficiencies of fibrinogen : 1 bag / 7Kg BW
2.vWF : 0.1 bag /kg every 6-12 hour
3. Hemophilia A
Liver disease
1. Decrease production coagulation factor( vWF )
2. dysfibrinogenemia
3. Decrease protein C , protein S, impair ability to
clear activated coagulation factor  DIC
4. Vitamin K deficiency
5. Thombocytopenia, Plt dysfunction
Rx
1. FFP PT < 3 S , Plt
2. Vit K : PT normal in 12-24 hrs
3. Cryoprecipitate : hypofibrinogen
Hemophilia A
1. cryoprecipitate : factor VIII 100 u
 serious viral
transmission
2 lyophilized factor VIII conc . 1 ขวด 250 u
3. Recombinant human factor VIII :250, 500,1,000 U
4. monoclonal purified factor VIII
Hemophilia B
1. prothrombin complex concentrates
: factors II, VII, X , IX,
ass with thrombogenic risk
2. cyro-remove plasma
3.monoclonal or recombinant product
Dosing
• calculated from
Concentration = dose administration/Vd
1.BW (kg),
= 1 U/0.5
2.volume of distribution
3. desired factor level = 2 U/cc = 2% activity

Vd factor VIII ~ 0.5;  1 u/Kg  2 %
activity

Vd factor IX : 1 u/Kg
 1 % activity
desired factor level = severity and location of
bleeding episode.
Initail
maintenance
dental surgery
50 %
Single
+ antifibrinolytic 7-10 days
major procedures
•Extensive dental Sx
•LP,epidural anesth
•CNS
•major orthropedic
(TKR)
60 -100 30-50 % until wound healed,
~ 2-3 days
7-10 days
3 week ( + PT)
• Factor levels checked
• T1/2 factor VIII 8 - 12 hoursrepeated 12 hour
factor IX : 16 - 17 hours every day
continuous infusion
• factor VIII : 2 - 4 U/kg / hr
• major surgery
Must check factor VIII inhibitor
• Low < 10 bethesda : High dose factor VIII
+ 10 U/kg/1 BU
• Plasmaphoresis
• High titer : Porcrine , Recombinant factor VIIa
OTHER THERAPIES
1. dDAVP :
mild moderate bleeding in mild hemophilia A,
2. Antifibrinolytic
– Tranexamic acid and EACA
3. microfibrillar collagen, fibrin glue
uiz
ผูป้ ่ วยชาย 26 ปี BW 60kg
hemophilia A มาด้วย ขาขวา
บวม มา 6 ปี
• Body weight x 0.5 units/kg x desired factor VIII
increase (%) = units factor VIII required
BW x 0.5 x % = unit
60 x 0.5 x 100 = 3000 units factor VIII
then 60 x 0.5 x 50 = 1500 units factor VIII
• Cyroprecipitae 100 u/bag = 30 U then 15 u
every 12 hr
anticoagulation
1.. risk of thromboembolism
2. Risk of bleeding with anticoagulant
anticoagulation
1. risk of thromboembolism
= indication for anticoagulation,
1. actual treatment.
1.1 Venous recurrent : first month 1 % / days
1.2 Artery recurrent : first month 0.5 %/ day
 avoid elective surgery
 DVT: within 2 weeks or if
risk of bleeding is high,
 vena caval filter
2. prophylaxis Arterial
thromboembolism
low risk
1. nonvalvular atrial fibrillation
2. prosthetic heart valve 4 % /-year
• mitral valve twice risk aortic valve
• Aortic: safety of temporary cessation
high-risk AF
2. Risk of bleeding
depend on age, other disease, drugs, type of
surgery ,anticoagulant regimen and intensity,
 prolonged, complex, and major surgery
 more bleeding
 3 % of major postoperative bleeding fatal
Must know
1. after discontinued require 2-3 days for effect to
resolve
2. Require 4-5 days to resumed a therapeutic level
3. Rebound hypercoagulability after discontinued
• Surgery increases risk of venous not arterial
thromboembolism , 100-fold risk
• changes in hemostatic markers( acute phase
response and wound healing process)
1. Heparin : Discontinue 6 hr before
• protamine:
2. Enoxaparin
• Antifactor Xa activity: ~12 hr 24 hr
• protamine
3. warfarin
• Vit K
• PT normal 12-14 hours
Post operative anticoagulant
•
High risk thomboembolism heparin
1. High risk arterial thomboembolism
2. After venous thomboembolism in 1 month
( artery if low risk bleeding)
• Restarting warfarin on 1-2 postoperative day
PT therapeutic range for at least 48 hours
before heparin is discontinued.
uiz
ผูป้ ่ วย Rheumatic heart disease S/P DVR ฟันผุ ทันต
แพทย์แนะนาให้ถอนฟัน
• check INR
• Reduce dose uutil INR < 2
• Tranexamine
• Splint
cancer
.
1.effects of malignancy
2.side effects of therapy
• Neutropenia and lymphopenia infection.
postponed except emergent
 Even neutropenia resolved remain relatively
immunocompromised
• Thrombocytopenia
• Hypercoagulability : risk for perioperative DVT
airway
•Anterior , middle mediastinal masses compress
•Flow volume loops
Cardio
•Pericardial disease
Chemotherapy
•Hepatotoxicity
•Nephrotoxicity
• cardio : anthracyclines, 550 mg/m2 doxorubicin
Preexisting heart disease, radiation,
other chemotherapeutic agents (taxanes)
EKG , echocardiogram
radiation therapy
1.Hypothyroidism – Radiation > 10 Gy to neck
2.Coronary artery disease , valvular disease
uiz
6. ชายไทย 38 ปี ปวดท้องน้อยด้านขวา มา 2 วัน dx
acute appendicitis
CBC preop
Hct 22 WBC 5,600 Blast 96 % neutrophil 2% Plt 65,000
uiz
• R/O TYphitis
• Check PT , APTT
• LPB , PLt
Drug dosage
1. IVIG AIHA very high doses (1000 mg/kg/day 5 days)
ITP : repeated following day if platelet <50,000/ตL
for 1-2 days
begin at 40 mL/h and then increase by 10 to 20 mL/h every
20 to 30 minutes. Infusion rates up to 30 mg/kg per min
mechanism is unknown, but could involve:
1. Competitive inhibition of autoantibody
adsorption to patient's platelets.
2. Prevention of RE uptake of autoantibody-coated
platelets through Fc-receptor blockade.
3. Interaction of autoantibodies with anti-idiotype
antibodies in IVIG.
2. tranexamic acids 25 mg/kg / dose every 6-8 hours,
• Hemophilia patients, tooth extraction:
1. I.V.: 10 mg/kg before surgery, then 25 mg/kg/dose orally
3-4 times/day for 2-8 days
2. Oral: 25 mg/kg 3-4 times/day beginning 1 day prior Sx
3. I.V.: 10 mg/kg 3-4 times/day in unable oral
RENAL IMPAIRMENT
• Clcr 50-80 mL/minute: 50% of normal dose or twice
daily 10 mg/kg I.V. or 15 mg/kg orally.
• Clcr 10-50 mL/minute: 25% of normal dose or OD.
• Clcr<10 mL/minute: 10% of normal dose or every 48
hours
FORMS : Injection, solution: 100 mg/mL (10 mL)
maximum rate of 100 mg/minute
: oral : 250-500
3. EACA is 75- 100 mg/kg /dose every 6 hours
4. NOVOSEVEN 50-100 µg/kg every 2-3 hrs until
stop than plus 1-2 dose
5. Pulse methylprednisolone (1 gm IV, daily 3 doses)
6. dDAVP
1 IV 0.3 microg/kg in 50 mL saline over 15 - 30 min
2 same dose subcutaneously
3 intranasally 3 microg/kg
Side effects 1.water retention hyponatremia..
2.vasodilatation  facial flushing, headache
3. hypotension and hypertension
7. Estrogen
1. 0.6 mg/kg IV ,OD 5 days : onset 6hr  14 days
2. 2.5 -25 mg oral Premarin : onset 2 days  5 dasys
3. or 50 -100 microg of transdermal twice weekly
8. protamine:
1.Heparin 1 mg per 100 units
2.Enoxaparin : 1 mg per 1 mg.
• Monitor aPTT 2-4 hrs after first infusion
• readministration 50% of original dose
• Note: anti-Xa activity is never completely neutralized
(60% to 75%).
9. Vit K Oral: 5-25 mg Onset 6-12 hrs
I.M., I.V., SubQ: 10 mg Onset 1-2 hrs
&
• ผูป้ ่ วย Rheumatic heart disease S/P DVR ฟัน
ผุ ทันตแพทย์แนะนาให้ถอนฟัน
• ชายไทย 34 ปี CKD จาก polycystic kidney
disease On regular hemodialysis 3 /สัปดาห์
นัดมาทา kidney transplantation
• DM , HT , CKD Cr 2.5 มาด้วย acute febrile
illness Dx melioid sepsis , acute ontop
chronic kidney disease , severe metabolic
acidosis , plan acute peritoneal dialysis
• ผูป้ ่ วยชาย 26 ปี hemophilia มาด้วย ขาขวาบวม มา 6 ปี
• ผูป้ ่ วยหญิงไทยคู่ 35 ปี เป็ น SLE (DLE, ANA,anti
DsDNA, LN) on prednisolone (5) 2*2
Dx acute gangrenous arterial occlusion left leg
CBC : Hct 21 , WBC 1,600 N 45 % L 50%
Plt 600,000 )
• ผูห้ ญิง 18 ปี CVT consult preoperative
mediastinal mass พบ anemia
CBC : Hct 18 WBC 5,600
Plt 560,000
• ชายไทย 38 ปี ปวดท้องน้อยด้านขวา มา 2 วัน dx acute
appendicitis CBC preop Hct 22 WBC 5,600
Blast 96 % neutrophil 2% Plt 65,000