Hospital Management of Sickle Cell Playing Fireman..

Transcription

1 Hospital Management of Sickle Cell Playing Fireman.. Brad Lewis SFGH bloods so mad, feels like coagulatin. Berry McGuire (Eve of Destruction) A pint of sweat will save a gallon of blood Gen. George Patton

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3 Case #1 A Pain in the 28yo woman with SSD presents with bilateral thigh and low back pain Stable sickle cell disease without Cx in past Long history of long hospital stays No recreational drugs, modest narcotic use between hospitalizations Well prior to abrupt onset pain Presents to ER

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5 Case #1 IV Dilaudid Pt had no preference But wanted IV benedryl with each injection for pruritus Meds: Vicoden, Folate PE unrevealing Labs WBC 14,000, no bands, Plt 473,000 Hgb 8.3 MCV 88, Retic 240

6 Question #1 3.5 Wks Later Still Inpt, Now What? 1. Frustrating, but not unusual 2. Dilaudid is not optimal, change to MS and Effexor 3. Look for the cause of the pain 4. Psychosocial factors are often underestimated

7 Question #1 3.5 Wks Later Still Inpt, Now What? 1. Frustrating, but not unusual 2. Dilaudid is not optimal, change to MS and Effexor 3. Look for the cause of the pain 4. Psychosocial factors are often underestimated

8 What is Sickle Cell? EM from U Chic

9 Mechanisms of Sickle Pathology PMN Induced Ischemic Endothelial Damage NO Reticulocyte Adherence Integrin vwf VCAM TNF IL-1 Thrombosis Mechanical Obstruction

10 NO and Thrombosis NO binds to Free Hgb/Arginine destroyed by Arginase Vasodilator Inhibits Platelet Adhesion Decrease Endothelial Adhesion Molecules Inflammatory Activation of Endothelium Decreased Release of Vasoconstrictors Decreased Tissue Factor Expression

11 Causes of VOC in Sickle Cell Dehydration Fluids (duh!) ETOH Illness Travel Infection / Inflammation Hypoxia??? (not sleep apnea) Local Problems Increased Time in distal circulation CHF, viscosity, RBC rigidity, Hemoglobin level Hemolysis Acidemia Psycho-social

12 Phenotypic Variability All Begin with Same Mutation (SS = SB 0 ) Alpha Thalassemia Haplotype Fetal Hgb (? >5%) interfere with polymerization dilution? Haplotype Dependence?? Other Polymorphisms NO metabolism

13 Chronic Pain In Sickle Cell Structural AVN Old Infarctions Neuropathic Chronic Pain related Sickle Cell Related Inflammation Related Analgesia related Behavioral/Learned Patient Physician Non-Sickle Cell

14 Pain Management in SSD Acute vs. Chronic Pain Avoid Undertreatment and SLOW Tx No Demerol, IV Benedryl PCA? Ancillary meds NSAID, Sedatives/Sleeper, Tylenol, Lido Patch IV to Equi-analgesic PO Expect 2-5 days?precipitant if longer Transfusions??

15 Case #2 23yo AA male with well-known SS Disease Frequent VOC with prolonged admissions Hx of incarceration for drug offenses Now c/o calf/leg pain, chest pain and malaise Nothing different to precipitate usual attack PE: VS stable Lungs clear, Cardiac normal Calf tenderness

16 Case #2 Hgb 7.5 Retic Count 280 WBC 20,000 70% PMN, 10% Bands Day 2, Calf and Chest pain worsen, RR 26, Temp 38 Utz Reveals popliteal DVT

17 Question #2 What Should We Do Now? 1. Improve pain management, consider sedatives and anti-depressants 2. Look for the serious CT angio, culture/rx for pneumonia 3. Time will tell-take a deep breath and suggest patient do the same 4. This is Acute Chest, start treatment now

18 Question #2 What Should We Do Now? 1. Improve pain management, consider sedatives and anti-depressants 2. Look for the serious CT angio, culture for pneumonia 3. Time will tell-take a deep breath and suggest patient do the same 4. This is Acute Chest, start treatment now

19 Case #2 Venous Utz + for popliteal DVT>>>Lovenox With trepidation Chest pain worsens, RR 26, Temp 38 High Res CT negative for PE but infiltrates Ceftriaxone, Fluids, Aggressive O 2, Exchange Transfusion considered 2 Hours Later, Pulmonary status worsens MOSF Pt Dies 2 hours later after unsuccessful Code

20 Death in SSD Median Age at Death= % of patients will die within 24hrs of admission, usu. presenting with pain Infection Acute Chest Thrombosis Renal Failure Pulmonary HTN

21 What Causes Sickling? Deoxygenation Acidosis Inflammation No GCSF Slow Flow Increased MCHC Dehydration

22 Acute Chest Physiology

23 Acute Chest Physiology Sickling NO depletion Inflammation local systemic Endothelial Activation spla 2 Paul, R; Euro J of Haem 87 ( )

24 Acute Chest Syndrome Dx: Chest Pain-may be chest wall Role of rib infarction? Fever Cough/ Wheezing Hypoxia One of These CXR nl in 30% initially Often follows VOC Occ. Falling hgb High Index of Suspicion >50% missed clinically Because of catastrophic severity (10% Adults Die)

25 Vichinsky, E. P. et al. NEJM 2000;342:

26 Fat Emboli Inflammation Occlusion Sickling / Occlusion Hypoxia Inflammation Infection Thromboembolic Difficult to evaluate Etiology of ACS

27 Risk Factors for ACS Younger Age for occurrence/ older for Cx SS or S-beta 0 AVN Previous Hx of pulmonary events High Hemoglobin High PMN Low Hgb F?Secretary PhospholipaseA 2

28 Risk Factors for Bad Outcome Age Pre-existing heart failure/ renal failure Multi-lobe or effusion Platelet count <200,000 Neurologic event Fever?

29 ACS Treatment Antibiotics (Strep, H. flu, Mycoplasma, Chlamydia ) Oxygen 13% on ventilators/ 80% recover Bronchodilators (20% w/o wheezing had improvement) Fluid (carefully) Analgesia Exchange Transfusion Simple Tx if Hct <30 at end?? Exchange if acute, target Hgb SS<30% 5-10% will die overall 7x RR of CVA during next 2 weeks (role of fat emboli?)

30 O 2 Delivery vs. Hgb Oxygen Delivery SS Nl 2 nd Polycythemia Hemoglobin

31 Role of Exchange Transfusion Acute Transfusion Therapy ACS CVA MOSF RUQ Syndrome Priapism Major Surg w/ Comorbidities Chronic Exchange Transfusions Recurrent ACS CVA Leg Ulcers Hypoxia??Pain

32 Question #3 Pt with acute chest, exchange transfused. 3d later with fever, worsening pain, anemia. What now? 1. Fever in splenectomized pt, begin broadspectrum Abx 2. Work-up for a transfusion reaction 3. Repeat exchange transfusion 4. Fever, pain, anemia >>worsening sickle VOC

33 Question #3 Pt with acute chest, exchange transfused. 3d later with fever, worsening pain, anemia. What now? 1. Fever in splenectomized pt, begin broadspectrum Abx 2. Work-up for a transfusion reaction 3. Repeat exchange transfusion 4. Fever, pain, anemia >>worsening sickle VOC

34 Delayed Transfusion Rxn 30-50% SS pts with alloab, 4-8% DHTRs Crude estimate 0.1% of non-ssd recipients HLA, Chronic inflammation Caucasian Donors (antigens E, C, Kell, Fya, Fyb, and Jkb) Presentation (VOC) Drop in Hct 3-20d after transfusion Increase in Hgb A in SSD Reticulocytopenia or Reticulocytosis (hyperhemolysis) LDH, Bili increased often, DIC in severe cases Positive DAT? / Crossmatch? Initial negative DAT in some Subsequent negative DAT if donor cells destroyed 34

35 Autoimmune Hemolysis post-tx DAT Positive (Like Delayed Tx Reaction) Often missed 10% Sickle Cell Patients I m worse than before the transfusion Often with VOC, etc Increased risk with increased transfusion burden May persist for 4-6 mo after Transfusion??Bystander, immune dysregulation Complement Activation?

36 Question #4 Sickle Cell Pt with VOC: WBC 18, Stable Hgb-7.5, LDH-300, Bili 2.3. What now? 1. Usual- fluids, O 2, IV Dilaudid 2. Begin Antibiotics for possible infection 3. Should have been sent home from the ER 4. I won t answer without a retic count

37 Evaluating Hemolysis The Bucket with The Hole

38 Evaluating Hemolysis The Bucket with The Hole

39 Aplastic Crisis Cherchez le tics Parvovirus B19 Infection Drug Chronic Disease Anemia All the usual causes of marrow failure folate, B12 Myeloma if older Etc.

40 An Approach to Anemia Anemia Retic Hi Retic Low MCV Lo MCV Nl MCV Hi

41 An Approach to Anemia Anemia Retic Hi Retic Low Loss Destruction MCV Lo MCV Nl MCV Hi Tissue On Floor Occult Intrinsic Extrinsic Splenic Mechanical Recovery Iron (Lead) Thal Frags Chronic Disease Renal Mixed Mild/Treated Early Transfused Endocrine Intrinsic BM Dilution B12 Folate Liver ETOH Thyroid Toxic MDS

42 Retic Hi Anemia Retic Low Loss Destruction MCV Lo MCV Nl MCV Hi Tissue On Floor Occult Intrinsic Hgb opathy Enzymopathy Membrane HS PNH Extrinsic Splenic Mechanical Recovery An Approach to Anemia

43 Retic Hi Anemia Retic Low Loss Destruction MCV Lo MCV Nl MCV Hi Tissue Intrinsic On Floor Extrinsic Occult AIHA Recovery cold warm Drug/Toxins Sepsis Burns Splenic/Hepatic Mechanical MAHA

44 Hydroxyurea Increases Hgb F production Recovery from cytotoxicity? Anti-inflammatory Effects? NO production? Decreased VOC, Acute Chest, Transfusions In 60% Why variable response? 40% Decreased Mortality S/E Cytopenias Rash Hepatotoxicity

45 Erythropoietin Small further increase Hgb F Increased Hgb in anemic Inappropriately low epo levels in SSD Renal failure CDA

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