Chest diseases Hospital Hematology Patient care plans Hematology Service in CDH in a consultation service for management of hematologic complications of cardiology/ cardiac surgery. Primary hematologic diseases are not diagnosed or treated in CDH. Patients are admitted in CDH for having a procedure or surgery which may need clearance from the hematology side. Evaluating the patient preoperatively is performed by the Surgeon/Anesthesiologist in charge. Hematologist play a role when the pre-operative hematology laboratory tests shows abnormalities which can affect patient outcome. Chronic cases ( e.g. chronic anemia, chronic thrombocytopenia are referred to their area hospital for detailed diagnosis, treatment and after correction sent to CDH cleared for the procedure/ surgery ) Patient who are candidates for urgent procedures/ surgeries & have hematologic problem are referred to the hematologist. Hematologist should asses the patient by history taking, clinical examination and further testing according to the results of the pre-operative tests. In emergency situation, where the patient requires urgent procedures, hematologist can be contacted by phone if required. Assessment of anemia: Ø Preoperative anemia should be properly diagnosed & managed in relation to the degree of urgency of the operation. Ø Anemia diagnosis and management is mainly based on classification according to RBCs indices and morphology on peripheral smear examination into : Microcytic hypochromic anemia which is mainly either iron deficiency anemia or Thalassemia. Normocytic normochromic anaemia which is mostly either hemorrhagic, hemolytic or secondary to chronic disease,rarely due to double deficiency. Macrocytic anemia mostly secondary to hypoproliferative marrow whether primary or secondry to vitaminb12 &/or Folate deficiency.
anemia care plan Urgent procedure Elective procedure Permissible HB HB 8-10gm/dl Type of anemia Threshold>/=10g/dl PRBCs Transfusion According to MCV,MCH MCV,MCH N MCV,MCH MCV Iron profile,serum ferritin & HB electrophoresis Smear Retics B12 Folate smear- Retics Thalassemia trait Iron deficiency DAT IAT RFT Iron supplements TFT &GI Consult Collagen screen LFT treatment is for the primary disease replacement therapy
Ø Preoperative sickling test & G6PD are usually requested by the surgeon in the last OPD visit, Positive tests should be confirmed by a further confirmatory & quantitative test. Ø Partial exchange transfusion is advised in sickle cell anemia to reduce HB S to < 30 % & keep HB >10 gm/dl. Ø Avoiding drugs that deteriorates the condition is clearly documented, with requesting substitute. Assessment of thrombocytopenia: Minimun platelet count can be accepted as a permissible ceiteria differs according to the procedure needed as follows in table 1 : Table1: permissive platelet count in relation to the procedure Procedure name Cardiac surgery Coronary angio/pci Central line placement Endoscopy ( without biopsy) Endoscopy ( biopsy) Lumber puncture Gastroscopy (biopsy) Permissive platelet count 50-70.000/Ul ( practice) 50.000/Ul 20.000/Ul 20.000/Ul 50.000/Ul 50.000/Ul 50.000/Ul If the surgery/ procedure is elective, patient has to be referred to area hospital for further diagnosis& treatment. If the surgery is urgent patients can be sent to OR ( considering that the other screening coagulation parameters are normal) after ensuring adequate platelet stock for probable transfusion. All thrombocytopenic patients,who had previous exposure to unfractionated heparin or Clexane HIT should be ruled out by clinical assessment ( 4T score ) or HIT serology. Special consideration is also given to postoperative drugs needed like postoperative antiplatelet drugs needed. Thrombocytopenia is a frequent complication that occurs to the hospitalized patients & specially tocdh patients. Treating physician usually sends a written request to the on call hematologist for proper diagnosis & further management. The hematologist follows the thrombocytopenia care plan as follows:
Thrombocytopenia care plan False ( Platelet clumps ) Request another properly collected samples True Thrombocytopenia EDTA R/O Bad sampling Citrate R/O EDTA induced clumps Check smear for Blast or immature cells Usually at admission Fragmented RBCs (v. rare) shift to left toxic changes Search for organomegaly Refer to KCC Order : Haptoglobin LFT Urine urobilinogen Septic screen Hypersegmented neutrophils & macrocytosis serum B12 & red cell folate and replacement therapy Ø If all are negative, drug history is reviewed & suspected drug is to be discontinued.
If HIT is suspected, 4T score calculated & heparin is discontinued & replaced with non heparin anticoagulant if a high score is obtained (6-8) Ø If all are negative, presentation is acute & patient had received blood within the last 2 weeks, Posttransfusion purpura is suspected, tested for & if confirmed I/V Ig & corticosteroids are to be started if platelet count is less than 30.000/ml. Ø Chronic cases are usually diagnosed and treated in their area hospitals & when admitted in CDH, hematologist only follow up the treatment plan scheduled for him. Assessment of erthrocytosis: Ø Patients with a raised venous haematocrit (Hct) (>52 % in males, >48% females) are referred to hematology. The recommendation will be : proper hydration, D/C diuretics ( after cardiologist/nephro approval). Ø If still not corrected : venesection is advised to reach a target of 45%. The volume removed should be commensurate with the patient s size and comorbidities. Ø Venesection is done by the ward nurse under supervision of the treating physician. Ø Patients with a congenital cyanotic heart disease, develop secondary polycythemia to their cyanosis, the haematocrit may reach levels greater than 65% and symptoms of hyperviscosity usually develop at higher cutoff. Venesection is usually advised on bases of symptoms together with the hematocrit level. Assessment of Neutropenia/neutrophelia: Cases of neutropenia ( ANC < 500/UL) to diagnose the cause of neutropenia & advices to cover the procedure by antibiotic if a benign chronic cause is suspected after reviewing the peripheral smear. Cases of leucocytosis ( WBCs >30.000/UL ) after smear review, if a hematologic malignancy is suspected, patient is to be referred to KCC and cleared from his hematologic oncologist. Assessment coagulation condition: Ideally, INR & aptt ratio are to be within the range of 1:0 to 1.3(each).In urgent conditions if INR is >1.4 & aptt >40 seconds, FFp transfusion in the dose of 15 ml /kg is given 4 hours before surgery & reassess pt/inr & aptt just before surgery. In more elective condition, the prolongation of the clotting time should be investigated, cause defined & treated. Clearance for urgent procedures :
There are many bedside procedures done during the patient stay in CDH, some of them need hematologic clearance. The decision varies when the patient is on anticoagulant/antiplatelet drugs, where he has to be evaluated bearing in the benefits & and risks of stopping/continuing the drug as follows :( considering the risk of the procedure is the bleeding risk, while the risk of the condition is the thrombotic risk that necessitates the anticoagulant/antiplatelet therapy) 1. Low risk procedure in a patient with high or low risk condition : a) Warfarin is kept, INR is kept therapeutic ( less than 3) b) Full dose antiplatelet therapy( Plavix) to be continued. 2. High risk procedures, low risk conditions ( bridging unnecessary): a) Warfarin to be stopped 5 days before the procedure ( INR should be less than 1.5) b) Warfarin to be restarted on the evening of the procedure in the usual daily dose. c) Plavix to be stopped 7 days before the procedure. d) Aspirin to be continued if already prescribed. If the patient was not on aspirin, aspirin can cover the period of plavix discontinuation. 3. High risk procedure,high risk condition ( bridging required) a) Warfarin to be stopped 5 days before the procedure. b) Bridging with LMWH (therapeutic dose ) to be started 2 days after discontinuing warfarin. Omit LMWH on the day of the procedure. c) Warfarin is to be restarted on the night of the procedure in the same dose. LMWH is to be continued till INR is therapeutic. d) Plavix is to be discontinued 7 days befor the procedure ( after cardiologist approval, if 6 months post DES placement/ or six weeks of BMS placement). Plavix is to be restarted the day after the procedure. Low risk procedures ( bleeding risk less than 1%) Central Venous line placement, IVC filter,tooth extraction, upper & lower GI endoscopy ( with biopsy),swan ganz catheter, arterial line, IABP, peritoneal aspiration,pericardiocentesis,tracheostomy,coronary angiography Ø Warfarin is kept with a target INR of 2.5. Ø Full-dose antiplatelet therapy (e.g., Plavix) to be continued through these procedures. High risk procedures ( bleeding risk more than 1%) Cardiac catherterization,pci, cardiac ablation,pacemaker placement, Transbronchial biopsy, arterial puncture, Lumber puncture, Ø low individual risk for thrombosis, anticoagulation can be interrupted without bridging therapy (heparin). Ø Most patients at high individual risk of thrombosis should receive bridging anticoagulation therapy.
Bridging therapy ( For patients used to take warfarin) is strongly recommended for people with: DVT or PE within the past 3 months or severe thrombophilia. Mechanical mitral valves. "Old" design mechanical aortic valves (caged-ball or tilting-disk design, i.e., nonbileaflet). Any mechanical valve with a history of stroke or transient ischemic attack, Non-valvular atrial fibrillation with a CHADS2 score 4 or greater. history of stroke or TIA, or cardiac thrombus. Low risk condition ( for thrombosis) 1.Metal valave in the Aortic position. 2.Tissue heart valve. 3. AF without valve disease 4.DVT after first 3 months of therapy 5.thromboembolism 1.Warfarin to be stopped 5 days before the procedure, INR should reach 1.5 before the procedure 2.Warfarin to be restarted within 24 hours High risk condition 1.Metal valve in the mitral position. 2.AF and any type of prothetic valve 3.AF with Mitral stenosis. 4.AF withvalvular heart disease ( surgically corrected or not) 5.AF with any of: thromboembolic disease, LVF ( EF less than 35%) hypercoagulable disease, DM, HTN, age more than 75 years 6.Recently Placed Coronary stent ( less than 1 year) 7. Acute Coronary Syndrome. 8. Mechanical valve with H/O thromboembolic disease. 9.Recent conversion of AF 10. First 3 months of treating DVT/PE 11. thrombophelic syndrome 1, Warfarin to be stopped 5 days before the procedure. 2. When INR less than 2, LMWH to be started 3. LMWH to be omitted4-6 hours before the procedure. 4. LMWH to be restarted after the procedure. 5.Warfarin to be started at the evening of the procedure. 3.LMWH to be continued till warfarin is
therapeutic. Patients on NOAC ( Dabigatran or rivaroxaban ) usually have non valvular AF, drug should be discontinued 2-3 days before the procedure/ surgery & restarted 2-3 days after the procedure / surgery, without bridging. Low dose LMWH( 0.4 mgod ) can be used postop till reinitiation of the drug. References: 1. Transfusion guidelines : when to transfuse : 2013 ; Szczepiorkowski &Dunbar, Transfusion Medicine 638-644 ( ASH Guidelines) 2. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients : 2013 : Retter et al.,british Journal of Hematology,160,445-464 3. Guidelines for the diagnosis, investigation and management of polycythaemia/erythrocytosis:2005: British Journal of Haematology, 130, 174 195 4. UpToDate 2014: Clinical & laboratory aspects of platelet transfusion therapy: http://www.uptodate.com/contents/clinical-and-laboratory-aspects-of-platelet-transfusiontherapy 5. Red Blood cell transfusion : A Clinical Practice guidelines from AABB : 2012: Carson et al., Annals of Internal Medicine,49-58 (American College of Physicians). 6. Recommendation for the transfusion of red cells :2009: Liumbruno etal., Blood Transfus :7:49-64 7. Evidence based Platelet Transfusion :2007, Slichter, Transfusion Medicine : 172-178 8. Australian Medical Association guidelines on Patient examination 1996. Revised 2012 9. The ACCP 9th edition clinical practice guidelines for prevention and treatment of venous thromboembolism,perioperative management of antithrombotic therapy 2012