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Hematologic Disorders in the ICU

Hematologic Disorders in the ICU. Bradley J. Phillips, M.D. Burn-Trauma-ICU Adults & Pediatrics. CASE # 1. 78 yom with rest pain R foot, ABI’s L 0.6, R 0.25 PMH - PVD, COPD, HTN, ? Cirrhosis (EtOH) PSH - R CEA ‘97, R 1st Toe Amp ‘98 Meds - Trental, Spirolactone, Inhalers

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Hematologic Disorders in the ICU

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  1. Hematologic Disorders in the ICU Bradley J. Phillips, M.D. Burn-Trauma-ICU Adults & Pediatrics

  2. CASE # 1 • 78 yom with rest pain R foot, ABI’s L 0.6, R 0.25 • PMH - PVD, COPD, HTN, ? Cirrhosis (EtOH) • PSH - R CEA ‘97, R 1st Toe Amp ‘98 • Meds - Trental, Spirolactone, Inhalers • SH - EtOH quit ‘90, Smoker 50 pk yrs. quit ‘95 • PE - ruddy complexion, L CEA scar, distant BS, mildly distended abd, R foot cool • Pulses 1+ R fem, doppler only R Pop/DT/PT

  3. CASE # 1 • Angiogram - severe plaque R ext iliac, occluded SFA, patent AK popliteal artery with marginal runoff via posterior tibia artery • Labs - Plts 100K, Hct 30, INR 1.4, PTT 40, Tbil 2.1 • OR - exploration of R iliac with endarterectomy, femoral to AK popliteal bypass with reversed vein • Blood Loss (intraop) 3 liters, given 6 units PRBC • Postop - transferred to ICU, pulmonary toilet, heparin qtt for graft patency

  4. CASE # 1 • Uneventful recovery until day 5, plt count dropped to 60 K, then 30 K the next day • Developed protracted bleeding from venopuncture sites and mild hematuria • HO transfused 6 units plts, but bleeding continued • ? Cause of hemorrhage ? • ? Evaluation (ie. exam, labs) ? • ? Plan of treatment ?

  5. CASE # 1 • Plan • Coagulation studies • R/O DIC • Exclude excessive anticoagulation with heparin • LFT’s - R/O worsening liver dysfunction • R/O Sepsis • Blood cultures • ? Broad-spectrum antibiotics • R/O drug reaction • ? Dilutional or consumptional thrombocytopenia • ? Bone marrow aspiration

  6. Case # 1 - Workup • Blood smear - thrombocytopenia, no fragmentation RBC • Coags - PTT 13 s, PTT 50 s, FDP < 4 mg/l • LFT’s - no significant changes from pre-op • Blood cultures draw - initial read negative • DX : HIT confirmed by heparin antibody

  7. Hemostasis Liver Disease Decreased and abnormal proteinsIntravascular consumption of factors Delayed clearance of activated products Nature of Abnormalities Underlying liver disease Severity of disease Speed of onset of impairment Liver Minimal generation of thrombin and plasmin Endothelium Bone Marrow

  8. Causes (Common) Lab error - clumping secondary to EDTA in test tube, need smear to exam Sepsis Peripherial consumption Dilutional Disseminated intravascular coagulation (DIC) Causes (Uncommon) Liver Disease Hypersplenism Bone marrow failure Drugs ( ie heparin, immunosuppressives, antibiotics) Viruses Rare diseases in surgical patients (TTP, ITP) Thrombocytopenia (ICU)

  9. DIC • Intravascular thrombin generated leads to consumption of both coagulation factors and platelets with secondary fibrinolysis releasing fibrin degradation products • Severe thrombocytopenia, coagulopathy

  10. Increased Tissue Factor Injured tissue trauma tissue necrosis burns Stimulated monocytes or endothelial cells endotoxin cell wall polysaccharides immune complexes Endothelial sloughing from acidosis ( pH < 7.2 , fully heparinized blood clots) Thrombogenic Phospholipids Obstetric disorders abruptio placentae eclampsia amniotic fluid embolism Intravascular hemolysis transfusion reactions infections Ascitic fluid Leveen or Denver shunts DIC - Etiology

  11. Bleeding More pronounced in liver disease Wound bleeding Waterhouse-Friderichsen Syndrome Thrombosis (microvascular) Organs at risk Lungs (ARDS) Kidneys (ARF) Liver Cardiac (MI) Brain (stroke) Purpura fulminans gangrene of digits or skin necrosis Clinical Presentation

  12. DIC – Lab Findings • Lab findings • Procoagulant and fibrinolytic activation • Reduced protein C and S activity • Fibrin degradation products (FDP) • Biochemical evidence of end organ dysfunction • Low-grade DIC - near normal labs • Trousseau’s syndrome • Subacute bleeding (qualitative platelet defect from FDP)

  13. DIC • Laboratory findings • Fribinolysis • FDP - measures fibrinogen and fibrin ( 85-100%) • D-dimer - measures plasmin degradation of cross-linked fibrin only ( 90%) • PT (unreliable) - prolonged in 50 - 75% • PTT (unreliable) - prolonged in 50% • Platelets usually low • Blood smear (schistocytes)

  14. DIC • Management • Identify and treat underlying condition • Supportive care • If condition rapidly reversible, watch and wait, use FFP and platelets as needed • Stop microvascular thrombosis • consider heparin, tPA, or urokinase • surgical intact vascular system • actual or potentially serious bleeding or clotting • Not rapidly reversible • Control bleeding, use FFP and platelets as needed

  15. Heparin Induced Thrombocytopenia (HIT) • Heparin-dependent IgG antibodies which bind platelet-bound heparin through specific antigen binding • Antibody Fc region then either binds complement or receptor on platelet membrance causing platelet activation and in vivo aggregation, in some causing thrombus formation • Thrombocytopenia >> thrombosis • Thrombosis = higher mortality • Incidence 0.5 to 5.0 %

  16. HIT - Diagnosis • Seen 5-12 days or more after treatment • Not dose-dependent, increased risk with length of treatment • Platelet count < 100 K • Diagnosis • follow platelet count daily 3-5 days • in vitro platelet aggregation studies (heparin antibody)

  17. HIT - Treatment • Treatment • Stop heparin • Danaparoid - immediate anticoagulant • cross reacts with plt factor 4 in 10% of cases • Ancrod - snake venom enzyme • no cross-reactivity, take 12 hours to onset • contraindicated in sepsis and DIC

  18. CASE # 2 • 46 yom motorcyle vs car, + EtOH • Hypotension in the field BP 90/P • Arrival to trauma bay • Airway patent, Breath sounds ok (RR 22) • BP 90/P, HR 110 • Alert and oriented • Given 2L of saline, BP 95/P • Complaining of L sided abdominal pain • FAST - positive fluid LUQ • OR - exploratory lap, 1.5 L of blood, shattered spleen, omental bleeding, liver laceration L lat lobe

  19. CASE # 2 • Perform splenectomy, controlled bleeding, repair liver lac, place JP under L liver lobe, EBL 4 L • Given intraop - 10 u PRBC, 3 FFP • Transferred to SICU, Hgb 10, P 76, BP 120/75 • Blood stain fluid from liver bed JP drain, next 3 hrs 400 cc • Pulse gradually increased to 110, BP 100/60 despite 2 u PRBC • Labs • Hgb 8.0, PT 32 sec, PTT 65 sec, Platelets 70K • ? Plan ?

  20. CASE # 2 • Blood products given • 10 U FFP • 2 U PRBC • Two hours • 450 ml of blood-stained fluid from abdominal drain • ? Etiology of Bleeding ? • ? Plan ?

  21. CASE # 2 • Further coagulation test ordered • Patient reexamined • Labs • Hgb 8.0, PT 17, PTT 42, FDP 4, Plt 84K • Cr 1.7, BUN 32 • ? PLAN ?

  22. CASE # 2 • Given • 10 U FFP • 6 U Cryoprecipitate • 6 U Platelets • 2 u PRBC • Continued bleeding from abdominal drain • ? PLAN ?

  23. Evaluation and Management • First step • Resuscitation and establish cause of bleeding • Blood volume should be increased to maintain tissue perfusion, rather than a normal hemoglobin concentration • Hgb useful as an index of hemorrhage as some blood loss may be concealed

  24. Etiology • Surgical Cause (missed injury, local hemostatic failure) • Acquired disorder of hemostasis • Drugs ( ie. ASA, heparin flushes) • Uremia • Dilutional effect ( massive blood loss or transfusion) • Consumption (sepsis or poor tissue perfusion) • Anemia • DIC • Liver disease • Pre-existing herditary hemorrhagic disorder • Mild hemophilia (Christmas factor) • von Willebrand;s disease • variety of platelet defects

  25. CASE # 2 • Bleeding is prolonged by anemia • progressive anemia may contribute to the bleeding tendency • ? Related to platelet-endothelial interaction at high shear rates with less interaction at low hematocrits • No clinical evidence of pre-existing coagulapathy • No drugs given to impair hemostasis • Protracted bleeding from isolated site - no bleeding at venipuncture sites, ET tube, abdominal wound • Mild coagulopathy documented with prolongation of PT and PTT but corrected with FFP • DX: Surgical bleeding, re-exploration revealed 2 L of blood, bleeding short gastric artery

  26. CASE # 3 • 53 yof with a three -year h/o menorrhagia admitted for elected TAH • On admission her Hgb was 9.0 with MCV 75 • She was taken FeSO4 200 mg/d but no other medications • No significant PMH • Three healthy children • In view of her anemia, her OB/GYN postponed her surgery and transfused her 3 u PRBC

  27. Case # 3 • On the day of surgery, she was found to be unwell, T 39.0 , pulse 105 and BP 105/60. • On PE no apparent vaginal blood loss or hemorrhage elsewhere • IVF were started and patient transferred to SICU where she was noted to have macroscopic hematuria

  28. CASE # 3 • Given 1.5 L of saline, HR 90, BP 115/60 • LAB’s • Hgb 6.2, normal PT and PTT • Creatinine 1.2 • Urology was consulted for cystoscopy • 4 U of PRBC were cross-matched for transfusion, but two where found incompatible and the cystoscopy was cancelled • ? DX ? • ? Incidence ?

  29. CASE # 3 • DX - delayed hemolytic transfusion reaction with intravascular hemolysis causing hemoglobinuria • Blood sample should be taken • direct coomb’s • determination of specificity of the antibody for incompatibility • serum bilirubin • Moderate hypochromic anemia on admission likely result of iron deficiency

  30. Indications for Transfusions • Hemoglobin concentration is a determinant of arterial oxygen concentration • CaO2 = HGB x O2 sat x 1.34 + PaO2 x 0.0031 • RBC infusion used to improve oxygen delivery • DO2 = CI x CaO2 x 10 • Animal experiments show that tissue oxygen extraction is maintained with an 80% reduction in red cell mass, so long as blood volume and blood flow are maintained

  31. Indications for Transfusions • In critical ill patients impaired tissue oxygen extraction may occur and red cell transfusion may not result in any improvement in tissue oxygen metabolism • Traditionally, patient for elective surgery transfused for Hgb< 10, Now data shows no difference in mortality if Hgb > 7 if euvolemic

  32. Infectious Hepatitis A Rare Hepatitis B 1/100,000 Hepatitis C 1/120,000 HIV 1/1,000,000 Creutzfeld-Jacob none CMV 1/4,000,000 Bacterial 1/1,000,000 Syhillis Rare Non-infectious Fever 1-2% Urticaria 1% Hemolytic 1/6000 Fatal hemolytic 1/100,000 Risks of Transfusion of RBC

  33. Hemolytic Transfusion Reaction • Signs and symptoms • fever, chills, headache, chest pain, anxiety, respiratory distress • Laboratory results • free Hgb in plasma • Hemoglobinuria • Decreased haptoglobin • Increased creatinine and ARF ( lysis of RBC membranes in golmerulus) • Fatal transfusion reactions are usually secondary to clerical error that results in giving the wrong blood to a particular patient

  34. Questions…?

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