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HAEMATOLOGY IN THE ICU Bryony Ross3/8/2010
Topics
Anaemia Thrombocytopaenia
DIC/TTP/HUS HITTS
– Blood products and their use Selected Recombinant products
Coagulation Interpretation of investigations Common causes of deranged coags
Tips and tricks A few quick notes on malignant
haematology
Anaemia
Develops in almost all patients in ICU for prolonged periods
Patients on mechanical ventilation receive ~75% of all red cell transfusions Usually multifactorial
erythropoietin production and blunted response
Bleeding Frequent phlebotomy
Anaemia – investigation of cause Simply,
production loss destruction of red cells
Exclude ongoing bleeding in surgical and trauma patients
Consider haemolysis Particularly in the transfused patient
(transfusion associated haemolysis) Bilirubin, reticulocyte count, LDH,
haptoglobins, characteristic blood film
Thrombocytopaenia
Plt count <100 ~40% of ICU patients
Plt count <50 ~ 10-20% of ICU patients
EXTENSIVE causes Again, usually multifactorial
Thrombocytopaenia – pt evaluation History of prior thrombocytopaenia and
setting in which it occurred Underlying marrow disease and
preexisting morbidities that can induce chronic thrombocytopaenia Liver disease (and Etoh intake) Neoplasia ITP Massive transfusion Medications
The blood film
EDTA clumping (pseudothrombocytopaenia) Exclude by repeating test with citrate tube
(note: can’t be added on if coags have already been performed on the sample)
Schistocytes underlying
thrombotic microangiopathy
TTP/HUS/DIC MAHA
Poikilocytes or nucleated RBC Myelophthisic
process (severe sepsis, MF, metastatic ca)
Abnormal leukocytes Malignancy,
myelodysplasia, or syndrome of congenital thrombocytopaenia
Thrombocytopaenia - infection Common in critically unwell patients
DIC “Endothelial damage syndrome” – eg
meningococcus, pneumococcus Platelets clump and block capillaries and platelet
consumption Enhanced clearance of platelets coated by
antiplatelet antibodies or nonspecifically bound immunoglobulin
Accelerated platelet phagocytosis induced by concentrations of macrophage colony-stimulating factor
Infection of bone marrow stromal cells and megakaryocytes with viruses
Treat underlying infection and plt transfusion Aim for plt count 15-20
Thrombocytopaenia – massive transfusion
Transfusion of more that 15-20 units of RBC can lead to dilutional thrombocytopaenia
Platelets still functionally normal Hypothermia, platelet dysfunction and
dilutional coagulopathy (if not properly treated) will also lead to bleeding in the massively transfused patient.
Levy JH. Massive transfusion coagulopathy. Sem Hematol.2006;43:S59–63.
Drug induced thrombocytopaenia Diagnosis of exclusion – need temporal
relationship, usually resolves about 7-10 days after cessation of drug
heparin – discuss separately Variety of mechanisms Usual offenders
trimethoprim/sulfamethoxazole, beta-lactam antibiotics (timentin), vancomycin, cephalothin, carbamazepine, hydrochlorothiazide, nonsteroidal antiinflammatory drugs, phenytoin, procainamide, quinidine and quinine, rifampin, sulfasalazine, sulfonylureas, and valproic acid.
Heparin induced thrombocytopaenia Most common cause of drug-induced,
antibody-mediated thrombocytopaenia 1-2 % of pts on heparin with develop
isolated thrombocytopania (HIT) In ~30 of those patients,
thrombocytopaenia is accompanied by thrombosis (HITT) Both conditions are 5-10 times more likely in
patients treated with UFH vs LMWH Neither condition has been reported with
fondaparinux
HITT
Clinical diagnosis Consider in patients with an otherwise
unexplained fall in plt count of at least 50% occurring 5-14 days after starting heparin NOTE: with recent heparin exposure (within the
preceding 3-6 months, HITT can occur within a much shorter timeframe (median 10.5 hours)
HIT should be considered in the differential diagnosis of patients with new or recurrent venous or arterial thromboembolism that develops during or shortly after exposure to heparin.
HITT
Several HITT screening questionnaires available, which indicate the pre-test probability prior to blood investigations (ask the Haem reg) Pre-test probability is extremely important when
interpreting results ie. Please don’t order this test without talking to us
HITT
Thrombocytopaenia is the lesser concern Bleeding is very uncommon
Thrombosis is often severe and life-threatening Venous thrombi more common except in pts with
underlying arterial vascular disease Mortality ~20% Limb amputation ~10%
50% of patients will develop thrombosis on cession of heparin if alternate anticoagulation is not initiated
HITT
HITT screen Immunologic measurement of antibodies against
heparin-PF4 complexes or the ability of such antibodies to activate platelets
Alternate anticoagulation Lepirudin
Intravenous infusion, Monitored using APTT Cease warfarin (associated with worsening venous
thrombosis, venous limb gangrene, and/or skin necrosis) Talk to Haematology
Warkentin TE. An overview of heparin-induced thrombocytopenia syndrome. Sem Thromb Haemost. 2004;30:273–83
Aster RH. Drug-induced immune cytopenias. Toxicology.2005;209:149–53.Warkentin TE, Kelton JG. A 14-year study of heparin-induced thrombocytopenia. Am J
Med. 1996;101:502–7.Warkentin TE, Kelton JG. Temporal aspects of heparin-induced thrombocytopenia. N
Engl J Med. 2001;344:1286–92.
Thrombocytopaenia – TTP/HUS TTP and HUS
Thrombotic microangiopathies associated with microangiopathic haemolytic anaemia and thrombocytopaenia Both can be associated with neurologic
abnormalities, renal dysfunction and fever TTP usually has incidence of neurologic
manifestations HUS usually has incidence of renal dysfunction Generally, microangiopathic haemolytic anaemia
and thrombocytopaenia without another apparent cause is sufficient criteria to start treatment
HUS
2 main variants Most common is following VTEC with abdominal
pain and bloody diarrhea ~ 20% of patients progress to HUS and ARF
within 5-6 days Most common in paediatrics and in epidemics Second is in post-partum period
Also familial form associated with deficiency of complement factor H
HUS not usually associated with ADAMTS13 Does not respond as well to plasma
exchange
TTP
Pathogenesis unclear, likely involves deficiency of vWF-cleaving protease (ADAMTS13) leading to in ultra-large vWF multimers that bind to platelets and induced agglutination
ADAMTS13 deficiency is most often due to antibodies against the protease
HAPS is the only lab in NSW that offers ADAMTS13 testing
However, ADAMTS13 can also occur in liver disease, pregnancy and DIC Levels in these conditions are usually about 5%
and levels below this range appear to have high specificity for TTP
TTP
Fatal in >90% of cases if untreated Plasma exchange induces remission in ~85% of
patients Corticosteroids controversial ~30% of cases will relapse within 12 months, and
some pts relapse multiple time Splenectomy can be useful to relapse Rituximab can be used for refractory cases
George JN. How I treat patients with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. Blood.2000;96:1223–9.
McCrae KR, Sadler JE, Cines DB. Thrombotic thrombocytopenic purpura and the hemolytic uremic syndrome. In: Hoffman R, Benz EJ Jr, Shattil SJ, et al., eds. Hematology: Basic Principles and Practice. Philadelphia: Elsevier, Churchill, Livingstone; 2005:2287–304.
Sadler JE, Moake JL, Miyata T, et al. Recent advances in thromboticthrombocytopenic purpura. Hematology: ASH Education Program Book. Washington DC: American Society of Hematology; 2004:407–23.
Thrombocytopaenia – catastrophic antiphospholipid antibody syndrome Rare Characterized by multiorgan involvement
by microthrombi and thrombocytopaenia Only 15% have shistocytes on film Guidelines for diagnosis
Lupus anticoagulant +/- antiphospholipid antibodies
Involvement of 3 or more organs Development of manifestations within 1 week
or less Confirmation of histopathology of small vessel
occlusion in at least one organ Treat with plasma exchange, aggressive
anticoagulation and antibiotics
DIC
DIC
DIC results from the disordered regulation of normal coagulation Excess thrombin generation with
secondary activation of the fibrinolytic system.
Uncontrolled thrombin and plasmin generation results in consumption of clotting factors and proteolysis of platelet membrane glycoproteins.
DIC is triggered by diseases that promote the expression of TF, which then complexes with factor VIIa to initiate coagulation
TNF, IL-1, and neutrophil elastase all damage the endothelium, causing the expression of TF.
DIC
DIC
Sources of TF (apart from trauma and sepsis) include damaged cerebral tissue; promyelocytic, myelomonocytic, and monocytic leukemia cells; and placental tissue substances associated with obstetric catastrophes.
Cysteine proteases and proteases derived from mucin- producing adenocarcinomas or snake venoms can also directly activate coagulation factors to induce DIC.
Acute hemolytic transfusion reactions promote DIC indirectly through the formation of circulating immune complexes that activate complement or directly by the toxic effects of damaged erythrocyte membranes; both of these processes result in endothelial cell damage.
Hypotension from any cause can result in endothelial cell damage, triggering DIC.
DIC
The clinical and laboratory manifestations of DIC result from the combined effects of thrombin and plasmin produced in excess of that required for normal hemostasis. Bleeding from venepuncture sites Spontaneous thrombosis
Lab diagnosis Evidence of fragmentary haemolysis, fibrinogen and platelet
consumption, combined with enhanced fibrinolytic activity ie fibrinogen, platelets, XDP’s, and characteristic
blood film PT is usually prolonged, reflecting coagulation factor
consumption APTT is variable, depending on FVIII levels TT is prolonged (interference by FDP with fibrin
polymerization +/- hypofibrinogenaemia)
DIC - treatment
Treat underlying disease process Treat the coagulopathy that results in
the thrombotic and haemorrhagic manifestions Patients who are bleeding or who have
thrombosis require treatment of their coagulopathy
Maintain platelets >20 FFP to replace consumed coagulation factors Cryoprecipitate if fibrinogen <1.5
DIC – further treatment
Failure of the plt count or fibrinogen level to increase despite vigorous replacement = ongoing consumption (common) Heparin (low doses, 10 units/kg/hr) may be
used to block activation of the coagulation system, or if there is thrombosis
Fibrinolytic inhibitors - ε-aminocaproic acid or tranexamic acid not useful (exaggerate the thrombotic component)
DIC – other treatment
Use of endogenous inhibitors of coagulation as a specific therapy for severe sepsis Often complicated by DIC
Recombinant APC in a 96 hr infusion was shown to improve survival in a recent trial Pts with significant coagulopathies or
thrombocytopaenia were excluded Antithrombin has not been shown to be
effective in improving survival with sepsis
Coagulation – the basics
The tissue-factor VIIa complex is the most important in vivo initiator of coagulation
Coagulation – the basics
TF is a transmembrane protein expressed by fibroblasts in the subendothelium During activation of coagulation in response to
vascular injury, TF is expressed on the surface of monocytes and endothelial cells
Coagulation is initiated when circulating FVIIa binds to TF, activating trace amounts of factor X and factor IX.
After VIIa and TF bind, generation of a definitive clot requires production of small amounts of thrombin (by factor Xa) followed by further generation of thrombin (mediated by XI, VIII, and V)
Large amounts of thrombin are crucial to cross-link fibrin (FXIIIa) and reduce fibrinolysis
Coagulation – the basics
In Vitro
Coagulation - tests
PT and APTT measure the integrity of the coagulation system Sensitivity of different PT and APTT
reagents to deficiencies of coagulation factors or to the presence of inhibitors may vary.
Ideally, results are abnormal only when a coagulation factor deficiency is severe enough to be clinically important Eg. APTT should not be sensitive to factor VIII or
IX levels that are >50% of normal
A few notes on coags “coags” on a request form = PT and APTT
The lab only adds on a TT if one or both is abnormal
The lab will do a protamine correction if there is a suspicion of heparin contamination (ie a prolonged APTT)
The lab will do a lupus anticoagulant if this is suspected (when there is a coag scientist in the lab) NOTE: Our coag machine corrects for lupus – ie. Lupus
anticoagulants will not give a prolonged APTT in our lab It is possible to have a normal PT and APTT and a
fibrinogen of <1.5 Fibrinogen levels are not affected by heparin
unless the sample is grossly heparin contaminated APTT > 100
A few notes on coags
pH At a pH < 7.2, clotting is severely impaired If pH <7.0, clotting WILL NOT occur Treatment is to reverse the acidosis and
give products as directed by APTT/PT/Fibrinogen as required.
Temp has similar effect
A few notes on coags
Don’t forget about vitamin K in chronic malnutrition (including those with
alcohol dependency) or conditions that limit absorption of dietary vitamins such as biliary obstruction, coeliac disease, ulcerative colitis, regional enteritis, cystic fibrosis, short bowel syndrome or intestinal resection (particularly of the terminal ileum, where fat-soluble vitamins are absorbed).
In addition, some drugs may reduce vitamin K levels by altering liver function or by killing intestinal flora that make vitamin K
Malignant Haematology in the ICU Usually post chemotherapy or diagnosis
febrile neutropaenia
Random other useful stuff
Blood transfusion site on the intranet Lists all blood products available Has protocols for administration
ARCBS Blood products Useful physiology stuff for exams
Paul says it is more up to date than Brandis
Massive Trauma
What’s in the MTP MTP1 – 4 PRC, 4 FFP, 10 Cryo MTP2 – 4 PRC, 4 FFP, 1 plt
Why can’t I use this outside the setting of trauma? In the absence of hypovolaemic shock and
significant liver dysfunction, exchange of one circulating plasma volume does not reduce the clotting factor activities below levels necessary to maintain haemostasis (ie 50%)
Use PT/APTT/fibrinogen to guide factor replacement therapy
Thrombocytopaenia is the most frequent abnormality associated with massive transfusion
Talk to haematology
Blood products in Children
Red blood cells Packed cells (mls) = wt (kg) x Hb rise required
(g/L) x 0.4 Platelets
5-20ml/kg (will raise plt count by 50-100) FFP
10-20 ml/kg Cryoprecipitate
5-10ml/kg See Clinical Practice Guideline on
Kaleidoscope
Warfarin Reversal Guidelines
Blood Products
Prothrombinex Indicated in prophylaxis and treatment of
bleeding in patients with single or multiple congenital deficiencies of factor II or X and in patient with single or multiple acquired prothrombin complex factor deficiency requiring partial or complete reversal (eg warfarin) Contraindicated in patients with thrombosis or
DIC
Blood Products Novo7
Treatment of deficiency of Factor VIIa or for treatment of massive uncontrolled bleeding Cardiac surgery, post partum haemorrhage and
trauma The use of Factor VIIa in those with
advanced hypovolaemic shock is futile MUST have
Surgical haemostasis pH above 7.18 Temp above 35 Platelet count above 50 Adequate fibrinogen to clot (give cryo first)
Last words Clexane can’t be reversed
Always monitor clexane – Xa levels in renal impariment (and pregnancy)
If someone is adequately anticoagulated, they don’t need a second anticoagulant ie. Wait for the INR to fall before starting a patient
on heparin All fragment comments on a film are not
haemolysis Most commonly seen in renal impairment Always do an LDH and retics if you suspect
haemolysis Everyone in ICU probably needs a Fibrinogen
when their coags are checked To assess coagulation requires APTT/PT/fibrinogen
and platelet count
Last words
Think about using Ptx for a prolonged PT/APTT in liver disease if there is bleeding or require surgery if fluid volume is an issue 25 units/kg + one bag of FFP (for extra VIIa) = about 4 bags of FFP
There is a finite number of plt bags in the shaker – that is why you need to ask for them – we often run out and have to triage usage
Please be nice to the lab staff – they are there to help you – if you really need a result, call and tell them it is urgent!
Don’t panic if your CXM gets refused – we can (and will) always give emergency O negative blood
In desperation you can use a (well labelled) swab for a blood group.
Please give blood – we need (and use) lots of it!!!
Thanks!
Feel free to drop in to the lab for advice and to meet the lab staff.
Any Questions???????