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Case Discussions in Hematology

Management of the Hospitalized Patient

Andrew  D.  Leavi3,  MD  

October  23,  2014  

Objectives

!  To engage in a discussion of clinical topics related to hematology.

!  To leave knowing more than when you came.

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Topics

!  A woman with post-op anemia

!  Prothrombin Complex Concentrates: What are they & use in warfarin overdose?

!  Platelet Transfusions

!  Thrombophilia Testing

!  Your cases and questions

Come ready to participate!

34 yo woman with BMI >40 underwent laparoscopic Roux-en-Y Gastric Bypass surgery in late August 2014.

POD #0: Upper GI bleed from Gastrojejunostomy staple line. Patient returned to the OR that evening for diagnostic laparoscopy demonstrating no bleeding in the abdomen. Upper endoscopy demonstrated clot at the GJ staple line, cauterized with argon beam. Her vital signs and lab values stabilized.

POD # 4: Discharged home.

Labs: Admit Post-Op POD #1 POD #4 Hgb 13.0 8.7 11.8 10.5 Hct 38.3 25.5 34.5 31.9 Plt 276 322 185 242

POD #14: Presents with fatigue, general malaise, and fever to 101oF. .

Hgb: 7.7 Hct: 23.4 Plt 296

A woman with post-op anemia

5U  P-­‐RBC  

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Prothrombin Complex Concentrates

3 factor….4 factor…..

Activated…..Not activated….

I dose on which factor?

What about the other factors?

Can someone help me with this?

Case 1. A 48-year-old male is admitted to the ICU with worsening

multiorgan system failure attributable to bacteria from an abdominal

wound. His platelet count was 160 x 109/L 5 days ago, and today his

platelet count is 33 x 109/L . He has mild anemia (Hgb 11.5), normal

aPTT (34 seconds), normal INR (1.1), and normal fibrinogen (2.0 g/L).

There are no overt signs of bleeding. You contemplate whether to

administer a platelet transfusion.

Blood 123:1146-51 2014

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Choosing Wisely®

!  A medical stewardship and quality improvement campaign spearheaded by the American Board of Internal Medicine Foundation

!  Challenges medical societies to identify 5 tests, procedures or treatments offered to patients despite lack of evidence demonstrating benefit

!  The Institute of Medicine estimates that nearly 1 in 3 dollars spent in healthcare is wasted and that diagnostic testing is a significant contributor

!  1 of the 5 American Society of Hematology (ASH) recommendations (#2) relates to hemostasis and thrombosis

Recommendation #2:

Do not test for thrombophilia in adult patients with venous thromboembolism occurring in the setting of major transient risk factors, such as surgery, trauma, or prolonged immobility

Choosing Wisely – The data*

“Do  not  offer  thrombophilia  tesJng  to  paJents  who  are  conJnuing  anJcoagulaJon  

treatment,  or  to  those  who  have  had  “provoked”  DVT  or  pulmonary  embolism  (that  is,  

paJents  who  in  the  past  three  months  have  had  a  transient  major  clinical  risk  factor  

for  venous  thromboembolic  disease)—for  example,  surgery,  trauma,  prolonged  

immobility  (confined  to  bed,  unable  to  walk  unaided,  or  likely  to  spend  a  substanJal  

proporJon  of  the  day  in  bed  or  in  a  chair),  pregnancy,  or  puerperium—or  paJents  who  

are  having  hormonal  therapy  (oral  contracepJon  or  hormone  replacement  therapy).”

*Chong et al BMJ 2012;344. “Management of venous thromboembolic diseases and the role of thrombophilia testing: summary of NICE guidance”

[recommenda)on  is  based  on  the  GDG’s  experience  and  opinion]  

*Baglin et al BJH 2010 (149) 209-20. “Clinical guidelines for testing for heritable thrombophilia”

“Thrombophilia  screening  of  hospitalized  paJents  to  idenJfy  paJents  at  risk  of  hospital-­‐acquired  venous  thrombosis  is  not  indicated  (1A).”  

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Thank  you  for  your  parJcipaJon!  

QuesJons?