Hematology

     hematology
      Anemia

        Anemia1.pdf


        Corrected Reticulocyte Count
        (absolute reticulocyte count)
        = (Reticulocyte percentage) X (Actual Hct / 45)
           
        Enter Reticulocyte percentage
        Enter Hematocrit
        Enter Normal Hematocrit
           
        		 
        Corrected Reticulocyte Count is   
        Microcytic anemia

          Ferritin <40 → definitely Fe defic
          Ferritin >300 → definitely not Fe defic
          Ferritin >100 & out-pt → definitely not Fe defic
          Ferritin 30 - 300 → need Fe, TIBC

            Iron Deficiency Chronic Disease Combined
          Serum Ferritin Low Normal or High Normal
          Serum Iron Low Low Low
          TIBC High Low Low
          Trans. Sat. (Fe/TIBC) Very Low Low Low
          Transferrin Recep. High Normal not known
          MCV Low Low or Normal Low
          RDW High High or Normal High

        Elemental Fe in peds: 4.5 - 6.0 μg/kg/d
        Check Hb in 4-6 wks

        Hemolytic anemia

          unconj bilirubin - ↑
          conj bilirubin - sl ↑
          LDH - ↑
          haptoglobin - ↓
          retics - ↑
          DAT +/-
      Bleeding

        E.g. intractable menorrhagia or epistaxis → tranexamic acid 25 mg/kg/d PO TID or 10 mg/kg IV TID

      DIC

        INR - ↑
        PTT - ↑
        platelet count - ↓
        fibrinogen - ↓
        d-dimer - ↑

        Factor VIII level may be helpful if severe, acute DIC must be differentiated from massive hepatic necrosis.
        Factor VIII level is elevated in hepatic necrosis, because factor VIII is made in hepatocytes and released as they are destroyed.
        Factor VIII is reduced in DIC because of the thrombin-induced generation of activated protein C, which proteolyses factor VIII.

        Tx:
        Platelet concentrates to correct thrombocytopenia
        Cryoprecipitate to replace fibrinogen and factor VIII
        FFP to increase levels of other clotting factors and natural anticoagulants (antithrombin, proteins C and S)

      HUS / TTP

        F ever
        A nemia
        T hrombocytopenia
        R enal
        N eurol

      Von Willerbrand disease

        At end of menses:
          INR - nl
          PTT - sometimes slightly ↑
          platelet count - nl
          bleeding time - ↑
          Von Willebrand factor (vWF) - ↓
          ristocetin cofactor activity - ↓
          factor VIII level - may ↓

        However, stimuli that temporarily increase VWF levels can cause false-negative results in mild VWD; screening tests may need to be repeated.

        Tx:
        Infusion of pasteurized intermediate-purity factor VIII concentrates, which contain components of VWF.
        Desmopressin (an analog of vasopressin) stimulates release of VWF into the plasma and may increase levels of factor VIII.

      Warfarin Tx

        Start warfarin 5 mg PO qd (b/c → ↓ protein C & S before ↓ clotting factors, thus, procoagulant in first few days)
        If necessary, start off with LMWH

        Contraindications
        Pregnancy, especially 6th to 10th weeks
        Hemorrhagic tendencies
        Recent surgery to CNS, eyes, large surfaces, especially within a week
        Inadequate monitoring facilities
        Unreliable patient or circumstances
        Malignant hypertension

        Management of supratherapeutic INR

          INR Bleeding present Recommended action
          > ther to 5.0 No Lower warfarin dose
          5.0 to 9.0 No Omit the next 1 to 2 doses of warfarin and resume treatment at a lower dose when INR is in therapeutic range
          > 9.0 No Hold warfarin and administer 5 to 10 mg vitamin K PO.
          Any Serious or life-threatening Hold warfarin and administer 10 mg vitamin K by slow IV infusion;
          supplement with prothrombin complex concentrate, fresh frozen plasma, or recombinant human factor VIIa, depending on clinical urgency.

          If INR > 8, send pt to pharmacy → vit K 2 mg PO