Preoperative evaluation and Management of

patient withHematologic

Problems

Preoperative evaluation

1. Disease : severity : curable

2. Surgery : emergency : risk of bleeding

Hematologic problem

• Anemia• Bleeding tendency

– Platelet : thrombocytopenia , dysfunction

–Coagulopathy– anticoagulant

• Hematologic malignancy

Low risk

• Nonvital organs • exposed site• limited degree dissection• Local hemostatic effective

Moderate risk

• Vital organs • deep or extensive dissection• Local hemostatic ineffective

high risk

• local fibrinolysis • CABG, brain injury, extensive malignancy)• Bleeding complications compromise result

Bleeding risk procedure

http://web.uct.ac.za/depts/liver/images/biopsy%20procedure.jpg

Anemia

Perioperative transfusion

European Journal Of Haematology July 2005Preoperative transfusion in sickle cell disease : a survey of practice in England

Complication transfusion1. independent predictor of postoperative

infections 2.new transfusion hazards : West Nile virus

and variant Creutzfeld Jacob disease 3. iron overload 4. red cell alloimmunisation• Review : transfusion not improve

postoperative complication• No RCT : transfusion VS non transfusion

  Vamvakas EC . Meta-analysis of randomized controlled trials investigating the risk of postoperative infection in association with white blood cell    containing allogeneic blood transfusion : the effects of the type of transfused red blood cell product and surgical setting . Transfusion 2004;16 : 304   314 .

• preoperative Erythropoietin• - < 7 8 g/dL should be given• Except : severe ill , >55 year ,

cardiac diseasae

Perioperative transfusion

Anemia

Iron deficiency anemia

• Elective surgery : postpone: Hct > 10 g/dL

• Emergency : Hct 8-10

http://www.ajronline.org/content/vol179/issue5/images/large/11_AC0200_03B.jpeg

Thalassemia

HCC syndromeHypertensive, Convulsion, Cerebral

hemorrhage• Risk : thalassemia major, Hct 9-20%• Onset : during 2 week ( cmm< 2 days)• Mortality 33%• Etiology : volume overload pressor

hyperresponsiveness, RAAS system, symphatetic

• Prevent : slow rate ,< 3 pack/d , interval 3 days, monitor BP,

• diuretic ,antihistamine before transfusion • Rx : diuretic , antihypertensie,

dexamethaxone

AIHA Laparoscopic Splenectomy

AIHA

2 . Transfusion : most patients tolerate serologically

incompatible blood

2 . corticosteroids 1. suppress HPA axis:

prednisolone ≥ 5 mg/day for - > 3 weeks 6 12 months prior to surge

ry LLLLLLLL LLLLLLLLL LLLLLLLLL.

2. Impaired wound healing 3. Increased risk infections,

4. gastrointestinal hemorrhage

uiz ผู้��ป่วยหญิ�งไทยคู่�� 35 ป่� เป่�น SLE (DLE, ANA,anti DsDNA,LN) on prednisolone (5) 2*2Dx MCA with abdominal injury need Explor laparoscopic CBC : Hct 21 , WBC 1,600 N 75 % L 20% Plt 600,000 )Peripheral blood smear

uiz• blood transfusion Hct 25• Steroid stress dose

uizผู้��หญิ�ง 18 ป่� CVT consult preoperative mediastinal mass พบ anemiaCBC : Hct 18 WBC 5,600Plt 560,000

Thrombocytopenia

• surgical bleeding low risk < 50,000/dL moderate to high risk < 100,000

/dL• standard dose - 0102: . .

u/Kg• - 58 units for prophylactic• - 610Single donor platelets =

LLLLL • Maintain postoperative 1 week

Thrombocytopenia

2. Antifibrinolytic

1. Tranexamic acid 2. epsilon aminocaproic acid (EACA)

• areas increased fibrinolysis,• - 7 14required for days depend on L

mount of tissue injury.

plasminogen

Plasminogen activator Tranexamic acid

3. microfibrillar collagen, fibrin glue

• Two plasma proteins; fibrinogen and thrombin

• are being used to develop fibrin glue

Refractoriness to platelet transfusion

American Society of Clinical Oncology

corrected platelet count increment (CCI), CCI = increment platelet count 1 h r) x BSA [m(2 )]

unit of platelets

• practical : 10000, /d L• 6 units to BSA 2 m2• 10,000= increment x2 platelet ~ 30,000/dL

at 1 hr 6

• refractoriness = CCI < 5,000~ absolute platelet count increment

≤2000, /dL /unit

Refractoriness to platelet transfusion

Vancomycin , amphotaracin B

alloimmunization1. - HLA matched platelets2. S ingle donor c - rossmatch compatible

platelet with patient's serum3. +/- IVIG , plasmaphoresis

avoid transfusion 1in . TTP/HUS

- 2. heparin induced thrombocytopenia.

worsening neurologic symptoms and ac ute renal failure,

ITP• Splenectomy• 50000platelet count > , /ตL 1. Pulse methylprednisolone : resp 4.7

day2 .LLLL 1 gm/kg IV, repeated following day if

5 0 000 LL 60% resp in day 3

3. Anti Rh D 4. platelet5. Emergency splenectomy : response

in 24-48 hrs

Infection • 2immunize weeks prior : at time of diagnosis.

Alternatives 1. splenic irradiation 2. partial splenic embolization.

postsplenectomy

Platelet dysfunction

Agonist

Adhesion

1. Bernard-Soulier synd2.vWF 2.1 congenital

PltFc VIII 2-3 daydDAVP

2.2 acquired 1. Ab : AI, Lymphoproliferative 2.absorb vWF : Lymphoma,WM

Rx cause

Secretion

1.Acquire storage pool disease :

1.1 CABG, activate clot i.e. DIC

1.2 CLL, myeloproliferative 1.3 ; Cirrhosis , SLE2.Drug : NSAID ,

dipyridamole

Mild Rx causePlt dDAVP

Aggregate

1. Glanzmann , antiPlt Ab: SLE, ITP

2. Dysproteinemia3. Drug , plavix,fibinolytic

PLt Ab NovosevenRx underlying

Mixed Uremia

Antiplatelet

2 0 0 4 ACC/AHA task force: not discontinue in CABG after STEMI

Platelet transfusion prophylaxis???

1. ASA: irrevesible : 5-10 days

2. . : 2 days3. ticlopidine and

clopidogrel : irreversibly : 7-10 days4. LLLLLL : 3 days

Antiplatelet

COX -2 ???

both aggregation , adhesion . 1. Intrinsic factors : GP,

ADP, TXA2 2 Extrinsic factors

1. uremic toxins ( guanidinosuccinic acid and phenolic

) NO production (inh

aggregation), 2. anemia, 3. impair vWF-Plt interaction

Uremia

aggregation ,adhesion

Correlate ????

uremia1. anemia Hct - 25 30

2 . Erythropoietin –increasingGPIIb/I I Ia

and improving platelet calcium signLLLLL

3 50. effective % patients 1improvement within hour and

- 4 24lasts hrs.• Repeat every 24 hrs• tachyphylaxis due to depletion of endothelial multimer stores. , limit 3

dose

4.Dialysis 5.Estrogen : due to decreased generation NO.

6. Cryoprecipitate – - 10 12 24units every hrs : eff

ect = LDAVP

uizชายไทย 34 ป่� CKD จาก polycystic kidney diseaseOn regular hemodialysis 3 /สั ป่ดาห" น ดมาท$า kidney transplantation• regular hemodialysis• Hct >30

uizDM , HT , CKD Cr 2.5 มาด�วย acute febrile illness Dx melioid sepsis , acute ontop chronic kidney disease , severe metabolic acidosis , plan acute peritoneal dialysis• bleeding time < 7 min• cryoprecipitate or dDAVP

Coagulopathy

FRESH FROZEN PLASMA• all coagulation factors• 1 units : 250 mL;• 1 cc = 1 % activity• hemostasis when factors activity ~ - 25 30

% of plasma volume(40 mL/kg,)

= FFP at 10-15 mL/kg, Indications

• multiple coagulation factors• DIC , warfarin overdose, vitamin K deficien

cy, liver failure, massive transfusion• Every 6 hrs ( T1/2 factor VII 4-6 hrs)

30% x 40 cc/kg= 12 cc/kg ~10-15cc/kg

15 cc/Kg x 50 Kg = 750/250 = 3 bag

CRYOPRECIPITATE

• factor VIII, XIII, fibrinogen, fibronectin, vWF

• - volume of 10 15 mL.• fibrinogen = 200 mg• Factor VIII = 1 0 0 u - (80 110 IU)

1 .deficiencies of fibrinogen : 1 bag / 7Kg BW

2.vWF : 0.1 bag /kg every 6-12 hour3. Hemophilia A

1. Decrease production coagulation factor( vWF )

2. dysfibrinogenemia3. Decrease protein C , protein S, impair

ability to clear activated coagulation factor DIC

4. Vitamin K deficiency5. Thombocytopenia, Plt dysfunction

Rx1. FFP PT < 3 S , Plt 2. Vit K : PT normal in 12-24 hrs3. Cryoprecipitate : hypofibrinogen

Liver disease

1 . cryoprecipitate : factor VIII 100 u serious viral transmission 2 lyophilized factor VIII conc . 1 ขวด

250 u 3. L LLLL LLLLLL LLL LL LLLLLL LLLL :250,

500,1,000 U 4. monoclonal purified factor VIII

Hemophilia A

1. prothrombin complex concentrates : factors II, VII, X , IX,

ass with thrombogenic risk 2. cyro-remove plasma

3. monoclonal or recombinant product

Hemophilia B

Dosing• calculated from

1.BW (kg), 2.volume of distribution

3. desired factor level 05Vd factor VIII ~ . ; 1 u/Kg

2 % activity Vd factor IX : 1 u/Kg 1 %

activity desired factor level = severity and locati

on of bleeding episode.

Concentration = dose administration/Vd

= 1 U/0.5

= 2 U/cc = 2% activity

Initail maintenance

dental surgery 50 %

Single + antifibrinolytic

- 710 days

major procedurLL •Extensive dental Sx •LP,epidural anesth •CNS •major orthropedic (TKR)

60 -100

- 3050% until wound healed, ~ 2-3

days- 710 days 3 week ( + PT)

• Factor levels checked• T1/2 - factor VIII 8 12 hours repeated 1 2

LLLL - 16 17factor IX : hours every day

continuous infusion • - 2 4factor VIII : U/kg / hr• LLLLL LLLLLLL

Must check factor VIII inhibitor• Low < 10 bethesda : High dose factor VIII + 10 U/kg/1 BU• Plasmaphoresis• High titer : Porcrine , Recombinant factor

VIIa

OTHER THERAPIES

1. dDAVP : mild moderate bleeding in mild hemo

philia A,2 . Antifibrinolytic – Tranexamic acid and EACA3. microfibrillar collagen, fibrin glue

uizผู้��ป่วยชาย 26 ป่� BW 60kg hemophilia A มาด�วย ขาขวาบวม มา 6ป่�

• 05Body weight x . units/kg x desired fa L LLLLL LLLLLL LLLL LLLLLLLL(%)=

BW x 0.5 x % = unit

60 05 100x . x = 3000 uni t s f act or VI I I

then 60 05 50x . x = 1500 uni t s f act or VI I I

• Cyroprecipitae 100 u/bag = 30 U then 15 u every 12 hr

1.. risk of thromboembolism 2. Risk of bleeding with anticoagulant

anticoagulation

anticoagulation

1. risk of thromboembolism= indication for anticoagulation,

1. actual treatment.1.1 Venous recurrent : first month 1 % /

days 1.2 Artery recurrent : first month 0.5 %/

day avoid e lective surgery DVT: within 2 weeks or if

risk of bleeding is high, vena caval filter

2. prophylaxis ArterialLLLLL LLLL LLLLLL

low risk1 . nonvalvular atrial fibrillation2 . 4prosthetic heart valve % L-year• mitral valve twice risk aortic valve• Aortic: safety of temporary cessatio

L- high risk AF

2. Risk of bleeding depend on age, other disease, drugs,

type of surgery , anticoagulant regim en and intensity,

prolonged, complex, and major sur gery

LLLL bleeding 3% of major postoperative bleedi

ng fatal

1. after discontinued require - 2 3 days f or effect to resolve

2. - Require 4 5 days to resumed a therap eutic level

3. Rebound hypercoagulability after discontinued

• Surgery increases risk of venous not - 100arterial thromboembolism , fold r

isk• changes in hemostatic

markers( acute phase response and w ound healing process)

Must know

1. Heparin : Discontinue 6 hr before• protamine:2. Enoxaparin • 12Antifactor Xa activity: ~ hr

24 hr• protamine 3. warfarin • Vit K • PT - 1214normal hours

• High risk thomboembolism heparin 1. High risk arterial thomboembolism 2. After venous thomboembolism in 1

month ( artery if low risk bleeding)

• - 12Restarting warfarin on postoperativL LLL

LLLLL LLL LL LLLLL L L L4 8 oursbef ore hepari n i s di scont i nued.

Post operative anticoagulant

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• check INR• Reduce dose uutil INR < 2• Tranexamine• Splint

.cancer

1.effects of malignancy 2.side effects of therapy

• Neutropenia and lymphopenia infection. postponed except emergent Even neutropenia resolved remain relatively immunocompromised • Thrombocytopenia • Hypercoagulability : risk for perioperative DVT

airway •Anterior , middle mediastinal masses compress •Flow volume loops Cardio•Pericardial disease

–

•Hepatotoxicity •Nephrotoxicity• cardio : anthracyclines, 550

mg/m 2 doxorubicin Preexisting heart disease, radiation, other chemotherapeutic agents (taxanes) EKG , echocardiogram

radiation therapy 1.Hypothyroidism – Radiation > 10

Gy to neck2.Coronary artery disease , valvular disease

Chemotherapy

uiz6. ชายไทย 38 ป่� ป่วดท�องน�อยด�านขวา มา 2 ว น dx acute appendicitis CBC preop

Hct 22 WBC 5,600 Blast 96 % neutrophil 2% Plt 65,000

uiz• R/O TYphitis• Check PT , APTT• LPB , PLt

Drug dosage1. IVIG AIHA 1000very high doses ( mg/kg/ L 5

LLLLL ITP : <50,000/ ต L-L LLLL 12 LL LL LL LLLLLLLL LLLLLLLL LLLLL LL LL 40/ 1020/2 03 0.

30mg/kg per minLLLLLLLLL LL LLLLLLLL LLL LLLLL LLLLLLLL

1. Competitive inhibition of autoantibody adsorption to patient's platelets.

2. Prevention of RE uptake of- -autoantibody coated platelets through Fc recep

tor blockade.

-3. Interaction of autoantibodies with anti idiot ype antibodies in IVIG.

2 . -25 6tranexamic acids mg/kg / dose every 8 ,

• LLLLL LLLLLLLLLLL ,: - L-L LLLL1. ..: 10 / ,25/ / 34 / 28

- 2 25 34. Oral: mg/kg times/day beginning 1 day prior Sx

3. - 10 34I.V.: mg/kg times/day in unable oral RENAL IMPAIRMENT

• - LL LLLL LL L5 0 8 0 /: 5 0 % L L L LLL1 0 / . . 1 5 /

L LLLLLLL• - 1050 25Clcr mL/minute: % of normal d

LLL LL ODL• 1010 48Clcr< mL/minute: %ofnormaldose or ever y hour sLLLLL : 100 10 100Injection, solution: mg/mL( mL) maximumrateof mg/mi nut e

: oral : 250-500

- 3 75100 6. EACA is mg/kg /dose every hours 4 . NOVOSEVEN 50-100 µg/kg every 2-3 hrs until stop than plus 1-2 dose

5. Pulse methylprednisolone LLLLL L LL(1 , 3ses)

6. dDAVP

1 IV 03 50. microg/kg in mL saline over - 15 30min

LLL L LLLL LLLLLLLLLLLLLL 2 3 3intranasally microg/kg

LLL LLLL LLLLLLLLL 1 . .. 2.vasodilatation facial flushing, headach

L 3. hypotension and hypertension

7. Estrogen1. 0.6 /mg kg IV ,OD 5 days : onset 6hr 14 days 2. - LL LLLL LLLLLLLL 25 25 : onset 2 days 5 dasys3. - 50 100or microg of transdermal twice weLLLL

8. :protamine1.Heparin 1 100mg per units2.Enoxaparin : 1 mg per 1 mg.• Monitor aPTT 2-4 hrs after first infusion• readministration 50% of original dose• Note: anti-Xa activity is never completely

neutralized (60% to 75%). 9. Vit K - -LL LLL: 5 25 6 12

L-L LLL.., .., : 10 12

&

• ผู้��ป่วย Rheumatic heart disease S/P DVR ฟั'นผู้( ท นตแพทย"แนะน$าให�ถอนฟั'น

• ชายไทย 34 ป่� CKD จาก polycystic kidney disease On regular hemodialysis 3 /สั ป่ดาห" น ดมาท$า kidney transplantation

• DM , HT , CKD Cr 2.5 มาด�วย acute febrile illness Dx melioid sepsis , acute ontop chronic kidney disease , severe metabolic acidosis , plan acute peritoneal dialysis

• ผู้��ป่วยชาย 26 ป่� hemophilia มาด�วย ขาขวาบวม มา 6 ป่�• ผู้��ป่วยหญิ�งไทยคู่�� 35 ป่� เป่�น SLE (DLE, ANA,anti DsDNA, LN) on prednisolone (5) 2*2 Dx acute gangrenous arterial occlusion left leg CBC : Hct 21 , WBC 1,600 N 45 % L 50% Plt 600,000 )• ผู้��หญิ�ง 18 ป่� CVT consult preoperative mediastinal mass พบ anemiaCBC : Hct 18 WBC 5,600Plt 560,000

• ชายไทย 38 ป่� ป่วดท�องน�อยด�านขวา มา 2ว น dx acute appendicitis CBC preop Hct 22 WBC 5,600 Blast 96 % neutrophil 2% Plt 65,000