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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?