10/25/16 Management of the Hospitalized Patient Case Discussions in Hematology: Musings from the UCSF Hematology (e)Consult Service Andrew D. Leavi4, MD October 21, 2016 Case #1: Unexpected Pre-op Labs 62 yo man scheduled for bilateral Total Hip Arthroplasty has the following pre-op CBC that shows an unexpected anemia. CBC: WBC: 7.1 Hgb 7.8 Hct 29.2 Plt 288 Consult to Heme: 1. Why is he anemic? 2. Please eval asap, patient in pain and needs surgery. Surgery cancelled until you give us an answer. 3. He is a physician How do you proceed? What do you want to know? 1
10/25/16 Case #1: Unexpected Pre-op Labs MCV, Retic, Smear, and … Case #1: Unexpected Pre-op Labs Major Spine Surgery No Retic on record Ferritin 9 (low); Iron sat 3% (low) 2
10/25/16 Case #1: Progression to Iron Def. Anemia * POINTS: 1. Microcytosis is late to the table. Trends can be useful. 2. Low ferritin should not be ignored when SI and %sat are normal *SI = serum iron Modified from Harrison’s 18 th ed Case 2: Anemia – Need a Marrow Biopsy? 64 yo woman: “Persistent microcytic anemia. Does she need a bone marrow biopsy?” Most recent CBC that prompted the referral: There was no retic & no smear to review when asked to see patient 3
10/25/16 Case 2: Anemia – Need a Marrow Biopsy? The Mighty EMR 1. Stable MCV 2. Iron studies in early 2015 not c/w iron deficiency 3. Hemoglobinopathy eval in early 2015 … Case 2: Anemia – Need a Marrow Biopsy? NORMAL <1.0 2.2 - 3.2 96.7 – 97.8 Normal? Abnormal? Tells you what? 4
10/25/16 Erythropoiesis: Hemoglobin Switching (Hgb: 2 alpha & 2 “ beta-like ” [aka, non-alpha; 3 options]) α 50 α Globin chain synthesis (%) γ β Alpha: Chromosome 16 Beta-like: Chromosome 11 ε ζ δ 0 Adult Embryo Fetus Birth 6 mo. HgA α 2 β 2 (96-98) HgF α 2 γ 2 (75) HgA 2 α 2 δ 2 (2-3) HgA α 2 β 2 (25) HgF α 2 γ 2 (<1) Hoffman et al. Hematology 2000 Erythropoiesis: Hemoglobin Switching (Hgb: 2 alpha & 2 “ beta-like ” [aka, non-alpha; 3 options]) α 50 α Globin chain synthesis (%) So … No Bone Marrow Biopsy γ YES Alpha Gene Analysis β Alpha: Chromosome 16 Beta-like: Chromosome 11 4 Alpha Genes: αα αα / αα αα ( Silent c.) αα / α - ( αα ε ( Trait) αα / -- ( αα ζ δ ( Trait) α - / α - ( 0 ( Hg H) α - / -- ( Adult Embryo Fetus Birth 6 mo. HgA α 2 β 2 (96-98) HgF α 2 γ 2 (75) ( hydrops) -- / -- ( HgA 2 α 2 δ 2 (2-3) HgA α 2 β 2 (25) HgF α 2 γ 2 (<1) Hoffman et al. Hematology 2000 5
10/25/16 Anemia?....then always MCV, Retic, Smear, and … EMR trends CASE #3: Anemia: What would you do? 6
10/25/16 Case #3: Does She Need RBC Transfusion? 34 YO woman with hx of Fe-deficiency anemia admitted for RLQ pain. Was found to be anemic and to have a R gonadal vein thrombosis The primary team wants to anti-coagulate for the gonadal vein thrombosis but is concerned because she (i) is so anemic and (2) is having her menses. Heme Consult WBC HGB HCT PLT RETIC Venofer: IV Iron Sucrose 200mg 100mg 200mg 100mg What is Your IV Iron Experience A. Never/almost never use it B. Typically use Ferric Carboxymaltose (Injectafer) C. Typically use Iron Dextran (InFed) D. Typically use Ferumoxytol (Feraheme) E. Typically use Iron Sucrose (Venofer) F. Typically use Ferric Gluconate (Ferrlecit) G. Typically use other 7
10/25/16 Parenteral Iron: Options Name Company Dose IV Infusion Iron Dextran Watson 1-2 grams 4 hours (InFeD) acetaminophen and diphenhydramine (prior reputation for anaphylaxis) Ferumoxytol AMAG 510 mg 10-15 min (Feraheme) Pharmaceutical (30mg/ml) acetaminophen or often nothing Iron Sucrose Vifor 200 mg 1-1.5 hours (Venofer) acetaminophen and diphenhydramine Ferric gluconate Sanofi-aventis 125 mg 1-1.5 hours (Ferrlecit) acetaminophen and diphenhydramine Ferric Carboxymaltose Vifor 750 mg 30-60 Min (Injectafer) acetaminophen and diphenhydramine Hepcidin & Iron RegulaIon BMP6 IL6 Body’s iron store - + Fe 2+ Synthesis Hepcidin MACROPHAGE Fe 2+ Fe 2+ Macrophages Ferroportin Ferroportin Duodenum Hepcidin Hepcidin DUDOENAL VILLOUS CELL Reduced Serum Iron 8
10/25/16 Case #3: Does She Need RBC Transfusion? ANSWER: NO But, tell me more about your iron deficiency … . For years. Very heavy and prolonged menstrual periods. Struggled with oral iron on and off for years. Factor 8 55 (43-168) vWF Antigen 40 (42-191) Ristocetin Co-Factor 33 (42-191) Case #4: Prolonged aPTT 22 yo man evaluated for possible living-related kidney transplant. Chemistries – fine Infectious Disease Testing – fine CBC – all normal values PT/INR – 12.4/1.0 aPTT 34. On repeat 35 (normal: 22.4 – 32.7) Can we take this patient safely to surgery? 9
10/25/16 Case #4: Prolonged aPTT 22 yo man evaluated for possible living-related kidney transplant. ---- Most common cause of an isolated prolonged aPTT? Concern for bleed? Concern for clot? Neither? Factor VIII 120 (nl) Factor IX 145 (nl) Factor XI 112 (nl) Factor XII 41 (low) Factor XII deficiency has no known clinical consequence Case #5: Prolonged PT 28 yo woman G2P1 36 weeks pregnant admitted for hypertension and proteinuria, concern for pre-eclampsia. INR 3.1. You are called as they are concerned about her coagulopathy. PT 30.2 WBC 11.2 (ANC 8.8; ALC 1.8) INR 3.1 Hgb 11.5 aPTT 22.1 MCV 79 Fibrinogen 525 Plt 262 -She was feeling well prior to this admission -Eats a balanced diet and was not on any medications other than her prenatal vitamins. -Afebrile What is on your differential diagnosis for her prolonged PT? 10
10/25/16 Isolated Prolonged PT (EXTRINSIC) Kallikrein PT XII XIIa � HMWK EXTRINSIC XI XIa IX IXa � VIIa VII � TF VIIIa � Ca ++ /PL � INTRINSIC TF/VIIa X Xa � Va � • Early Liver Dz Ca ++ /PL � • Early Vit K II IIa (thrombin) � • Warfarin • Early DIC Fibrinogen � Fibrin � XIIIa � • F VII def/inhib COMMON � X-linked Fibrin � Case #5: Prolonged PT Tests Ordered: Mixing Study: Factor VII activity: <6% (54-169%) 11
10/25/16 Case #6: Bleeding in the Neuro ICU Ø 73 y.o. man w/PMH of cardiac stent ten years ago w/o MI in usual state of health. Ø Watching TV with his wife, got up & went to adjacent room. The wife heard a "loud crash" in the other room and found husband down on the ground w/ some shaking movements that quickly resolved. Ø Brought to ER: Man had no recollection of the event and denied any pain or complaints. EMS note enlarged right pupil and repetitive speech but o/w neuro intact. No other medical complaints or trauma. Ø Taking aspirin. Not on any other anticoagulants. Ø IN ER: Neuro exam non focal but he was confused. Ø Non contrast head CT obtained. Case #6: Bleeding in the Neuro ICU R R Non Contrast Head CT: 1. Large right holohemispheric extra-axial collection with an apparent epidural component spanning the right parietal lobe measuring 2.4cm. There is right-to-left midline shift measuring 1.7 mm and mass effect on the falx. 2. Adjacent bi-hemispheric areas of punctate hyperdensity at the vertex and superior parietal lobe which could represent hemorrhagic contusions or shear injury in the correct clinical setting. 3. Comminuted and displaced frontoparietal calvarial fractures extending to the sagittal suture with depression/step off measuring 2mm superiorly and inferiorly 12
10/25/16 Case #6: Bleeding in the Neuro ICU Timeline of Events: 6:44pm CT results communicated to ER To OR for emergent right craniotomy for hematoma evacuation 9:59 Brief Op Note: R craniotomy and hematoma evacuation Condition at end of operation : Stable IN OR: 2 units platelets; 2 P-RBC 10:15 Shortly after arrival to ICU – Hypotensive to 50s. Neo qtt and NS bolus Developed “Coagulopathy - INR 2.1 post-op for unclear reasons, may be 2/2 EBL of 800. Pre-op LFT's normal, but will recheck. Transfusing 2 FFP.” OR 2RBC 2 FFP Call to Heme Hemoglobin 12.0 9.3 9.4 What is the problem? Platelets 202 105 136 Causes of Prolonged PT and aPTT Prolonged PT & aPPT Prolonged PT • Severe liver dz • Early Liver Dz • Warfarin - supra-Tx • Early Vit K • Severe Vitamin K def. • Warfarin • High dose heparin (Xa & IIa) • Early DIC • Dilutional • F VII def/inhib • DIC • A/hypo/Dysfibrinogenemia • Paraproteins (Factor X) Prolonged aPPT • Common Pathway def./inhib. • F VIII* � • Lupus anticoagulant (rarely; F II*) BLEED • vWD � • F IX* � • Heparin � • F XI � BLEED • F XII � NO • Contact factors � • Lupus anticoag (clotting) � *Factor II = Prothrombin 13
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