Haematology handbook Flashcards
What are the investigations at dx of leukemia?
a. Blood tests
CBP, PT/APTT
D-dimer, fibrinogen (if suspicious of APL or DIC)
G6PD, HBsAg, anti-HBc, anti-HBs
RFT, LFT, Ca/P, Urate, Glucose, LDH, Type & Screen
HCV Ab, HIV Ab, HBV DNA for HBV carrier
Flow cytometry, Coombs’ test and SPE
Fluorescence in situ hybridization (FISH) for CLL
b. Bone marrow aspiration and trephine
Contact haematologist for cytogenetic and molecular studies before BM biopsy
What is initial management of patient with leukemia?
a. Start allopurinol (or febuxosat). Consider rasburicase in high risk patients: *note – contraindicated in G6PD deficient patients
b. Ensure adequate hydration
c. Blood product support:
RBC/blood transfusion if symptoms of anaemia are present Platelet transfusion if platelet count ≤10109/L or ≤20109/L if fever or bleeding (keep platelet > 50109/L in APL)
Give plasma if there is evidence of bleeding due to DIC
d. Do sepsis workup if patient has fever
e. Antibiotic therapy:
Give appropriate antibiotic if there is evidence of infection
PCP prophylaxis for patients with acute lymphoblastic leukaemia:
i. Septrin tab 2 daily three days per week, or
ii. Pentamidine inhalation 300 mg/dose once every 4 weeks.
f. Record patient’s performance status (PS)
What are the medical emergencies in leukemic patient that you must inform to haematologist?
a. Hyperleucocytosis (e.g. WBC 100109/L) for chemotherapy leucopheresis. Avoid blood transfusion till WBC is lowered
b. APL (acute promyelocytic leukaemia) for early use of all-trans- retinoic acid (ATRA)
What is the subsequent management of leukemia patient?
a. Consult haematologist for long-term treatment plan
b. Arrange Hickman line insertion if indicated
c. Arrange HLA typing for patient’s siblings if HSCT is
anticipated
d. CMV negative blood product for potential HSCT recipient if
patient is CMV seronegative.
What are the investigations at diagnosis of lymphoma?
a. Blood tests
CBP, ESR, PT/APTT, G6PD
RFT, LFT, Ca/P, LDH, Urate, Glucose, Direct Coombs’ test Serum IgG/IgA/IgM levels, SPE
HBsAg, anti-HBc, anti-HBs, HBV DNA (optional)
b. Biopsy
Excisional biopsy of lymph node or other tissue (send fresh specimen, no formalin) for study (markers, EM, DNA)
c. Bilateral bone marrow aspiration and trephine
d. Radiology
PET/CT scan (preferred, especially in diffuse large B cell lymphoma, Hodgkin’s lymphoma) or CT scan of thorax, abdomen and pelvis or other sites of involvement
e. Other investigations
Endoscopic and Waldeyer’s ring exam for GI lymphoma
LP with cytospin for patients with high risk of CNS lymphoma (high grade lymphoma, nasal/ testicular/ marrow lymphoma)
What is initial management of lymphoma patient?
a. Start allopurinol (or febuxostat) Consider rasburicase in high risk patients: note –contraindicated in G6PD deficient patients
b. Record patient’s performance status (PS)
What are the medical emergencies in lymphoma to be concerned with?
a. SVC obstruction due to huge mediastinal lymphoma
b. Hypercalcaemia
c. Tumour lysis syndrome
d. Spinal cord compression
What are the investigations at diagnosis of multiple myeloma?
a. Blood tests
CBP, ESR, RFT, LFT, Ca/P, LDH, Urate, Glucose SPE with immunofixation for paraprotein
Serum IgG/IgA/IgM level, Serum free light chain level 2 M, CRP, HBsAg, anti-HBc, anti-HBs, G6PD
b. Urinalysis - Bence Jones Protein (BJP) and free light chains
c. Radiology – skeletal survey or Total Body MRI or PET/CT
d. Bone marrow aspiration and trephine (+/- FISH)
What is the staging done multiple meyloma: ISS and symptomatic vs asymptomatic myeloma?
Symptomatic vs asymptomatic myeloma
Symptomatic: presence of end-organ damage:
CRAB:
Calcium elevation: (corrected serum Ca > 2.75 mmol/L)
Renal insufficiency: (creatinine >176.8 mol/L)
Anaemia (Hb <10 or 2g < normal)
Bone disease (lytic or osteopenic)
What is the initial management of multiple myeloma patient?
a. Ensure adequate hydration and start allopurinol 300 mg daily or febuxostat
b. Correct hypercalcaemia – pamidronate or Zometa.
c. Renal dialysis for patients with renal failure
d. Record patient’s performance status (PS)
e. Consult Radiotherapy or Orthopaedic Team for patients
presenting with skeletal complications (pathologic fracture or spinal cord compression)
What is the prevention of cytotoxics in malignancies?
When is extravasation suspected and management?
What is the procedure for prescribing, dispending, consent and administration of intrathecal chemotherapy?
What is performance status scale?
What is the haematological toxicity scale?
What aer the Ix and results for acute haemolytic disorders?
Management
What are the common agents reported to induce haemolytic anemia in subjects with G6PD deficiency?
What is ITP and causes?
What are Ix for ITP
What is the management?
What is management of ITP in pregnant women?
Consult haematologist
How to make dx of heparin induced thrombocytopenia?
How to make dx of TTP
What Ix?
What is treatment?
What is approach to determine cause of pancytopenia?
What are tests for thrombophilia screening
What are the indications?
What are antiemetic therapy options?
What are indications for Immunoglobulin therapy
Dosage
Contraindications
What are the indications for usage of rF8a (novoseven)
What are the different DOACs
What are there indications and dosage?
What are the usual times to discontinue DOACs before surgery or invasive procedures for which anticoag needs to be stopped
What is the specific antidote of DOACs?
What is the suggested plasma peak level and duration of admin in hemophilia A and B replacement?
1 unit/kg BW of infused Factor VIII raises plasma level by 2%
1 unit/kg BW of infused Factor IX raises plasma level by 1%
DDAVP is useful for mild haemophilia A if a 3x increase in Factor VIII suffices. Each patient’s response should be tested prior to therapeutic use as there are individual variations. 0.3 microgram/kg in 50 ml normal saline iv in 20 minutes causes a peak in Factor VIII level at 30 minutes.
Prolonged use of DDAVP causes tachyphylaxis
Replacement therapy for Rare Bleeding Disorders
What are the dosage and indications for transfusion
Fresh whole blood
Whole blood
Platelets
Leukocytes
Plasma
Plasma methylene blue treated
What are the dosage and indications for transfusion
Cryoprecipitate
Leukodepleted red cells
Irradiated cellular blood components
CMV-ve cellular blood components
Rhesus D negative red cells
What is the management workflow for patients with suspected acute transfusion reaction
