1. Haematology

2. Help I need blood! Both O negative and group specific are unsuitable for patients with antibodies…

3. How well do you know your blood products? FFP –How long does it take? …… 30mins –Does it need to be XM’ed? …. Yes –What does it contain? …. All CF’s + fibrinogen ….. BUT it’s large volumes and needs to be thawed –When else to use? …warfarin, factor deficiencies, TTP Cryo –How long does it take? …..30mins –Does it need to be XM’ed? …..preferable –What does it contain? …VIII, XIII, fibrinogen, vWF –When else to use? ….just in bleeding when fibrinogen <1 Platelets –How long does it take? …. 15-30mins –Does it need to be XM’ed? ….no –When else to use? …..ITP, DIC, bleeding and more… Prothrombinex –How long does it take? ……theoretically stat –Does it need to be XM’ed? …..no –What does it contain? …II, V, VII, IX, X, antithrombin, heparin –When else to use? …. Warfarin, factor deficiencies, significant bleeding –Do I need haematology consent to use it? ……no –Where is it stocked? …..blood bank –How do I get it? …..fill out form just like blood

4. Picture from JehovahsWitness.net – highly recommended source material

5. What about factor VIIa? Trials have not identified clinically significant improval of outcome Increased mortality in blunt trauma 5% increased risk of VTE Indications? –As last resort in generalised bleeding only if control of bleeding has been obtained

6. Massive Transfusion Definition of massive transfusion? –>50% patient’s blood volume at once –100% patient’s blood volume over 24hrs Prognosis: 45-65% survival rate Name the movie…

7. Fill in the blanks… Remember ratio PRBC : FFP : plt : cryo 5 : 5 : 1-2 : 1-2

9. In Summary… O neg 2iu PRBC + 2iu FFP 4iu PRBC + 4iu FFP + 3iu cryo 4iu PRBC + 4iu FFP + 1iu plts Alternate the above Check bloods every 30mins Aim INR 1, plts >75, Ca >1

10. DIC What is it? –Acquired diffuse inappropriate intravascular coagulation with 2Y fibrinolysis or inhibition of fibrinolysis  microvascular thrombi, consumptive coagulopathy  ARF, ARDS, ALF, CCF, bleeding, purpura fulminans, gangrene

11. Part II Pneumonic H Hepatic failure O Obstetric (eg amniotic fluid embolism, eclampsia, fetal death, placental abruption, septic abortion) T Trauma (eg. Fat embolism, rhabdo, HI, burns, envenomation, hypothermia) M Malignancy I Immune (eg. Rejection, tranfusion reaction, anaphylaxis) S Sepsis (esp G-ives) S Shock

12. Management Remember this? Give Vit K to all Give PRBC if needed; May need large volumes of FFP If not bleeding, can tolerate platelets >20 Give folate supplementation; consider APC, factor VIIa; heparin if organ survival is threatened by thrombus

13. Warfarin Overdose Remember basics –Charcoal if <1hr

14. Summary before the test… INR <5 and stable If normal INR and no therapeutic need –Give 10-20mg PO Vit K –Discharge with repeat INR in 48hrs If INR <5 and therapeutic need –Omit dose –Consider 10% dose reduction

15. INR >5 and stable If no therapeutic need –10mg IV Vit K –Consider discharge with follow up INR If therapeutic need –Don’t overshoot –Consider 1-5mg PO Vit K –Recheck INR at 6-12hrs and give repeat dose until INR <5 then restart warfarin at lower dose –Heparin if INR <2 and at high risk

16. INR >5 and stable but high risk –Active peptic ulcer –Recent OT in 2/52 –On aspirin –Plt <50 –INR >9 PO / IV Vitamin K Consider PTX (25-50iu/kg depending on INR)

17. INR >5 and unstable / life threatening bleed –ICH, spinal, intra-abdominal, intraocular –Haematemesis, melaena, significant haemoptysis –SBP <90 –Oliguria –Decr Hb >20 –Or “at risk of significant bleeding” – use common sense 1-2iu FFP 50iu/kg PTX 5-10mg IV Vit K

19. Vit K can be given as slow IV push over 2-3mins IV Vit K onset of action: 3-6hrs PO Vit K onset of action: 6-24hrs PTX onset of action: 15mins After PTX completed (3ml/min, 500iu in 20ml therefore up to 140ml needed to give 50iu/kg to 70kg male) can repeat INR after 15mins. Repeat dose as necessary as per INR.

20. Dabigatran Mechanism of action –Direct thrombin inhibitor Duration of action –12-24hrs –Longer if renal impairment Reversal agent –There is none Treatment –Treat as per any haemorrhagic episode –Additional measures to ‘reverse’ if ‘significant bleeding’ and above not working –There is no published data on dabigatran reversal

21. What do coagulation tests mean in dabigatran??? There is no linear correlation between blood tests and bleeding risk APTT –Higher risk of bleeding if >80, but <80 ‘may be acceptable’; moderate sensitivity PR / INR –Higher risk if >1.5; lower sensitivity dTCT –Very sensitive; levels >80 seen in low or high dabigatran levels APTT and PR normal = low risk APTT <50 and PR <1.5 = levels ‘probably low to moderate’ Can you do dabigatran levels? –Yes –Therapeutic = 0.09mcg/ml (trough) to 0.18mcg/ml (peak) –If level 30, then levels will decrease over 12- 24hrs –Threshold for dialysis UNKNOWN

22. Rever

23. In Summary Stop dabigatran If OD – consider charcoal Check bloods, inc TCT, and crossmatch Vit K + tranexamic acid (easy to do) If bleeding: fluids, RBC, FFP If plt <80 or on anti-plt: plts If bad bleeding / brain bleeding: PTX + factor VII If severe and renal failure: haemodialysis

24. Neutropenic Sepsis Febrile neutropenic patient has >60% likelihood of ‘being infected’, and 37% chance of +ive blood culture (usually G-ives) What’s the definition of neutropenic sepsis? –T >38.5 (or >38 twice over 2hrs) –Neutrophils < 1.0 X 109/L Assessment –2x blood cultures –Central and peripheral blood cultures if line –Take down dressing and check site if recent aspirate / line

25. Treatment of Low Risk Patient

26. Treatment of High Risk Patient What’s a high risk patient? (hidden on haematology website) –Neutrophils <0.5 –“Rapid decrease” in neutrophils –“Protracted” neutrophils <0.5 –“Other contributing factors” eg. Immunocompromised, steroids, central line, GVHD –BMT patient with impaired B and T cell function

27. Treatment of High Risk Treatment