Hematologic Emergencies

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Brenda Shelton, who will be talking with us about any and all questions you have regarding hematologic emergencies. Welcome Brenda!

 sheltbr 

Hi all. Welcome to the chat. Send me your burning questions.

 Laurl at ONS 

Brenda, to get us started, can you tell us how can we determine the difference between sepsis and engraftment?

 sheltbr 

Engraftment syndrome and sepsis fundamentally look very similar. Let me summarize key differences.

 sheltbr 

Engraftment begins when lymphocytes engraft the marrow and release cytokines, creating a sepsis-like picture.

 sheltbr 

Engraftment differs in that you are more likely to see whole erythema, transaminase elevations, hematuria.

 sheltbr 

Both have fever, hypotension, respiratory difficulties. Often only diagnosed when counts return and patients get better fast.

 sheltbr 

Has anyone been challenged such patients and have stories to tell?

 MarieLindsay 

I'd like to know more about how to interpret "iron study" lab results, especially transferrin and ferritin.

 sheltbr 

Well, not easy to do off the cuff, let me create my thoughts.

 sheltbr 

Ferritin is an iron precursor and is tested to make sure the body has the building blocks for hemoglobin.

 sheltbr 

Transferrin is an important carrier protein that re-circulates iron for reuse. Both are important for production of new RBC's.

 sheltbr 

If either is low, no amount of "stimulation" of RBC's will create new RBC's. I have not committed values to memory, and many lab normals differ. Does this help?

 lccpurple@aol.com 

How often do you do labs when giving tx for iron overload?

 MarieLindsay 

This helps a little, thanks.

 sheltbr 

Regarding iron overload, the chelating agents do not work overnight, but do work more quickly when levels are high, so initially check weekly, then back off to every 2 weeks, then every 4 weeks. Good question.

 sheltbr 

Regarding the interpretation of RBC tests. I will post a reference article on the transcript so check back.

 lccpurple@aol.com 

I asked because we are checking twice weekly and also qow giving blood so I am confused.

 sheltbr 

Does anyone work with leukemia patients and see leukostasis?

 sheltbr 

Regarding iron overload, I am not familiar with this plan of care, but I will post any info I can find on the transcripts.

 sheltbr 

Re iron overload, I don’t want to mislead you with an off the cuff opinion, so I will check my references.

 Laurl at ONS 

Brenda, in leukostasis, the platelets and RBCs are so low, yet transfusions are not recommended- why is this?

 sheltbr 

Leukostasis is defined as high WBCs with high percentage of blasts. This causes hyperviscosity. More..

 sheltbr 

The packed marrow and hyperviscous blood with immature WBCs causes decreased production, but giving blood products causes worsened viscoscity and can lead to stroke or hemorrhage.

 sheltbr 

It is a common mistake by non-oncology clinicians to try to help us by giving transfusions until they can transfer the patient. They don't realize how dangerous it can be. I always explain this to ED's and ICUs when I get report.

 Laurl at ONS 

So how do you treat?

 lccpurple@aol.com 

Is this with BMT pts. or just diagnosed leukemia pts?

 sheltbr 

Fluids is the mainstay of early immediate therapy. Next chemo or pheresis.

 sheltbr 

Regarding who gets this... it requires the presence of blasts, so BMT patients usually present in remission or minimal disease, but if they relapse post BMT they may present like this.

 sheltbr 

There is controversy about whether to give immediate high dose chemo like cytoxan or pherese. Have any of you a standard practice?

 sheltbr 

Chemo provides drop in counts in hours to days but more tumor lysis, pheresis may not drop the counts as quickly, but less tumor lysis therefore less renal failure.

 sheltbr 

It does depend upon MD preference. As a CC nurse, I think pheresis is a more gentle way because most who get chemo immediately get very sick.

 sheltbr 

There are lots of people here in the chat. Would any of you like to share your work setting or practice specializations?

 lccpurple@aol.com 

I work outpt. infusion area bmt and med/onc doing any type of infusion.

 bhart 

Regarding standard of practice for leukostasis, we pherese until the count is stable at 40,000 or lower if possible, then we give the chemo

 sheltbr 

Thank you for answering. That sounds like a solid practice that may help us resolve our differences of opinion.

 bhart 

We are mostly outpatient infusion but we asked our pheresis charge nurse to comment about the leukostasis.

 sheltbr 

Re: your standard of care: I like it!!! I am going to check with our heme team.

 Laurl at ONS 

Are there any pearls for determining which of the febrile neutropenic patients are most likely to develop sepsis or septic shock?

 sheltbr 

Good question!. We have learned a great deal about sepsis in the most recent decade.

 sheltbr 

I hear the ICU sepsis standards are going to become a JCAHO standard and will cross specialties.

 sheltbr 

If patients present with resp distress of hypotension it holds the poorest prognosis and greatest risk for shock. But the real pearl for practice is...

 sheltbr 

Check a lactate. In patients suffering from sepsis induced organ poor perfusion, the lactate will rise and may be the only symptom other than tachycardia or tachypnea.

 sheltbr 

Other risk factors for sepsis to septic shock are: ANY abdominal source, any fungal source and let me think some more- am sure there are a few more

 sheltbr 

Have many of you experienced patients who looked merely febrile neutropenia rapidly progress to shock?

 lccpurple@aol.com 

I have- it was so fast and with a poor outcome.

 sheltbr 

If we can better identify these high risk profiles or the lab predictors, it would be nice to help us plan for the crisis.

 bhart 

We had a patient recently who was febrile at home and did not report it for 24 hours. When he came in his fever was normal but he felt "lousy" as our patients often report. His fever spiked rapidly and his blood pressure bottomed out. Our oncologist was trying to get the abx (antibiotics) in before transfer to admit, but he was crashing within 2 hours. His ANC was very low (I can't remember the exact count) around 500.

 stemcell 

i have an experience that an aplastic anemia pt who was going on ATG therapy. As we know, that drug induces a fever with shivering. A doctor ordered 'just give tylenol' and then some hours later, the pt went to septic shock.

 gmwk 

bhart was this in an outpatient setting - medical oncology office?

 sheltbr 

Bhart-Yipes that is scary. Delay in presentation is a key problem. I commend you for trying to get antibiotics in, as it may have been delayed with transfer.

 bhart 

Yes, outpatient, hospital based clinic but the hospital is off site

 sheltbr 

stemcell- that has been a common mistake for all of us at one time or another. High index of suspicion is key- then look for subtle indicators like low urine output, changes in mentation with chills (not usually allergic rxn).

 stemcell 

that's right

 bhart 

Our septic shock patient presented with all of the above.

 sheltbr 

Bhart- alot of oncology practices are off site and this presents challenges in recognizing manageable versus unmanageable complications.

 sheltbr 

Since many of you may be in areas with limited emergency resources, think FLUIDS, antibiotics, airway, but most important suspect for high risk and key symptoms.

 stemcell 

Can anybody share 'mini' BMT prognosis?

 bhart 

We are in the process of RCA ( root cause anaylsis) to try to standardize procedures for septic patients.

 sheltbr 

stem cell- what exactly do you mean by prognosis- of transplant itself?

 stemcell 

yeah, I have seen it before but I'm not quite sure if it works.

 sheltbr 

bhart- good idea re: root cause analysis. When did this once we discovered that we often missed the patient with subnormal temp as an impending sepsis.

 stemcell 

outcome

 stemcell 

Re: mini BNT- the outcome I have seen wasn't good....

 bhart 

Patient survived - RCA stiil in process. Do you have an opinion about transfer to hospital as priority over abx?

 sheltbr 

Stemcell- re: mini BMT outcomes -are still in the process of eval. As you know most who get mini BMT have contraindications for regular BMT- e,g, post solid organ transplant, comorbid health, etc. I have seen a fair bit of critical illness with these patients, but some successes as well.

 sheltbr 

bhart-re: opinion re: immed. Transfer vs. Antibiotics first- in most circumstances immediate antibiotics should be give as preparing for transport. I would always go that route and if BP drops, give fluid. No respsonse after 2L, they need pressors and transfer. You can always send the antibiotics with ambulance to give or push some of them, but if you don’t start antibiotics, they won't get until triaged- maybe 30-60 min.

 lccpurple@aol.com 

Our BMT out pt has standing orders for temps , I could fax this to you for info bhart

 bhart 

Thanks!

 Laurl at ONS 

bhart if you'd like to share your email address, please email me at lmatey@ons.org and I'll forward it to iccpurple.

 bhart 

(510) 204-3508

 Laurl at ONS 

What are the earliest signs and symptoms of hepatic veno-occlusive disease?

 sheltbr 

Hepatic VOD is much less common these days with more knowledge of risk factors- high dose alkylating agents, TBI, hepatitis, more..

 sheltbr 

It still presents with the typical abdominal pain, I > O, weight gain as early symptoms. Bilirubin rise comes next and SGOT rise follows. Also seen with mylotarg and gemcitabine.

 sheltbr 

I know we have some that work with BMT pts- do you see VOD often? Anyone using heparin or defibrotide to prevent or treat?

 sheltbr 

We recently had a rather severe early case of VOD and started continuous dialysis with gentle fluid removal. Pt did not get hepato-renal syndrome or any LT complications even though Bilirubin went to 15.

 Laurl at ONS 

We have about 5 more minutes - please continue to ask your questions! Also, at the end of today’s chat, please take a moment to cut and paste this URL into your browser and take our very brief survey- we’d love to hear what you think of these chats! The URL is: http://research.zarca.com/k/RsTUTRsRYVsVXVSVsPsP . Thank you!

 Laurl at ONS 

What is typhlitis?

 sheltbr 

It is an interesting unique complication seen most often in immunocompromised...

 sheltbr 

Gram negative bugs in gut cause inflammation, primarily in appendix area or cecum that is poorly perfused. Presents like acute abdomen- fever, hypotension, etc

 bhart 

That's what our septic patient had

 Laurl at ONS 

Welcome connie sam...we are just about to end the chat but can take a few questions if you have them!

 sheltbr 

Re: typhlitis- Immediate antibiotics, gut rest, fluids and consideration if percutaneous drain may help. We see less now with growth factors and and norflox as oral prophylaxis.

 conniesam 

that's okay---I just thought I'd take the chance in case it was a 2 hr chat

 Laurl at ONS 

The transcript will be posted on Monday- check it out then!

 conniesam 

sounds good

 sheltbr 

Re: typhlitis, my thoughts are if can be kept at low level with antibiotics and support, then fine, but if me and get to pressors- give me the knife.

 sheltbr 

It is a bad prognosis because usually gram negative organisms

 Laurl at ONS 

Well, folks, I'm sorry but our time has ended! Thank you for your participation tonight! We hope that you enjoyed. Please come to the next chat next Wednesday at 11am EASTERN on cardio-pulm onc emergencies. The transcript for tonight will be posted on Monday.

 sheltbr 

Thanks to all for coming and adding to the great conversation. Hope to see some of you next week.