Draft

46  Hematologic Emergencies In The ICU

46.1 What this covers

  • Acute Promyelocytic Luekemia
  • Leukostasis
  • DIC

46.2 Learning objectives

  • Acute Promyelocytic Luekemia
  • Leukostasis
  • DIC
  • SVC
  • Cord Compression
  • TLS
  • Cytokine Release Syndrome

46.3 Bottom line / summary

  • Often leukopenic (due to fragile cells) vs hyperleukocytosis in other AML, present in DIC/ecchymosis/severe coagulopathy.
  • (note: differentiate from hyperviscosity syndrome caused by hyper-proteinemia)
  • Definition: 25% increase from baseline of K, Phos, Uric or 25% decrease of Ca
  • Go to the binder and call oncology
  • ATRA, low risk so makes sense to treat if ambiguous and not excluded.

46.4 Approach

  1. ATRA, low risk so makes sense to treat if ambiguous and not excluded.
  2. Beware of ATRA differentiation syndrome -> capillary leak physiology. Treat with dexamethasone
  3. ATRA induced leukocytosis -> differentiation leads to high WBC. Add doxorubicin
  4. Psuedotumor cerebri
  5. Hyperleukocytosis over 100k

46.5 Red flags / when to escalate

  • TODO: List red flags that require urgent escalation.

46.6 Common pitfalls

  • Beware of ATRA differentiation syndrome -> capillary leak physiology. Treat with dexamethasone
  • avoid diuretics, PRBCs -> increase viscocity

46.7 References

TODO: Add landmark references or guideline citations.

46.8 Source notes

46.8.1 Hematologic Emergencies In The ICU

47 Hematologic Emergencies in the ICU

47.1 Acute Promyelocytic Luekemia

Often leukopenic (due to fragile cells) vs hyperleukocytosis in other AML, present in DIC/ecchymosis/severe coagulopathy.

Treatment:

  • ATRA, low risk so makes sense to treat if ambiguous and not excluded.

Side effects:

  • Beware of ATRA differentiation syndrome -> capillary leak physiology. Treat with dexamethasone
  • ATRA induced leukocytosis -> differentiation leads to high WBC. Add doxorubicin
  • Psuedotumor cerebri

47.2 Leukostasis

  • Hyperleukocytosis = over 100k
  • Leukostasis = hyperleukocytosis and symptoms (though can be lower than 100k, esp if acute leuk blast crisis = large blasts)

(note: differentiate from hyperviscosity syndrome caused by hyper-proteinemia)

Symptoms:

  • CNS: vision changes, headache, somnolence
  • Lungs: dyspnea, hypoxemia

Workup:

  • CNS imaging - risk of bleed
  • Hypoxemia: can have falsely low Po2 due to metabolism of O2 in ABG tube. Use SpO2

Treatment:

  • fluids
  • avoid diuretics, PRBCs -> increase viscocity
  • aggressive platelet support due to increased risk of CNS bleed which continues for several days after reduction
  • cytoreduction with treatment and/or leukopheresis

47.3 DIC

47.4 SVC

47.5 Cord Compression

47.6 TLS

Definition: 25% increase from baseline of K, Phos, Uric or 25% decrease of Ca

  • IVF
  • Allopurinol
  • Add rasburicase if AML WBC over 50 or ALL WBC over 100.
  • Dialysis

47.7 Cytokine Release Syndrome

Go to the binder and call oncology

47.8 Source materials