Transcript Common Blood Abnormalities

Common Blood
Abnormalities
Miss Samantha Chambers
CT1 General Surgery
3rd August 2015
Aims
 Recognising common blood abnormalities including;
 Deranged potassium, sodium, phosphate, magnesium
and haemoglobin
 Learn how to manage these in an acute setting
 Understand importance of the clinical picture, not just
the numbers
 Hopefully feel a little less scared about Wednesday!
Case 1
 Mrs A is an 83 yr old lady on the surgical ward admitted
today with an incarcerated inguinal hernia
 You check the bloods for Mrs A at 4.30pm, just as you
are about to leave
 Unfortunately her blood results are as follows;
 Hb110, WBC 12, CRP 25, Na 138, K+6.5, Ur 6, Creat 102
 How are you going to manage this lady?
High potassium
(hyperkalaemia)
 Normal range 3.5 – 5.5
 >5.5mmol considered raised
 Threshold for treatment is 6.0 or ECG changes/symptoms
 Can be caused by AKI (or ESRF)
 ECG changes in hyperkalaemia:
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Low, flat p waves
Broad, bizarre QRS
Slurring into the ST segment
Tall tented T waves
Management
 Acute treatment:
 ECG
 Stop any antagonistic drugs
 10mls 10% Calcium Gluconate (cardiac monitoring)
 10 units actrapid insulin in 50mls of 50% dextrose(can do 20%)
dextrose over 30 mins
 Salbutamol 5mg nebs
 Repeat K+ 4 hours post infusion
 Longer-term treatment
 Find cause
 Calcium resonium 15g TDS
Case 2
 75 yr old lady, Mrs B, has been on the medical ward
with a LRTI for a few days
 You check her blood results at 6pm, just as you are
about to leave and they are as follows (sorry!);
 Hb 120, WBC 6, CRP16, Na 136, K+2.0, Urea 4.3, Creat
99
 How would you manage this lady?
Low potassium
(hypokalaemia)
• Lethargy
• Cardiac arrhythmias
• Management;
• Depends on level
• Find the cause
• <3 IV replacement – max
80mmol KCl per day via
peripheral line
• 40mmol in 5% Dextrose
or 0.9% N Saline over 412 hours
• >3 oral – 2 tablets Sando-K
TDS for 3 days only (monitor
K+)
 You are an excellent F1 doctor and have been diligently
replacing Mrs B’s potassium inravenously for the past
two days
 You check her blood results today at 7pm, ad are
certain that they will have improved;
 Hb 120, WBC 5, CRP10, Na 135, K+1.9, Urea 4.0, Creat
97
 Uh oh!
 Why hasn’t Mrs B’s potassium improved? What
else do you need to check?
 Remember;
 In hypokalaemia, always check the magnesium
level
 K+ will not rise if Mg low
Low magnesium
(hypomagnesaemia)
 Can be due to poor diet, diuretics (loop), refeeding
syndrome
 Can lead to arrhythmias!
 Replace as per trust guidelines
 Either:
 Magnesium Glycerophosphate 2 tabs (8mmol) TDS for 3
days
 Or 20mmols MgSO4 in 500/1000ml N.Saline/5% dextrose
over 4-8 hours
Low phosphate
(hypophosphataemia)
 Can be due to poor diet, GI losses (diarrhoea)
 Beware REFEEDING SYNDROME
 If patient not eaten for 5/7 at risk
 When fed, serum levels of Ca, Mg, PO4, K all plummet
 Low PO4 can lead to seizures
 See Intranet guidelines for replacement regimes:
 Phosphate Sandoz 2 tabs TDS for 3 days
 Or if <0.5 – Phosphate polyfusor as per guidelines
 Rate of 9mmol over 12 hours
 500ml bag contains 100mmol phosphate
 So give 100ml over 24 hours – will deliver 20mmol phosphate
(must discard rest of bag)
Indications for haemofiltration
 Persistent hyperkalaemia, resistant to treatment
 Acidosis, resistant to treatment
 Pulmonary oedema, resistant to treatment
Low sodium (hyponatraemia)
 <135mmol
 Very common – causes are many, commonest are drugs!
PPIs, Diuretics, SSRIs
 In reality unlikely to cause problems unless < 120-125
 Can cause seizures
 If <135 & >125 and stable can usually just observe
 Trust guideline on hyponatraemia is good
 Treatment depends on cause (hypovolaemic, euvolaemic,
hypervolaemic)
 Management;
 Find the cause;
 Send urine osmolality and serum osmolality, urine sodium
and serum sodium
 Check drug kardex for culprit drugs
 Can fluid restrict to 1.5L per day (not if hypovolaemic!)
High sodium
(hypernatraemia)
 >145mmol
 Usually due to dehydration, or too much 0.9% Saline!
 Treat with IVI (Dextrose, not Hartmann’s or 0.9%
Saline!!)
 If the patient is well, ask them to drink more!
 Recheck U&E’s
Low haemoglobin (anaemia)
 With low MCV
 With normal MCV
 With high MCV
 Consider the cause
 Is the patient acutely
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bleeding?
Occult haemorrhage?
Post-op?
Chronic
disease/malignancy?
Renal failure?
 Management;
 If Hb <80 or patient is
symptomatic then usually
a role for transfusion –
discuss with senior as
some clinicians may wish
for higher levels in
specific situations
 Transfusion written as
RBC to be given over 2-3
hours (in stable patients)
 If acutely bleeding and
massive haemorrhage
suspected then activate
MHP by calling 2222
High WBC (leucocytosis)
 Usually a sign of infection
 Elderly or immunosuppressed (eg. steroids or
transplant patients) – dampened immune response so
may not mount a leucocytosis in response to sepsis
 Remember SIRS – WBC <4 or >12
 N.B. Patients on steroids may have a neutrophilia
Low WBC (neutropenia)
 Can be caused by sepsis (e.g. atypical infections or elderly)
 Or by bone marrow suppression e.g. post chemo, or bone marrow
failure e.g. MDS
 Neutropenia <1.0 x109
 If <1.0 and signs of SIRS/Sepsis – follow trust neutropenic sepsis
guidelines
 Side room
 Cultures and CXR
 IV Abx ( as per guidelines)
 IVI
 Discuss with haematology
Raised CRP
 Acute phase inflammatory
marker
 24 hour lag
 Can be raised in
inflammation, infection,
malignancy
 Will be raised postoperatively
 Management;
 Search for cause/source
 Are there obvious signs of
infection eg. urine, chest?
 If signs of SIRS/sepsis then
do a septic screen – CXR,
urine dip, ABG, blood
cultures, bloods, if indicated:
wound, line, drain cultures
 If suspected source of
infection then treat
accordingly – sepsis six
 Do not treat purely on basis
of the numbers
SIRS and Sepsis
 SIRS criteria;
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Temperature <36 or >38
HR >90 bpm
RR >20 or PaCO2 >4.3kPa
WBC <4 or >11
 Sepsis = SIRS + source
of infection/suspected
source
 Septic shock = Sepsis +
organ hypoperfusion
leading to organ
dysfunction
Low platelets
(thrombocytopaenia)
 Sepsis
 Post-chemotherapy
 Coagulopathy
 Drugs
 LMWH-induced
thrombocytopaenia
 HITT syndrome
 If <80 can’t have
procedures e.g. liver
biopsy or surgery
 If <50 hold LMWH
 Management;
 May need discussion with
haematology
 May require platelets prior
to procedure
Raised platelets
(thrombocytosis)
 Usually a reactive finding
 Can be raised due to infection, inflammation, surgery,
hyposplenism, splenectomy
 If persistently raised platelets with no explanation –
discuss with haematology re: further investigations ?
myelodysplastic syndrome eg. polycythaemia rubra
vera, CML
Deranged clotting factors
 DIC – low fibrinogen, raised PT, INR, low platelets
 Raised INR;
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Stop warfarin (if on warfarin)
Look for cause (if not on warfarin)
Trust guidelines for management
If INR raised but no acute bleeding – Vitamin K 5mg PO,
or Vitamin K 5mg IV – depends on level, and whether
operation is likely to take place
 If acutely bleeding and INR >8 then prothrombin complex
(octaplex)  needs discussion with haematology first
LFT’s made easy…
 Standard LFTs: Albumin, Bilirubin, ALT/AST, ALP/GGT
 Raised bilirubin = Jaundiced (>50)
 Pre-hepatic (unconjugated) e.g. haemolysis, Gilbert’s syndrome
 Hepatic (mixed) e.g. viral hepatitis, drugs, ischaemia
 Post hepatic/ obstructive (conjugated) – dark urine, pale stools
 ALP/GGT are markers of obstructive jaundice i.e. gallstone in CBD
 ALT/AST are makers of hepatic damage i.e. viral hepatitis
 If ALP/GGT rise is > than ALT/AST it’s a post hepatic problem
 If ALT/AST rise is >ALP/GGT it’s a hepatic problem
Hepatitis screen
 Serology – Hep B, Hep C, (Hep A and E), HIV
 Autoantibodies – AMA, SMA, ANCA, LKM
 Iron studies – Ferritin, Serum Iron, TIBC, Transferrin
sats
 Others – A1AT genotype, Caeruloplasmin & Copper
levels
 Don’t forget to USS the liver
 P.S. You don’t need to get a gastro review before doing
these!
Low albumin
(hypoalbuminaemia)
 Negative phase inflammatory marker
 In sepsis it will drop – this doesn’t mean they’re
malnourished
 Can be low as a marker of malnutrition if chronic (but
Anorexics often have normal levels)
 When <20-24 can develop oedema
 No role for IV albumin replacement!!
Low calcium (hypocalcaemia)
 Can occur due to drugs
(diuretics), poor diet,
refeeding syndrome
 <2.2 (adjusted calcium)
 Symptoms includes
cramps and tetany
 Management;
 ECG
 AdCal1-2 tabs OD
 or IV replacement
 10mls 10% Calcium
gluconate
 Prolongation of QT interval (QTc)
Raised calcium
(hypercalcaemia)
 Can occur in renal failure,  Management;
dehydration and
malignancy (particularly
breast)
 Stones, bones, moans,
psychological groans
 Renal tract calculi
 Bone pain / fractures
 Constipation
 Depression
 ECG
 IV fluid replacement
 Bisphosphonates eg.
Pamidronate – only if
calcium >3
 Discuss with renal team if
associated renal failure
 Shortening of QT interval
Case 3
 78 yr old man, Mr C
 PC – ‘Off legs’
 HPC – Care staff state he has been unwell for past few days in the care
home. No appetite. Unable to mobilise today. Seems more confused
 PMH – IHD, MI x 3 previously, previous TIA’s, prostate cancer and chronic
back pain
 Allergies – Nil
 Medications – Ramipril, spironolactone, omeprazole, MST (recently started by
pain team)
 Social – Lives in a care home, usually lucid and able to undertake personal
care for himself
 O/E:
 Unkempt and strong smell of urine
 Temp 38.6, BP 130/80, HR 68bpm, regular, RR 16, 02
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sats 98% on air
Appears very confused – believes he is at his marital
home, and that the year is 1972
Not oriented in time/place/person
HS 1+11+0
Chest - Reduced air entry at left base
Abdomen soft, non-tender
Investigations
 Bedside
 Urine dip – positive for leucocytes, nitrites and protein
 ECG- no acute ischaemic changes
 Bloods
 Hb 120, WBC 16, Ur 8.9, Creat 109, K+4, Na 125, CRP
40, INR 1
 Imaging
 CXR- cardiomegaly, shadowing at left base suggestive of
consolidation
Differentials?
 Acute confusion secondary to;
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UTI
LRTI
Hyponatraemia
Opioids
Confusion screen
 Acute confusion, acute delirium or undiagnosed
dementia?
 Septic screen inc FBC, U&Es, LFTs, CRP, BCMs, urine
dip, CXR
 Check TSH, B12, Folate
 Consider CT head
 Check the drug chart!!
Case 4
 A 92 yr old gentleman, Mr D, is admitted having sustained a right
NOF fracture. He was given diclofenac in A&E as he was in a lot of
pain.
 He is operated on, on the same day of admission (which is a
Saturday, Jeremy), and is taken back to the orthopaedic ward.
 Unfortunately they are extremely understaffed, and Mr D, who
usually requires assistance to eat and drink, gets slightly
overlooked as there is a very sick patient overnight who is periarrest
 His initial blood results were;
 Hb 140 WBC 6 CRP 6 Na 140 K+4.5 Ur 5 Creat 90
 You are the F1 on call on Sunday and are asked to recheck his
blood results…
 His blood results today are;
 Hb 135 WBC 10 CRP 15 Na 144 K+4.4 Ur 10 Creat 190
 O/E:
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Appears very dehydrated, with dry mucous membranes
Observations stable
No oozing from wound site
HS1+11+0
Chest clear
Abdomen soft, non-tender
Urine output for past 3 hours ~ 15ml
 How will you manage Mr D?
Acute kidney injury
 In adults, a diagnosis of
AKI can be made if:
 Blood creatinine level has
risen from the baseline
value for that person (by
26 micromoles per litre or
more within 48 hours)
 Blood creatinine level has
risen over time (by 50% or
more within the past 7 days)
 Oliguria (less than 0.5ml
per kg per hour for more
than 6 hours)
 Management;
 Try to identify a cause eg.
recent contrast?
Dehydration?
 Stop any culprit drugs
(especially NSAID’s in
elderly)
 IV fluid replacement
 Discuss with renal team
Dehydration
 A proportional rise in both
urea and creatinine
membranes, patient feels
thirsty, oliguria or anuria
 However, urea may be
slightly more raised than
creatinine
 Note: If urea is dramatically
raised out of proportion to
creatinine – suspect GI
bleed (as the blood acts as a
protein meal)
 Clinically – dry mucous
 Management;
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Search for the cause
IV fluid replacement
Catheterise patient
Meet fluid demand eg. if
high output fistula/stoma
 Discuss with renal team
Summary
 Remember to repeat the sample if you suspect a
spurious result
 Common things are common – low/high potassium and
sodium and anaemia
 Trust guidelines can be very useful
 Don’t panic!
 If in doubt, ask!
Questions?