CHAPTER 29. Hematological Care
Wanda Rodriguez
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Describe normal and abnormal laboratory values and initiate appropriate nursing interventions as needed.
2. Describe the nursing care of a patient with a hematological disorder.
3. Describe the nursing interventions for a patient with a disorder in hemostasis.
4. Describe nursing responsibilities associated with blood and blood component transfusions.
5. Identify the types of transfusion reactions and the appropriate nursing interventions.
I. OVERVIEW
A. Common blood dyscrasias in the following areas:
1. Hematology
2. Hemostasis
B. Chapter broadly presents:
1. Clinical signs
2. Laboratory results
3. Nursing interventions
II. PERIANESTHESIA ISSUES RELATE TO HEMATOLOGY
A. Preoperative clinical assessment with laboratory tests
1. Alterations affect outcomes, especially oxygenation and hemostasis.
a. Critically assess potential for:
(1) Anemia
(2) Coagulopathy
b. Review clinical indications and medical history.
c. No established minimum value for presurgical hemoglobin (Hgb)
d. Routine laboratory screening is neither required nor recommended for every preoperative patient.
(1) When preoperative Hgb low, continue with surgery as planned depending on:
(a) Acuity of anemia
(b) Patient’s cardiopulmonary response
(c) Surgical urgency
e. Preoperative hemoglobin selectively recommended for:
(1) Neonates to detect physiological anemia
(2) Elderly patients
(3) Menstruating women
(4) Bone marrow suppression
(5) Malignancy
(6) Genetically determined anemic conditions
f. Preanesthetic screening may uncover unrecognized coagulopathy.
(1) Documented coagulation disorder seldom appropriate for surgery in the nonacute ambulatory setting.
2. American Society of Anesthesiologists (ASA) “Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies”
a. Preoperative intervention recommendations
(1) Discontinue anticoagulation in advance of surgery.
(2) Delay surgery in elective cases until drug effects (e.g., warfarin, clopidogrel, aspirin) dissipate.
B. Transfusion is not innocuous; there are potential risks.
1. Complications cannot be overlooked or minimized.
a. Hemolytic reactions (Refer to section V, subsection C.)
b. Transfusion-related acute lung injury
(1) Occurs usually within 2 hours of beginning of transfusion or appears within 6 hours
(2) Food and Drug Administration (FDA) reporting indicates leading cause of transfusion-related fatality
(3) In-hospital mortality rate: 5% to 10%
(4) Causes
(a) Antibodies in plasma against human white blood cell antigen lead to immune-mediated response.
(b) Lipid inflammatory agents mediate granulocyte antigens.
(5) Signs and symptoms
(a) Acute dyspnea
(b) Noncardiogenic pulmonary edema
(c) Frothy sputum
(d) Diffuse bilateral infiltrates
(e) Crackles
(f) Fever
(g) Tachycardia
(h) Hypotension
(6) Treatment
(a) Stop transfusion.
(b) Administer oxygen.
(c) Intubate.
(d) Place on mechanical ventilation.
(e) Hypotension not responding to fluids, administer vasopressors.
(f) Involves noncardiogenic pulmonary edema
(g) No diuretics as can worsen the situation
(h) Nonsteroidal anti-inflammatory drugs (NSAIDs)
(i) Prostaglandins
c. Transfusion transmitted
(1) Human immunodeficiency virus (HIV)
(2) Cytomegalovirus (CMV)
(a) Carried by 70% of donors
(3) Viral infections such as hepatitis
(a) Hepatitis not detected by donor testing: long “seronegative” period; most (>90%) transmitted hepatitis is hepatitis C.
(4) Especially threatening to the immunosuppressed
(a) Occurs 3 to 6 weeks post transfusion of large amounts of fresh blood
(5) Bacterial contamination: in blood bank
(a) Stored units can cause severe septicemia.
(b) Mortality nearly 60% because of endotoxins producing gram-negative organisms
(c) FDA reporting indicates third most common cause of transfusion- related fatality
d. Transfusion-related immunomodulation
(1) Immunosuppression occurs after transfusion.
(2) May cause reactivation of latent viruses such as CMV
(3) Causal relationship not proven but linked in recurrence of:
(a) Resected malignancies (especially colorectal cancer)
(b) Inflammatory bowel disease
(c) Spontaneous abortions
(4) Associated in development of postoperative infections
(5) Leukocyte-depleted transfusions suggested as an alternative
2. Weigh against serious anemia risk: oxygen deficit, decreased perfusion
a. If mild:
(1) Palpitations
(2) Tachycardia
(3) New ejection murmur
b. If severe:
(1) Stroke
(2) Myocardial infarction
c. ASA “Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies”
(1) Intraoperative and postoperative management recommendations
(a) “Red blood cells should usually be administered when the hemoglobin level is low (e.g., less than 6 g/dL in a young healthy patient), especially when anemia is acute.”
(b) “Red blood cells are usually unnecessary when the level is more than 10 g/dL.”
(c) “These conclusions may be altered in the presence of:
(i) Anticipated blood loss.
(ii) Active critical (i.e., myocardium, central nervous system, or renal) organ ischemia.”
(2) “The determination of whether intermediate Hgb concentrations (i.e., 6-10 g/dL) justify or require red blood cell transfusion should be based on:
(a) Any ongoing indication of organ ischemia
(b) Potential or actual ongoing bleeding (rate and magnitude)
(c) The patient’s intravascular volume status
(d) The patient’s risk factors for complications of inadequate oxygenation.”
(3) “These risk factors include a:
(a) Low cardiopulmonary reserve
(b) High oxygen consumption.”
3. Metabolic effects of stored blood: a 35- to 42-day “shelf life”
a. Toxic enzymes from dead white blood cells (WBCs) and platelets “significant” after 14 days of storage
b. Hypocalcemia: ionized calcium binds with citrate used to preserve stored blood.
c. Aging blood results in:
(1) Hyperkalemia: potassium released from cell lysis
(2) Acidosis
(3) Independent risk factors for multiple organ failure
d. Postoperative infection and immunosuppression risk
(1) May not be evident for months posttransfusion
(2) After spinal fusion, joint replacement, transfusion associated with iatrogenic wound infection, longer hospital stay, and more days of fever, antibiotic therapy
(3) Tumor recurrence linked to transfusion, unproven
C. Autologous transfusion: alternative to allogenic transfusion
1. Preoperative autologous donation. Patient predonates units of own blood.
a. Patients may be ineligible for presurgical donation because of:
(1) Weight
(2) Age
(3) Restrictions
(4) Anemia
(5) Cardiac conditions
b. Advantages
(1) Prevention of disease transmission
(2) Some adverse transfusion reactions
(3) Reassurance about blood risks
c. Disadvantages
(1) Higher cost
(2) Wastage of unused blood
(3) Potential for clerical error
(4) Likelihood of requiring transfusion due to risk of perioperative anemia
2. Reinfusion of salvaged blood intraoperatively or postoperatively
a. Recovered red blood cells (RBCs) have oxygen transport properties equivalent to allogenic transfusions.
b. As long as the salvaged blood stays connected with the patient’s circulation, intraoperative blood salvage is often acceptable to Jehovah’s Witnesses.
3. Acute normovolemic hemodilution
a. Removal of patient’s blood and restoring intravascular volume with:
(1) Crystalloid
(2) Colloid
b. Done before start of the operative procedure after induction
c. Dilution of patient’s blood reduces RBC losses, when blood is lost during surgery.
d. Reinfusion can occur at any time during or after surgery.
D. Alternatives to allogenic transfusions
1. Epoetin alfa (recombinant human erythropoietin)
a. Stimulates erythropoiesis in the bone marrow
b. Frequently used in:
(1) Cancer-related anemia
(2) Anemia with renal insufficiency
(3) Anemia in the critically ill
c. Products: Epogen or Procrit
2. Antifibrinolytic agents
a. Blood loss reduction after surgery, especially cardiac, and in trauma
b. Products
(1) Aprotinin (Trasylol)
(2) Aminocaproic acid (Amicar)
(3) Tranexamic acid (Cyklokapron)
c. FDA issued a Public Health Advisory for aprotinin.
(1) Adverse effects
(a) Myocardial infarction
(b) Stroke
(c) Renal dysfunction
E. Bloodless medicine programs
1. Team approach in providing best medical care to all patients using alternative to allogenic transfusions
2. Advocating for patients who do not accept transfusions (e.g., Jehovah’s Witness)
III. HEMATOLOGY COMPONENTS: BLOOD CELLS AND CLOTTING FACTORS
A. Hemoglobin: carried on RBCs
1. RBC physiology (Box 29-1)
a. Critical transporter of oxygen to tissues
(1) Carried on hemoglobin molecule to tissues
(2) Normally concave on both sides (biconcave)
(3) Proportion (percentage) in total blood volume is hematocrit.
b. Produced in bone marrow and removed by the spleen
c. Production stimulated by erythropoietin, which is produced by the kidney
d. Life span approximately 120 days
BOX 29-1
HEMATOLOGY: NORMAL LABORATORY VALUES*
Red blood cells (RBCs)
▪ Male: 4.6-6.2 million per microliter
▪ Female: 4.2-5.4 million per microliter
Hemoglobin (Hgb)
▪ Male: 13-18 grams per deciliter (g/dL)
▪ Female: 12-16 g/dL
Hematocrit (HCT): proportion of RBCs in circulating blood volume
▪ Male: 40%-54%
▪ Female: 37%-47%
White blood cells (WBCs): 4500-11,000 per microliter
Differential:
▪ Segmented neutrophils: 54%-62%
▪ Band neutrophils: 3%-5%
▪ Lymphocytes: 25%-33%
▪ Monocytes: 3%-7%
▪ Eosinophils: 1%-3%
▪ Basophils: 0-1%
Platelets: 150,000-400,000 per microliter
Prothrombin time (PT): 12-14 seconds
Usually expressed as International Normalized Ratio (INR): 0.7-1.8
Activated partial thromboplastin time (APTT): 30-40 seconds
Partial Prothrombin time (PTT): 25-41 seconds
Fibrinogen level: 200-400 mg/100 mL
Thrombin time (TT): 14-16 seconds
Fibrin degradation (split) products: 2-10 mcg/mL
D-dimer <250 ng/mL
*Guidelines only: normal values vary with clinical laboratory.
2. Anemia: hemoglobin or RBC deficit; hematocrit reduction
a. Cardiovascular symptoms vary with hemoglobin level and acuity of cell loss: weakness and fatigue common.
b. Assess and suspect acutely low hemoglobin if:
(1) Low oxygen saturation as measured by pulse oximetry (Sp o 2), particularly if intraoperative blood loss was significant
(2) Hypotension, perhaps noted by orthostatic changes when head of bed raised or ambulatory surgery patient stands
(3) Tachycardia, likely a compensatory way to sustain cardiac output and sustain normal blood pressure
(a) A multipurpose indicator representing a response by sympathetic nerves of the autonomic system
(b) Consider hypovolemia.
(i) With or without low hemoglobin
(ii) Heart rate increases
(c) Heart rate increased with:
(i) Stress
(ii) Anxiety
(iii) Fever
(d) Patients who cannot respond with tachycardia
(i) Patients taking beta-blocker medications
(ii) Patients with transplanted hearts, which are denervated and so lack autonomic responses
c. Causes of hemoglobin deficit
(1) Loss
(a) Hemorrhagic: usually acute as in:
(i) Trauma
(ii) Surgical loss
(iii) Gastrointestinal
(iv) Uterine
(v) Nasal
(vi) Vascular
(b) Hemodilution from fluid volume expansion
(i) Normal during pregnancy
(ii) Replacement with non-RBC colloid or crystalloids
(c) Researchers implicate laboratory draws (phlebotomy) as source of accumulated blood loss, especially for intensive care unit patients: up to 40 to 70 mL daily.
(2) Inadequate RBC production
(a) Insufficient vitamin B 12 (intrinsic factor) needed for erythropoiesis
(i) Postgastrectomy: insufficient hydrochloric acid secretion along with atrophy of gastric parietal cells
(ii) Pernicious anemia: autoimmune destruction and atrophy of the gastric parietal cells along with insufficient hydrochloric acid secretion
(b) Endocrine factors: insufficient erythropoietin production, as in:
(i) Chronic renal failure
(ii) Addison’s disease
(iii) Thyroid diseases
(c) Liver disease: drug or alcoholic induced
(d) Aplasia: bone marrow suppression
(i) Decreased
[a] Hemoglobin
[b] RBCs
[c] WBCs
[d] Platelet count
(ii) Etiology
[a] Malignancy: infiltration of marrow
[b] Chemotherapy
[c] Chemical or radiation exposure: dose dependent
[d] Medications: phenytoin, chloramphenicol
(e) Inflammatory conditions
(i) Rheumatoid arthritis
(ii) Autoimmune diseases such as lupus erythematosus
(iii) About 15% of asymptomatic HIV-positive patients are anemic.
(f) Genetic predisposition: mutation or recessive traits
(i) Alters a link in the chain of hemoglobin formation
(ii) Produces hemolytic anemias such as:
[a] Sickle cell anemia (Box 29-2)
[1] Affects 1% of African Americans
[2] Hypoxia, fever, acidosis spur RBC change from biconcave to sickled.
[3] Severe pain: joints, limbs, abdomen
[4] Jaundice, ischemia, organ infarction
BOX 29-2
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SICKLE CELL ANEMIA: PREDISPOSED BY HEREDITY
Genetic Characteristics
Most commonly, patients inherit the HbS trait from both parents.
Specific stimuli cause RBCs to alter shape and function.
Forms mutant HbS rather than normal HbA
Trait carried by 10% of African Americans
Fewer than 1% of African Americans develop disease.
Clinical Concerns
Abnormal HbS cell forms have decreased affinity for oxygen.
Oxygen deficit causes cells to change shape and sickle.
Sickled cells rupture or clog small vessels.
Sickling crisis stimulated by:
▪ Altered temperature: fever or cold
▪ Acidosis and hypoventilation
▪ Dehydration
▪ Changes in altitude
Clinical Outcomes
Chronic anemia one of the hallmark clinical signs and exacerbations
Sluggish peripheral circulation due to sludging or vaso-occlusion
▪ Thrombosis, organ infarction
▪ Cerebral changes, altered renal function, cardiopulmonary compromise
▪ Limb ulcerations, necrosis
Ischemic pain, especially at limbs, joints, bones, and abdomen
Infection susceptibility
Nursing Responsibility: Crisis Prevention and Anemia Management
Ensure oxygenation: Prevent hypoventilation, acidosis.
▪ Monitor respiratory quality, rate, and depth.
▪ Provide supplemental oxygen; titrate to oxygen saturation.
▪ Adequately reverse muscle relaxants.
▪ Position patient for effective lung expansion.
▪ Early mobility
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