Pediatric emergency medicine trisk 676
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (135.7 KB, 4 trang )
TABLE 98.7
TRANSFUSIONS IN ONCOLOGY PATIENT IN THE EMERGENCY
DEPARTMENT
Platelets
• Platelet count <100,000/mm3 and
active bleeding or major surgery or
trauma
• Platelet count <50,000/mm3 and
minor surgery (e.g., lumbar puncture)
or trauma or moderate mucosal
bleeding (e.g., epistaxis)
• Platelet count <20,000/mm3 and mild
mucosal bleeding
• Platelet count <10,000/mm3 to
prevent spontaneous intracranial
hemorrhage
Red cells
• Hemoglobin <7 mg/dL
• To support circulation in a setting of
acute blood loss or sepsis
• Elective transfusion of symptomatic
patient to avoid admission (only if per
institutional policy and feasible to
transfuse in ED)
Product
specifications
Platelets
Red cells
Type and cross
needed
Yes a
Yes
ABO matched
If product available Yes
Rh matched
Preferred
Yes
Irradiated
Yes
Yes
Leukoreduced
Yes
Yes
Comment
Slightly better
response to ABOmatched platelets
If Rh+ platelets to
Rh donor, anti-D
product within 72
hrs
Prevent WBCs in
product from
proliferating and
causing graftversus-host
disease
Prevent CMV
transmission in
donor white cells
b
HLA matched
Possible
No
May be useful in
setting of patient
refractory to
platelets. Takes
time to arrange;
generally unable
to obtain in the
ED
Single donor
Preferred c
No
Premedication
Possible
Possible
Quantity
General
guidelines:
1 unit <10 kg
3 units 10–30 kg
6 units 30–80 kg
8 units >80 kg
a Not
Highly transfused
population are at
risk for reactions
Acetaminophen if
h/o febrile
reactions
Diphenhydramine if
h/o allergic
reaction
Hydrocortisone if
h/o allergic
reaction despite
diphenhydramine
or very severe
allergic reaction
pRBC elective
Volume-reduced
transfusion:
platelets in
patients very
10–15 mL/kg or 2
sensitive to
units for >50-kg
volume overload
patient
decrease
effectiveness of
transfusion
Continuous infusion
for plateletrefractory patient
with ongoing
significant
bleeding
required if type previously performed at blood bank.
product unnecessary if product has been leukoreduced.
c Apheresis platelets from a single donor preferred.
b CMV-negative
ED, emergency department; ABO, blood group system; Rh, Rheus (Rh) blood group system; WBC, white blood
cell; CMV, cytomegalovirus; HLA, human leukocyte antigen; h/o, history of; pRBC, packed red blood cells.
The differential diagnosis of a pediatric renal mass also includes benign lesions
such as hydronephrosis, multicystic or polycystic kidneys, and mesoblastic
nephroma. A renal mass in a neonate is less likely to be malignant and more likely a
congenital malformation of the genitourinary (GU) tract. Both neuroblastoma and
Wilms tumor most commonly develop in the 1- to 5-year age range. Other less
common malignant tumors include rhabdoid tumor of the kidney, clear cell sarcoma,
and mesoblastic nephroma. Carcinomas, including medullary carcinoma and renal
cell carcinoma, are extremely rare. Hematologic malignancies often metastasize to
the kidney but rarely present with a solitary lesion.
Clinical Considerations
Clinical Recognition
Wilms tumors most commonly present with a painless mass found incidentally by
either the parents or pediatrician in a child who is otherwise well appearing (see Fig.
98.2 ). Masses are deep in the flank, smooth, and may be firm or soft. Wilms tumor
may have more serious or life-threatening presentations including the following:
Hypertension due to increased renin secretion from renal artery compression, in
less than 15% of cases;
Gross hematuria in less than 25% of cases (although microscopic hematuria is very
common);
Hematologic complications such as anemia, tumor thrombus in the renal veins
with or without extension into the inferior vena cava; and
Abdominal compartment syndrome from a massive renal tumor in a very small
child.
Clinical Assessment
A thorough history and physical examination is needed, including assessment of
measured blood pressure against normal values for age. Because Wilms tumor can
be associated with other syndromes, such as Beckwith–Wiedemann syndrome and
WAGR (Wilms tumor, Aniridia, GU anomalies, Range of developmental delays)
syndrome, the physical examination should screen for physical anomalies that may
signal that the renal mass is part of a larger picture. The clinician should assess and
treat pain as needed. Laboratory evaluation should include a CBC to look for
evidence of bleeding, a urinalysis, and liver and renal function testing (BUN and
creatinine). Serum calcium may be elevated in rhabdoid tumor of the kidney or
congenital mesoblastic nephroma.
