Pediatric emergency medicine trisk 2719 2719
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or increasing the dose of growth factor although this is the practice at some
institutions. The literature is inconclusive about the use of WBC transfusions in
neutropenic patients with bacteremia, if the neutrophil recovery is expected within
the next 7 to 10 days.
The urgency of the need for platelet transfusion varies with the circumstance. In
the ED, it may be more expedient to give platelets during a procedure rather than
transfusing in advance and rechecking a platelet count prior to the procedure.
Institutional guidelines should prevail regarding blood type matching, use of anti-D
products in males, and prophylactic transfusion criteria. In a patient with active lifethreatening bleeding, transfusion should not be delayed to await apheresis platelets.
If there is severe bleeding in a patient who is refractory to platelet transfusions, the
blood bank should be consulted to arrange a continuous infusion of platelets.
The need for transfusion in the ED varies with the severity of the anemia and
clinical circumstances ( Table 98.7 ). Additional information on transfusions in the
actively bleeding patient and administration guidelines can be found in Chapter 93
Hematologic Emergencies . The oncology-specific history is critical to identify
contributing factors. The platelet count should always be checked immediately and
transfusion given as indicated ( Table 98.7 ). Reversal of any anticoagulation should
be considered in a patient with significant bleeding.
Management of thrombosis is discussed in Chapter 93 Hematologic Emergencies
. If a central venous sinus thrombosis is suspected, CT scans may not be sensitive
enough to secure a diagnosis. Addition of intravenous contrast may be helpful, or
MRI is generally reliable. Once the diagnosis is established, management consists of
supportive care and initiation of anticoagulation. Of note, for patients on
asparaginase receiving anticoagulation for a thrombus, the antithrombin level must
be monitored regularly and should generally be replaced with antithrombin III when
levels fall below 50%.
INFECTIOUS COMPLICATIONS OF CANCER TREATMENT
Goals of Treatment
Oncology patients are at high risk for life-threatening infection, and prompt
initiation of volume resuscitation and antibiotic administration is critical to optimal
outcome. Early administration of empiric broad-spectrum antibiotics can prevent
morbidity and mortality in febrile neutropenic oncology patients.
CLINICAL PEARLS AND PITFALLS
