Common Blood Abnormalities

Miss Samantha ChambersCT1 General Surgery

3rd August 2015

AimsRecognising 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 1Mrs 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:Low, flat p wavesBroad, bizarre QRSSlurring into the ST segmentTall 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 treatmentFind causeCalcium resonium 15g TDS

Case 275 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 4-12 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 daysOr 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 hours500ml bag contains 100mmol phosphateSo 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 sodiumCheck drug kardex for culprit drugsCan 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

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 CRPAcute phase inflammatory

marker

24 hour lag

Can be raised in inflammation, infection, malignancy

Will be raised post-operatively

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;

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 haematologyMay 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 factorsDIC – low fibrinogen, raised PT, INR, low platelets

Raised INR;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 screenSerology – 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;ECGAdCal1-2 tabs ODor IV replacement

10mls 10% Calcium gluconate

Prolongation of QT interval (QTc)

Raised calcium (hypercalcaemia)

Can occur in renal failure, dehydration and malignancy (particularly breast)

Stones, bones, moans, psychological groansRenal tract calculiBone pain / fracturesConstipationDepression

Management;ECG IV fluid replacementBisphosphonates 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 urineTemp 38.6, BP 130/80, HR 68bpm, regular, RR 16,

02 sats 98% on air Appears very confused – believes he is at his

marital home, and that the year is 1972Not oriented in time/place/personHS 1+11+0Chest - Reduced air entry at left baseAbdomen soft, non-tender

InvestigationsBedside

Urine dip – positive for leucocytes, nitrites and protein

ECG- no acute ischaemic changes

BloodsHb 120, WBC 16, Ur 8.9, Creat 109, K+4, Na 125,

CRP 40, INR 1

ImagingCXR- cardiomegaly, shadowing at left base

suggestive of consolidation

Differentials?Acute confusion secondary to;

UTILRTIHyponatraemiaOpioids

Confusion screenAcute 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 peri-arrest

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: 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

DehydrationA proportional rise in both

urea and creatinine

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 membranes, patient feels thirsty, oliguria or anuria

Management; Search for the cause IV fluid replacement Catheterise patient Meet fluid demand eg. if

high output fistula/stoma Discuss with renal team

SummaryRemember 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?