Hematologic Challenges in the Critically Ill

439 Pages·2018·6.72 MB·English

by  Aryeh Shander

Hematologic
Challenges in the
Critically Ill
Aryeh Shander
Howard L. Corwin
Editors
123
Hematologic Challenges in the Critically Ill
Aryeh Shander • Howard L. Corwin
Editors
Hematologic Challenges
in the Critically Ill
Editors
Aryeh Shander Howard L. Corwin
Department of Anesthesiology Department of Critical Care Medicine
Critical Care and Hyperbaric Medicine Geisinger Health System
Team Health Research Institute Danville, PA
Englewood, NJ USA
USA
Englewood Health
Englewood, NJ
USA
ISBN 978-3-319-93571-3 ISBN 978-3-319-93572-0 (eBook)
https://doi.org/10.1007/978-3-319-93572-0
Library of Congress Control Number: 2018957332
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To my parents and sister. To my children for
their inspiration, Noah, Hannah, Nina, and
Eytan, and the wind in my sails, one and
only, Susan.
Aryeh Shander
To my wife Randi and children
Julie and Greg with love.
Howard L. Corwin
Foreword
It is perhaps surprising that a book on hematologic challenges in critical care medi-
cine has not surfaced in the past. However, critical care medicine had its origins in
pulmonary medicine with the development of positive pressure mechanical ventila-
tion during the 1950’s polio epidemics. At the time, hematology was an adolescent
speciality, and blood transfusion was increasingly regarded as the logical therapy
for deficiencies of the blood.
The central importance of the blood to the healthy and diseased human body is
not new as William Harvey (1578–1657) stated: “The life then inheres in the blood,
because therein the life and the soul are manifest first and fail last.”
Sir William Osler, the father of integrated scientific and personalized medicine,
a doyen of internal medicine, established clinical pathology and the medical school
at Johns Hopkins Hospital in the 1890s placing the study of blood central to his
teaching, research, and clinical practice (British Medical Journal 14 Jan 1899). Dr.
Henry Hewes, a Harvard medical school physician, stated in 1899: “The utilisation
of the examination of the blood as an aid to diagnosis in ordinary clinical work is far
less common than its value in this regard warrants” (Boston Medical and Surgical
Journal 13 July 1899).
During the twentieth century and as medical practice entered the new millen-
nium, remarkable advances in science and technology have dramatically impacted
on the management of critically ill patients, especially the hematological aspects. A
patient’s hematological and immunological systems, whether normal or abnormal,
are now accepted as having a central role in the pathophysiology and clinical man-
agement of most diseases. The publication of this book is an acknowledgment of
this reality and answers the need for a source of knowledge and clinical expertise in
the complex world of critical care medicine. The broad range of clinical settings and
the eclectic range of experienced contributing authors acknowledge and address the
importance and relevance of the blood to the care of critically ill patients.
vii
viii Foreword
A highlight of this book is a focus on patient blood management with allogeneic
blood transfusion no longer a default therapy, but only indicated when there are no
alternative safer and effective interventions.
James P. Isbister
Clinical Professor of Medicine
University of Sydney
Emeritus Consultant Physician in Hematology
and Transfusion Medicine
Royal North Shore Hospital of Sydney
Camperdown
Australia
Preface
The origins of hematology date back to Hippocrates and the ancient Greeks, a time
when blood was believed to be one of four humors whose balance was responsible
for health and disease. As such, phlebotomy or bloodletting, implemented to restore
balance in the body, was for several thousand years the mainstay of medical therapy
for the seriously ill. No therapy matches bloodletting for longevity, but not until the
nineteenth century did the practice of phlebotomy finally begin to fall into disfavor.
On the other hand, critical care medicine as we know it today dates back just
60 years. Today, the old and the new have merged, and hematologic issues are inte-
gral to the care of the critically ill. Whether disease or therapy, hematologic condi-
tions present significant challenges to clinicians in the ICU because of the range of
afflictions, diagnostic difficulties, and paucity of available therapeutic
interventions.
The most prominent intersection between hematology and critical care medicine
over the last 25 years has centered on the role of red blood cell (RBC) transfusion.
Historically, RBC transfusions have been viewed as a safe and effective means of
improving oxygen delivery to tissues. Beginning in the early 1980s, transfusion
practice began to come under systematic scrutiny. Initially, primary concerns related
to the risks of transfusion-related infection. While advances in transfusion medicine
have greatly decreased the risk of viral transmission during RBC transfusion, other
risks have driven the debate over transfusion practice and have continued the reex-
amination of the approach to RBC transfusion. At the same time, examination and
debate over RBC transfusion risks over the last quarter century have led to a more
critical examination of transfusion benefits. These issues are particularly important
in the critically ill patient population, and much of the progress in our understanding
of the risks and benefits of RBC transfusion has been a direct result of efforts to
better define the risks and benefits of RBC transfusion in the critically ill. Today, it
is becoming clear that the risks and benefits of transfusion are not the same for all
critical care populations.
While RBC transfusion has dominated the conversation regarding the intersec-
tion of hematology and critical care, over recent years, other aspects of hematology
have become more prominent in the critically ill. Advances in hematologic therapies
ix
x Preface
such as bone marrow transplant have introduced a new group of complicated criti-
cally ill patients. Other advances such as therapeutic apheresis and novel hemato-
logic testing are also playing more of a role in the ICU. Advances in coagulation
have been important in increasing our understanding of both the etiology and com-
plications of critical illness. Improvements in monitoring the coagulation process
and the availability of coagulation factors have facilitated the care of bleeding
trauma and surgical patients. The relationship of the vasculature interaction with
coagulation represents a new challenge in identifying the causes of thrombotic
microangiopathy, the impact of fluids we use on hematologic outcome, and the
newly available interventions. Key to early intervention is recognition of severe
clotting syndromes that originate in endothelium disruption and in turn further
aggravate the disruption culminating in a vicious cycle leading significant morbidity
or death. From sepsis to trauma, understanding the coagulation and other hemato-
logic events is essential if we are to improve management of patient to achieve the
desired outcomes.
Critical care medicine from its origins has relied upon collaboration between all
members of the health-care team in a true multidisciplinary approach to best serve
our patients. This book attempts to span current hematologic challenges of the criti-
cally ill patient using this multidisciplinary approach, bringing together experts who
are either directly providing care at the bedside or indirectly involved in the care of
these patients facing hematologic challenges, whether primary hematologic or a
result of an underlying condition.
The first section addresses general issues in the critically including anemia in the
critically ill, coagulation abnormalities, and the hematologic impact of fluid resus-
citation. Also discussed are advances in hematologic testing. This latter topic is of
particular importance as the challenge when it comes to hematologic diseases and
conditions is being able to render a quick and accurate diagnosis. Viewing the chal-
lenges faced from the point of view of laboratory medicine may help the ICU clini-
cian understand the pitfalls of the available tests, their intended use, and new
advances that may improve our ability to both diagnose conditions and follow
response to therapy.
The second section addresses hematologic challenges associated with specific
clinical situations. It has become clear over recent years that both the hematologic
challenges that arise and the approach to specific hematologic challenges are very
much influenced by the underlying disease process and/or organ system involved.
For example, the approach to anemia is very different in the patient with cardiac
disease than the surgical or trauma patient. Similarly, massive transfusion and
hemostasis in the trauma patient present a unique set of challenges. Specific clinical
areas addressed include trauma, sepsis, cardiovascular disease, GI and liver disease,
obstetrics, neurologic disease, solid organ transplant, malignancy, and ECMO.
In the final section, topics of more general interest, not specific to any organ
system or condition, are addressed. Several topics discussed revolve around special
issues around RBC transfusion including risk of transfusion, age of blood, and treat-
ment modalities other than transfusion. Also included is the increasingly important
topic of the use of anticoagulants in the critically ill and the approach to reversing
Preface xi
anticoagulation. There is also a discussion of the appropriate role of therapeutic
apheresis in the critically ill as well as the role of two important partners of the ICU,
the blood bank and the pharmacy, in dealing with hematologic challenges. Finally,
the growing role of patient blood management in applying evidence-based practice
to the treatment of underlying hematologic diseases and the use of blood compo-
nents is reviewed.
This book attempts to span current and future hematologic challenges of the
critically ill patient by bringing together experts in their respective areas. While our
goal is to be complete, we understand that some issues may have either been left out
or not covered in sufficient depth for some. That aside, we feel that we have excel-
lent representation across disciplines to render a complete and clear view of the
challenges one faces with ICU patients with hematologic conditions, whether pri-
mary, associated, or a result of an underlying condition.
Englewood, NJ, USA Aryeh Shander
Danville, PA, USA Howard L. Corwin