Hematologic Emergencies in the ICU

Acute Promyelocytic Luekemia

Often leukopenic (due to fragile cells) vs hyperleukocytosis in other AML, present in DIC/ecchymosis/severe coagulopathy.

Treatment:

• ATRA, low risk so makes sense to treat if ambiguous and not excluded.

Side effects:

• Beware of ATRA differentiation syndrome -> capillary leak physiology. Treat with dexamethasone
• ATRA induced leukocytosis -> differentiation leads to high WBC. Add doxorubicin
• Psuedotumor cerebri

Leukostasis

• Hyperleukocytosis = over 100k
• Leukostasis = hyperleukocytosis and symptoms (though can be lower than 100k, esp if acute leuk blast crisis = large blasts)

(note: differentiate from hyperviscosity syndrome caused by hyper-proteinemia)

Symptoms:

• CNS: vision changes, headache, somnolence
• Lungs: dyspnea, hypoxemia

Workup:

• CNS imaging - risk of bleed
• Hypoxemia: can have falsely low Po2 due to metabolism of O2 in ABG tube. Use SpO2

Treatment:

• fluids
• avoid diuretics, PRBCs -> increase viscocity
• aggressive platelet support due to increased risk of CNS bleed which continues for several days after reduction
• cytoreduction with treatment and/or leukopheresis

DIC

SVC

Cord Compression

TLS

Definition: 25% increase from baseline of K, Phos, Uric or 25% decrease of Ca

• IVF
• Allopurinol
• Add rasburicase if AML WBC over 50 or ALL WBC over 100.
• Dialysis

Cytokine Release Syndrome

Go to the binder and call oncology