0521779407-10 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:44
864 Intravascular, Non-immune Hemolytic Anemia■TTP
■thrombocytopenia, bleeding, anemia, neurologic abnormalities,
renal failure
■HUS
■renal failure, hypertension, anemia, bleeding
Treatment options
■DIC
■in bleeding patients replace coagulation factors, platelets and red
blood cells by transfusion with fresh frozen plasma, cryoprecipitate,
platelets, and packed red blood cells as needed
∗the following two bullets are recommending full-dose hepariniza-
tion for those with thrombotic complications, which is appropriate;
however, in cases of DIC wherein frank macrovascular thrombosis is
not evident, there is also the option of using lower continuous infu-
sion doses of heparin (not necessarily with a bolus) – i.e., 100–500 u/h
(10–50% of the therapeutic dose) rather than the typical 1000 u/h (as
per the 18 u/kg/h calculation), the rationale being the provision of an
approach that quells the disseminated intravascular coagulation. which
is the source of the consumptive coagulopathy.
■heparin therapy for patients with thrombotic complications (typi-
cally patients with chronic DIC secondary to neoplasm); 80 U hep-
arin/kg intravenously followed by 18 U/kg/hr infusion; for long-term
outpatient therapy give 35,000 U subcutaneously daily in divided
doses 12 hours apart
■low-molecular-weight heparin: enoxaparin subcutaneously at 30 mg
every 12 hours for prophylaxis against thrombosis or therapeutically
1 mg/kg every 12 hours; dalteparin subcutaneously 2,500 U daily for
prophylaxis or therapeutically at 100 U/kg every 12 hours
■TTP
■plasma exchange: daily (1.0 to 1.5 plasma volume) exchanges
with fresh frozen plasma, solvent-detergent treated plasma, donor-
retested plasma, or cryo-poor supernatant (refractory patients) until
platelet count and LDH within normal range for three consecutive
days
■oral prednisone 1 to 2 mg/kg/day; taper at rate of 5 to 10 mg per
week; iv methylprednisolone in divided doses ranging from 2 to
4 mg/kg/day for critically ill patients
■adjunctive therapies: vincristine, cyclophosphamide, cyclosporine,
splenectomy, aspirin, dipyridamole, IVIG, protein A columns
■HUS