Hematologic, Oncologic, and Coagulation Disorders
Transfusion and reversal
Restrictive transfusion (hemoglobin under 7 g/dL, under 8 in cardiac surgery or active ischemia) with single-unit dosing and reassessment is standard. Platelets are given for counts under 10,000/µL prophylactically, under 20,000 before procedures, or with active bleeding.
Coagulation emergencies
- Heparin-induced thrombocytopenia: stop all heparin, start a non-heparin anticoagulant (argatroban, bivalirudin), avoid warfarin alone and avoid platelet transfusion, confirm with functional assay.
- Warfarin-related major bleeding: four-factor prothrombin complex concentrate plus IV vitamin K; plasma is slower and less complete.
- Dabaparin-type DOAC reversal: idarucizumab for dabigatran, andexanet alfa or PCC for factor Xa inhibitors.
- Disseminated intravascular coagulation: treat the underlying cause; replace factors and platelets if bleeding.
Oncology emergencies
- Tumor lysis syndrome: aggressive hydration, monitor potassium, phosphate, calcium, creatinine; allopurinol for prophylaxis, rasburicase for high risk (contraindicated in G6PD deficiency).
- Febrile neutropenia: antipseudomonal beta-lactam within one hour, no waiting for cultures.
- Thrombotic thrombocytopenic purpura: urgent plasma exchange; platelet transfusion is contraindicated unless life-threatening bleeding.
Traps
Giving platelets in TTP or HIT; using vitamin K alone for life-threatening warfarin bleeding; missing the five-day platelet nadir pattern of HIT; forgetting that rasburicase requires G6PD screening.
Worked example
Platelets fall from 250,000 to 80,000/µL on day 6 of unfractionated heparin with a new thrombosis - think HIT: stop heparin, start argatroban, and do not give platelets.