Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Fall 2007
Bob Richard
rrichard@u.washington.edu
James B. Herrick
OXY-STATE DEOXY-STATE
Deoxyhemoglobin S Polymer Structure
A) Deoxyhemoglobin S B) Paired strands of C) Hydrophobic pocket
14-stranded polymer deoxyhemoglobin S for 6b Val
(electron micrograph) (crystal structure)
Emboli 0 0 0 9.9
Home
Pain
Emergency In-patient
Out-patient
Department Admission
Clinic
30-60 mg (or more) SR-MS every 12 hrs + 5-
NSAID and/or 5-15 mg IV MS+ 30-60 mg 15 mg IV- MS every 4 hrs prn
(or more) SR-MS Increase SR-MS* daily until breakthrough use
acetaminophen /codeine #3 (40 tabs)
and/or Repeat IV MS every 45-60 is minimal
minutes until comfortable. or
acetaminophen/oxycodone (30 tabs) 20-40 mg SR-oxycodone* (or more) every 12
and or hours + 1-3 mg IV- hydromorphone every 4
SR- MS (30 tabs) 1-3 mg IV hydromorphone hrs prn
+ 20-40 mg SR-oxycodone until breakthrough use is minimal
or
(or more)
SR-oxycodone (30tabs) If patient is very ill or has ileus, convert to
Repeat IV hydromorphone IV, either bolus or PCA, and later back to SR
every 45-60 minutes until medication
comfortable
Send home or admit Convert from IV to oral breakthrough
using po MS or oxycodone in 1-2 days
Discharge when stable and improving on SR-
Home MS or SR-oxycodone
Chest syndrome
• New or progressive pulmonary infiltrate in
a patient with sickle cell disease.
– Admit and treat
• At least one of the following additional
features is required for the diagnosis: the
onset of chest pain, a temperature higher
than 38.5°C, tachypnea, wheezing, or
cough.
Causes and Outcomes of the Acute Chest Syndrome in
Sickle Cell Disease
NEJM, Volume 342:1855-1865 June 22, 2000
Infarction of the Femoral Head
• JAMA. 2003;289:1645-1651.
• 1.5 (5.8) deaths per 3-month period on HU
vs 2.6 (7.9) deaths per 3 months for
people off HU; (P = .04)
• Increased Hgb F correlated with improved
survival
What effect has HU had on sickle
patients?
• In clinical trials, 44% decrease in
hospitalizations, 40% decrease in mortality.
• But a review of records in MD before and
after HU approval for sickle, no change in
hospitalization rates or costs
• Lanzkron et al., Am J Heme, 2006
• Same group at JHU have surveyed care
givers and found less than half prescribed HU
to all eligible patients
Transfusion in Sickle Cell
http://www.nhlbi.nih.gov/health/prof/blood/sickle/index.htm
Transfusion in Sickle Cell
Exchange transfusion:
1. Bleed one unit (500 ml), infuse 500 ml of saline
2. Bleed a second unit and infuse two units.
3. Repeat. If the patient has a large blood mass,
do it again.
Transfusion in Sickle Cell
(exchange transfusion)
– Stroke
– Chronic debilitating pain
– Pulmonary hypertension
– Setting of renal failure and heart failure
Transfusion in Sickle Cell
(chronic transfusion therapy)
Controversial uses:
– Prior to contast media exposure
– Sub-clinical neurological damage
– Priapism
– Leg Ulcers
– Pregnancy
Transfusion in Sickle Cell
Inappropriate uses of transfusion:
– Chronic steady-state anemia
– Uncomplicated pain episodes
– Infection
– Minor surgery
– Uncomplicated pregnancies
– Aseptic necrosis
Other therapies:
Potential treatment with ICA-17043
or
ICA-17043
The Process of Vaso-Occlusion in Patients with Sickle Cell Disease
http://www.nhlbi.nih.gov/health/prof/blood/s
ickle/sc_mngt.pdf