TRAINING and EDUCATION
You Make the Call
Each month in “You Make the Call,” we’ll pick a challenging clinical question
submitted through the Consult-a-Colleague program and post the expert’s
response. But, what would YOU do? We’ll also pose a submitted question
and ask you to send your responses. See how your answer matches up to the
experts’ in the next print issue.
This month, Allison King, MD, MPH, PhD, advises on how a patient with sickle
cell disease (SCD) undergoing bariatric surgery should be managed.
Clinical Dilemma:
A 33-year-old female presents with SCD. Past hemoglobin electrophoresis shows double heterozygosity for Hb S and
Hb C: HGB F 3.2 Hb S = 46.7% Hb C = 50.1%. Baseline hemoglobin is in the 10s. She has relatively mild disease clinically, with mild-mod pain crises once every one to two years, none in the last few years. The patient attributes this to
having moved to Hawaii. (She experienced more pain crises previously, when she lived at elevation.) Her most recent
significant hospitalization was in 2009 when she had pneumonia, Hb of 5 g/dL with fevers, HAs, and required 4-5U
PRBCs. She has been transfused ~10 times in her lifetime.
She is going to have bariatric surgery with a Roux en Y procedure. There are limited data published on how to manage these patients through such surgery, and we feel she should have exchange transfusion prior to surgery, though this
is not available at our center or on the island of Hawaii. We do not have great experience with partial exchange. Please
provide recommendations on how this patient should be managed.
“Dr. King, thank you so much for your response. The only
article regarding surgery in patients with SCD I could
find was from 1998 (Neumayr L, et al. Surgery in patients
with hemoglobin SC disease. Am J Hematol. 1998;57:101-8.).
• Anemias
• Hematopoietic cell
transplantation
• Hemoglobinopathies
• Hemostasis/thrombosis
• Lymphomas
• Leukemias
• Multiple myeloma & Waldenström
macroglobulinemia
Allison King, MD, MPH, PhD
Associate Professor
Medical Director, Survivorship Program for Siteman Cancer Center
Program in Occupational Therapy
Departments of Pediatrics and Medicine, Division of Hematology and Oncology
Department of Surgery, Division of Public Health Sciences
Washington University School of Medicine
Washington University
Saint Louis, MO
Editor’s note: The doctor asking the question responded
to Dr. King, asking for additional help over email. Here is
that exchange:
Consult a Colleague is a service for ASH
members that helps facilitate the exchange of information between hematologists and their peers. ASH members
can seek consultation on clinical cases
from qualified experts in 11 categories:
• Lymphoproliferative disorders
Experts Make the Call
Unless this patient has a history of stroke/acute chest/
asthma, I would not exchange the patient. If she does
have stroke/acute chest/asthma, we would do a manual
exchange: pull off 10 cc/kg and give back 5 cc/kg of
packed red blood cells. If you would like our protocol for
manual exchange, please let me know.
Consult a Colleague
Through ASH
• Myeloproliferative disorders
• Myelodysplastic syndromes
• Thrombocytopenias
Assigned volunteers (“colleagues”) will
respond to inquiries within two business
days (either by email or phone).
It found that patients undergoing abdominal surgery had
high rates of sickle cell crises if they were not transfused,
but I recognize the study was small and the article is old.
An article in UpToDate only included a small paragraph
that recommends partial exchange in the pre-op setting
to keep Hgb S <30 percent, so it’s not clear. We just don’t
have a large population with this disorder.”
Dr. King then shared a sickle cell order set, developed by
the sickle cell team (comprising mostly nurses and nurse
practitioners) at St. Louis Children’s Hospital – Washington University, with the doctor who asked the question.
To view the order set, visit ashclinicalnews.org/category/
training-education/you-make-the-call.
Have a puzzling clinical dilemma?
Submit a question, and read more
about Consult-a-Colleague volunteers at
hematology.org/Clinicians/Consult.aspx
or scan the QR code.
*If you have a request related to a
hematologic disorder not listed here, please
email your recommendation to ashconsult@
hematology.org so it can be considered for
addition in the future.
DISCLAIMER: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and
disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is
solely at your own risk.
Next Month’s Clinical Dilemma:
In 2012, I treated a young man with
follicular lymphoma with four cycles
of bendamustine/rituximab. He developed prolonged neutropenia (presumed
ASHClinicalNews.org
rituximab associated) that lasted eight
months. He now has diffuse large B-cell
lymphoma. Would you restart rituximab
as part of a new chemotherapy regimen?
Is he at higher risk for recurrence of
rituximab-associated neutropenia?
How would you respond? Email us at
[email protected].
ASH Clinical News
53