Persons with
hematologic malignancies bleed for a variety of reasons, including alterations in platelet function and numbers,
clotting factor deficiencies,
circulating anticoagulants, and defects in vascular integrity. The management of
bleeding begins with a full characterization of the
hemostatic defect.
Vitamin K deficiency always should be considered and excluded by clinical history and laboratory tests. Localized
bleeding is treated by packing, topical
hemostatic agents, dressings, vessel
ligation,
laser beam coagulation, or embolization.
Platelet transfusions are administered for
hemorrhage secondary to severe platelet dysfunction or
thrombocytopenia, but usually are not indicated if there is no
bleeding, even though platelets may be as low as 10,000/microL.
Bleeding due to
thrombocytopenia that is refractory to random-donor platelets may respond to cross-matched compatible platelets, or to
recombinant factor VIIa (
rFVIIa). Fresh frozen plasma is indicated infrequently;
bleeding due to coagulopathies is better managed with cryoprecipitate if
fibrinogen is low, or with
clotting factor concentrates appropriate for the specific
clotting factors found to be deficient.
rFVIIa or activated
prothrombin complex concentrate usually controls
hemorrhage due to
autoantibodies directed against
factor VIII, and acquired
von Willebrand's disease may be responsive to
desmopressin or intravenous
gamma globulin infusion.
Antifibrinolytic agents often enhance other
hemostatic therapies, but should be withheld if there is genitourinary
bleeding or evidence of
disseminated intravascular coagulation. Finally,
plasmapheresis and immunoadsorption to remove
paraproteins may be helpful when other measures fail to curb
bleeding.