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(A) bleeding of leukemia can be over the whole body, fatal bleeding needs to be processed.
1, due to acute leukemia complicated by disseminated intravascular coagulation (DIC) caused serious or widespread bleeding in acute leukemia cells release thromboplastin-like substances start the coagulation system, resulting in typical DIC, especially M3, the highest incidence, followed by M5 type, while less common ALL. M3-acute onset characterized type, a more dangerous disease, bleeding tendency can be serious, natural course of disease is short, about two weeks or so, and often died of cerebral hemorrhage or gastrointestinal bleeding and infection. This typed reported in 1957, accounting for 6% of acute leukemia, in the past with high mortality rate in recent years, more effective chemotherapy drugs, M3 greatly improved the prognosis, if treated timely and appropriate treatment, often receive long-term survival. If of patients with bleeding in the skin was blood spots or large areas of ecchymosis, prone to skin puncture site bleeding or hematoma, or bleeding site; such as the nose, gums, oral mucosa, combined with the ball under the membrane, fundus bleeding, severe hemoptysis, blood in the stool, hematuria, etc., liver, spleen and lymph node swelling and tenderness in the sternum were not obvious, especially emergency peripheral blood smear investigation, while venous blood to determine blood clotting time, prothrombin time, 3P test, fibrinogen and a half quantitative, ELT test, FDP Quantitative such inspection. If the blood smears found in most of abnormal promyelocytic (cytoplasm filled with coarse and deeply stained azurophilic granules, but sometimes light yellow fine particles), M3 type can be essential to determine more (still need to be diagnosed with bone marrow , but sometimes smears often are not satisfied, so the early-type high coagulation, bone marrow is easy to solidification). If the clotting time, prolonged prothrombin time, fibrinogen decrease, 3P test positive, FDP is suggesting the quantitative increase in DIC, heparin therapy should be given. As the leukemia cells increased procoagulant activity is the cause of DIC occurred, not eliminate these cells is not a fundamental solution, requiring early chemotherapy. However, chemotherapy has also caused extensive damage leukemia cells, and often they induce or aggravate DIC, chemotherapy and anticoagulation must be carried out simultaneously, , 1 to 2 days after heparin therapy began chemotherapy at the same time. Current M3 type anticoagulant therapy and other causes of DIC caused a bit different, that is, the dose of heparin should be more smaller, generally the first 1 to 50 ~ 100mg intravenously, after maintaining 25 ~ 50mg per day, 5 to 7 days can be disabled. As for chemotherapy, a few years ago China to use more HO-AP programs (Middle School fortunei, vincristine, cytarabine and prednisone), 1987 National Symposium of leukemia chemotherapy, Shanghai Institute of Hematology, use the whole trans-retinoic acid induced differentiation of treatment, 23 cases of M3, the 21 cases achieved complete remission, and no case of DIC. Therefore, half the amount can be used HOAP program or low-dose oral administration of retinoic acid plus Cephalotaxus Middle School program. As for the DIC process is combined with fibrinolysis inhibitor depends on the clinical course (DIC advanced or ELT to use less than 90 time-sharing). Such as severe bleeding tendency, heparin or after chemotherapy has been used after the commencement of a daily or every other day should be lost to the new blood (stored blood will increase DIC, should not use) to add the missing clotting factor. M3, most of the white blood cell count was low, should not be delayed chemotherapy.
2. As thrombocytopenia or vascular wall damage caused by hemorrhagic infiltration
(1) cerebral hemorrhage: usually one of the reasons for the death of leukemia. Leukemia, often before the first cerebral hemorrhage has been mucocutaneous bleeding and anemia and other medical history, diagnosis can not clear the general principles of the former, such as keeping quiet to avoid moving, oxygen and so on. After diagnosis, suspension or a new infusion of blood platelet concentrates, intravenous infusion of drugs such as the adrenal cortex of dexamethasone 20mg / d, graded infusion, and every 6 ~ 8h intravenous drip rate of 20% mannitol 250ml, aims to reduce brain edema to prevent herniation.
(2) Gastrointestinal Bleeding: Because thrombocytopenia or local infiltration of leukemic cells induced ulcer bleeding are possible. In addition to input new blood, the upper gastrointestinal tract bleeding can be oral or gastric tube into the ice in 200ml normal saline plus epinephrine 8 ~ 10mg, also can be taken orally Yunnanbaiyao, March 7 powder, or fresh Ouzhi thrombin can also try intravenous infusion of cimetidine. Lower gastrointestinal bleeding can try Succinate 100 ~ 200mg test plus 100ml normal saline enema.
(3) vaginal bleeding: the case of excessive menstrual blood through can be injected testosterone propionate 100mg, 1 day, once every 3 to 5 days, and at the 5 day period of Compound 18 A (contraceptives) than long-term use, for the time being to avoid menstrual cramps, so as not to aggravate anemia. The case of young women to try to achieve hemostasis benzyl alcohol purpose of the female. Uterine bleeding usually come from internal bleeding, such as functional uterine bleeding, but should still pay attention to young women than abortion, ectopic pregnancy and so may be. In addition there are about the use of triple drug (testosterone propionate, diethylstilbestrol and progesterone), but the unfortunate patients with leukemia, because there are still bleeding after the withdrawal bleeding problems, older women may request gynecological consultation, the possible use of gossypol treatment to promote menopause. If the large amount of bleeding can not be stopped, should also seek the views of gynecological uterine packing or hysterectomy with or without indication.
(4) Epistaxis: Bleeding is the most common leukemia. Small amount of bleeding, the nasal cold packs, local hemostasis can be stained with adrenaline, ephedrine and other vasoconstrictor agents gauze, or stained with thrombin, Chinese medicine powder to stop bleeding gauze. If large amount of bleeding need medical assistance, please ear before and after nasal packing all. Note that the stuffing should be 48h, and no later than 72h out, or easily result in local secondary infection.
(5) gingival bleeding: the local ice or pressure can be used to stop bleeding (with drugs to stop bleeding), accompanied by 1.5% hydrogen peroxide or cooling blood, stop bleeding gargle decoction of Chinese medicine.
3. Acquired coagulation factor abnormalities have been diagnosed with leukemia some bleeding in the outpatient chemotherapy, high dose chemotherapy in patients with advanced liver function is sometimes obvious damage, such as ALL the late application of L-asparaginase, or Middle to high-dose methotrexate Diep Ding and other treatment, if the occurrence of bleeding emergency, they should think of this possibility. Because many coagulation factors are synthesized in the liver, liver injury prone to substantial bleeding tendency, which the vitamin K-dependent coagulation factor synthesis obstacles to the most common. In addition to chemotherapy should be stopped, it should be infusion of fresh plasma, and given intravenous vitamin K and liver protection therapy.
(B) of the fever in patients with leukemia If a fever emergency, if not detailed physical examination can often mistaken for flu, etc.; should pay attention to check for skin, mucous membranes pale, bleeding, asymmetric proptosis (eyes green tumor The predilection sites), the nipple is swollen gums, proliferation, easy bleeding, oral ulceration, with or without enlargement of the salivary glands and lacrimal glands, with or without substernal pain, limb bones and joints with or without tenderness, liver, spleen, lymph node enlargement. Should check any suspicious as whole blood, white blood cell count only easy to check missed. Fever and infection mainly due to reduction of normal white blood cells and immune function caused. Second, the proliferation of white blood cells and the metabolism of hyperthyroidism. Onset of leukemia in untreated early before the fever usually easier to control; and after repeated chemotherapy without disease recurrence, and advanced control or difficult to control the patient’s fever. After repeated chemotherapy because of low immune function, to be neutropenia, inflammatory reaction is low, the potential site of infection are many and often difficult to find obvious infection focus. In particular, patients often go to hospital, but hospital pathogens are many and complex, and often resistant strains or fungi, viruses. Leukemia, but have not been encountered in long-term control of fever, shall actively seek infection focus and attention ① pathogens, as it may chest films, blood culture (including anaerobic culture), throat swab and sputum culture, sputum acid-fast bacilli and oral smears and other tests. ② According to hospital data confirmed by bacterial infections, Gram-negative bacilli infections was higher than that of gram-positive cocci infection, therefore, without the bacterial culture result, options include effective against gram-negative bacteria, broad-spectrum antibiotics , or in combination with targeted antibiotics, preferably by intravenous injection. ③ Note that except for fungal infections, it may be oral or sputum smear test, if there is thrush, and the suspect and a fungal infection of respiratory tract or gastrointestinal tract, may increase by 5 – fluorocytosine or clotrimazole treatment. ④ If the fever and symptoms were good, those who can not find a clear infection focus try a period of anti-tuberculosis therapy trial. ⑤ neutrophils were significantly reduced, conditional or lost during transmission myeloid cells of new blood components (centrifugation to remove plasma). ⑥ all locally foci should note at the same time local processing, such as oral ulcers, perianal infections, soft tissue infections can be partially cleaned plus traditional Chinese medicine for external use and other treatment. ⑦ initial treatment or relapse with fever without clear infection focus was found when the leukemia itself may be due, while in anti-infective chemotherapy.
(C) anemia and leukemia, anemia and sometimes bleeding is not a parallel level, because anemia is due to inhibition of erythropoiesis, and shortened life expectancy with the red blood cells, increased production of invalidity and loss of the hemolysis or extensive bleeding. Early ANLL than ALL anemia generally obvious, especially M6 type. Offenders are usually leukemia with chemotherapy, increased anemia, such as chemotherapy-induced anemia and bone marrow suppression is more evident. Severe anemia can lead to heart failure induced by the emergency, then promptly lost red blood cells or fresh whole blood, and given diuretics, oxygen inhalation, etc., simply are not beneficial to cardiac drugs. CLL patients in about 20% to 30% of patients can occur in late own immune hemolytic anemia (Coombs test positive), should give the adrenal cortex hormone therapy.
(D) bone and joint pain in a large number of leukemia cell proliferation and invasion of bone cortex and periosteum of bone and joints can cause pain, but no local redness, swelling, heat phenomenon. This situation more common in ALL, and sometimes when seen in CML blast crisis. Patients often call and, after unrest in such cases should be vigilant to avoid mistaken for rheumatism. Need to give after diagnosis potent analgesic and give chemotherapy in a timely manner as soon as possible.
(5) acute renal failure in acute leukemia a large number of white blood cells due to destruction of more elevated blood uric acid. If the gastrointestinal tract weight during chemotherapy (vomiting, eating less), then dehydrated oliguria, when the tubular pH lower than 5.5, it easily in the distal renal tubular uric acid, precipitation of collecting duct, causing obstructive renal damage, severe produce acute renal failure. At this point should be fluid, intravenous sodium bicarbonate for alkalinization of urine, blood dialysis when necessary, or peritoneal dialysis.
(6) violations of the central nervous system central nervous system leukemia cell infiltration is very common, especially in the high incidence of ALL. Central nervous system leukemia can occur at any stage in the course of leukemia, although most cases have occurred in the leukemia diagnosis, or even often the treatment of leukemia after complete remission, therefore, not difficult to diagnose. However, a small portion (approximately 11.2% of hospital data) are headache, vomiting, cranial nerve palsy, urinary retention, and even coma as the first symptom, although for the time of lumbar puncture in the emergency, but did not find naive cells for CSF examination, can also be mistaken for tuberculous meningitis. If careful physical examination at this time most patients have anemia, such as whole blood, as checks can often discover leukemia. Therefore, raising awareness in this regard, many to be vigilant, to make correct and timely diagnosis is not difficult. Meningeal leukemia diagnosed after lumbar puncture, intrathecal methotrexate 10mg and dexamethasone 2mg, but the injection should be slow, repeated suction side injection of cerebrospinal fluid and liquid side mixing, so as not to stimulate the high concentration of liquid cerebrospinal.
(Vii) other CML patients as individual cases in the diagnosis of splenomegaly before and after the rupture may occur due to trauma and emergency, time required emergency surgery. Certain chemotherapy drugs such as daunorubicin injection into the extravascular and local swelling or necrosis occurred emergency, or chemotherapy side effects, such as hemorrhagic cystitis