Leukemia

Pull the numbers before you start - CBC with differential and platelet count, PT, aPTT, fibrinogen, and D-dimer, plus a comprehensive metabolic panel with LDH, potassium, phosphate, uric acid, and creatinine. Those results define both the bleeding risk and the tumor lysis risk.

Bleeding is the acute killer in APL - About 90% of APL patients present with hemorrhagic complications from DIC, and the brain and lungs are the usual sites. Management is frequent coagulation labs with active fibrinogen replacement using cryoprecipitate, alongside platelets and plasma as the numbers dictate.

Antifibrinolytics are off-limits on ATRA - Tranexamic acid and other antifibrinolytics, the reflex drugs for postpartum and surgical hemorrhage, are not recommended in a patient on all-trans retinoic acid because of the increased thrombosis risk with concomitant therapy. Know what the patient is taking before you reach for them.

Neutropenia changes your aseptic threshold - Chemotherapy, stem cell transplant, and the leukemia itself cause immunosuppression. Fever with neutropenia demands immediate evaluation for a source and broad-spectrum antibiotics. Antibiotic prophylaxis is recommended, and line placement, regional blocks, and neuraxial technique all deserve full sterile technique.

Image the chest in ALL before induction - ALL can present with a mediastinal mass and superior vena cava syndrome; chest x-ray or CT is the study. Plan for a patient who may not tolerate supine positioning or loss of spontaneous ventilation, and have a strategy before the patient is asleep.

Tumor lysis syndrome - Rapid cell death releases intracellular contents and floods the circulation with potassium, phosphate, and uric acid, overwhelming the kidneys. Hyperkalemia and hypocalcemia cause significant cardiac toxicity and need urgent correction. Management is aggressive hydration, frequent labs, and allopurinol or rasburicase for the hyperuricemia — watch the ECG and serial potassium.

Ask about anthracyclines - The standard '7+3' AML regimen pairs cytarabine with daunorubicin or idarubicin, and cardiac evaluation is required before anthracyclines are given. Echocardiography for ventricular function is the study you want in anyone who has completed those cycles.

Differentiation syndrome - ATRA can push arrested promyeloblasts to mature and trigger fever, respiratory distress with pulmonary infiltrates, and capillary leak with edema, any time from 48 hours to three weeks after starting therapy. It mimics sepsis. Treatment is dexamethasone, commonly 10 mg every 12 hours until symptoms and counts improve. ATRA also raises intracranial pressure — headache and papilledema are the tells.

CNS disease and intrathecal therapy - CNS involvement is common in ALL, with cranial neuropathies and meningeal signs of raised ICP. Patients receive 8 to 16 intrathecal treatments, often needing sedation or general anesthesia; check platelets and coagulation before any lumbar puncture or neuraxial block.

Vascular access - Most of these patients have an indwelling port or central catheter for chemotherapy. Confirm it is patent and accessed rather than burning time on peripheral access in a patient with poor veins from repeated cycles.

APL in pregnancy - Emergent cesarean under general anesthesia with antibiotic prophylaxis, no antifibrinolytics while on ATRA, and expect pulmonary edema after massive transfusion — have ICU ventilation available. Postoperative low-molecular-weight heparin prophylaxis is given for venous thromboembolism.

Leukemia is malignant transformation of hematopoietic stem cells producing dysfunctional leukocytes. It is classified acute or chronic by how fast the cells proliferate and myeloid or lymphoid by cell of origin, giving the four major subtypes AML, ALL, CML, and CLL. Acute disease means more than 20% blasts in blood or marrow; chronic means fewer than 20% with partially mature, poorly functioning cells.

Blasts crowd the marrow and displace normal hematopoiesis, so the perioperative patient arrives anemic, thrombocytopenic, and neutropenic. Presentation is nonspecific: fever, fatigue, bone pain, bruising or bleeding, hepatosplenomegaly, lymphadenopathy. ALL adds CNS involvement with raised intracranial pressure and can present with a mediastinal mass or superior vena cava syndrome. Acute promyelocytic leukemia (APL, t(15;17), PML-RARA) presents with disseminated intravascular coagulation and hemorrhage.