This is from my colleague Scott Kramer, a board certified clinical specialist
in oncology physical therapy from the University of Kansas Medical Center:
I used to be very cautious with counts and still monitor them closely, but I am
less likely to hold therapy sessions due to counts these days. When counts are
low however, I avoid resistance and repetitive exercise and mostly focus on
functional transfers and potentially endurance activity if the patient feels
well enough to do so. The only hard holds we have with counts is when we have
Jehovah’s Witness patients that do not accept blood products, then we have
strict bedrest protocols.
My argument is this for counts: Yes their platelets are low or their Hgb is
low, but in the risk/reward situation, if we can safely and skillfully get them
out of bed and to a chair or teach nursing staff how to safely transfer the
patient to avoid risk, then the reward is high as that patient doesn’t remain
in bed for multiple days. Waiting on counts to rise can take hours, days and
weeks for some. Any cancer patient, in my opinion, doesn’t have days or weeks
to be stuck in a bed with no activity waiting on counts. I like to use bike
ergometers in patient’s rooms that have low counts as I typically would not be
walking them in the hall but a light endurance activity may be a good exercise
for them to improve cardiovascular endurance as well as general blood
circulation through the body, rather than being bed ridden.
I think we have to think in terms of the likelihood of our BMT/heme patient’s
with functional decline with 2-3 days of bedrest as compared to a non-cancer
patient with 2-3 days of bedrest. It is easier to say hold on that non-cancer
patient but for me, to leave a BMT/heme patient on bedrest for multiple days
with no form of activity could be very costly to their long term success as
well as drastically impact their discharge destination (home vs rehab).
Scott J. Capozza, PT, MSPT
Board Certified Clinical Specialist in Oncologic Physical Therapy
Outpatient Rehab Services
175 Sherman Ave
New Haven, CT 06511
Phone: 203-789-3271
Fax: 203-687-5254
Smilow Cancer Hospital Adult Cancer Survivorhship Clinic
Phone: 203-785-2273
Fax: 203-737-8357
Mailing Address:
PO Box 208028
New Haven, CT 06520-8028
Email: scott.capozza@xxxxxxxx<mailto:scott.capozza@xxxxxxxx>
[https://www.ynhh.org/~/media/images/Email/signature/ynhhs_ynhh_esignature_logo.png]
From: aptaoncology-bounce@xxxxxxxxxxxxx
[mailto:aptaoncology-bounce@xxxxxxxxxxxxx] On Behalf Of Andrew Chongaway
Sent: Thursday, August 13, 2020 8:08 AM
To: aptaoncology@xxxxxxxxxxxxx
Subject: [aptaoncology] Re: Oncology Lab Values Reference
EXTERNAL EMAIL: Do NOT click links or open attachments unless you trust the
sender AND know the content is safe.
Similar to what Shai and Chitra have said, the hospital I am currently at will
hold for a platelet count under 10k/uL, as they will likely be getting a
transfusion during the day and then round back with them once labs have been
drawn again. However, there have been a few situations where patients have had
a platelet level lower than 10k/uL even after a transfusion and want to
participate in PT. In this situation the attending physician will usually
re-consult PT, if they deem it safe, with guidance at what level to hold based
on their assessment of the patient, as they are still at a high risk for
bleeding.
For Hgb, our hospital has a "soft" hold point of <7 as these patients will
usually get a transfusion once they drop below 7 but like Shai said I have
worked with patients that had a Hgb of almost 6 that were nearly running up and
down the hall and doing jumping jacks in their room. In that situation we take
a close look at pre-existing conditions, lab value trends, and discuss with the
RN staff and physicians about safety and upper limits of exercise tolerance.
And then discuss with the patient about goals of working with PT and what to
expect as well as safety concerns when working with us.
On Wed, Aug 12, 2020 at 10:27 PM chitra Srinivasan
<chithrats@xxxxxxxxxxx<mailto:chithrats@xxxxxxxxxxx>> wrote:
Hi,
With the BMT and at times general
Oncology patients we may have to deal with conditions where there is no hope of
platelet counts improving and this may be the patient’s new normal. In these
cases however the risks of hemorrhage is nevertheless high.
However in order to improve quality of life we still work with them to assess
functional acitivies, fall risk etc.
We do request written orders from the MD in the chart mentioning therapy can
work with these patients with low platelets ( below 5000 units etc)
We once had someone that had to live with a platelet count of 2-5(thousand)
units. We educate them about the risks .
There are no studies where the patients with low platelets were subjected to
intensive therapy/ resisted exercises, etc and I doubt if there ever will be.
However based on patient accounts , we can collect retrospective data. Some
have been just fine and some develop intracranial hemorrhages, GI bleeds etc at
home and there is no way of saying if this was caused by activity or was bound
to happen anyway.
Hope this helps.
On Aug 12, 2020, at 8:45 PM, Shai Sewell
<ssewell1989@xxxxxxxxx<mailto:ssewell1989@xxxxxxxxx>> wrote:
Thanks so much for your question. I think it’s a very important one, and one we
don’t necessarily have concrete answers to, although we do have some pretty
good evidence.
I think there are some things going on here that are tough to address, like the
possibility that the nursing staff doesn’t want to ambulate with patients and
therefore trying to get PT to do it when it may be contraindicated, or when we
have more skilled services we can provide. But I don’t want to assume that is
what’s happening so having said that let's dive in.
There are acute care guidelines for a reason. While the BMT population is very
different than the “normal” acute setting, those values are pretty good
starting points. Having worked at two inpatient BMT units in two different
hospitals, there have been some constants such as what blood values we hold at.
We are not an “ASAP” service for the most part. Therefore I always ask myself,
what is the risk vs reward for waiting 3, 4, maybe 5 hours for a patient to get
a platelet transfusion and then to work with them? Risk, I’d say none. Reward,
possibly a lower chance of bleeding if performing more skilled, higher level
therapy services.
I’ve followed these guidelines myself and in my short-ish career, have had no
adverse events (yet): Hold anything more than an ADL if <10,000 for platelets
(most facilities will require transfusions regardless if platelets fall below
<10,000). Pt’s still need to use the bathroom, and eat, etc. If the Hgb and Hct
is <7 or < 20 (respectively) we discuss pt’s overall status with the RN after a
thorough chart review. The hgb and hct guidelines are not “firm” guidelines.
I’ve had pt’s with hgb of <7 walk a mile at a time with no assistance.
We must also consider the pt’s cardiovascular function, PMH, PLOF etc, when
treating with such low counts. How is that pt’s EF? Do they have any
arrhythmias? I’m sure these are all things that YOU as a physical therapist are
thinking about as it pertains to skilled therapy, that the RN’s may not be
considering. Unfortunately, at times RN goals are for patients to ambulate, and
the refer to us to get this done for them. There is no blame here, as RN’s are
VERY busy, but we offer more than this, and our clinical decision making is
what puts us apart as it pertains to rehabilitation.
In terms of “official” guidelines, I’m not sure of any, but I did find this
article which reviews a few of the specific papers I've referenced in the past
for exercise in the BMT population. I’ve used these articles to educate on
rehab therapists, and RN staff when it pertains to what we do.
https://www.tandfonline.com/doi/full/10.1080/16078454.2020.1730556
I hope I’ve helped a little bit, although I know a part of me has made this
political and takes this a bit further than anyone would have liked. I do
believe it’s important to educate the RN staff about what we do know, and use
evidence as a guideline.
Shai Sewell, PT, DPT
University of Florida Health
Shands Cancer Hospital
Inpatient Hematology Oncology and Bone Marrow Transplant
415.299.2086
On Aug 12, 2020, at 8:10 PM, Allison Brookins
<brookina@xxxxxxxx<mailto:brookina@xxxxxxxx>> wrote:
Hi!
I’m a new member of this group.
We are developing some guidelines for our PT/OT team when treating our general
oncology patients and also for our BMT patients.
We generally use the Academy of Acute Care Physical therapy Laboratory Values
Interpretation Resource (Updated 2017) as our reference point. Lately we are
having some challenges with our RN colleagues “pushing us” to see patients who
we might feel are not physiologically ready/stable enough for certain
activities.
Does anyone have/is anyone developing an Oncology-specific lab values resource?
One of our PTs today had 2 patients whose platelets were 5,000 or below.
(diagnoses were AML and lymphoma)
In both cases, our RN colleagues were not-so-gently pushing for us to engage
these patients in activity.
Thanks for your input!
Allison Brookins, PT
Staff PT and Clinical Educator
________________________________
"This message is intended for the use of the person or entity to which it is
addressed and may contain information that is confidential or privileged, the
disclosure of which is governed by applicable law. If the reader of this
message is not the intended recipient, you are hereby notified that any
dissemination, distribution, or copying of this information is strictly
prohibited. If you have received this message by error, please notify us
immediately and destroy the related message."
This message originates from the Yale New Haven Health System. The information
contained in this message may be privileged and confidential. If you are the
intended recipient you must maintain this message in a secure and confidential
manner. If you are not the intended recipient, please notify the sender
immediately and destroy this message. Thank you.