Laura Gilchrist and Lynn Tanner provided some food for thought in terms of
dealing with patients with thrombocytopenia. These investigators looked at
the utility of symptoms in helping to make clinical decisions regarding
therapy in this patient population. While their work focused on pediatric
patients, I suspect the physiology of clotting in kids is very similar to
that of adults. Their findings may provide some "food for thought".
[Gilchrist,
Laura; Tanner, Lynn R. Rehabilitation Oncology. 35(1):3-8, January 2017.Steve
Morris
<https://journals.lww.com/rehabonc/Fulltext/2017/01000/Safety_of_Symptom_Based_Modification_of_Physical.3.aspx>
On Thu, Aug 13, 2020 at 8:08 AM Andrew Chongaway <achongaway@xxxxxxxxx>
wrote:
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>
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> 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> 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
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