Yes it’s about trends, adaptations of the patient- are they chronically living
this way and transfusion dependent? Always best to wait and see the patient
after transfusions- they feel and perform better if nothing else. AND most
important of all, but not yet mentioned here- prognosis. As much as no one may
be admitting it or talking about it, chances are this patient is up against a
poor prognosis if they are persistently transfusion dependent and living with
very low platelet counts (single digits). SO what can our goal for these
patients genuinely and realistically be? Denial all around will loom large in
the presentation. We need to bring compassion yet realistic presentation to our
decisions.
Greta conversation here. Thank you,
Heidi Engel, PT
UCSF
Sent from my iPad
On Aug 13, 2020, at 6:37 AM, Capozza, Scott <Scott.Capozza@xxxxxxxx> wrote:
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
<image001.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>
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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