Haematology House Officer Guide

Team structure

Consultants: Hugh Goodman, Vidya Mathavan, Shahid Islam, Humphrey Pullon, Niranjan
Rathod, Natalia Gavrilova (they take turns being on the ward for 1 month each)

Laboratory: Helen Moore ± advanced trainee

Blood bank: Deepak Sadani ± advanced trainee

Thrombosis/thrombophilia specialist: Julie-Anne Bell, Julia Phillips

Ward: house officer and registrar

Consult services: on-call consultant and acute registrar

4th year students on specialty medicine rotation – 3 weeks doing a mixture of outpatient +
inpatient

Trainee interns doing cohort option – 2 weeks doing a mixture of outpatient + inpatient

Good contacts

Haematology outpatient clinic (Dean) – 94058 or

haematologyclinicbookings@waikatodhb.health.nz

Rotorua clinic coordinator – Aurora Wilson Aurora.WilsonBall@lakesdhb.govt.nz

Clinical nurse specialists – Chris Corkery (transfusion), Robyn Segedin (bone marrow
transplant), Maureen Hayes (haemophilia), Amanda Foster, Tracey Williams

RBC/platelet transfusions in Waikato hospital –

meadedaycareinfusionsandtransfusions@waikatodhb.health.nz

Chemotherapy: Waikato (chemotherapysuite@waikatodhb.health.nz), Rotorua (Chemo day

stay via operator)

PICC line coordinator: 95421 (Sherlock phone is never answered!), you can also check the
status of the patient on the acute theatre list – interventional radiology tab

Written by Dong Kim, haematology house officer 2020

Haematology House Officer Guide
What needs to be done

Print the patient list (progress notes on Enterprise Reporting) and bloods (via CWS).

Ward rounds: consultant ward round varies e.g. some consultants see one registrar’s
patients on Monday then other half on Tuesday and again on Thursday/Friday.

MON TUE WED THU FRI SAT SUN

Usual bloods ✓ ✓ ✓ ✓ ✓ ✓ ✓
(on pre-filled
blood forms)
LFT + CRP (if ✓ ✓ ✓
neutropenic,
infection or
inflammation)
Coags ✓ ✓
To do before Unackno Unacknowl Unacknowl Unacknowle Unacknowl Unackno Unacknowle
end of the day wledged edged edged dged bloods edged wledged dged bloods
bloods bloods bloods Outpatient bloods bloods Outpatient
Outpatie Outpatient Outpatient bloods Outpatient Outpatie bloods
nt bloods bloods bloods Elective bloods nt bloods Elective
Elective Elective Elective admissions Elective Elective admissions
admissio admissions admissions admissions admissio Update
ns Bug list Do bloods ns patient
Update for Sat, progress
patient Sun, Mon notes
progress
notes
Meetings/teac 1100 MDT 1330 Ward 1400
hing meeting meeting/P Haem
1300 GY2 RMO
PGY1 teaching teaching
teaching

Blood tests

If patients have central lines or PICC it is done by night nurses.

Phlebotomist comes at 0800 and 1300

If microbiology results come back positive annotate it so it is easier to see. If someone has
new blood cultures it means they spiked. If you have a patient that you want to be discussed
with the infectious diseases team fill out the “bugs list” in “Haem Files”

Tumour lysis: daily/BD usual bloods + urate and LDH – consultant/reg will tell you if required

CD34: needs to be done for stem cell harvest usually requested by Robyn Segedin. Double
check to make sure it is requested

Myeloma screen: Ca, PO4, ALP, protein, albumin, immunoglobulins, serum protein
electrophoresis, beta 2 microglobulin, serum free light chains, Bence Jones protein is going
out of fashion as it shows up late, and electrophoresis tells you what you need…

Haemolysis screen – CBC, reticulocytes, bilirubin, LDH, haptoglobins, Coomb’s

Methotrexate level: done by the nurses. Need to check results, and follow the protocol (on
chemo chart). Follow the protocol to determine the plan for patients.

Written by Dong Kim, haematology house officer 2020

Haematology House Officer Guide
Unfortunately we are in the haematology ward and we need to do blood everyday. Save time
by pre-filling the blood forms. In the “Haem Files” in the shared drive there is a “Blood forms”
file. Then:

***Remember to reset the setting otherwise people will complain that the printer is not
working!!!***

We are also responsible for checking outpatient bloods – in “Haem Files.” If you are worried
about the patients e.g. neutropenic, anaemic, hypokalaemic ->d/w registrar/consultant about
management, or manage them yourself if you feel comfortable – you will see a pattern.

Common prescriptions

Blood products (prescribe on fluid chart)

 Consent – usually straightforward as patient has had blood products before!

 Platelets: 1 unit over 30 mins (<10, <20 if febrile, <50 for procedures)
 RBC: 1 unit over 2-3 hours (<70 or higher if symptomatic, elderly, or ischaemic heart
disease etc)
 Irradiated blood products required for stem cell transplant, fludarabine/cladribine,
Hodgkin’s lymphoma – usually the nurses and blood bank are aware.

Written by Dong Kim, haematology house officer 2020

Haematology House Officer Guide
Potassium

 Slow K 2 tabs PO TDS

 10 mmol KCl in 100 ml of 0.29% NaCl q1h
 20-40 mmol KCl in 1L Normal saline q4-8h

Magnesium

 Tablets 150 mg PO BD
 10 mmol MgSO4 in 100 ml normal saline q1h

Calcium

 Calcium carbonate 2.5g PO BD

 10 ml calcium carbonate 10% in 100 ml normal saline q1h – no need for cardiac
monitoring for low doses, but need telemetry if you need significant replacement

Prophylaxis – started by reg/consultant

 Cotrimoxazole 960 mg PO Mon/Wed/Fri for PJP prophylaxis in fludarabine or

steroids is allergic – dapsone or IV pentamidine (d/w pharmacist)
 Valaciclovir 500 mg PO daily prevent HSV in lymphopenia, chemo, stem cell
transplant
 Fluconazole 200 mg PO daily for stem cell transplant
 Posaconazole tablet 300 mg PO daily for acute leukaemia, only during
perineutropenia (need famotidine instead of omeprazole)
 Entecavir 500 microgram PO daily (if Hep B surface or core antigen positive)

G-CSF

 Filgrastim 300 or 480 (>80kg) microgram subcut daily *needs special authority for
discharge prescription
 Peg-filgrastim 6 mg subcut once *needs special authority

Neutropenic mouth cares (if neut <0.5)

 Amphotericin lozenges 1 loz PO QID

 Chlorhexidine mouth wash 15 ml PO QID
 Nilstat 1ml PO QID

Tumour lysis syndrome

 Rasburicase 3 mg IV once
 Allopurinol 300 mg PO daily *If rasburicase was given don’t give allopurinol for 2
days

Analgesia

 Paracetamol 1g PO QID – but avoid using regularly in neutropenic patients as it can

mask fevers
 Tramadol 50-100 mg PO QID
 *NSAIDS for analgesia are taboo on the haem ward as patients are already at risk of
bleeding + renal impairment
 Short courses of morphine are your best friend

Written by Dong Kim, haematology house officer 2020

Haematology House Officer Guide
Bowels

 Laxsol 2 tabs PO BD
 Movicol 1-2 sachets PO BD
 *Lactulose – personally not a big fan as it causes bloating, and it acidifies the gut
content when metabolised by gut bacteria. Great for hepatic encephalopathy though!
 Ultraproct – 1 application PR QIDfor anal fissures/pain
 Loperamide 2 mg PO QID/PRN

Antiemetic

 Domperidone 10 mg PO QID PRN before meals - prokinetic

 Ondansetron 8mg PO TDS or Granisetron 3 mg IV TDS - constipating
 Levomepromazine 6.25-12.5 mg PO/IV TDS/PRN - sedating

Other

 When patients are stepping down to oral Abx after neutropenic fevers many go to
augmentin or ciprofloxacin (step down is a consultant/reg decision)
 Alteplase 2 mg PICC once – when PICC line is blocked
 Fluids are usually normal saline. Hartmann’s is generally avoided as it precipitate
blood products (contains calcium)

Elective admission guide

Admissions for the day is written on the whiteboard in nurses’ office. They will usually come
in the afternoon.

Most elective admissions are straight forward

 Basic check to see if they are well

 Chart their regular medications + PRN (e.g. paracetamol, laxsol, antiemetic) + check
for interaction with chemo
 Check elective admission form/clinic letter/discharge summary e.g. what chemo they
are having, if they need special investigations.
 Check their chemotherapy chart – usually being checked by the ward pharmacist.
 Check recent bloods and request bloods

Common chemo for admission

 R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin/doxorubicin,

oncovin/vincristine, prednisone)
 R-DA-EPOCH (ritiuximab, Dose Adjusted Etoposide, prednisone, vincristine,
cyclophosphamide, doxorubicin
 FLAG-Ida (fludarabine, Ara-C, G-CSF, Idarubicin)
 HiDAC (high dose Ara-C)
 First dose rituximab infusion

Special cases

Written by Dong Kim, haematology house officer 2020

Haematology House Officer Guide
 High dose methotrexate – need special care with drug interactions. Make sure they
do not have omeprazole, penicillins, NSAIDS, cotrimoxazole – use drug interaction
checker and check with pharmacist
 Autologous stem cell transplant – d/w Robyn Segedin
o Stem cell mobilisation – uses G-CSF, cyclophosphamide
o Stem cell harvest – need G-CSF and vascath (Robyn Segedin organises this
via Renal team)
o Stem cell return – usually with melphalan
o *Allogenic is not done in Waikato, done in Auckland
 If patient on steroid – need BSL monitoring and PPI

Discharge checklist

 Need blood top up? Much harder to organise in the community

 Follow up plan: Clinic (email/call haematology clinic)? Re-admission (fill out form in
admission folder)?
 Do bloods need to be checked as outpatient? Especially important for new diagnoses
that are awaiting clinic f/u. Give them a outpatient blood form (pre-printed ones in the
haematology box)
 Prescriptions. Remember G-CSF requires special authority. Posaconazole requires
special authority from consultant, and it is very difficult to get in the community –
hope they don’t need it on discharge.
 Advise patients that they should have a low threshold for calling for help!

Neutropenia

When patients have intensive chemotherapy or stem cell return, they will get neutropenic
(Neut < 0.5).

If fever – review ASAP (protocol says 20 mins), and the nursing staff will kindly do the blood
cultures.

 After cultures given Tazocin 4.5g IV Q8h. If eGFR <30 4.5g Q12h. If allergic to
penicillin use cefepime 2g Q12h IV
 If signs of shock given Stat Tobramycin (5mg/kg IV) + fluids
 After Abx take history – sore throat, runny nose, cough, abdo pain, dusuria,
diarrhoea, cuts, pain, bleeding, PICC line.
 Full head to toe examination
 Septic screen – CXR, MSU, stool spec.
 Also requires registrar review
 If patient still unwell/spiking temps vancomycin (check calculator or dose adjustment
calculator) or meropenum – decision will be made by consultant

Do not do rectal exam or enemas/suppositories in neutropenic patients

Weekend guide

Written by Dong Kim, haematology house officer 2020

Haematology House Officer Guide
The weekends are weird in M5… The ward is staffed by on-call haematologist, on-call
oncologist, 1 reg (onc/haem), 1 HO (onc/heam), and radiation oncology reg.

In general you will do a ward round with the consultant on Saturday and round yourself on
Sunday (HO ward round! But consultant may come in for new or sick patients) for either
oncology and haematology. It is a bit variable whether you will be the haem or onc house
officer. In most cases you will do haem, but if the registrar really wants to do haem you will
be onc (very unlikely – happened to me when I was doing a weekend with the advanced
trainee in haem and there was only 4 oncology patients).

1. Print the list + bloods

2. Prescribe platelets to patients if <10 (if platelets <10 risk of spontaneous
haemorrhage is increased)
3. Have fun ward rounding with consultant. Consultant usually arrives between 0800 -
0900
4. You are on call from 1600, try to leave hospital at 1600!
5. Call backs from 1600-2230. You are paid in 3 hours blocks (max 2 blocks) so try to
not make them overlap. Also put patient stickers on the backside of the call-back
from as evidence of your call backs.
a. Example of getting 6 hour callback: admit patient at 1700 then leave hospital
at 1800. Then return at 2100 to review patient with fever
6. You are also expected to admit elective admissions for haem + onc. Acute patients
are seen by the reg.

*Radiation oncology patients are managed by the rad onc reg

Chemotherapy

Only reg/consultant can chart chemo

Day 1, day 2 = 1st day of chemo, 2nd day of chemo

Day + 1 = 1 day after the last day of chemo

Day 0 = day of stem cell return, Day -1 = 1 day before stem cell return

Double check regular medication for interactions

Ideally use the chemo chart only for chemo related stuff

Good resources

https://www.eviq.org.au/

Oxford handbook of clinical haematology

Intranet haematology guidelines – esp. tumour lysis syndrome, antifungal

Our haematology department loves reading UpToDate

Written by Dong Kim, haematology house officer 2020