Treatments for Hemolytic uremic syndrome

Treatment list for Hemolytic uremic syndrome:

The list of treatments mentioned in various sources for Hemolytic uremic syndrome includes the following list. Always seek professional medical advice about any treatment or change in treatment plans.

• Supportive treatments
• Fluids
• Salts
• Blood transfusions
• High blood pressure treatments
• Dialysis

Treatments of Hemolytic uremic syndrome: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review the full text of medical books online, free, without registration, for more information about the treatments of Hemolytic uremic syndrome.

Purpura: Treatment
(In a Page: Signs and Symptoms)

• Discontinue causative medications
• Correct coagulopathies as necessary
• Treat malignancy as necessary
• Sun protection and avoidance of trauma will prevent actinic and age-related purpura
• Treat stasis-associated lower extremity purpura with compression stockings, elevation, and diuretics if edema is present
• Infections: Prompt antimicrobial treatment (e.g., doxycycline for RMSF, ceftriaxone for meningococcemia) is imperative to prevent mortality
• Autoimmune diseases: High-dose corticosteroids followed by steroid-sparing medications (e.g., methotrexate, cyclosporine, azathioprine, mycophenolate mofetil) for long-term treatment
• Idiopathic pigmented purpuras are most common on the lower legs of men, and may resolve spontaneously or persist indefinitely; high potency topical steroids and oral vitamin C sometimes hasten their resolution

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Anemia: Treatment
(In a Page: Signs and Symptoms)

• Severe cases of anemia require immediate intervention if hemodynamic compromise occurs
• Administer supplemental O₂ as needed
• In cases of ongoing acute blood loss, establish two large-bore IVs; monitor and send for blood type and cross
• IV fluids as necessary to maintain blood pressure
• Blood transfusion is generally indicated for Hb <8
  –Young, healthy patients should only be transfused if symptomatic or have ongoing acute blood losses
  –Cardiac patients may require transfusion at Hb <10
  –Avoid transfusing beyond Hb >12, as this may increase blood viscosity and impair O₂ delivery
• Supplement vitamin B₁₂, folate, and iron as necessary
• Patients with primary marrow disorders require transfusions, further evaluation, and possibly a bone marrow transplant
• Treat underlying disease according to established protocols

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Diarrhea - Acute: Treatment
(In a Page: Signs and Symptoms)

• Treatment is generally supportive
• Fluid resuscitation (oral, if possible, or IV)
• Antimotility agents: Opiates (e.g., loperamide) and parasympathetic inhibitors (e.g., diphenoxylate plus atropine); former concerns that these agents may slow the clearance of pathogens have been disproved
• Antibiotic therapy is reserved for severe disease
  –Most authorities recommend empiric treatment with a fluoroquinolone or trimethoprin-sulfamethoxasole in patients with severe or bloody diarrhea, fever, or fecal leukocytes
  –If Giardia, C. difficile, or E. histolytica is suspected, treat empirically with metronidazole
  –Antibiotic therapy increases the risk of hemolytic-uremic syndrome in children with E. coli O157:H7
  –There is no good evidence that antibiotics prolong the carrier state in Salmonella infections
• Advise patient to hydrate with glucose-containing, caffeine-free beverages, and to avoid lactose, sorbitol-containing gum, and raw fruit until symptoms subside

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Diarrhea - Chronic: Treatment
(In a Page: Signs and Symptoms)

• Fluid resuscitation: Oral, if possible, or IV (e.g., normal saline or lactated Ringer's)
• Nonspecific antidiarrheal agents (e.g., loperamide, codeine, tincture of opium) and fiber supplementation may be attempted initially
• Diabetic neuropathy: Control blood sugar, metoclopramide may be used
• Irritable bowel syndrome: High-fiber diet, anticholinergics
• Inflammatory bowel disease is treated with steroids for acute exacerbations and daily prophylactic therapy with 5-aminosalicyclic agents
  –Bowel resection may be necessary
• Lactose intolerance: Lactose-free diet
• Diseases of malabsorption: Gluten-free diet, long-term antibiotics
• Intestinal neoplasm: Consultation with gastroenterology, oncology, and/or surgery

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Purpura: Treatment
(In A Page: Pediatric Signs and Symptoms)

• HSP: Analgesia, hydration, treat complications
  –Corticosteroid use is controversial

• ITP with platelet count <20,000
  –IV immunoglobulin to block macrophage receptors
  –Anti-Rh immunoglobulin binds to RBCs so the spleen destroys RBCs instead of platelets, corticosteroids
  –Treat to raise platelet count and decrease risk of intracranial hemorrhage
  –Emergency: Platelet transfusion
  –Chronic: Immunosuppressant or splenectomy

• Hemophilia A: Recombinant F VIII
  –IV or intranasal DDAVP (desmopressin) releases F VIII and vWF from endothelial cells
• Hemophilia B: Recombinant or plasma-derived F IX
• DIC: Treat cause; transfuse platelets, cryoprecipitate, or fresh frozen plasma
• vWD: DDAVP or plasma-derived vWF
• PAN: Oral or IV corticosteroid

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Diarrhea – Chronic, No Blood or Weight Loss: Treatment
(In A Page: Pediatric Signs and Symptoms)

• Treatment is directed at cause
• Chronic nonspecific diarrhea
  –Restriction of fluid intake to <90 mL/kg/day
  –Reduction of fruit juices (<8 ounces/day)
  –Elimination of sorbitol-containing juices
• Carbohydrate malabsorption
  –Trial elimination or reduction of offending sugar
  –Lactase (Lactaid) for lactose intolerance
  –Sucrase (Sucraid) for sucrase-isomaltase deficiency
• Small intestine bacterial overgrowth
  –Antibiotic therapy with metronidazole alone or in combination with ampicillin or Bactrim
  –Surgery for partial small bowel obstruction
• Low-fat diet: Increase fat intake to approximately 40% of total daily calorie intake
• Irritable bowel syndrome
  –Anticholinergic therapy or antidepressants
• Acrodermatitis enteropathica: Zinc supplements

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Diarrhea – Chronic, with Weight Loss: Treatment
(In A Page: Pediatric Signs and Symptoms)

• Correct malnourished states
• IBD: Anti-inflammatories (e.g., steroids, 6MP, 5ASA)
• CD: Lifelong gluten-free diet
• CF: Pancreatic enzyme and nutritional supplements including fat-soluble vitamins (ADEK)
• Allergy: Food antigen avoidance
• Sucrase-isomaltase deficiency: “Sucraid” enzyme
• Neural crest tumors: Surgical resections
• VIPoma: Somatostatin
• Gastrinoma: Proton pump inhibitors
• Whipple disease: Trimethoprim-sulfamethoxazole
• Abetalipoprotenemia: No specific treatment
  –Supplements of fat-soluble vitamins and MCT oil
• Acrodermatitis enteropathica: Zinc supplements
• Giardiasis: Metronidazole or nitazoxamide
• Hyperalimentation: Parenteral nutrition may be needed for familial enteropathies

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Anemia: Treatment
(In A Page: Pediatric Signs and Symptoms)

• Dependent upon etiology; if secondary, treat underlying cause or remove offending drug/agent
• Iron deficiency
  –Iron (6 mg/kg/day elemental iron) for 3 months
  –Decrease milk and tannic acid intake
  –Increase vitamin C intake (helps iron absorbtion)
  –Response to therapy is diagnostic
• Thalassemias, hemoglobinopathies, and membrane abnormalities: Referral to pediatric hematologist, may require chronic transfusions
• Folic acid/vitamin B12 deficiency
  –Identify cause (pernicious anemia, drugs, malnutrition, malabsorption, alcoholism, hemolysis, pregnancy)
  –Provide repletion
  –Treat B12 deficiency early to prevent neurologic damage

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Diarrhea – Acute: Treatment
(In A Page: Pediatric Signs and Symptoms)

• Mainstay of treatment is rehydration to correct fluid and electrolyte deficits
  –Oral route is best in mildly to moderately dehydrated children who can tolerate PO fluid
  –IV fluids: Useful in severe to moderate dehydration
  –Estimate fluid deficit using % of weight loss, and add this to maintenance requirement and ongoing losses
  – Correct over 24–48 hours

• Antibiotics
  –Not necessary in most cases, can precipitate HUS
  –Indicated for V. cholerae, Shigella, and G. lamblia
  –Indicated in selected circumstances: Salmonella in very young infant, if febrile, or positive blood culture
  –Metronidazole for C. difficile (if antibiotic elimination doesn’t help)
• Refeeding: No benefit to withholding milk, incidence of lactose intolerance overstated
• Probiotics: Lactobacillus rhamnosus for rotavirus

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Thrombocytopenia: Treatment
(In A Page: Pediatric Signs and Symptoms)

• Dependent upon etiology, severity, and presence of acute bleeding

• ITP
  –Bone marrow exam before treatment with steroids
  –Treatment with IVIG or WinRho does not need bone marrow exam
  –Platelet transfusion is ineffective in ITP but should be considered at counts <20,000 in the neonate or with life-threatening hemorrhage
  –Severe injury is unlikely if count >10,000
  –Treatment does not hasten resolution of ITP
  –About 90% of children have resolution in 3–6 months
  –Older girls more likely to become chronic

• Acute, isolated thrombocytopenia is almost never malignancy
  –Marrow exam should be done in children with chronic or complex illness or with no response to therapy

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Allergic purpuras: Treatment
(Professional Guide to Diseases (Eighth Edition))

Treatment is generally symptomatic; for example, severe allergic purpura may require steroids to relieve edema and analgesics to relieve joint and abdominal pain. Some patients with chronic renal disease may benefit from immunosuppressive therapy with azathioprine along with identification of the provocative allergen. An accurate allergy history is essential.

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Idiopathic thrombocytopenic purpura: Treatment
(Professional Guide to Diseases (Eighth Edition))

Acute ITP may be allowed to run its course without intervention or may be treated with glucocorticoids or immune globulin. For chronic ITP, corticosteroids may be the initial treatment of choice. Patients who fail to respond within 1 to 4 months or who need high steroid dosage are candidates for splenectomy, which may be successful in 50% of cases. Alternative treatments include immunosuppression, high-dose gamma globulin injections, and immunoabsorption apheresis using staphylococcal protein-A columns, which filter antibodies out of the bloodstream. Anti-RhD therapy can also be useful in people with specific blood types.

Before splenectomy, the patient may require blood, blood components, and vitamin K to correct anemia and coagulation defects. After splenectomy, he may need blood and component replacement and platelet concentrate. Normally, platelets increase spontaneously after splenectomy.

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Aplastic anemias: Treatment
(Professional Guide to Diseases (Eighth Edition))

Effective treatment must eliminate any identifiable cause and provide vigorous supportive measures, such as packed RBC, platelet, and experimental histocompatibility locus antigen-matched leukocyte transfusions. Even after elimination of the cause, recovery can take months. Bone marrow transplantation is the treatment of choice for anemia due to severe aplasia and for patients who need constant RBC transfusions. (See Bone marrow transplantation.)

Patients with low leukocyte counts need special measures to prevent infection. The infection itself may require specific antibiotics; however, these aren’t given prophylactically because they tend to encourage resistant strains of organisms. Patients with low Hb levels may need respiratory support with oxygen in addition to blood transfusions.

For older patients, or for those who don’t have a matched bone marrow donor, antithymocyte globulin (ATG) is an alternative treatment. ATG is a horse serum that contains antibodies against human T cells. It may be used in an attempt to suppress the body’s immune system, allowing the bone marrow to resume its blood cell-generating function. Other immunosuppressant agents, such as cyclosporine, may also be used.

Other treatments may include corticosteroids to stimulate erythroid production, marrow-stimulating agents such as androgens (which remain controversial), and colony stimulation factors to encourage growth of specific cellular components.

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Folic acid deficiency anemia: Treatment
(Professional Guide to Diseases (Eighth Edition))

Treatment consists primarily of folic acid supplements and elimination of contributing causes. Folic acid supplements may be given orally or parenterally (to patients who are severely ill, have malabsorption, or are unable to take oral medication). Many patients respond favorably to a well-balanced diet. If the patient has combined B₁₂ and folate deficiencies, folic acid replenishment alone may aggravate neurologic dysfunction.

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Iron deficiency anemia: Treatment
(Professional Guide to Diseases (Eighth Edition))

The first priority of treatment is to determine the underlying cause of anemia. Once this is determined, iron replacement therapy can begin. Treatment of choice is an oral preparation of iron or a combination of iron and ascorbic acid (which enhances iron absorption). However, in some cases, iron may have to be administered parenterally — for instance, if the patient is noncompliant to the oral preparation, if he needs more iron than he can take orally, if malabsorption prevents adequate iron absorption, or if a maximum rate of Hb regeneration is desired.

Because total dose I.V. infusion of supplemental iron is painless and requires fewer injections, it’s usually preferred to I.M. administration. Pregnant patients and geriatric patients with severe anemia, for example, should receive a total dose infusion of iron dextran in normal saline solution over 8 hours. To minimize the risk of an allergic reaction to iron, an I.V. test dose of 0.5 ml should be given first. For more patient care information, see Supportive management of patients with anemia, page 1034.

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Pernicious anemia: Treatment
(Professional Guide to Diseases (Eighth Edition))

Early parenteral vitamin B₁₂ replacement can reverse pernicious anemia, minimize complications and, possibly, prevent permanent neurologic damage. An initial high dose of parenteral vitamin B₁₂ causes rapid RBC regeneration. Within 2 weeks, Hb levels should rise to normal, and the patient’s condition should markedly improve. Because rapid cell regeneration increases the patient’s iron and folate requirements, concomitant iron and folic acid replacement is necessary to prevent iron deficiency anemia.

After the patient’s condition improves, the vitamin B₁₂ dosage can be decreased to maintenance levels and given monthly. Because such injections must be continued for life, the patient should learn self-administration of vitamin B₁₂.

If anemia causes extreme fatigue, the patient may require bed rest until Hb levels rise. If Hb levels are dangerously low, he may need blood transfusions. Digoxin, a diuretic, and a low-sodium diet may be necessary for a patient with heart failure. Most important is the replacement of vitamin B₁₂ to control the condition that led to this failure. Antibiotics help combat accompanying infections.

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Sickle cell anemia: Treatment
(Professional Guide to Diseases (Eighth Edition))

Treatment begins before age 4 months with prophylactic penicillin. If the patient's Hb drops suddenly or if his condition deteriorates rapidly, he'll need to be hospitalized for a transfusion of packed RBCs. In a sequestration crisis, treatment may include sedation, administration of analgesics, a blood transfusion, oxygen administration, and large amounts of oral or I.V. fluids.

Daily folic acid supplementation is recommended to prevent megaloblastic crisis. Hydroxyurea, which causes an increase in the synthesis of fetal Hb and a significant reduction in crises, is being used for some patients with sickle cell anemia. Researchers have found it helpful for some patients because it reduces the frequency of painful crises and episodes of acute chest syndrome and decreases the need for blood transfusions.

Newer drugs are being developed to manage sickle cell anemia. Some of these agents try to induce the body to produce more fetal Hb, which helps decrease the amount of sickling. Others work by increasing the binding of oxygen to sickle cells. Currently, bone marrow transplantation offers the only cure for sickle cell anemia. Gene therapy (replacing HbS with normal HbA) may be the ideal treatment, but it's difficult to perform.

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Sideroblastic anemias: Treatment
(Professional Guide to Diseases (Eighth Edition))

Treatment of sideroblastic anemias depends on the underlying cause. The hereditary form usually responds to several weeks of treatment with high doses of pyridoxine (vitamin B₆). The acquired secondary form generally subsides after the causative drug or toxin is removed, or the underlying condition is adequately treated. Folic acid supplements may also be beneficial when concomitant megaloblastic nuclear changes in RBC precursors are present. Elderly patients with sideroblastic anemia (usually the primary acquired form) are less likely to improve quickly and are more likely to develop serious complications. Deferoxamine may be used to treat chronic iron overload in selected patients.

Carefully crossmatched transfusions (providing needed Hb) or high doses of androgens are effective palliative measures for some patients with the primary acquired form of sideroblastic anemia. However, this form is essentially refractory to treatment and usually leads to death from acute leukemia or from respiratory or cardiac complications.

Some patients with sideroblastic anemia may benefit from phlebotomy to prevent hemochromatosis (the accumulation of iron in body tissues). Phlebotomy steps up the rate of erythropoiesis and uses up excess iron stores; thus, it reduces serum and total-body iron levels.

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Acute renal failure: Treatment (Tx)
(Professional Guide to Diseases (Eighth Edition))

Strict fluid management, supportive care (electrolyte replacement; high-calorie, low-

protein diet), hemodialysis or peritoneal dialysis

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Chronic renal failure: Treatment
(Professional Guide to Diseases (Eighth Edition))

Treatment focuses on controlling the symptoms, minimizing complications, and slowing the progression of the disease. Associated diseases that cause or result from chronic renal failure must be controlled such as hypertension. Conservative treatment aims to correct specific symptoms. A low-protein diet reduces the production of end products of protein metabolism that the kidneys can’t excrete. (A patient receiving continuous peritoneal dialysis should have a high-protein diet.) A high-calorie diet prevents ketoacidosis and the negative nitrogen balance that results in catabolism and tissue atrophy, and restricts sodium and potassium.

Maintaining fluid balance requires careful monitoring of vital signs, weight changes, and urine volume (if present). If some renal function remains, administration of loop diuretics such as furosemide, and fluid restriction can reduce fluid retention. Cardiac glycosides may be used to mobilize edema fluids; antihypertensives, to control blood pressure and associated edema. Antiemetics taken before meals may relieve nausea and vomiting; cimetidine or ranitidine may decrease gastric irritation. Methylcellulose or docusate can help prevent constipation.

Treatment may also include regular stool analysis (guaiac test) to detect occult blood and, as needed, cleaning enemas to remove blood from the GI tract. Anemia necessitates iron and folate supplements; severe anemia requires infusion of fresh frozen packed cells or washed packed cells. However, transfusions relieve anemia only temporarily. Epoetin alpha (erythropoietin) increases RBC production.

Drug therapy often relieves associated symptoms: an antipruritic, such as trimeprazine or diphenhydramine, for itching and aluminum hydroxide gel to lower serum phosphate levels. The patient may also benefit from supplementary vitamins (particularly B vitamins and vitamin D) and essential amino acids.

Careful monitoring of serum potassium levels is necessary to detect hyperkalemia. Emergency treatment for severe hyperkalemia includes dialysis therapy and administration of 50% hypertonic glucose I.V., regular insulin, calcium gluconate I.V., sodium bicarbonate I.V., and cation exchange resins such as sodium polystyrene sulfonate.

Alert Cardiac tamponade resulting from pericardial effusion may require emergency pericardial tap or surgery.

Blood gas measurements may indicate acidosis; intensive dialysis and thoracentesis can relieve pulmonary edema and pleural effusions.

Hemodialysis or peritoneal dialysis (particularly continuous ambulatory peritoneal dialysis and continuous cyclic peritoneal dialysis) can help control most manifestations of end-stage renal disease; altering dialyzing bath fluids can correct fluid and electrolyte disturbances. (See Comparing peritoneal dialysis and hemodialysis, page 806. Also see Continuous ambulatory peritoneal dialysis, page 807.) But anemia, peripheral neuropathy, cardiopulmonary and GI complications, sexual dysfunction, and skeletal defects may persist. Maintenance dialysis itself may produce complications, such as protein wasting, refractory ascites, and dialysis dementia. Kidney transplantation may eventually be the treatment of choice for some patients with end-stage renal disease.

PEDIATRIC TIP Children require more dialysis in relation to their body weight than adults because their metabolic rates and, therefore, food intake, are higher.

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Introduction: Renal and Urologic Disorders: Treatment methods
(Professional Guide to Diseases (Eighth Edition))

Treatment of intractable renal or urinary system dysfunction may require urinary diversion, dialysis, or kidney transplantation. Urinary diversion is the surgical creation of an outlet for excreting urine. The types of urinary diversion include ileal conduit, cutaneous ureterostomy, ureterosigmoidostomy, and creation of a rectal bladder.

In dialysis, a semipermeable membrane, osmosis, and diffusion imitate normal renal function by eliminating excess body fluids, maintaining or restoring plasma electrolyte and acid-base balance, and removing waste products and dialyzable poisons from the blood. Dialysis is most often used for patients with acute or chronic renal failure. The two most common types of dialysis are peritoneal dialysis and hemodialysis.

In peritoneal dialysis, a dialysate solution is infused into the peritoneal cavity. Substances then diffuse through the peritoneal membrane. Waste products remain in the dialysate solution and are removed.

Hemodialysis separates solutes by differential diffusion through a cellophane membrane placed between the blood and the dialysate solution, in an external receptacle. Because the blood must actually pass out of the body into a dialysis machine, hemodialysis requires an access route to the blood supply by an arteriovenous fistula or cannula or by a bovine or synthetic graft. When caring for a patient with such an access route, monitor the patency of the access route, prevent infection, and promote safety and adequate function. After dialysis, watch for such complications as headache, vomiting, agitation, and twitching.

Patients with end-stage renal disease may benefit from kidney transplantation, despite its limitations: a shortage of donor kidneys, the chance of transplant rejection, and the need for lifelong medications and follow-up care. After kidney transplantation, maintain fluid and electrolyte balance, prevent infection, monitor for rejection, and promote psychological well-being.

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Thrombocytopenia: Treatment
(Professional Guide to Diseases (Eighth Edition))

Treatment varies with the underlying cause and may include corticosteroids or immune globulin to increase platelet production. The treatment of choice is removal of the offending agents in drug-induced thrombocytopenia or treatment of the underlying cause. Platelet transfusions are helpful only in treating complications of severe hemorrhage.

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Diarrhea: Emergency interventions
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s diarrhea is profuse, check for signs of shock—tachycardia, hypotension, and cool, pale, clammy skin. If you detect these signs, place the patient in the supine position and elevate his legs 20 degrees. Insert an I.V. line for fluid replacement. Monitor the patient for electrolyte imbalances, and look for an irregular pulse, muscle weakness, anorexia, and nausea and vomiting. Keep emergency resuscitation equipment handy.

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Allergic purpura: Treatment
(Handbook of Diseases)

Most patients with Henoch-Schönlein syndrome recover completely. When therapy is required, the glucocorticoid prednisone is given in doses of 1 mg/kg, and tapered to response, to relieve edema. An analgesic may be given to relieve joint and abdominal pain. Some patients with chronic renal disease may benefit from intensive plasma exchange combined with an immunosuppressant, along with identification of the provocative allergen. An accurate allergy history is essential.

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Idiopathic thrombocytopenic purpura: Treatment
(Handbook of Diseases)

Acute ITP may be allowed to run its course without intervention or may be treated with a glucocorticoid or immune globulin. For chronic ITP, a corticosteroid may be the initial treatment of choice. Patients who fail to respond within 1 to 4 months or who need high steroid dosage are candidates for splenectomy, which has an 85% success rate. Alternative treatments include immunosuppression, high-dose I.V. gamma globulin, and immunoabsorption apheresis using staphylococcal protein-A columns.

Clinical tip  Before splenectomy, the patient may require blood, blood components, or vitamin K to correct anemia and coagulation defects. After splenectomy, he may need blood and component replacement and platelet concentrate. Normally, platelets increase spontaneously after splenectomy.

The patient may find complementary therapies to be helpful. He may explore such therapies with his physician.

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Aplastic and hypoplastic anemias: Treatment
(Handbook of Diseases)

Identifiable causes must be eliminated and vigorous supportive measures must be provided, such as transfusions of packed RBCs and platelets. Human leukocyte antigen–matched leukocytes or antithymocyte globulin, used alone or in combination with cyclosporine, has especially impaired outcomes for children and severely neutropenic patients. Experimental trials of androgen therapy are in process. Even after elimination of the cause, recovery can take months. Bone marrow transplantation is the treatment of choice for patients with anemia resulting from severe aplasia and for patients who need constant RBC transfusions.

Preventing infection

Patients with low leukocyte counts need special measures to prevent infection. The infection itself may require specific antibiotics; however, they aren’t given prophylactically because they tend to encourage resistant strains of organisms. Patients with low hemoglobin (Hb) levels may need respiratory support with oxygen, in addition to blood transfusions.

Other treatments

Other appropriate treatments include a corticosteroid to stimulate erythroid production (tends to be successful in children but not adults); a marrow-stimulating agent, such as an androgen (which is controversial); an antilymphocyte globulin (which is experimental); an immunosuppressant (if the patient doesn’t respond to other therapy); and a colony-stimulating factor to encourage growth of specific cellular components.

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Folic acid deficiency anemia: Treatment
(Handbook of Diseases)

Folic acid supplements and the elimination of contributing causes are the primary treatments. Supplements may be given orally (usually 1 to 5 mg/day) or parenterally (to patients who are severely ill, have malabsorption, or are unable to take oral medication).

Clinical tip The clinical features of anemia usually disappear within 1 to 2 weeks after administration of folate.

Many patients also respond favorably to a well-balanced diet.

If the patient has combined vitamin B₁₂ and folate deficiencies, folic acid replenishment alone may aggravate neurologic dysfunction.

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Iron deficiency anemia: Treatment
(Handbook of Diseases)

The first priority of treatment is to determine the underlying cause of anemia. When this is determined, iron replacement therapy can begin. The treatment of choice is an oral preparation of iron or a combination of iron and ascorbic acid (which enhances iron absorption). In some cases, iron may have to be administered parenterally — for example, if the patient is noncompliant to the oral preparation, if she needs more iron than she can take orally, if malabsorption prevents adequate iron absorption, or if a maximum rate of Hb regeneration is desired. (See Injecting iron solutions.)

Because a total-dose I.V. infusion of supplemental iron is painless and requires fewer injections, it’s usually preferred over I.M. administration. Pregnant patients and elderly patients with severe anemia, for example, should receive a total-dose infusion of iron dextran in normal saline solution over 8 hours. To minimize the risk of an allergic reaction to iron, an I.V. test dose of 0.5 ml should be given first.

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Pernicious anemia: Treatment
(Handbook of Diseases)

Early parenteral vitamin B₁₂ replacement can reverse pernicious anemia, minimize complications, and possibly prevent permanent neurologic damage.

Vitamin B₁₂ replacement

An initial high dose of parenteral vitamin B₁₂ causes rapid RBC regeneration. Within 2 weeks, the Hb level should rise to normal, and the patient’s condition should markedly improve. Because rapid cell regeneration increases the patient’s iron and folate requirements, concomitant iron and folic acid replacement is necessary to prevent iron deficiency anemia.

After the patient’s condition improves, the vitamin B₁₂ dosage can be decreased to maintenance levels and given monthly. Because such injections must be continued for life, patients should learn how to do the injections themselves.

Other measures

If anemia causes extreme fatigue, the patient may require bed rest until his Hb level rises. If his Hb level is dangerously low, blood transfusions, digoxin, a diuretic, and a low-sodium diet for heart failure may be needed. Most important is the replacement of vitamin B₁₂ to control the condition that led to this failure. Antibiotics help combat accompanying infections.

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Sickle cell anemia: Treatment
(Handbook of Diseases)

Prophylactic antibiotics are given in certain treatments and at follow-up, even when the patient isn’t in crisis. If the patient’s Hb drops suddenly or if his condition deteriorates rapidly, a transfusion of packed RBCs is needed. Supplementation with folic acid is required because of rapid RBC turnover.

In a sequestration crisis, treatment may include sedation, administration of analgesics, blood transfusion, oxygen administration, and large amounts of oral and I.V. fluids. A good antisickling agent isn’t available yet; the most commonly used drug, sodium cyanate, has many adverse effects.

Partial exchange transfusions may be done in crisis situations. Bone marrow transplants are also successful in treatment.

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Sideroblastic anemias: Treatment
(Handbook of Diseases)

The underlying cause determines the type of treatment.

Hereditary form

Hereditary sideroblastic anemia usually responds to several weeks of treatment with high doses of pyridoxine (vitamin B₆).

Primary acquired form

Elderly patients with sideroblastic anemia — most commonly the primary acquired form — are less likely to improve quickly and are more likely to develop serious complications. Deferoxamine may be used to treat chronic iron overload in selected patients.

Carefully cross-matched transfusions (providing needed Hb) or high doses of androgens are effective palliative measures for some patients with the primary acquired form of sideroblastic anemia. However, this form is essentially refractory to treatment and usually leads to death from acute leukemia or from respiratory or cardiac complications.

CLINICAL TIP: Some patients with sideroblastic anemia may benefit from phlebotomy to prevent hemochromatosis. Phlebotomy steps up the rate of erythropoiesis and uses up excess iron stores; thus, it reduces serum and total-body iron levels.

Secondary acquired form

The secondary acquired form generally subsides after the causative drug or toxin is removed or the underlying condition is adequately treated. Folic acid supplements may also be beneficial when concomitant megaloblastic nuclear changes in RBC precursors are present.

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Renal failure, acute: Treatment
(Handbook of Diseases)

The goals of treatment include identifying and treating reversible causes, such as nephrotoxic drug therapy, obstructive uropathy, and volume depletion. Supportive measures include a diet high in calories and low in protein, sodium, and potassium, with supplemental vitamins and restricted fluids. Meticulous electrolyte monitoring is essential to detect hyperkalemia.

If hyperkalemia occurs, acute therapy may include dialysis, hypertonic glucose and insulin infusions, and calcium — all administered I.V. — and oral or rectal administration of potassium exchange resin to remove potassium from the body.

If measures fail to control uremic symptoms, hemodialysis or peritoneal dialysis may be necessary.

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Renal failure, chronic: Treatment
(Handbook of Diseases)

Conservative treatment aims to correct specific symptoms, minimize complications, and slow progression of the disease. Underlying conditions that cause chronic renal failure must be controlled.

Diet

A low-protein diet reduces the production of end products of protein metabolism that the kidneys can’t excrete. (A patient receiving continuous peritoneal dialysis should receive a high-protein diet.)

A high-calorie diet prevents ketoacidosis and the negative nitrogen balance that results in catabolism and tissue atrophy. Such a diet also restricts sodium and potassium.

Fluid status

Maintaining fluid balance requires careful monitoring of vital signs, weight changes, and urine volume (if present). Loop diuretics, such as furosemide (if some renal function remains), and fluid restriction can reduce fluid retention. A cardiac glycoside may be used to mobilize edema fluids; an antihypertensive, especially an angiotensin-converting enzyme inhibitor, to control blood pressure and associated edema.

Treatment of GI and blood problems

An antiemetic taken before meals may relieve nausea and vomiting; cimetidine, omeprazole, or ranitidine may decrease gastric irritation. Methylcellulose or docusate can help prevent constipation.

Treatment may also include regular stool analysis (guaiac test) to detect occult blood and, as needed, cleansing enemas to remove blood from the GI tract.

Anemia necessitates iron and folate supplements; severe anemia requires infusion of fresh frozen packed cells or washed packed cells. However, transfusions relieve anemia only temporarily. Synthetic erythropoietin (epoetin alfa) may be given to stimulate the division and differentiation of cells within the bone marrow to produce RBCs. An-drogen therapy (testosterone or nandrolone) may increase RBC production.

Drug therapy, surgery, and dialysis

Drug therapy can help relieve associated symptoms: an antipruritic, such as trimeprazine or diphenhydramine, to relieve itching and aluminum hydroxide gel to lower serum phosphate levels.

CLINICAL TIP: Be alert for aluminum toxicity, an adverse reaction to aluminum hydroxide.

The patient may also benefit from supplementary vitamins (particularly B vitamins and vitamin D) and essential amino acids.

Careful monitoring of serum potassium levels is necessary to detect hyperkalemia. Emergency treatment for severe hyperkalemia includes dialysis therapy and administration of 50% hypertonic glucose I.V., regular insulin, calcium gluconate I.V., sodium bicarbonate I.V., and cation exchange resins such as sodium polystyrene sulfonate. Cardiac tamponade resulting from pericardial effusion may require emergency pericardial tap or surgery.

Blood gas measurements may indicate acidosis; intensive dialysis and thoracentesis can relieve pulmonary edema and pleural effusions.

Hemodialysis or peritoneal dialysis (particularly continuous ambulatory peritoneal dialysis and continuous cyclic peritoneal dialysis) can help control most manifestations of end-stage renal disease. (See Continuous ambulatory peritoneal dialysis, page 718.) Altering dialyzing bath fluids can correct fluid and electrolyte disturbances. However, anemia, peripheral neuropathy, cardiopulmonary and GI complications, sexual dysfunction, and skeletal defects may persist.

Maintenance dialysis may produce complications, such as protein wasting, refractory ascites, and dialysis dementia. A kidney transplant may eventually be the treatment of choice for some patients with end-stage renal disease.

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Thrombocytopenia: Treatment
(Handbook of Diseases)

Effective treatment varies with the underlying cause and may include corticosteroids or immune globulin to increase platelet production. When possible, treatment consists of correction of the underlying cause or, in drug-induced thrombocytopenia, removal of the offending agents. Platelet transfusions are helpful in thrombocytopenia only in treating complications of severe hemorrhage. Splenectomy may be performed in patients whose thrombocytopenia was caused by platelet destruction.

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Diarrhea: Nursing considerations
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Administer an analgesic for pain and an opioid to decrease intestinal motility, unless the patient has a possible or confirmed stool infection. Ensure the patient’s privacy during defecation, and empty bedpans promptly. Clean the perineum thoroughly, and apply ointment to prevent skin breakdown.

ALERT: Excessive diarrhea may cause skin breakdown and excoriation. To decrease excoriation and facilitate drainage measurement, insert a rectal tube or large indwelling catheter.

Help the patient maintain adequate hydration, administering I.V. fluid replacements. Measure liquid stools, and weigh the patient daily. Monitor electrolyte levels and hematocrit.

Quantify the amount of liquid stool and carefully observe intake and output.

Patient teaching

Explain the purpose of diagnostic tests to the patient. These tests may include blood studies, stool cultures, X-rays, and endoscopy.

Advise the patient to avoid spicy or high-fiber foods (such as fruits), caffeine, high-fat foods, and milk. Suggest smaller, more frequent meals if he has had GI surgery or disease. If appropriate, teach the patient stress-reducing exercises, such as guided imagery and deep-breathing techniques, or recommend counseling.

Stress the need for medical follow-up to patients with inflammatory bowel disease (particularly ulcerative colitis), who have an increased risk of developing colon cancer.

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Purpura: Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Reassure the patient that purpuric lesions aren’t permanent and will fade if the underlying cause can be successfully treated. Warn him not to use cosmetic fade creams or other products in an attempt to reduce pigmentation

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Diarrhea: Emergency Actions
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient’s diarrhea is profuse, check for signs of shock, including tachycardia, hypotension, and cool, pale, clammy skin. If you detect these signs, place the patient in the supine position and elevate his legs 20 degrees. Insert an I.V. line for fluid replacement. Monitor patient for electrolyte imbalances, and look for an irregular pulse, muscle weakness, anorexia, and nausea and vomiting. Keep emergency resuscitation equipment handy.

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Purpura: Nursing considerations
(Nursing: Interpreting Signs and Symptoms)

▪ Prepare the patient for diagnostic tests, including a peripheral blood smear, bone marrow examination, and blood tests to determine platelet count, bleeding and coagulation times, capillary fragility, clot retraction, prothrombin time, partial thromboplastin time, and fibrinogen levels.

▪ If the patient has a hematoma, apply pressure and cold compresses initially to help reduce bleeding and swelling. After the first 24 hours, apply hot compresses to help speed blood absorption.

Patient teaching

▪ Explain the underlying cause and treatment plan.

▪ Reassure the patient that purpuric lesions aren't permanent and will fade if the underlying cause can be successfully treated.

▪ Warn the patient not to use cosmetic fade creams or other products in an attempt to reduce pigmentation.

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Diarrhea: Nursing considerations
(Nursing: Interpreting Signs and Symptoms)

▪ Administer an analgesic for pain and an opiate to decrease intestinal motility, unless the patient has a possible or confirmed stool infection.

▪ Ensure the patient's privacy during defecation, and empty bedpans promptly.

▪ Clean the perineum thoroughly, and apply ointment to prevent skin breakdown.

▪ Note the amount and characteristics of the patient's stool.

▪ Monitor intake and output.

▪ Obtain serum samples for electrolytes and treat imbalances.

▪ Provide fluid replacement orally or I.V., as appropriate.

Patient teaching

▪ Stress the need for medical follow-up to patients with inflammatory bowel disease (particularly ulcerative colitis) who have an increased risk of developing colon cancer.

▪ Emphasize the importance of maintaining adequate hydration.

▪ Explain food or fluids that should be avoided.

▪ Discuss stress reduction techniques.

▪ Explain the diagnosis and treatment plan.

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Discussion of treatments for Hemolytic uremic syndrome:

Hemolytic Uremic Syndrome: NIDDK (Excerpt)

Once HUS develops, there is no known treatment that can stop the progress of the syndrome. Unfortunately, it must run its course. Most treatments are supportive in nature and aimed at easing the immediate symptoms and signs of this disease and at preventing further complications. Supportive therapy consists of maintaining specific levels of fluids and salts, which are replaced only as needed. Blood transfusions (packed red blood cells) are sometimes needed. Treatment of high blood pressure is often necessary. Dialysis is also needed at times to help the kidneys perform their function. Other complications, such as neurologic complications, necessitate additional medications. (Source: excerpt from Hemolytic Uremic Syndrome: NIDDK)

Escherichia coli O157:H7 General: DBMD (Excerpt)

Hemolytic uremic syndrome is a life-threatening condition usually treated in an intensive care unit. Blood transfusions and kidney dialysis are often required. With intensive care, the death rate for hemolytic uremic syndrome is 3%-5%. (Source: excerpt from Escherichia coli O157:H7 General: DBMD)

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