PANCYTOPENIA

INTRODUCTION
Pancytopenia is an important clinico-hematological entity encountered in our day-to-day clinical practice. There are varying trends in
its clinical pattern, treatment modalities, and outcome. It is a disorder in which all three major formed elements of blood (red blood
cells, white blood cells and platelets) are decreased in number. It is not a disease entity but a triad of findings that may result from a
number of disease processes — primarily or secondarily involving the bone marrow. The severity of pancytopenia and the underlying
pathology determine the management and prognosis of the patients. In India, the causes of pancytopenia are not well defined, so the
present study has been undertaken to evaluate the various causes and to correlate the peripheral blood findings with bone marrow
aspirate. Thereby, this data would help in planning the diagnostic and therapeutic approach in patients with pancytopenia.
 MEDICATIONS
FUROSEMIDE
Classifications: ELECTROLYTIC AND WATER BALANCE AGENT; LOOP DIURETIC
Actions
Rapid-acting potent sulfonamide "loop" diuretic and antihypertensive with pharmacologic effects and uses almost identical to those of
ethacrynic acid. Exact mode of action not clearly defined; decreases renal vascular resistance and may increase renal blood flow.

Therapeutic Effects
Inhibits reabsorption of sodium and chloride primarily in loop of Henle and also in proximal and distal renal tubules; an
antihypertensive that decreases edema and intravascular volume. Reportedly less ototoxic than ethacrynic acid.

Uses
Treatment of edema associated with CHF, cirrhosis of liver, and kidney disease, including nephrotic syndrome. May be used for
management of hypertension, alone or in combination with other antihypertensive agents, and for treatment of hypercalcemia. Has
been used concomitantly with mannitol for treatment of severe cerebral edema, particularly in meningitis.

Contraindications
History of hypersensitivity to furosemide or sulfonamides; increasing oliguria, anuria, fluid and electrolyte depletion states; hepatic
coma; pregnancy (category C), lactation.

Cautious Use
Infants, older adults; hepatic cirrhosis, nephrotic syndrome; cardiogenic shock associated with acute MI; history of SLE, history of
gout; patients receiving digitalis glycosides or potassium-depleting steroids.

Route & Dosage

Edema
Adult: PO 20–80 mg in 1 or more divided doses up to 600 mg/d if needed IV/IM 20–40 mg in 1 or more divided
doses up to 600 mg/d
Child: PO 2 mg/kg, may be increased by 1–2 mg/kg q6–8h (max: 6 mg/kg/dose) IV/IM 1 mg/kg, may be
increased by 1 mg/kg q2h if needed (max: mg/kg/dose)
Neonate: PO 1–4 mg/kg q12–24h IV/IM 1–2 mg/kg q12–24h

Hypertension
Adult: PO 10–40 mg b.i.d. (max: 480 mg/d)
Adverse Effects ( 1%)
CV: Postural hypotension, dizziness with excessive diuresis, acute hypotensive episodes, circulatory
collapse. Metabolic: Hypovolemia, dehydration, hyponatremia hypokalemia, hypochloremia metabolic alkalosis, hypomagnesemia,
hypocalcemia (tetany), hyperglycemia, glycosuria, elevated BUN, hyperuricemia. GI: Nausea, vomiting, oral and gastric burning,
anorexia, diarrhea, constipation, abdominal cramping, acute pancreatitis, jaundice. Urogenital: Allergic interstitial nephritis,
irreversible renal failure, urinary frequency. Hematologic: Anemia, leukopenia, thrombocytopenic purpura; aplastic anemia,
agranulocytosis (rare). Special Senses: Tinnitus, vertigo, feeling of fullness in ears, hearing loss (rarely permanent), blurred
vision. Skin: Pruritus, urticaria, exfoliative dermatitis, purpura, photosensitivity, porphyria cutanea tarde, necrotizing angiitis
(vasculitis). Body as a Whole: Increased perspiration; paresthesias; activation of SLE, muscle spasms, weakness; thrombophlebitis,
pain at IM injection site.

Nursing Implications
Assessment & Drug Effects
 Observe patients receiving parenteral drug carefully; closely monitor BP and vital signs. Sudden death from cardiac arrest has
been reported.
 Monitor for S&S of hypokalemia (see Appendix F).
 Monitor BP during periods of diuresis and through period of dosage adjustment.
 Observe older adults closely during period of brisk diuresis. Sudden alteration in fluid and electrolyte balance may precipitate
significant adverse reactions. Report symptoms to physician.
  Lab tests: Obtain frequent blood count, serum and urine electrolytes, CO2, BUN, blood sugar, and uric acid values during first
few months of therapy and periodically thereafter.
 Monitor I&O ratio and pattern. Report decrease or unusual increase in output. Excessive diuresis can result in dehydration and
hypovolemia, circulatory collapse, and hypotension. Weigh patient daily under standard conditions.
 Monitor urine and blood glucose & HbA1C closely in diabetics and patients with decompensated hepatic cirrhosis. Drug may
cause hyperglycemia.
 Note: Excessive dehydration is most likely to occur in older adults, those with chronic cardiac disease on prolonged salt
restriction, or those receiving sympatholytic agents.

Patient & Family Education

 Consult physician regarding allowable salt and fluid intake.
 Ingest potassium-rich foods daily (e.g., bananas, oranges, peaches, dried dates) to reduce or prevent potassium depletion.
 Learn S&S of hypokalemia (see Appendix F). Report muscle cramps or weakness to physician.
 Make position changes slowly because high doses of antihypertensive drugs taken concurrently may produce episodes of
dizziness or imbalance.
 Avoid replacing fluid losses with large amounts of water.
 Avoid prolonged exposure to direct sun.
 Do not breast feed while taking this drug.

DIGOXIN
Classifications: CARDIOVASCULAR AGENT; CARDIAC GLYCOSIDE; ANTIARRHYTHMIC
Actions
Widely used cardiac glycoside of Digitalis lanata. Acts by increasing the force and velocity of myocardial systolic contraction
(positive inotropic effect). It also decreases conduction velocity through the atrioventricular node. Action is more prompt and less
prolonged than that of digitalis and digitoxin.

Therapeutic Effects
Increases the contractility of the heart muscle (positive inotropic effect).

Uses
Rapid digitalization and for maintenance therapy in CHF, atrial fibrillation, atrial flutter, paroxysmal atrial tachycardia.

Contraindications
Digitalis hypersensitivity, ventricular fibrillation, ventricular tachycardia unless due to CHF. Full digitalizing dose not given if patient
has received digoxin during previous week or if slowly excreted cardiotonic glycoside has been given during previous 2 wk.

Cautious Use
Renal insufficiency, hypokalemia, advanced heart disease, acute MI, incomplete AV block, cor pulmonale; hypothyroidism; lung
disease; pregnancy (category A), lactation, premature and immature infants, children, older adults, or debilitated patients.

Route & Dosage

Digitalizing Dose
Adult: PO 10–15 mcg/kg (1 mg) in divided doses over 24–48 h IV 10–15 mcg/kg (1 mg) in divided doses over 24 h
Child: PO/IV <2 y, 40–60 mcg/kg; 2–10 y, 20–40 mcg/kg; >10 y, 10–15 mcg/kg (1.5–2 mg)
Neonate: PO/IV 30–50 mcg/kg
Premature neonate: PO/IV 20 mcg/kg

Maintenance Dose
Adult: PO/IV 0.1–0.375 mg/d
Child: PO/IV <2 y, 7.5–9 mcg/kg/d; 2–10 y, 6–7.5 mcg/kg/d; >10 y, 0.125–0.25 mg/d
Neonate: 6–7.5 mcg/kg/d
Premature neonate: 3.75 mcg/kg/d
Adverse Effects ( 1%)
CNS: Fatigue, muscle weakness, headache, facial neuralgia, mental depression, paresthesias, hallucinations, confusion, drowsiness,
agitation, dizziness. CV: Arrhythmias, hypotension, AV block. Special Senses:Visual disturbances. GI: Anorexia, nausea, vomiting,
diarrhea. Other: Diaphoresis, recurrent malaise, dysphagia.

Nursing Implications

Assessment & Drug Effects

 Take apical pulse for 1 full min, noting rate, rhythm, and quality before administering drug.
 Withold medication and notify physician if apical pulse falls below ordered parameters (e.g., <50 or 60/min in adults and <60
or 70/min in children).
 Be familiar with patient's baseline data (e.g., quality of peripheral pulses, blood pressure, clinical symptoms, serum
electrolytes, creatinine clearance) as a foundation for making assessments.
 Lab tests: Baseline and periodic serum digoxin, potassium, magnesium, and calcium. Draw blood samples for determining
plasma digoxin levels at least 6 h after daily dose and preferably just before next scheduled daily dose.
 Monitor for S&S of drug toxicity: In children, cardiac arrhythmias are usually reliable signs of early toxicity. Early indicators
in adults (anorexia, nausea, vomiting, diarrhea, visual disturbances) are rarely initial signs in children.
 Monitor I&O ratio during digitalization, particularly in patients with impaired renal function. Also monitor for edema daily
and auscultate chest for rales.
 Monitor serum digoxin levels closely during concurrent antibiotic–digoxin therapy, which can precipitate toxicity because of
altered intestinal flora.
 Observe patients closely when being transferred from one preparation (tablet, elixir, or parenteral) to another; when tablet is
replaced by elixir potential for toxicity increases since 30% of drug is absorbed.

Patient & Family Education

  Report to physician if pulse falls below 60 or rises above 110 or if you detect skipped beats or other changes in rhythm, when
digoxin is prescribed for atrial fibrillation.
 Suspect toxicity and report to physician if any of the following occur: Anorexia, nausea, vomiting, diarrhea, or visual
disturbances.
 Weigh each day under standard conditions. Report weight gain >1 kg (2 lb)/d.
 Take digoxin PRECISELY as prescribed, do not skip or double a dose or change dose intervals, and take it at same time each
day.
 Do not to take OTC medications, especially those for coughs, colds, allergy, GI upset, or obesity, without prior approval of
physician.
 Continue with brand originally prescribed unless otherwise directed by physician.
 Do not breast feed while taking this drug without consulting physician.

CLINDAMYCIN HYDROCHLORIDE
Classifications: ANTIINFECTIVE; ANTIBIOTIC

Actions
Semisynthetic derivative of lincomycin with a greater degree of antibacterial activity in vitro, better absorption, and lower incidence of
GI adverse effects than lincomycin. Suppresses protein synthesis by binding to 50 S subunits of bacterial ribosomes, and, therefore,
inhibits other antibiotics (e.g., erythromycin) that act at this site.

Therapeutic Effects
Particularly effective against susceptible strains of anaerobic streptococci, Bacteroides (especially B. fragilis), Fusobacterium,
Actinomyces israelii, Peptococcus, and Clostridium sp. Also effective against aerobic gram-positive cocci, including Staphylococcus
aureus, Staphylococcus epidermidis, Streptococci (except S. faecalis), and Pneumococci.

Uses
Serious infections when less toxic alternatives are inappropriate. Topical applications are used in treatment of acne vulgaris. Vaginal
applications are used in treatment of bacterial vaginosis in nonpregnant women.

Unlabeled Uses
In combination with pyrimethamine for toxoplasmosis in patients with AIDS.

Contraindications
History of hypersensitivity to clindamycin or lincomycin; history of regional enteritis, ulcerative colitis, or antibiotic-associated
colitis; pregnancy (category B), lactation.

Cautious Use
History of GI disease, renal or hepatic disease; atopic individuals (history of eczema, asthma, hay fever); older patients >60 y.

Route & Dosage

Moderate to Severe Infections
Adult: PO 150–450 mg q6h IM/IV 300–900 mg q6–8h (max: 2700 mg/d)
Child: PO 10–30 mg/kg/d q6–8h. IM/IV 25–40 mg/kg/d q6–8h
Neonate: IM/IV = 7 d: 10–15 mg/kg/d divided q8–12h; >7 d: 10–20 mg/kg/d divided q6–12h

Acne Vulgaris
Adult: Topical Apply to affected areas b.i.d.; 1% foam qd application

Bacterial Vaginosis
Adult: Topical Insert 1 suppository intravaginally at bedtime times 3 d, or insert 1 applicator full of cream intravaginally at bedtime
times 7 d

Nursing Implications
Assessment & Drug Effects

 Lab tests: Culture and susceptibility testing should be performed initially and periodically during therapy. Periodic CBC with
differential and platelet count.
 Monitor BP and pulse in patients receiving drug parenterally. Hypotension has occurred following IM injection. Advise patient
to remain recumbent following drug administration until BP has stabilized.
 Severe diarrhea and colitis, including pseudomembranous colitis, have been associated with oral (highest incidence),
parenteral, and topical clindamycin. Report immediately the onset of watery diarrhea, with or without fever; passage of tarry or
bloody stools, pus, intestinal tissue, or mucus; abdominal cramps, or ileus. Symptoms may appear within a few days to 2 wk
after therapy is begun or up to several weeks following cessation of therapy.
 Closely observe older adult and bedridden patients, as they are at a higher risk of developing severe colitis.
 Be alert to signs of superinfection (see Appendix F).
 Be alert for signs of anaphylactoid reactions (see Appendix F), that require immediate attention.

Patient & Family Education

 Take drug for the full course of therapy as prescribed.

 Report loose stools or diarrhea promptly.
 Stop drug therapy if significant diarrhea develops (more than 5 loose stools daily) and notify physician.
 Do not self-medicate with antidiarrheal preparations. Antiperistaltic agents may prolong and worsen diarrhea by delaying
removal of toxins from colon.
  If using topical preparation for acne, discontinue other acne preparations unless otherwise directed by physician. Keep
medication away from eyes.
 Since 10% absorption of topical medication is possible, report the onset of systemic reactions to physician.
 Do not breast feed while taking this drug.

OMEPRAZOLE
Classifications: GASTROINTESTINAL AGENT; PROTON PUMP INHIBITOR

Actions
An antisecretory compound that is a gastric acid pump inhibitor. Suppresses gastric acid secretion by inhibiting the H+, K+-ATPase
enzyme system [the acid (proton H+) pump] in the parietal cells.

Therapeutic Effects
Suppresses gastric acid secretion relieving gastrointestinal distress and promoting ulcer healing.

Uses
Duodenal and gastric ulcer. Gastroesophageal reflux disease including severe erosive esophagitis (4 to 8 wk treatment). Long-term
treatment of pathologic hypersecretory conditions such as Zollinger-Ellison syndrome, multiple endocrine adenomas, and systemic
mastocytosis. In combination with clarithromycin to treat duodenal ulcers associated with Helicobacter pylori.

Unlabeled Uses
Healing or prevention of NSAID-related ulcers.

Contraindications
Long-term use for gastroesophageal reflux disease (GERD), duodenal ulcers; proton pump inhibitors (PPIs), hypersensitivity; children
<2 y; use of OTC formulation in children <18 y or GI bleeding; pregnancy (category C); use of Zegerid in metabolic alkalosis,
hypocalcemia, vomiting, GI bleeding.

Cautious Use
Dysphagia; metabolic or respiratory alkalosis; lactation.

Route & Dosage

Gastroesophageal Reflux, Erosive Esophagitis, Duodenal Ulcer

Adult: PO 20 mg once/d for 4–8 wk

Gastric Ulcer
Adult: PO 20 mg b.i.d. for 4–8 wk

Hypersecretory Disease
Adult: PO 60 mg once/d up to 120 mg t.i.d.

Duodenal Ulcer Associated with H. pylori

Adult: PO 40 mg once/d for 14 d, then 20 mg/d for 14 d, in combination with clarithromycin 500 mg t.i.d. for 14 d

Nursing Implications

Assessment & Drug Effects

 Lab tests: Monitor urinalysis for hematuria and proteinuria. Periodic liver function tests with prolonged use.

Patient & Family Education

 Report any changes in urinary elimination such as pain or discomfort associated with urination, or blood in urine.
 Report severe diarrhea; drug may need to be discontinued.
 Do not breast feed while taking this drug.

CEFEPIME HYDROCHLORIDE
Classifications: ANTIINFECTIVE; ANTIBIOTIC; FOURTH-GENERATION CEPHALOSPORIN

Actions
Cefepime, considered to be a fourth-generation cephalosporin antibiotic, is similar to third-generation cephalosporins with respect to
broad gram-negative coverage; however, cefepime has broader gram-positive coverage than third-generation cephalosporins. It is
highly resistant to hydrolysis by most beta-lactamase bacteria. Cefepime preferentially binds to one or more of the penicillin-binding
proteins (PBPs) located on cell walls of susceptible organisms. This inhibits the third and final stage of bacterial cell wall synthesis,
thus killing the bacteria (bactericidal).

Therapeutic Effects
Effectively treats pneumonia, skin and soft tissue infections, febrile neutropenia, respiratory tract, intra-abdominal infections, and
urinary tract infections by reducing or eliminating signs and symptoms of infection.

Uses
Uncomplicated and complicated UTI, skin and skin structure infections, pneumonia caused by susceptible organisms (Escherichia
coli, Klebsiella pneumoniae, Proteus mirabilis, Staphylococcus aureus [methicillin-sensitive], Streptococcus pyogenes, Streptococcus
pneumoniae, Pseudomonas aeruginosa, Enterobacter sp). Empiric monotherapy for febrile neutropenic patients.

Contraindications
Hypersensitivity to cefepime, other cephalosporins, penicillins, or other beta-lactam antibiotics.

Cautious Use
Patients with history of GI disease, particularly colitis, renal insufficiency; pregnancy (category B), lactation. Safety and efficacy of
cefepime in children <12 y not known.

Route & Dosage

Mild to Moderate Infections

Adult: IV/IM 0.5–1g q12h times 7–10 d

Moderate to Severe Infections

Adult: IV 1–2g q12h times 10 d

Febrile Neutropenia
Adult: IV 2 g q8h for 7 d or until resolution of neutropenia

Adjustment for Renal Impairment

Clcr 30–60 mL/min: dose q24h; 11–29 mL/min: give 50% of normal dose q24h; <10 mL/min: 250–500 mg q24h

Nursing Implications

Assessment & Drug Effects

 Determine history of hypersensitivity reactions to cephalosporins, penicillins, or other drugs before therapy is initiated.
 Lab tests: Perform culture and sensitivity tests before initiation of therapy. Dosage may be started pending test results.
 Monitor for S&S of hypersensitivity (see Appendix F). Report their appearance promptly and discontinue drug.
 Monitor for S&S of superinfection or pseudomembranous colitis (see Appendix F); immediately report either to physician.
 With concurrent high-dose aminoglycoside therapy, closely monitor for nephrotoxicity and ototoxicity.

Patient & Family Education

 Promptly report any S&S of hypersensitivity, superinfection, and pseudomembranous colitis.
 Do not breast feed while taking this drug without consulting physician.