Pseudohypoxemia Due to the rapid consumption of oxygen by leu-

6.9.1.3 Pseudohypoglycemia Consumption of glucose by excess leukocytes

can lead to pseudohypoglycemia in patients with HL Elrishi et al. 2010 . Samples that are kept cold and run promptly can avoid this potential spurious result.

6.9.1.4 Pseudothrombocytosis Leukemic blast lysis can lead to cell fragmenta-

tion which automated counters may read as plate- lets leading to an artifi cial increase in the platelet count. Since DIC is a common presentation with HL and platelet transfusion may be required to prevent bleeding with underlying true thrombo- cytopenia, it is important to examine the periph- eral smear if the automated platelet count reading does not correlate with previous values or the sta- tus of the patient.

6.9.2 Transfusion Practice with

Underlying Hyperleukocytosis As described by Lichtman 1973 , blood viscosity is usually unaltered in HL secondary to a decrease in the erythrocrit concomitant with the increased leukocrit. Therefore, blood transfusion should be avoided as it can lead to increased risk of leukosta- sis by increasing blood viscosity. Harris 1978 noted that the mean hemoglobin concentration was signifi cantly higher in adult AML patients who suf- fered an early death with three patients dying soon after blood transfusion. Therefore, asymptomatic patients should not be transfused and in general hemoglobin concentration should be maintained below 10 gdL Harris 1978 . Evidence regarding this recommendation in ALL patients is less clear Lowe et al. 2005 ; Vaitkevičienė et al. 2013 .

6.9.3 Anesthetic Procedures

Due to the risk of pulmonary complications, anesthesia should be undertaken with extreme care in the patient with HL but is often required due to the need for diagnostic procedures such as lumbar puncture and bone marrow aspiration. Fong et al. 2009 retrospectively reviewed 52 pediatric cases with HL that required anesthesia; 3 children required postanesthesia intensive care and 13 had less serious adverse events, all of a respiratory nature. In patients with respiratory distress or mediastinal mass at presentation, con- sideration should be given for utilizing peripheral blood for leukemia cytomorphology and cytoge- netics rather than bone marrow aspiration Vaitkevičienė et al. 2013 .

6.10 Summary

Although signifi cant gains have been made in the treatment of pediatric leukemia, notably ALL, APL, and CML, HL continues to pose risk both in regard to early death and decreased long-term survival. An evidence basis for sup- portive care guidelines is lacking in HL; yet, even without such consensus, intensive support- ive care has signifi cantly improved early death, especially in AML patients. Many patients who ultimately have early death present with fea- tures, chiefl y ICH, for which no intervention will likely improve survival. Additionally, many therapies that have been suggested have no impact on overall survival; in fact, secondary to the underlying aggressive phenotypes, the over- all survival is often shorter with HL. Based on the available evidence, we present our recom- mendations in Table 6.1 . 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