8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 1/26
ANEMIA POST HEMORRAGE
HEMATOLOGY – ONCOLOGY DIVISION
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 2/26
DEFINITION
Anemia is characterized by a reduction in the
number of circulating
• red blood cells (RBCs)
• the amount of hemoglobin
or• the volume of packed red blood cells (hematocrit)
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 3/26
CLASSIFICATION
Anemia is classified based on occurrence
as:• Acute
• Chronic
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 4/26
TERMINOLOGY
• Acute anemia denotes a precipitous drop in
the RBC population due to hemolysis or acute
hemorrhage
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 5/26
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 6/26
ETIOLOGY OF ACUTE ANEMIA
In the emergency department
(ED)
acute hemorrhage is by far themost common etiology
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 7/26
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 8/26
• Decreased hemoglobin oxygen affinity
• Redistribution of blood flow
• Increase cardiac output
Physiologic compensation for decrease RBC mass
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 9/26
Increased oxygen extraction of anemic blood by the tissues produces
Increased concentration of deoxyhemoglobin in the rbc
The production of 2,3-diphosphoglycerate (2,3-DPG).
2,3-DPG shifts the hemoglobin-oxygen dissociation curve to the right,
thus allowing the tissues to more easily strip the hemoglobin of its precious
electron-accepting cargo
stimulates
Decrease hemoglobin oxygen affinity
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 10/26
Decrease hemoglobin oxygen affinity
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 11/26
• In anemia selective vasoconstriction of blood vessels subserving certain nonvital
areas allows more blood to flow into critical areas
• The main donor sites who sacrifice their aerobic lifestyle are the skin and kidneys
• Shunting of blood away from cutaneous sites is the mechanism behind the clinical
finding of pallor, a cardinal sign of anemia
• Although the kidney can hardly be thought of as a nonvital area, it receives (in the
normal state) much more blood flow than is needed to meet its metabolic
requirements
• Although (by definition) total body red cell mass is decreased in anemia, in the
chronically anemic patient the total blood volume paradoxically is increased,
due to increased plasma volume
• It is as if the body were trying to make up in blood quantity what it lacks in quality
Redistribution of blood flow
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 12/26
• The heart can respond to tissue hypoxia by increased cardiac output
• The increased output is matched by decreased peripheral vascular resistance
and decreased blood viscosity (thinner blood flows more freely than thick
blood), so that cardiac output can rise without an increase in blood pressure
• Generally, anemia must be fairly severe (hemoglobin < 7 g/dL) before
cardiac output rises
Increased cardiac output
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 13/26
HOW THE BODY IS AFFECTED BY ANEMIA
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 14/26
Assume that the hemoglobin level drops from 15 gm/dL to 5 gm/dL
This patient will be at risk of hypotensive shock (the blood pressure dropping
below normal values)
This shock phenomenon can be initiated with a blood loss of 15% to 25%
The patient will experience and even complain of
[1] tachycardia
[2] tachypnea[3] pallor
[4] diaphoresis
[5] oliguria
[6] apprehension
[7] restlessness
Intense cutaneous vasoconstriction is the rule and the patient will probably
not recognize this
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 15/26
Hemorrhage
Blood loss
Hypovolemia
Shock
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 16/26
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 17/26
Shock classification
Class I (<15% blood loss)
- mild tachycardia may be present
but
- blood pressure is normal.
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 18/26
Shock classification
Class II (15-30% blood loss)
• tachycardia
• tachypnea and
• a decreased pulse pressure are seen
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 19/26
Shock classification
Class III (30-40% blood loss)
• always leads to a measurable decrease in bloodpressure as well as a significant tachycardia
and
• a narrow pulse pressure
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 20/26
Shock classification
Class IV (40% and greater blood loss)
• leads to patient demise unless prompt resuscitative
measures are taken
• Marked tachycardia and significantly decreased blood
pressure are common findings.
• Blood loss greater than 50% leads to loss of pulse and
blood pressure.
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 21/26
Management
• Emergency Department Care
• Evaluate ABCs and immediately treat any life-threateningconditions
• Crystalloid is the initial fluid of choice
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 22/26
Management
Acute anemia due to blood loss
– Monitor with pulse oximetry, cardiac monitor, and a
sphygmomanometer
– Provide supplemental oxygen via nasal cannula or face
mask
– Establish 2 large-bore intravenous lines and rapidly infuse
1-2 L of crystalloids while monitoring the patient carefully
for signs and symptoms of iatrogenic congestive heart
failure
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 23/26
Management
Acute anemia due to blood loss
– Blood transfusions for patients who remain hypotensive
after 2 L of crystalloid infusion for young healthy patientswith a hematocrit level below 20 or for elderly patients
with a hematocrit level below 30
– Vasopressors are relatively contraindicated in thetreatment of hypovolemic shock
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 24/26
Management
Acute anemia due to blood loss
– Obtain fresh frozen plasma (FFP), coagulation factors, and
platelets, if indicated
– Patients with hemophilia should have samples of the
deficient factors sent for measurement
– Once the patient is stabilized, begin specific measures to
treat the underlying cause of bleeding
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 25/26
Blood transfusion in hemorrhagic anemia
• Blood component
• Complete whole blood if
loss blood volume > 50 % of body blood volume
8/10/2019 Anemia Post Hemorrage
http://slidepdf.com/reader/full/anemia-post-hemorrage 26/26