2. BIKHABIKHA
Objectives
• An overview and approach to the
anemic patient.
• An overview and approach to the
thrombocytopenic patient
• An overview of blood transfusions
with an evidence based approach
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3. BIKHABIKHA
Anemia
• A reduction below normal in the
concentration of hemoglobin or red
blood cells in the blood.
• Hematocrit (<40% in men,<36% in
women)
• Hemoglobin (13.2g/dl in men,
11.7g/dl in women)
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4. BIKHABIKHA
Symptoms of Anemia
• Nonspecific and reflect tissue
hypoxia:
– Fatigue
– Dyspnea on exertion
– Palpatations
– Headache
– Confusion, decreased mental acuity
– Skin pallor
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5. BIKHABIKHA
History and Physical in Anemia
• Duration and onset of symptoms
• Change in stool habits: Stool
Guaiacs in all
• Splenomegaly?
• Jaundiced?
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6. BIKHABIKHA
Components of
Oxygen Delivery
• Hemoglobin in red cells
• Respiration (Hemoglobin levels
increase in hypoxic conditions)
• Circulation (rate increases with
anemia)
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8. BIKHABIKHA
Anemia: A Kinetic Perspective
• Erythrocytes in circulation represent a
dynamic equilibrium between
production and destruction of red cells
• In response to acute anemia (ie blood
loss) the healthy marrow is capable of
producing erythrocytes 6-8 times the
normal rate (mediated through
erythropoietin)
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9. BIKHABIKHA
Reticulocyte Count
• Is required in the evaluation of all patients
with anemia as it is a simple measure of
production
• Young RBC that still contains a small amount
of RNA
• Normally take 1 day for reticulocyte to
mature. Under influence of epo takes 2-3
days
• 1/120th
of RBC normally
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10. BIKHABIKHA
Absolute Retic count
• Retic counts are reported as a
percentage: RBC count x Retic % =
Absoulte retic count(normal: 40-
60,000/μl3
)
• Absolute Retic counts need to be
corrected for early release ( If
polychromasia is present)
• Absolute retic/2 (for hct in mid 20’s)
• Absolute retic/3 (hct <20)
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11. BIKHABIKHA
Indirect Bilirubin: a marker of
RBC destruction
• 80% of normal Bilirubin production is a
result of the degradation of hemoglobin
• In the absence of liver disease Indirect
Bilirubin is an excellent indicator of RBC
destruction
• LDH and Haptoglobin are other markers
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12. BIKHABIKHA
Anemia
Low Retic count & Normal
Bili/LDH
Hypoproliferative Anemia
High Retic count & High
Bili/LDH
Hemolytic Anemia
Low Retic count & High
Bili/LDH
Ineffective Erythropoiesis
High Retic count & normal
Bili/LDH
Blood Loss
Rafi
13. BIKHABIKHA
Hypoproliferative Anemias
• Iron deficiency anemia
• Anemia of chronic disease
• Aplastic anemia and pure red cell aplasia
• Lead poisoning
• Myelophthistic anemias (marrow replaced by
non-marrow elements)
• Renal Disease
• Thyroid disease
• Nutritional defieciency
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14. BIKHABIKHA
Lab Evaluation of
Hypoproliferative Anemias
Fe TIBC Ferritin
Fe Deficiency low High(>300) low
Anemia of
Chronic Dx
low low Normal to
high
Aplastic anemia High Extremely
high
Normal to
high
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15. BIKHABIKHA
Anemia of Chronic Disease
• “Excessive cytokine release” (aka,
infections, inflammation , and cancer)
• Pathophysiology
– Decreased RBC lifespan
– Direct inhibition of RBC progenitors
– Relative reduction in EPO levels
– Decreased availability of Iron
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20. BIKHABIKHA
RBC Transfusion
• What is the best strategy for transfusion
in a hospitalized patient population?
• Is a liberal strategy better than a
restrictive strategy in the critically ill
patients?
• What are the risks of transfusion?
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21. BIKHABIKHA
Risks of RBC Transfusion
in the USA
• Febrile non-hemolytic RXN: 1/100 tx
• Minor allergic reactions: 1/100-1000 tx
• Bacterial contamination: 1/ 2,500,000
• Viral Hepatitis 1/10,000
• Hemolytic transfusion rxn Fatal: 1/500,000
• Immunosuppression: Unknown
• HIV infection 1/500,000
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22. BIKHABIKHA
Packed Red Blood Cells
• 1 unit= 300ml
• Increment/ unit: HCT: 3% Hb1/g/dl
• Shelf life of 42 days
• Frozen in glycerol+up to 10 years for
rare blood types and unusual Ab
profiles
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23. BIKHABIKHA
Special RBC’s
• Leukocyte-reduced= 108
WBCs prevent
FNHTR
• Leukocyte-depleted= 106
WBCs prevent
alloimmunization and CMV
transmission
• Washed: plasma proteins removed to
prevent allergic reaction
• Irradiated: lymphocytes unable to
divide, prevents GVHD
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24. BIKHABIKHA
Hebert et. al, NEJM, Feb 1999
• A multicenter randomized, controlled
clinical trial of transfusion requirements
in critical care
• Designed to compare a restrictive vs. a
liberal strategy for blood transfusions in
critically ill patients
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25. BIKHABIKHA
Methods: Hebert et. al
• 838 patients with euvolemia after initial
treatment who had hemoglobin
concentrations < 9.0g/dl within 72 hours
of admission were enrolled
• 418 pts: Restrictive arm: transfused for
hb<7.0
• 420 pts: Liberal arm: transfused for Hb<
10.0
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26. BIKHABIKHA
Exclusion Criteria
• Age <16
• Inability to receive blood products
• Active blood loss at time of enrollment
• Chronic anemia: hb< 9.0 in preceding
month
• Routine cardiac surgery patients
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27. BIKHABIKHA
Study population
• 6451 were assessed for eligibility
• Consent rate was 41%
• No significant differences were noted
between the two groups
• Average apache score was 21(hospital
mortality of 40% for nonoperative
patients or 29% for post-op pts)
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32. BIKHABIKHA
Conclusions
• A restrictive approach to blood
transfusions is as least as effective if
not more effective than a more liberal
approach
• This is especially true in a healthier,
younger population
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35. BIKHABIKHA
Pseudothrombocytopenia
• Considered in patients without evidence
of petechiae or ecchymoses
• Most commonly caused by platelet
clumping
– Happens most frequently with EDTA
– Associated with autoantibodies
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38. BIKHABIKHA
Increased Destruction
• Most common cause of thrombocytopenia
• Leads to stimulation of thrombopoiesis and
thus an increase in the number, size and rate
of maturation of the precursor
megakaryocytes
• Increased consumption with intravascular
thrombi or damaged endothelial surfaces
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40. BIKHABIKHA
Altered Distribution of Platelets
• Circulating platelet count decreases,
but the total platelet count is normal
– Hypersplenism
– Leukemia
– Lymphoma
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41. BIKHABIKHA
Prophylactic Versus Therapeutic
Platelet Transfusions
• Platelet transfusions for active bleeding
much more common on surgical and
cardiology services
• Prophylactic transfusions most common
on hem/onc services
• 10 x 109
/L has become the standard
clinical practice on hem/onc services
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42. BIKHABIKHA
Factors affecting a patients
response to platelet transfusion
• Clinical situation: Fever, sepsis,
splenomegaly, Bleeding, DIC
• Patient: alloimunization, underlying
disease, drugs (IVIG, Ampho B)
• Length of time platelets stored
• 15% of patients who require multiple
transfusions become refractory
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43. BIKHABIKHA
Strategies to improve response to
platelet transfusions
• Treat underlying condition
• Transfuse ABO identical platelets
• Transfuse platelets <48 hrs in storage
• Increase platelet dose
• Select compatible donor
– Cross match
– HLA match
Rafi
44. BIKHABIKHA
Platelet Transfusions
Reactions
• Febrile nonhemolytic transfusion:
caused by patients leucocytes reacting
against donor leukocytes
• Allergic reactions
• Bacterial contamination: most common
blood product with bacterial
contamination
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