Hematology & Aenmia

Plasma comprise what % of blood?

55%

RBCs comprise what % of blood?

45%

Is a deficiency in:

• # of RBCs

• Quantity or quality of Hgb

• Volume of packed RBCs (Hct)

Anemia

Causes of anemia

• Decreased RBC production

• Blood loss

• Increased RBC destruction (hemolysis)

Function of RBCs

Transport O2 from lungs to systemic tissues, and CO2 from tissues to lungs

Normal Hgb

• Female 12-16 g/dL

• Male: 14-18 g/dL

Normal WBC

5,000-10,000/uL

Normal platelets (plt)

150,000-400,000/uL

Mild anemia is classified as

Hgb 10 to 12 g/dL

Moderate anemia is classified as

Hgb 6 to 10 g/dL

Severe anemia is classified as

Hgb < 6 g/dL

May exist without causing symptoms (asymptomatic). If symptoms develop, it is because the patient has an underlying disease or has a compensatory response to heavy exercise. Symptoms include palpitations, dyspnea, and mild fatigue.

• Classified as Hgb 10 to 12 g/dL

Mild anemia

There is an increase in cardiopulmonary symptoms. The patient may have them while resting as well as with activity.

• Classified as Hgb 6 to 10 g/dL

Moderate anemia

The patient has many manifestations involving multiple body systems 

• Classified as Hgb < 6 g/dL

Severe anemia

Normal CBC

Hgb

• Female 12-16 g/dL

• Male: 14-18 g/dL

WBC

• 5,000-10,000/uL

Plt

• 150,000-400,000/uL

S&S of mild anemia

• May be asymptomatic

• Response to heavy exericse:

  • Palpitations

  • Dyspnea

  • Mild fatigue

S&S of moderate anemia

• Fatigue

• Palpitations-bounding pulse

• Dyspnea

S&S of severe anemia

• Pallor

• Dizziness

• HA/vertigo/impaired cognition

• Exhausted/lethargic

• Severe palpitations, tachycardia/bounding pulse

• Orthopnea, dyspnea at rest

• Sensitive to cold

• Anorexia

• Pallor

• Dizziness

• HA/vertigo/impaired cognition

• Exhausted/lethargic

• Severe palpitations, tachycardia/bounding pulse

• Orthopnea, dyspnea at rest

• Cold sensitivity

• Anorexia

What condition do these symtpoms describe?

Severe anemia

• Fatigue

• Palpitations-bounding pulse

• Dyspnea

What condition do these symtpoms describe?

Moderate anemia

• May be asymptomatic

• Response to heavy exericse:

  • Palpitations

  • Dyspnea

  • Mild fatigue

What condition do these symtpoms describe?

Mild anemia

This morphology describes what anemia?

• Normal size and color

• MCV 80-100fL, MCH 27-34 pg

Normocytic, normochromic anemia

This morphology describes what anemia?

• Small size, pale color

• MCV <80 fL, MCH <27 pg

Microcytic, hypochromic anemia

This morphology describes what anemia?

• Normochromic (large size, normal color)

• MCV >100 fL, MCH >34 pg

Macrocytic (megaloblastic) anemia

This etiology describes what anemia?

Acute blood loss, hemolysis, CKD, chronic disease, cancer, endocrine problems, starvation, aplastic anemia, sickle cell anemia, pregnancy

Normocytic, normochromic anemia

This etiology describes what anemia?

IDA, vitamin B6 deficiency, copper deficiency, thalassemia, lead poisoning

Microcytic, hypochromic anemia

This etiology describes what anemia?

Cobalamin (vitamin B12) deficiency, folic acid deficiency, liver disease (including effects of alcohol use)

Macrocytic (megaloblastic) anemia

What are the causes of normocytic normochromic anemia?

Acute blood loss, hemolysis, CKD, chronic disease, cancer, endocrine problems, starvation, aplastic anemia, sickle cell anemia, pregnancy

What are the causes of microcytic hypochromic anemia?

IDA, vitamin B6 deficiency, copper deficiency, thalassemia, lead poisoning

What are the causes of macrocytic (megaloblastic) anemia?

Cobalamin (vitamin B12) deficiency, folic acid deficiency, liver disease (including effects of alcohol use)

• MCV 80-100 fL

• MCH 27-34 pg

This indicates which anemia?

Normocytic normochromic anemia

• MCV <80 fL

• MCH <27 pg

This indicates which anemia?

Microcytic hypochromic anemia

• MCV >100 fL

• MCH > 34 pg

This indicates which anemia?

Macrocytic (megaloblastic) anemia

Patients who drink alcohol have increased risk of

Macrocytic anemia (liver disease, folic acid, and vit B12 deficiency)

Diagnostic studies for anemia

• CBC (Hgb, Hct, WBC, plts)

• RBC indices

  • Mean Corpuscular Volume (MCV)

  • Mean Corpuscular Hemoglobin (MCH)

  • Serum ferritin

  • Serum iron

  • TIBC

• B12

• Folate

• Schilling test to evaluate B12 absorption

Hct = 3 times of

Hgb

RBC indices (part of diagnostic study of anemia)

• Mean Corpuscular Volume (MCV)

• Mean Corpuscular Hemoglobin (MCH)

• Serum ferritin

• Serum iron

• Total iron binding capacity (TIBC)

CBC (part of diagnostic study of anemia)

Hgb, Hct, WBC, plts

Nutritional studies for diagnostic study of anemia

• B12

• Folate

• Schilling test to evaluate B12 absorption

• Iron

Decreased RBC production can be caused by

• IDA

• Thalassemia

• Sideroblastic (bone marrow RBC production disorder)

Decreased # of RBC precursors can be caused by

• Aplastic anemia

• Medications & chemicals

• Radiation

Nutritional anemias include

• IDA

• Macrocytic/megaloblastic anemias (B12 or folate deficiency)

Hereditary (intrisnic) disorder that can lead to anemia

Sickle cell idsease

Acute OR chronic blood loss can both lead to anemia. True or false?

True

Management of anemia:

• Depends on Hgb & Hct

• Stop the bleeding/treat underlying cause

• Blood transfusions

Acute interventions for anemia may include

• Blood transfusions

• Drug therapy (e.g. iron supplements, narcotics for sickle cell crisis)

• O2 therapy

Anemic patients with fatigue education

• Tell them to alternate rest and activity

• Focus on priortizing activities

  • Accomodate energy levels

  • Maximize O2 supply for vital functions

• Aid to minimize r/o injury from falls

• Monitor cardiopulmonary response

• Evaluate nutrition needs (B12, folic, iron deficiencies)

Identifying patients correctly to eliminate transufsion errors

• 2 licensed personnel identificaiton process (transfusion staff and another licensed provider)

• Verification of HCP’s order

• Verification of consent to receive blood

• Verification of blood type w/ transfusion product

Causes of IDA

• Chronic blood loss (GI or GU system), or hemolysis

• Menstruation

• Inadequate dietary iron intake

• Inadequate iron absorption in GI tract

• GI surgeries, involving bypass of duodenum

• Malabsorption syndromes

S&S of IDA

• Depneds on age and severity

• Few symptoms until HCT < 30

  • Pallor

  • Glossitis

  • Chelities

  • HA, paresthesia

When do patients with IDA typically manifest symptoms?

• Few symptoms until HCT < 30

  • Pallor

  • Glossitis

  • Chelities

  • HA, paresthesia

• Depends on age & severity

History for IDA

• Menstrual hx

• Onsert and duration of symptoms

• Change in stool patterns (black, tarry stools = chronic blood loss/occult bleeding)

• Dietary intake

• Medication hx

Physical exam for IDA

• Skin & nails assessment

  • Assess skin for pallor, jaundice, pruritis

  • Assess nails for koilonychias (spoon shaped nails)

• Tongue/mouth assessment

  • Examine tongue for atrophic glossitis, burning sensation

  • Examin corners of mouth for cheilosis (red, cracked skin at corners of mouth)

• Palpate abdomen for tenderness

• Splenomegaly

• Stool assessment

  • Obtain stool for occult blood

Tongue/mouth assessment for IDA

• Examine tongue for atrophic glossitis, burning sensation

• Examin corners of mouth for cheilosis (red, cracked skin at corners of mouth)

Skin & nails assessment for IDA

• Assess skin for pallor, jaundice, pruritis

• Assess nails for koilonychias (spoon shaped nails)

Diagnostic studies for IDA

• Labwork: Hgb, HCT, Plts, MCV, MCH, MCHC, reticulocytes, serum iron, TIBC, bilirubin

• Stool occult blood test

• Endoscopy and colonoscopy

• Bone marrow biopsy

Labwork for IDA:

Hgb, HCT, Plts, MCV, MCH, MCHC, reticulocytes, serum iron, TIBC, bilirubin

What does the typical labwork for IDA patient look like?

• CBC → eventually low

• Serum iron → decreased

• TIBC → high

• Serum ferritin → low

• MCV → low

• MCH → low

• CBC → eventually low

• Serum iron → decreased

• TIBC → high

• Serum ferritin → low

• MCV → low

• MCH → low

What do these lab findings indicate?

IDA

Goal for treating IDA

• Treat underlying problems, causing blood loss, reduced intake, or poor absorption of iron

• Replacd iron via:

  • Nutrition therapy

  • Oral iron supplements

  • Transfusion of packed RBCs

What is the first lab to drop in early IDA?

Serum ferritin

Lab value that measures iron stores; is the first to drop in IDA

Serum ferritin

Lab value that measures circulating iron, carried by transferrin). Drops after serum ferritin in IDA

Serum iron

Lab value that measures ability of cells to bind to iron. Is normally inversely related to serum iron (when serum iron is low, TIBC is high)

TIBC

TIBC is directly proportional to serum iron (TIBC will be high if serum iron is high). True or false?

False

Treatment of IDA

• Oral iron therapy (supplements

• Teach about foods high in iron

• Take iron between meals or one hours before

• Take with vitamince (OJ if not DM) improves absorption

• May cause constipation (can also cause diarrhea in some)

• Correct the cause of bleeding

Iron-rich foods include:

• Animal sources

  • Meat (esp red meat)

  • Fish

  • Eggs

• Plant sources

  • Leafy greens

  • Legumes (beans, lentils, peas)

  • Whole-grain

Why should you take iron supplements between meals or one hour before?

Iron supplements are absorbed best on an empty stomach because food can significantly interfere with iron absorption (food in stomach binds with iron, decreasing absorption)

Why take iron with vitamin C (OJ)?

Improves iron absorption

What do you need to teach the patient about their stools when they are taking oral iron supplements?

Their stool will be black in color