Anemias: Fe deficiency and Blood transfusions

Gas Exchange and Alveoli

• Alveolus serves as the site of gas exchange between air and blood.
• Oxygen in, carbon dioxide out across the alveolar wall and capillary interface.
• Red blood cells (RBCs) travel in capillaries to pick up O₂ and release CO₂ for elimination.

Anemia: Overview

• Anemia is a reduction in:
  • Number of RBCs
  • Amount of hemoglobin (Hb)
  • Amount of hematocrit (Hct)
• Hb/Hct are clinical indicators and not disease-specific; many causes for anemia.
• Reduction in RBCs and Hb leads to decreased oxygen delivery to tissues.

Normal RBCs vs Anemia

• Normal RBCs vs anemic states differ in:
  • Hemoglobin content
  • Hematocrit percentage
  • Morphology (e.g., microcytosis, hypochromia in Fe deficiency)
• Decreased RBCs can result from:
  • Increased destruction
  • Decreased production
  • Blood loss

Causes of Decreased RBCs: Three Main Categories

• Increased Destruction
  • Autoimmune hemolytic anemia
  • G6PD deficiency anemia
• Decreased Production
  • Iron deficiency (Fe) due to poor intake/absorption
  • Chronic diseases affecting hematopoiesis
• Blood Loss/Destruction from other causes
  • Chronic blood loss (e.g., gastritis, menstruation, hemorrhoids)
• Nursing interventions are the same regardless of the cause

Hgb and Hct: Part of the CBC

• Hemoglobin (Hb):
  • Iron-rich protein in RBCs
  • Oxygen-carrying capacity of RBCs
  • Units: g/dL
  • Varies with age:
  • Men: 13.5–17.5 g/dL
  • Women: 11.5–15.5 g/dL
• Hematocrit (Hct):
  • Percentage of packed RBCs per deciliter of blood
  • Label is %
  • Varies with age
  • Typical ranges:
  • Men: <38%
  • Women: <35%

Visual difference: Hematocrit

• Normal Hct around 40%
• Anemia Hct around 30%
• These values illustrate the impact of RBC mass on oxygen transport

Causes of Low vs High Hemoglobin

• Low Hb causes
  • Low iron intake or poor absorption
  • Menstrual bleeding
  • Bleeding from any cause
  • Cancer (especially blood cancers)
  • Chemotherapy
• High Hb causes
  • Polycythemia vera
  • Lung or heart disease
  • Kidney or liver cancer
  • Smoking
  • Chronically low oxygen levels

Hb/Hct Reference Values by Group

• Adult Male: Hb $13.5-17.5 ext{ g/dL}$
• Adult Female: Hb $11.5-15.5 ext{ g/dL}$
• Child (1 year to puberty): Hb $11.0-13.5 ext{ g/dL}$
• Baby (3 months): Hb $9.5-12.5 ext{ g/dL}$
• Newborn: Hb $15.0-21.0 ext{ g/dL}$
• (Hct reference: Men <38%, Women <35%)

Common Causes of Anemia

• Dietary problems
• Genetic disorders
• Bone marrow disease
• GI bleeding

Types of Anemia

• Fe deficiency anemia
• Sickle cell disease
• Vitamin B12 deficiency anemia
• Folic acid deficiency anemia
• Hemolytic anemia
• Aplastic anemia
• G6PD deficiency

Fe Deficiency Anemia (Fe-Deficiency) Overview

• Most common anemia worldwide, especially in women, elderly, and those with poor diets
• Decreased iron supply from:
  • Blood loss
  • Poor GI absorption
  • Inadequate diet
  • Chronic alcoholism
  • Rapid metabolic activity (pregnancy, adolescence)
• RBCs are microcytic (small) and hypochromic (pale)

Anemia and Gas Exchange

• Anemia reduces RBC count and Hb, impairing O₂ transport to tissues
• Tissue hypoxia is a key mechanism behind many signs and symptoms of anemia

Signs and Symptoms of Anemia

• Skin: pallor (circumoral, ears, nailbeds); cool to touch; poor tolerance to cold
• Nails: brittle, concave (spoon nails)
• Cardiovascular: tachycardia (especially with meals/activity); abnormal heart sounds (murmurs/gallops); orthostatic hypotension
• Respiratory: dyspnea on exertion; reduced O₂ saturation
• Neurologic: fatigue; increased need for sleep; reduced energy

Severity Categories of Anemia

• Mild anemia: Hb 10–14 g/dL
  • Often asymptomatic or mild symptoms; symptoms reflect underlying disease
  • Exercise intolerance possible
• Moderate anemia: Hb 6–10 g/dL
  • Increased heart rate at rest and with activity
  • Fatigue, paleness
• Severe anemia: Hb < 6 g/dL
  • Pallor, jaundice (if hemolysis), pruritus, retinal hemorrhages
  • Tachycardia, tachypnea, orthopnea, dyspnea at rest; headache, vertigo; irritability; sore mouth; difficulty swallowing; bone pain

Pathophysiology: Ischemia and Compensation (Overview)

• Ischemia leads to: claudication (muscle), angina (heart)
• Etiologic events (erythropoiesis disruption, blood loss, destruction) cause ↓ red blood cells and Hb
• Oxygen-carrying capacity ↓ → tissue hypoxia
• Respiratory adjustments: ↑ respiratory rate/depth (exertional dyspnea)
• Compensatory mechanisms include:
  • Liver fat/fatty changes (in certain conditions)
  • CNS dizziness, fainting, lethargy
  • Increased fatigue and pallor
  • ↑ Erythropoietin → stimulates bone marrow
  • Cardiovascular: ↑ heart rate, hyperdynamic circulation, capillary dilation, murmurs
  • Renal response: ↑ renin-angiotensin-aldosterone → ↑ Na⁺/H₂O retention
  • Extracellular fluid shifts, high-output cardiac failure in severe cases
  • RBCs release oxygen more readily from Hb in tissues

Fe Deficiency Anemia: Laboratory Findings

• CBC: decreased Hb and Hct
• Serum iron: decreased
• Total Iron-Binding Capacity (TIBC): elevated
• Ferritin: decreased
• Transferrin: normal or decreased (as per slide; note typical clinical pattern is increased transferrin in iron deficiency)
• MCV (mean corpuscular volume) and MCH (mean corpuscular hemoglobin): decreased

Fe Deficiency Anemia: Ferritin and Serum Iron Ranges

• Normal iron availability: $2 ext{ to }6 ext{ grams}$ (total body iron)
• Serum ferritin: < $10 ext{ ng/mL}$ (normal range $10 ext{–}300 ext{ ng/mL}$)

Fe Deficiency Anemia: Treatment Goals and Approaches

• Goal: treat underlying cause of reduced iron intake or absorption
• Replace iron:
  • Educate patient on iron-rich foods (see nutrition section)
  • If nutrition alone is insufficient, use oral or occasionally parenteral iron supplements
  • Drug therapy requires considerations for administration and side effects
• If iron deficiency is due to acute blood loss, transfusion of packed RBCs may be needed

Iron-Rich Foods (Dietary Considerations)

• Pork, beef
• Chicken
• Liver
• Broccoli
• Potatoes
• Dried beans / green peas with skin
• Spinach
• Iron-fortified cereals
• Note: Diet should balance iron intake with vitamin C to enhance absorption

Oral Iron Therapy: Practical Guidelines

• Use oral iron when possible: inexpensive and convenient
• Key considerations:
  • Enteric-coated or sustained-release capsules are counterproductive for iron absorption
  • Iron is absorbed best in the duodenum and proximal jejunum; enteric-coated forms release further down the GI tract
  • Daily elemental iron dose: $150 ext{–}200 ext{ mg}$
  • Ferrous sulfate commonly used: a 300 mg tablet typically contains $60 ext{ mg}$ elemental iron
  • Best absorbed in an acidic environment; take on an empty stomach, about an hour before meals; taking with vitamin C enhances absorption
  • GI side effects common; may require dose adjustments or switching formulations
  • If taking liquid iron, dilute and use a straw to avoid teeth staining
  • Constipation is common; stool softeners/laxatives may be needed
  • Some side effects may necessitate adjustment of dose/type

Parenteral Iron Therapy

• Indications:
  • Malabsorption or poor tolerance of oral iron
  • Need for iron beyond what oral preparations can provide
  • Poor adherence to oral therapy
• Routes: intramuscular (IM) or intravenous (IV)
• Precautions:
  • Some IV iron preparations carry allergy risk; monitor accordingly
  • IM injections may stain the skin; use separate needles for drawing and injecting
  • Use a Z-track technique for IM administration

Nursing Interventions: General Care for Fe-Deficiency Anemia

• ADLs: Encourage alternate rest and activity periods to manage fatigue
• Monitor cardiorespiratory response to activity to assess tolerance
• Medications: explain purpose, action, dosage, route, duration, and potential adverse effects
• Diet: encourage protein, iron-rich foods, and vitamin C to enhance iron absorption and Hb production

Fe Deficiency Anemia Across the Lifespan

• Infants: preterm, low birth weight; breastfed without Fe-containing foods after 6 months; at 1 year, switch to whole milk (lower Fe content)
• Adolescent girls: start of menstruation increases Fe needs
• Pregnancy: higher Fe needs
• Older adults: risk due to poor diet, chewing issues; NSAID-related gastritis; colon cancer; chronic disease

Blood Transfusions: Nursing Care and Considerations

• Indications:
  • RBC transfusions: replace cells lost from trauma or surgery (hemorrhagic shock) or symptomatic anemia
  • Platelet transfusions: low platelets, active bleeding, prior to invasive procedures
  • Plasma transfusions: replace blood volume and clotting factors

Transfusion Responsibilities: Pretransfusion

• Verify order with another RN
• Send a type and crossmatch per orders
• Test donor and recipient blood for compatibility
• Verify patient identity with another RN
• Inspect blood bag label, attached tag, and requisition Slip for ABO and Rh compatibility with patient (with another RN)
• Check expiration date with another RN
• Inspect blood for discoloration, gas bubbles, or cloudiness
• Prepare blood tubing (Y tubing with filter)

Transfusion Responsibilities: During Transfusion

• Provide patient education about the transfusion
• Monitor vital signs: immediately before starting, then every 15 minutes for the first hour, every 30 minutes for the next hour, then hourly as per protocol
• Hang blood with 0.9% saline only, using the special blood administration tubing (Y tubing with filter)
• Use an infusion pump as ordered
• Start slowly and stay with the patient for the first 15–30 minutes
• Instruct patient to report unusual sensations (e.g., chills, shortness of breath, hives, itching)
• Administer blood product according to protocol
• Monitor for signs of hyperkalemia

Transfusion Reactions: Overview

• Transfusion reactions can occur within minutes to hours of initiation
• Common types include:
  • Febrile reaction
  • Hemolytic reaction
  • Allergic reaction
  • Bacterial contamination reaction
  • Circulatory overload
  • Transfusion-associated graft-versus-host disease (GVHD)

Transfusion Reactions: Mild to Severe Presentations

• Mild allergic reaction
  • Symptoms: facial flushing, hives/pruritus
  • Management: stop transfusion if symptoms worsen; notify physician; may require antihistamines as ordered
• Severe allergic reaction
  • Symptoms: severe shortness of breath, bronchospasm, possible anaphylaxis
  • Management: stop transfusion, maintain IV with NS, administer prescribed treatments (e.g., epinephrine), notify physician
• Febrile reaction
  • Symptoms: fever, headache, chills, flushing, tachycardia, anxiety
  • Management: stop transfusion if indicated; treat symptoms; re-crossmatch if needed
• Hemolytic reaction
  • Symptoms: low back pain, hypotension, tachycardia, fever and chills, chest pain, tachypnea, hemoglobinuria
  • Timing: may have immediate onset
  • Management: stop transfusion, notify physician, obtain new samples, monitor fluids/electrolytes, recheck crossmatch

Transfusion Reactions: Documentation and Follow-Up

• Stop the transfusion and maintain IV line with normal saline
• Notify physician immediately
• Obtain blood and urine samples for evaluation when indicated
• Re-check patient’s identity, blood product compatibility, and crossmatch records
• Provide supportive care per physician orders

Acute Transfusion Reactions (Summary)

• Febrile transfusion reaction
• Hemolytic transfusion reaction
• Allergic transfusion reaction
• Bacterial contamination reaction
• Circulatory overload
• Transfusion-associated graft-versus-host disease (GVHD)

Quick Reference: Signs and Immediate Actions

• If any reaction is suspected:
  • Stop the transfusion
  • Keep IV line open with NS
  • Notify physician and blood bank
  • Document time of reaction and symptoms
  • Obtain necessary specimens (blood/urine) for testing
  • Reassess patient’s vital signs and symptoms

Important Notes and Practical Tips

• Always verify identity, blood product, and crossmatch before starting transfusion
• Use proper IV access and tubing with a dedicated IV solution (NS only)
• Stay with the patient during the first 15–30 minutes of the transfusion and monitor closely for any adverse signs
• Educate patients about potential transfusion reactions and what to report
• For Fe deficiency anemia, focus on iron replacement, dietary optimization, and addressing the underlying cause to prevent recurrence
• In cases of acute blood loss, transfusion may be necessary to stabilize the patient quickly