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11..blood transfusion anemia thrombocyt

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  • 1. BIKHABIKHAAnemia,Thrombocytopenia,& Blood TransfusionsDr. Rafi Ahmed GhoriFCPSProfessor MedicineLiaquat University of Medical & Health Sciences,JamshoroRafi
  • 2. BIKHABIKHAObjectives• An overview and approach to theanemic patient.• An overview and approach to thethrombocytopenic patient• An overview of blood transfusionswith an evidence based approachRafi
  • 3. BIKHABIKHAAnemia• A reduction below normal in theconcentration of hemoglobin or redblood cells in the blood.• Hematocrit (<40% in men,<36% inwomen)• Hemoglobin (13.2g/dl in men,11.7g/dl in women)Rafi
  • 4. BIKHABIKHASymptoms of Anemia• Nonspecific and reflect tissuehypoxia:– Fatigue– Dyspnea on exertion– Palpatations– Headache– Confusion, decreased mental acuity– Skin pallorRafi
  • 5. BIKHABIKHAHistory and Physical in Anemia• Duration and onset of symptoms• Change in stool habits: StoolGuaiacs in all• Splenomegaly?• Jaundiced?Rafi
  • 6. BIKHABIKHAComponents ofOxygen Delivery• Hemoglobin in red cells• Respiration (Hemoglobin levelsincrease in hypoxic conditions)• Circulation (rate increases withanemia)Rafi
  • 7. BIKHABIKHAClassification of AnemiaKinetic classification• Hypoproliferative• Ineffective Erythropoiesis• Hemolysis• BleedingMorphologic classification• Microcytic• Macrocytic• NormocyticRafi
  • 8. BIKHABIKHAAnemia: A Kinetic Perspective• Erythrocytes in circulation represent adynamic equilibrium betweenproduction and destruction of red cells• In response to acute anemia (ie bloodloss) the healthy marrow is capable ofproducing erythrocytes 6-8 times thenormal rate (mediated througherythropoietin)Rafi
  • 9. BIKHABIKHAReticulocyte Count• Is required in the evaluation of all patientswith anemia as it is a simple measure ofproduction• Young RBC that still contains a small amountof RNA• Normally take 1 day for reticulocyte tomature. Under influence of epo takes 2-3days• 1/120thof RBC normallyRafi
  • 10. BIKHABIKHAAbsolute Retic count• Retic counts are reported as apercentage: RBC count x Retic % =Absoulte retic count(normal: 40-60,000/μl3)• Absolute Retic counts need to becorrected for early release ( Ifpolychromasia is present)• Absolute retic/2 (for hct in mid 20’s)• Absolute retic/3 (hct <20)Rafi
  • 11. BIKHABIKHAIndirect Bilirubin: a marker ofRBC destruction• 80% of normal Bilirubin production is aresult of the degradation of hemoglobin• In the absence of liver disease IndirectBilirubin is an excellent indicator of RBCdestruction• LDH and Haptoglobin are other markersRafi
  • 12. BIKHABIKHAAnemiaLow Retic count & NormalBili/LDHHypoproliferative AnemiaHigh Retic count & HighBili/LDHHemolytic AnemiaLow Retic count & HighBili/LDHIneffective ErythropoiesisHigh Retic count & normalBili/LDHBlood LossRafi
  • 13. BIKHABIKHAHypoproliferative Anemias• Iron deficiency anemia• Anemia of chronic disease• Aplastic anemia and pure red cell aplasia• Lead poisoning• Myelophthistic anemias (marrow replaced bynon-marrow elements)• Renal Disease• Thyroid disease• Nutritional defieciencyRafi
  • 14. BIKHABIKHALab Evaluation ofHypoproliferative AnemiasFe TIBC FerritinFe Deficiency low High(>300) lowAnemia ofChronic Dxlow low Normal tohighAplastic anemia High ExtremelyhighNormal tohighRafi
  • 15. BIKHABIKHAAnemia 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 IronRafi
  • 16. BIKHABIKHAIneffective Erythropoiesis• B12 and Folate Deficiency– Macrocytosis– Decreased serum levels– Elevated homocysteine level• Myelodysplastic Syndromes– Qualitative abnormalities of platlets/wbc– Bone marrowRafi
  • 17. BIKHABIKHAHemolysis• Thalassemia– Microcytosis– RBC count elevated– Family history• Microangiopathy– Smear with schistocytes and RBCfragments– HUS/TTP vs. DIC vs. Mechanical ValveRafi
  • 18. BIKHABIKHAHemolysis (cont.)• Autoimmune (warm hemolysis)– Spherocytes– + Coomb’s test• Autoimmune (cold Hemolysis)– Polychromasia and reticulocytosis– Intravascular hemolysis– + cold agglutinins– Hemoglobinuria/hemosiderinuriaRafi
  • 19. BIKHABIKHABleeding• Labs directed at site of bleeding andclinical situationRafi
  • 20. BIKHABIKHARBC Transfusion• What is the best strategy for transfusionin a hospitalized patient population?• Is a liberal strategy better than arestrictive strategy in the critically illpatients?• What are the risks of transfusion?Rafi
  • 21. BIKHABIKHARisks of RBC Transfusionin 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 1/500,000Rafi
  • 22. BIKHABIKHAPacked 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 forrare blood types and unusual AbprofilesRafi
  • 23. BIKHABIKHASpecial RBC’s• Leukocyte-reduced= 108WBCs preventFNHTR• Leukocyte-depleted= 106WBCs preventalloimmunization and CMVtransmission• Washed: plasma proteins removed toprevent allergic reaction• Irradiated: lymphocytes unable todivide, prevents GVHDRafi
  • 24. BIKHABIKHAHebert et. al, NEJM, Feb 1999• A multicenter randomized, controlledclinical trial of transfusion requirementsin critical care• Designed to compare a restrictive vs. aliberal strategy for blood transfusions incritically ill patientsRafi
  • 25. BIKHABIKHAMethods: Hebert et. al• 838 patients with euvolemia after initialtreatment who had hemoglobinconcentrations < 9.0g/dl within 72 hoursof admission were enrolled• 418 pts: Restrictive arm: transfused forhb<7.0• 420 pts: Liberal arm: transfused for Hb<10.0Rafi
  • 26. BIKHABIKHAExclusion Criteria• Age <16• Inability to receive blood products• Active blood loss at time of enrollment• Chronic anemia: hb< 9.0 in precedingmonth• Routine cardiac surgery patientsRafi
  • 27. BIKHABIKHAStudy population• 6451 were assessed for eligibility• Consent rate was 41%• No significant differences were notedbetween the two groups• Average apache score was 21(hospitalmortality of 40% for nonoperativepatients or 29% for post-op pts)Rafi
  • 28. BIKHABIKHASuccess of treatment4.3%1.4%Noncompliance>48hrs5.6+ 5.32.6+ 4.1# of transfusions10.7+0.78.5+0.7AverageHemoglobinLiberalGroupRestrictive GroupRafi
  • 29. BIKHABIKHAOutcome MeasuresRestrictivegroupLiberal groupRate of death at 30days18.7% 23.3Mortality rates 22.2% 28.1Rafi
  • 30. BIKHABIKHAComplications while in ICUrestrictive liberal P valuecardiac 13.2% 21.0% <0.01MI 0.7% 2.9% 0.02Pulm edema 5.3% 10.7% <0.01ARDS 7.7% 11.4% 0.06Septic shock 9.8% 6.9% 0.13Rafi
  • 31. BIKHABIKHASurvival curve• Survival curve was significantlyimproved in the following subgroups:– Apache<20– Age<55Rafi
  • 32. BIKHABIKHAConclusions• A restrictive approach to bloodtransfusions is as least as effective ifnot more effective than a more liberalapproach• This is especially true in a healthier,younger populationRafi
  • 33. BIKHABIKHAThrombocytopenia• Defined as a subnormal amount ofplatelets in the circulating blood• Pathophysiology is less well definedRafi
  • 34. BIKHABIKHAThrombocytopenia:Differential Diagnosis• Pseudothrombocytopenia• Dilutional Thrombocytopenia• Decreased Platelet production• Increased Platelet Destruction• Altered Distribution of PlateletsRafi
  • 35. BIKHABIKHAPseudothrombocytopenia• Considered in patients without evidenceof petechiae or ecchymoses• Most commonly caused by plateletclumping– Happens most frequently with EDTA– Associated with autoantibodiesRafi
  • 36. BIKHABIKHADilutional Thrombocytopenia• Large quantities of PRBC’s to treatmassive hemmorhageRafi
  • 37. BIKHABIKHADecreased Platelet Production• Fanconi’s anemia• Paroxysmal Nocturnal Hemoglobinuria• Viral infections: rubella, CMV, EBV,HIV• Nutritional Deficiencies: B12, Folate, Fe• Aplastic Anemia• Drugs: thiazides, estrogen, chemotherapy• Toxins: alcohol, cocaineRafi
  • 38. BIKHABIKHAIncreased Destruction• Most common cause of thrombocytopenia• Leads to stimulation of thrombopoiesis andthus an increase in the number, size and rateof maturation of the precursormegakaryocytes• Increased consumption with intravascularthrombi or damaged endothelial surfacesRafi
  • 39. BIKHABIKHAIncreased Destruction (Cont.)• ITP• HIV associated ITP• Drugs: heparin, gold, quinidine,lasix,cephalosporins, pcn, H2 blockers• DIC• TTPRafi
  • 40. BIKHABIKHAAltered Distribution of Platelets• Circulating platelet count decreases,but the total platelet count is normal– Hypersplenism– Leukemia– LymphomaRafi
  • 41. BIKHABIKHAProphylactic Versus TherapeuticPlatelet Transfusions• Platelet transfusions for active bleedingmuch more common on surgical andcardiology services• Prophylactic transfusions most commonon hem/onc services• 10 x 109/L has become the standardclinical practice on hem/onc servicesRafi
  • 42. BIKHABIKHAFactors affecting a patientsresponse to platelet transfusion• Clinical situation: Fever, sepsis,splenomegaly, Bleeding, DIC• Patient: alloimunization, underlyingdisease, drugs (IVIG, Ampho B)• Length of time platelets stored• 15% of patients who require multipletransfusions become refractoryRafi
  • 43. BIKHABIKHAStrategies to improve response toplatelet transfusions• Treat underlying condition• Transfuse ABO identical platelets• Transfuse platelets <48 hrs in storage• Increase platelet dose• Select compatible donor– Cross match– HLA matchRafi
  • 44. BIKHABIKHAPlatelet TransfusionsReactions• Febrile nonhemolytic transfusion:caused by patients leucocytes reactingagainst donor leukocytes• Allergic reactions• Bacterial contamination: most commonblood product with bacterialcontaminationRafi
  • 45. BIKHABIKHA