Disorders of Tissue Perfusion & Hematological System

Disorders of Tissue Perfusion
&
Hematological System
4/6/2023 By: Yonatan Solomon (Ass. Professor) DDU Nursing 1

RBC Disorders

Anemia
 Anemia is a qualitative or quantitative deficiency of hemoglobin, in red
blood cells that transports oxygen.
 It is a lower than normal number of red blood cells, usually measured by a
decrease in the amount of hemoglobin.
 Is the most common disorder of blood which leads to hypoxia in organs.
 Not speciﬁc disease but a sign of underlying disorder.

Cont…
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 Functional definition: A significant reduction in red cell mass and a
corresponding decrease in the 02 carrying capacity of the blood.
 Laboratory definition: A reduction of the Hemoglobin concentration, red
cell mass or Hematocrit, to below normal levels.
 Anemia is not a specific disease by itself but a syndrome of other
underlying disorders.
 Is a condition in which the hemoglobin concentration is lower than normal,
reflects the presence of fewer than normal RBCs within the circulation.

The normal ranges
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• Hemoglobin
• Males: 13–18 gm/dl
• Females: 12–16 gm/dl)
• Hematocrit
• Males: 42%–52%
• Females: 35%–47%)

Classifications of Anemia
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1. Impaired RBC Production
☞ Aplastic anemia,
☞ Iron deficiency,
☞ Megaloblastic anemia,
☞ Anemia of chronic diseases, and
☞ Drug related.

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2. RBC loss or destruction
☞Bleeding
☞Hereditary hemolytic anemia
☞Bleeding from uterus, GIT, nose, or a wound.
Cont…

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3. Morphological classification
☞Hypochromic microcytic anemia
☞Macrocytic anemia
☞Normochromic normocytic
Cont…

Potential causes
1. Loss of RBCs—bleeding, (e.g.. GIT, uterus, nose, or wound)
2. Decreased production of RBCs (ineffective hematopoiesis): deﬁciency in
cofactors for erythropoiesis; bone marrow suppression or lack of
erythropoietin.
3. Hemolysis: overactive RES (e.g. hypersplenism) or production of
abnormal RBCs (e.g., sickle cell anemia)

Iron deficiency anemia (IDA)
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☞ Occurs when body iron stores become inadequate for the needs of
normal RBC production (erythropoiesis)
☞ It is a manifestation of diseases, not by itself a complete diagnosis
☞ It is the commonest cause of anemia world wide

Etiologies of Iron Deficiency Anemia
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Chronic blood loss
 Uterine bleeding
 Gastrointestinal, e.g. Esophageal varices; hiatal hernia; PUD; aspirin ingestion;
 Hook worm infestation;
 Poor diet
 Mal absorption of iron (chronic gastritis, gastroectomy)

Clinical manifestation
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 Is insidious in onset and progressive in course
 Usually non-specific symptoms
 Smooth, sore tongue, brittle and ridged nails, and angular cheliosis (an
ulceration of the corner of the mouth).
 These signs subside after iron-replacement therapy.
 GI bleeding, and pica (a craving for unusual substances, such as ice, clay)

Treatment of IDA
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 Identify underlying cause and treat it
 Ferrous sulfate 300mg (60 mg elemental iron) 3x/day for 4-6 months
 Absorption increased by giving between meals, but side effects are less if
given with meals
 Iron could be also given IM or IV
 Response to treatment; an expected daily rise of hemoglobin by 0.1-0.2 gm /dl

Aplastic Anemia
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 It is a rare disease caused by
o a decrease in or damage to marrow stem cells,
o damage to the microenvironment within the marrow, and
o replacement of the marrow with fat.
 It can be congenital or acquired, but most cases are idiopathic

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Etiology is unknown, but it is hypothesized that the body’s t cells mediate
an inappropriate attack against the bone marrow resulting in bone marrow
aplasia (i.e., markedly reduced hematopoiesis).
Infections and pregnancy can trigger it, or it may be caused by certain
medications, chemicals, or radiation damage.
Cont…

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Manifested by infection and symptoms of anemia (e.g., fatigue, pallor,
dyspnea), Purpura (bruising)
Severe anemia, significant neutropenia and thrombocytopenia (a deficiency
of platelets) are also seen.
Managed by Bone marrow transplantation (BMT) or
peripheral stem cell transplantation (BSCT), immunosuppressive therapy
Cont…

Megaloblastic Anemia
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It is a delayed in maturation of the RBC due to deficiencies of vitamin B12
or folic acid, which is essential for normal DNA synthesis.
The RBCs that are produced are abnormally large and are called
megaloblastic RBCs.

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 Pernicious anemia: is megaloblastic anemia due to destruction of the
Parietal cells in the stomach, which produce intrinsic factors, as in
chronic atrophic gastritis, which results impaired production of
intrinsic factors.
Cont…

Management
20
 Correct underlying cause
 Antibiotics for bacterial over growth and treatment of fish tapeworm
 Vit B12 Deficiency: is treated with Hydroxocobalamine
 Prophylactic therapy: is indicated in patients with Total gastroectomy
and Ileac resection
 Folic acid given orally 5 mg Po daily

Sickle cell anemia
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 Is hemolytic anemia that results from inheritance of the sickle
hemoglobin gene which causes the hemoglobin molecule to be
defective.
 Sickle hemoglobin (HbS) acquires a crystal-like formation when
exposed to low oxygen tension.

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 RBC is deformed, rigid, and sickle-shaped, long, rigid which can
adhere to the endothelium of small vessels; and reduce blood flow to
organ causes ischemia to distal part.
Cont…

Sickle Cell Anemia
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Clinical Manifestations
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All sign of Anemia
 Abdominal pain; fever, signs of infection (any part could be infected)
Chest pain; dyspnea, Weakness, Dehydration
Bone pain, especially hips
Pain, skin ulcer
↓ Vision; blindness,

Management
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☞ Usually supportive management
☞ Bone marrow transplantation
☞ Hydroxyurea (Hydrea), a chemotherapy agent, has been shown to be
effective in increasing hemoglobin
☞ Long term RBC transfusion.

Prevention of anemia
 Eat foods high in iron
 Eat and drink foods that help your body absorb iron,
 Don't drink coffee or tea with meals.
 Make sure to consume enough folic acid and vit. B12.
 Make balanced food choices.
 Avoid food fads and dieting
 Talk to doctor about taking iron pills (supplements): ferrous and ferric.

Possible complications of Anemia
☞ Diminishes the capability to perform physical activities.
☞ Hypoxemia
☞ Brittle or rigid fingernails,
☞ Cold intolerance,
☞ Possible behavioral disturbances in children.
☞ Exacerbation of pre-existing cardio-pulmonary problems

Shock
 Shock is a serious, life-threatening medical condition where
insufficient blood flow reaches the body tissues.
 Reduced blood flow hinders oxygen and nutrients delivery to the
tissues, and can stop the tissues from functioning properly.
 It is a medical emergency and one of the most common causes of
death for critically-ill people.

Stages of shock
 There are four stages of shock, although shock is a complex and
continuous condition
Initial stages
Compensatory (Compensating)
Progressive (Decompensating)
Refractory (Irreversible)

Initial stage
 Changes attributed to this stage occur at the cellular level and not
detectable clinically.

Compensatory Stage
Blood pressure remains within normal limits.
Vasoconstriction, increased HR and contractility to maintain adequate
cardiac output (SNS)
The patient displays the “ﬁght or ﬂight” response.
The body shunts blood to the brain and heart
Skin is cold and clammy, bowel sounds are hypoactive, and urine
output decreases

Cont…
Anaerobic metabolism and metabolic acidosis.
Respiratory rate increases causing compensatory respiratory alkalosis.
Mental status changes, such as confusion
If treatment begins in this stage of shock, the prognosis for the patient
is good

Progressive Stage
 The mechanisms that regulate BP can no longer compensate and the
MAP falls below normal limits,
 The overworked heart becomes dysfunctional;
 Ischemia and myocardial depression
 The autoregulatory function of the microcirculation fails, increased
capillary permeability, vasoconstriction
 Interstitial edema and return of less fluid to the heart.

Irreversible Stage
 Organ damage is so severe that the patient does not respond to treatment
and cannot survive.
 Despite treatment, blood pressure remains low.
 Complete renal and liver failure, compounded by the release of necrotic
tissue toxins, metabolic acidosis.
 Anaerobic metabolism contributes to a worsening lactic acidosis.
 Reserves of ATP are almost totally depleted.
 Multiple organ dysfunctions progressing to complete organ failure and
death is imminent.

Summary of Clinical Findings in Shock

Pathophysiology of shock

Types of shock
• There are four common types of shock:
1. Hypovolaemic,
2. Cardiogenic,
3. Distributive and
4. Obstructive shock

Hypovolemic shock
 This is the most common type of shock and is caused by insufficient
circulating volume.
 Cause and risk factors
Internal: Fluid Shifts
o Hemorrhage
o Severe Burns
o Ascites
o Dehydration
External: Fluid Losses
o Trauma
o Surgery
o Vomiting
o Diarrhea
o Diuresis

Pathophysiologic events in hypovolemic shock

Cardiogenic shock
 This type of shock is caused by the failure of the heart to pump
effectively.
 Cause
 Myocardial infarction
 Arrhythmias
 Cardiomyopathy
 Congestive heart failure (CHF)
 Cardiac valve problems

Pathophysiologic events in cardiogenic shock

Distributive shock
 As in hypovolaemic shock there is an insufficient intravascular
volume of blood.
 This form of "relative" hypovolaemia is the result of dilation of
blood vessels which diminishes systemic vascular resistance.

Examples of Distributive shock
A. Septic shock: is a type of shock caused by infection
Cause
Infections leading to vasodilatation caused by:
– Gram negative bacteria i.e. E.coli, Proteus species,
– Gram-positive cocci, such as streptococci
– Certain fungi
May be related to:
◦ Immunosuppression, Extremes of age, Malnourishment, Chronic illness, Invasive
procedures

Cont…
B. Anaphylactic shock - Caused by a severe anaphylactic reaction to an
allergen, antigen, drug or foreign protein causing the release of histamine
which causes widespread vasodilation, leading to hypotension and increased
capillary permeability.
May be due to:
☞Penicillin sensitivity
☞Transfusion reaction
☞Bee sting allergy
☞Latex sensitivity

Cont…
C. Neurogenic shock : is the rarest form of shock
Cause
☞ Trauma to the spinal cord resulting in the sudden loss of autonomic and
motor reflexes below the injury level
☞ Spinal anesthesia
☞ Depressant action of medications
☞ Glucose deﬁciency

Pathophysiologic events in circulatory shock

Obstructive shock
In this situation the flow of blood is obstructed which impedes
circulation and can result in circulatory arrest.
Causes
 Cardiac tamponade
 Constrictive pericarditis
 Tension pneumothorax
 Massive pulmonary embolism
 Aortic stenosis- obstruct the ventricular outflow tract

Endocrine shock
• Recently a fifth form of shock has been introduced due to endocrine
disturbances

Clinical manifestations of shock
Type
of
shock
Hypovolemic Cardiogenic Obstructive Distributive shock
Septic shock Neurogenic Anaphylactic
Sign
and
Symptoms
o Anxiety, restlessness,
altered mental state
o Hypotension
o A rapid, weak, thready
pulse
o Cool, clammy, mottled skin
o Rapid and shallow
respirations
o Hypothermia
o Thirst and dry mouth
o Fatigue
o Dilated pupil
S/S of
hypovolaemic
shock PLUS
Distended
jugular veins,
Absent pulse
S/S of
hypovolaemic
shock PLUS
Distended jugular
veins,
Pulsus paradoxus
S/S of
hypovolaemic
shock PLUS
Pyrexia and fever,
or hyperthermia-
in the initial stage
Vasodilation &
increased cardiac
output
S/S of
hypovolaemic
shock PLUS
warm and dry skin
Skin eruption
Localized edema
Weak & rapid
pulse
Breathlessness &
cough

Diagnosis
o Clinical
o CBC
o Blood cultures

Treatment of shock
 In the early stages, shock requires immediate intervention to preserve life,
even before a diagnosis is made.
 Re-establishing perfusion to the organs is the primary goal through
restoring and maintaining the circulating blood volume to effective cardiac
function, and preventing complications.
 Raising blood pressure to be able to transport "safely"
 If surgery is required, it should be performed within the first hour to
maximize the patient's chance of survival.

Cont…
1. Hypovolaemic shock
If caused by bleeding
Control bleeding
Restore volume with infusions of balanced salt solutions
Blood transfusions -for loss of large amounts of blood (e.g. >20% of blood
volume)

If due to burns, diarrhoea, vomiting, etc:
Infusions of electrolyte solutions that balance the lost fluid
Prevent metabolic acidosis
As soon as the airway is maintained and oxygen administered the next
step is to commence replacement of fluids via the intravenous route
Cont…

The most common fluids used are:
Crystalloids - Such as sodium chloride (0.9%), Ringer's lactate
Blood - Essential in severe hemorrhagic shock
Colloids
Cont…

2. Cardiogenic shock
 Depending on the type of MI, one can infuse fluids or in shock refractory
to infusing fluids give drugs
 Inotropic agents- (like calcium, Digoxin, Dopamine, Dobutamine,)
 Fluid replacement with intravenous infusions;
 Use of vasopressing drugs to induce vasoconstriction;
 Use of anti-shock trousers
Cont…

3. Distributive shock
Treating infection with antibiotics and supportive care
Anaphylaxis is treated with adrenaline & Corticosteroids
Neurogenic shock
 Trendelenburg position to shunt blood back to the body's core
 Vasopressors like adrenaline, noradrenaline, dubutamine, dopamine,
ephederine etc.
Cont…

Trendelenburg position

4. Obstructive shock
The only therapy consists of removing the obstruction.
Pneumothorax/haemothorax is treated by inserting chest tube
Pulmonary embolism requires thrombolysis or embolectomy
Tamponade is treated by draining fluid from the pericardial space through
pericardiocentesis
Cont…

5. Endocrine shock
Correctting the hormone disturbances.
Hypothyroidism -supplementation by means of levothyroxine
Adrenal insufficiency is treated by supplementing corticosteroids
Cont…

Disorders of Tissue Perfusion & Hematological System

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