anemia and anesthesia

1. ANAEMIA

2. Case1
◦ 19 yr old male presented with complaints of malaena, on and off, generalised weakness and
abdominal pain since 3 days.
◦ Patient was apparently normal 1 yr ago when he started developing multiple episodes of dark
tarry stools on andoff and generalised weakness. The episodes settles by itself. 3 days back he
developed abdominal pain which was sudden in onset. No h/o of hemetemesis, fever, loosestool
◦ No significant personal or family history

3. ◦ O/E: Pallor +
◦ No cyanosis, clubbing , lymphadenopathy or deems
◦ Vitals stable
◦ Systemic examination
GIT: P/A soft, non tender, BS+
RS:Clear,b/l Air entry +
CVS: S1s2+, no murmur
CNS: NFND

4. Investigations
◦ Hb- 5.7
◦ MCV , HCT, MCHC, MCH Reduced
◦ PBS:microcytic hypochromic blood
Picture with moderate anisocytosis
Elliptocytes,fragmented RBCs ,
tear drop Cells+
◦ USG: wNL
◦ UpperGI endoscopy:2021
◦ hiatal hernia,
◦ Antral nonerosive gastritis
◦ Duodenitis
◦ Nov 2022: Antral gastritis , h pylori+
◦ Colonoscopy: grade 2 hemorrhoids

5. Impression
◦ Upper GI bleed with severe anemia .
◦ ? Iron deficiency anemia

6. Definition
◦ WHO defines anemia as hemoglobin level
◦ < 13 g/dl in adult men
◦ <12g/dl in women
◦ <11g/dl in pregnacy

7. Classification
◦ Hypoprolifferative Hyperproliferative(haemolytic)
◦ Macrocytic( alcoholism, liver disease, hypothyroidism, vitamin B12
◦ Normocytic( CKD,heart failure, cancer, acute blood loss)
◦ Microcytic
◦ Iron deficiency anemia( including chronic blood loss)
◦ Anemia of chronic disease
◦ Sideroblastic anemia
◦ Thalessemia trait

8. Anaemia- Pathophysiology
NORMAL
◦ Oxygen carried- oxygen Hb& dissolved
oxygen
◦ Tissue oxygen delivery determined by
oxygen content of blood and cardiac
output
ANAEMIA
◦ Increased oxygen extraction
◦ Redistribution and increase inCO ( in
tissues with high oxygen demand)
◦ Altered affinity of Hb for O2 –right shift
◦ In perioperative period compensatory
mechanism overwhelmed resulting I
imbalance b/w oxygen supply and demand
that predispose to ischemia and adverse
perioperative outcome

10. Anaesthetic implications
◦ Preoperaive anemia is a consistently risk factor for post operative death and complications
including AKI, stroke and infections
◦ This risk is proportional to degree of anemia &
independent of patients other comorbidities
◦ During preoperative evaluation of known or suspected anemia, the overarching goal is to
determine its ethology, duration, related symptoms and therapy
◦ It is import to enquire about any h/o anemia( including family history), colon cancer,GI
bleed,menorrhagia,chronic infections,inflammatory diseases, nutritional deficiencies and prior
weight reduction procedures ( eg. Bariatric sx)
◦ History – chronic tissue hypo perfusion- fatigue, tiredness, breathlessness,palpitations, chest
pain

11. Consider
Type of surgical procedure and anticipated blood loss
Comorbid conditions that may affect oxygen delivery or be affected by decreased oxygen
delivery ( eg pulmonary, renal ,hepatic,cerebrovascular, cardiology disease)

12. ◦ CBC should be done
◦ Collaboration with primary care physician/ haematologist helpful for further evaluation of newly
diagnosed anemia
◦ Initial studies include peripheral smear and MCV
◦ Subsequent studies iron studies( ferritin, transferrin saturation), vitamin B12, folate levels
◦ MCV high&low vit B12/ folate- macrocyttic anemia associated with these deficiencies
◦ Low MCV, ferritin (<30g/mic L)and transferrin saturation (<20%)- Iron deficiency anemia
◦ Ferritin and transferrin normal or high- anemia of chronic disease

13. ◦ Blood type and screening may be necessary based on level of preoperative anemia and
anticipated degree of surgical blood loss
◦ Elective procedures should be postponed in patients with significant anemia regardless
anticipated surgical blood loss
This delay allows evaluation of underlying cause such as occult blood loss, vitamins deficiency or
undiagnosed chronic conditions ( eg CKD)
When delay in elective procedure is possible updated 2015guidelinesASA suggest preoperative
treatment with erythropoietin’s stimulating agent and iron in some patient subgroups( eg
CKD,anemia of chronic disease, patients refusal to Receive bloood transfusion), especially for
anemic individuals scheduled for procedures with significant blood loss.
Preoperative iron therapy in patients with IDA when time permits

14. Perioperative consideration
◦ Avoid hypoxia
◦ Minimiize drug induced drop of cardiac output
◦ Avoid factors that lead to ODC shilft to left
◦ ( avoid hyperventilatiion,hypocapnia,alkalosis)
◦ Monitor
◦ Regional anaesthesia preferred

15. THANK YOU