Anemia in critical illness

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Anemia in critical illness

  1. 1. Critical Illness: Hematologic Complications Susan E. Segreti, MS, MEd, NP-C Syracuse Veterans Administration
  2. 2. Background <ul><li>55,000 ICU patients per day in USA </li></ul><ul><li>Incidence of hemorrhage, respiratory failure, multiple organ system failure, sepsis, and hemodynamic abnormalities </li></ul>Thrombocytopenia Anemia Neutropenia
  3. 3. <ul><li>29% ICU patients anemic with admission </li></ul><ul><li>95% ICU patients develop anemia < 3 days </li></ul><ul><li>30% of critically ill have active bleeding </li></ul><ul><li>Stress ulcers lead to GI bleeding (PPIs) </li></ul><ul><li>Proinflammatory cytokines cause vasodilatation and increased permeability in intestinal wall 30% of bleeds in ICU are GI related </li></ul><ul><li>Phlebotomy – 4 draws (41 ml) = 164 cc/day arterial lines > volume/frequency </li></ul>Anemia
  4. 4. Destruction RBC life span = 120 days Intrinsic defect – sickle cell, thalassemia, or enzyme deficiencies Extrinsic process – hemolysis: 1) transfusions – antibody attacks RBC membrane 2) stasis – enlarged spleen 3) malfunctioning valves 4) rapid infusions of hypotonic solutions 5) mechanical trauma (invasive devices) 6) medications – PCN, sulfa, APAP, procainamide, methyldopa
  5. 5. Production Erythropoiesis
  6. 6. Production <ul><li>Erythropoiesis – development of mature RBCs: </li></ul><ul><li>O2 (Hgb) levels signals kidney to erythropoietin </li></ul><ul><li>With critical illness there is a blunted response </li></ul><ul><li>Proinflammatory cytokines also blunt response </li></ul>
  7. 8. Management <ul><li>Identify the cause </li></ul><ul><li>Transfuse – 10/30 rule (tradition) Hgb < 10 g/dL or Hct < 30% Absence of acute bleeding Hgb < 7.9 g/dL </li></ul><ul><li>Establish iron deficiency ( ferritin/ TIBC) </li></ul><ul><li>Caution replacement – iron overload, GI issues, binding with other drugs </li></ul><ul><li>Pseudomonas, Escherichia coli, Salmonella, & Klebsiella with presence free iron </li></ul><ul><li>VA guidelines for Procrit ® </li></ul>Anemia
  8. 9. <ul><li>WBC – infection/inflammation </li></ul><ul><li>Neutrophils – 60-70% WBCs </li></ul><ul><li>Kill bacteria </li></ul><ul><li>Limited lifespan (13-20 days) </li></ul><ul><li>Absolute Neutrophil Count ( Segs + Bands x WBC ) 100 </li></ul><ul><li>Neutropenia is ANC < 1500/mcL </li></ul><ul><li>ANC < 500/mcL – risk of infection </li></ul>Neutropenia
  9. 10. <ul><li>Increased production </li></ul><ul><li>May be neutropenic (immature) </li></ul><ul><li>What neutrophil is predominant? </li></ul><ul><li>Leukemic – acute blast crisis </li></ul><ul><li>Bacterial infection – increase in WBC, up to 4x </li></ul><ul><li>Stress, trauma, hemorrhage, and hypoxia </li></ul><ul><li>Glucocorticosteroids </li></ul>Leukocytosis
  10. 11. <ul><li>Decreased production </li></ul><ul><li>Depression of bone marrow </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Rxs – Bactrim & Zyvox </li></ul><ul><li>Sepsis – inflammatory mediators </li></ul><ul><ul><li>1. Leukocytosis – neutrophils </li></ul></ul><ul><li>2. Leukopenia – consumption, sequestration, and decreased WBCs 3. APACHE – early identification/intervention </li></ul><ul><li>4. Surviving Sepsis Campaign </li></ul>Leukopenia

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