Anemia: Difference between revisions
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==Background== | ==Background== | ||
*Anemia is a condition of decreased hemoglobin (Hb) concentration compared to age-matched and gender-matched controls. | |||
**Males: Hb < 13 g/dL | |||
**Non-Pregnant Females: Hb < 12 g/dL | |||
**Pregnant-Females: Hb < 11g/dL | |||
**Children: Hb < <11-12 g/dL (depends on age) | |||
*Affects 1/3 of the world's population | *Affects 1/3 of the world's population | ||
*Most common causes are uterine and GI bleeding | *Most common causes are [[vaginal Bleed Non-Pregnant|uterine]] and [[GI bleeding]] | ||
===Pathophysiology=== | ===Pathophysiology=== | ||
4 mechanisms: | 4 mechanisms: | ||
*Loss of RBCs by hemorrhage (e.g. [[GI bleed]], [[trauma]]) | |||
*Increased destruction ([[sickle cell disease|SCD]], [[hemolytic anemia]]) | |||
*Impaired production (iron deficiency, [[folate deficiency]], [[B12 deficiency]], [[aplastic anemia]]/[[myelodysplastic syndrome]]) | |||
*Dilutional (rapid [[IVF]] infusion) | |||
==Clinical Features== | ==Clinical Features== | ||
| Line 17: | Line 22: | ||
==Evaluation== | ==Evaluation== | ||
''Severe anemia is defined as a hemoglobin level of 5 to 7 g/dL with symptoms of hypoperfusion including lactic acidosis, base deficit, shock, hemodynamic instability, or coronary ischemia<ref> Posluszny JA Jr, Napolitano LM. How do we treat life-threatening anemia in a Jehovah's Witness patient? Transfusion. 2014;54(12):3026-3034</ref>'' | ''Severe anemia is defined as a hemoglobin level of 5 to 7 g/dL with symptoms of hypoperfusion including [[lactic acidosis]], base deficit, shock, hemodynamic instability, or [[myocardial ischemia|coronary]] ischemia<ref> Posluszny JA Jr, Napolitano LM. How do we treat life-threatening anemia in a Jehovah's Witness patient? Transfusion. 2014;54(12):3026-3034</ref>'' | ||
===Acute Anemia=== | ===Acute Anemia=== | ||
Assess for any signs of bleeding or trauma before considering other causes of chronic anemia. | *Assess for any signs of bleeding or trauma before considering other causes of chronic anemia. | ||
[[File:Anemia.png|thumb|Algorithm for the Evaluation of Anemia]] | [[File:Anemia.png|thumb|Algorithm for the Evaluation of Anemia]] | ||
===Chronic Anemia=== | ===Chronic Anemia=== | ||
*CBC for evaluation, look at MCV | |||
**Microcytic: Iron Levels, Reticulocyte Count, Ferritin, TIBC | |||
**Macrocytic: Folate Level, B12 Level, Reticulocyte Count | |||
====Microcytic Anemia (<81 fL)==== | ====Microcytic Anemia (<81 fL)==== | ||
*RDW high | *RDW high → evaluate Ferritin, which is a measurement of iron storage | ||
**Ferritin low: Iron deficiency anemia | **Ferritin low: Iron deficiency anemia | ||
**Ferritin normal: Anemia chronic disease or sideroblastic anemia (e.g. lead poisoning) | **Ferritin normal: Anemia chronic disease or sideroblastic anemia (e.g. [[lead poisoning]]) | ||
*RDW normal | *RDW normal | ||
**RBC count low: Anemia chronic disease, hypothyroidism, Vitamin C deficiency | **RBC count low: Anemia chronic disease, [[hypothyroidism]], [[Vitamin C deficiency]] | ||
**RBC count | **RBC count normal or high: [[Thalassemia]] | ||
====Normocytic Anemia (81-100 fL)==== | ====Normocytic Anemia (81-100 fL)==== | ||
*Retic count normal | *Retic count normal | ||
**RDW normal: Anemia chronic disease, anemia of renal insufficiency | **RDW normal: Anemia chronic disease, anemia of renal insufficiency | ||
**RDW high: Iron, Vit B12, or folate deficiency | **RDW high: Iron, Vit [[b12 deficiency|B12]], or [[folate deficiency]] | ||
*Retic count high | *Retic count high | ||
**Coombs Positive: Autoimmune cause | **Coombs Positive: Autoimmune cause | ||
**Coombs negative: G6PD, SCD, spherocytosis, microangiopathic hemolysis | **Coombs negative: [[G6PD]], [[sickle cell disease|SCD]], spherocytosis, [[microangiopathic hemolytic anemia|microangiopathic hemolysis]] | ||
====Macrocytic Anemia (MCV>100 fL)==== | ====Macrocytic Anemia (MCV>100 fL)==== | ||
*RDW high: Vit B12 or folate deficiency | *RDW high: [[B12 deficiency|Vit B12]] or [[folate deficiency]] | ||
*RDW normal: ETOH abuse, liver disease, hypothyroidism, drug induced, myelodysplasia | *RDW normal: [[ETOH abuse]], [[hepatic failure|liver disease]], [[hypothyroidism]], drug induced, [[myelodysplastic syndrome|myelodysplasia]] | ||
==Management== | ==Management== | ||
*[[Transfusions]] | *[[Transfusions]] | ||
**Consider if patient is symptomatic, hemodynamically unstable, hypoxic, or acidotic | **Consider if patient is symptomatic, hemodynamically unstable, hypoxic, or acidotic | ||
** | **Using a restrictive transfusion strategy (transfusing <6-8) has found to be beneficial, as liberal transfusion strategy (transfusing <10) not showing any benefit and has shown harm | ||
***GI bleeds using restrictive transfusion strategy saw a decreased mortality and rebleed rate | |||
**Always draw labs necessary for diagnosis prior to transfusing | **Always draw labs necessary for diagnosis prior to transfusing | ||
**1 unit PRBCs should raise the Hgb by 1gm/dL | **1 unit PRBCs should raise the Hgb by 1gm/dL | ||
*[[iron supplementation|Iron-deficiency anemia]] | |||
**PO: Ferrous sulfate 325mg (65mg elemental iron) with Vitamin C (to aid in absorption) | |||
**IV: Ferrous Sucrose 300mg in 250mL NS over 2hrs | |||
==Disposition== | |||
''Depends on underlying cause of anemia'' | |||
===Admission=== | |||
*Evidence or potential for ongoing blood loss | |||
*Signs of end-organ dysfunction (altered mental status, cardiac ischemia, etc.) | |||
===Discharge=== | |||
*Most stable patients can be discharged w/ outpatient follow-up if they are asymptomatic or only mildly symptomatic following an incidental finding of anemia. | |||
==See Also== | ==See Also== | ||
*[[Transfusions]] | *[[Transfusions]] | ||
*[[ | *[[Myelophthisic Anemia]] | ||
*[[Microangiopathic Hemolytic Anemia (MAHA)]] | *[[Microangiopathic Hemolytic Anemia (MAHA)]] | ||
==External Links== | ==External Links== | ||
*[http://ddxof.com/anemia/ DDxOf: Differential Diagnosis of Anemia] | *[http://ddxof.com/anemia/ DDxOf: Differential Diagnosis of Anemia] | ||
*[http://www.emdocs.net/anemia-in-the-ed-setting-pearls-and-pitfalls/ emDOCS - Anemia in the ED Setting: Pearls and Pitfalls] | |||
==References== | ==References== | ||
Latest revision as of 21:02, 22 August 2021
Background
- Anemia is a condition of decreased hemoglobin (Hb) concentration compared to age-matched and gender-matched controls.
- Males: Hb < 13 g/dL
- Non-Pregnant Females: Hb < 12 g/dL
- Pregnant-Females: Hb < 11g/dL
- Children: Hb < <11-12 g/dL (depends on age)
- Affects 1/3 of the world's population
- Most common causes are uterine and GI bleeding
Pathophysiology
4 mechanisms:
- Loss of RBCs by hemorrhage (e.g. GI bleed, trauma)
- Increased destruction (SCD, hemolytic anemia)
- Impaired production (iron deficiency, folate deficiency, B12 deficiency, aplastic anemia/myelodysplastic syndrome)
- Dilutional (rapid IVF infusion)
Clinical Features
General Anemia Symptoms
- Most patients begin to be symptomatic at ~7gm/dL
- Weakness, fatigue, lethargy, dyspnea on exertion, palpitations
- Skin, nail bed, mucosal pallor
- Widened pulse pressure
- Jaundice, hepatosplenomegaly (hemolysis)
- Peripheral neuropathy (B12 deficiency)
Differential Diagnosis
Anemia
RBC Loss
RBC consumption (Destruction/hemolytic)
- Hereditary
- Acquired
- Microangiopathic Hemolytic Anemia (MAHA)
- Autoimmune hemolytic anemia
Impaired Production (Hypochromic/microcytic)
- Iron deficiency
- Anemia of chronic disease
- Thalassemia
- Sideroblastic anemia
Aplastic/myelodysplastic (normocytic)
Megaloblastic (macrocytic)
- Vitamin B12/folate deficiency
- Drugs (chemo)
- HIV
Evaluation
Severe anemia is defined as a hemoglobin level of 5 to 7 g/dL with symptoms of hypoperfusion including lactic acidosis, base deficit, shock, hemodynamic instability, or coronary ischemia[1]
Acute Anemia
- Assess for any signs of bleeding or trauma before considering other causes of chronic anemia.
Chronic Anemia
- CBC for evaluation, look at MCV
- Microcytic: Iron Levels, Reticulocyte Count, Ferritin, TIBC
- Macrocytic: Folate Level, B12 Level, Reticulocyte Count
Microcytic Anemia (<81 fL)
- RDW high → evaluate Ferritin, which is a measurement of iron storage
- Ferritin low: Iron deficiency anemia
- Ferritin normal: Anemia chronic disease or sideroblastic anemia (e.g. lead poisoning)
- RDW normal
- RBC count low: Anemia chronic disease, hypothyroidism, Vitamin C deficiency
- RBC count normal or high: Thalassemia
Normocytic Anemia (81-100 fL)
- Retic count normal
- RDW normal: Anemia chronic disease, anemia of renal insufficiency
- RDW high: Iron, Vit B12, or folate deficiency
- Retic count high
- Coombs Positive: Autoimmune cause
- Coombs negative: G6PD, SCD, spherocytosis, microangiopathic hemolysis
Macrocytic Anemia (MCV>100 fL)
- RDW high: Vit B12 or folate deficiency
- RDW normal: ETOH abuse, liver disease, hypothyroidism, drug induced, myelodysplasia
Management
- Transfusions
- Consider if patient is symptomatic, hemodynamically unstable, hypoxic, or acidotic
- Using a restrictive transfusion strategy (transfusing <6-8) has found to be beneficial, as liberal transfusion strategy (transfusing <10) not showing any benefit and has shown harm
- GI bleeds using restrictive transfusion strategy saw a decreased mortality and rebleed rate
- Always draw labs necessary for diagnosis prior to transfusing
- 1 unit PRBCs should raise the Hgb by 1gm/dL
- Iron-deficiency anemia
- PO: Ferrous sulfate 325mg (65mg elemental iron) with Vitamin C (to aid in absorption)
- IV: Ferrous Sucrose 300mg in 250mL NS over 2hrs
Disposition
Depends on underlying cause of anemia
Admission
- Evidence or potential for ongoing blood loss
- Signs of end-organ dysfunction (altered mental status, cardiac ischemia, etc.)
Discharge
- Most stable patients can be discharged w/ outpatient follow-up if they are asymptomatic or only mildly symptomatic following an incidental finding of anemia.
See Also
External Links
References
- ↑ Posluszny JA Jr, Napolitano LM. How do we treat life-threatening anemia in a Jehovah's Witness patient? Transfusion. 2014;54(12):3026-3034