Oral Review: Anemia

Question 1

Lab values indicating anemia:

Answer 1

Female: 11 Hgb, 36% Hct
Male: 12 Hgb, 40% Hct

Question 2

Considerations for pre-op transfusion:

Answer 2

Cause of anemia
Degree/duration of anemia
Intravascular fluid volume
Urgency of surgery
ABL during surgery
Age
Co-existing dieases

Question 3

Co-existing pathologies that increase likelihood for transfusion:

Answer 3

Cardiovascular
Cerebrovascular
Lung disease
PVD

Question 4

General points of anesthesia management of anemia:

Answer 4

Increase FiO2 and use PEEP to maximize O2 delivery
Avoid decreasing CO and myocardial depression (etomidate +/- ketamine, high opioid technique)
Inhaled agents with low B/G coefficients
Avoid left shifts (don’t hyperventilate, keep warm)

Question 5

Compensatory changes in anemia of chronic disease:

Answer 5

Decreased SVR

Increased 2-3 DPG, CO, plasma volume, and blood flow to organs with high extraction ratios

Question 6

Induction in anemia of chronic disease:

Answer 6

Avoid marked reductions in CO; choose agents based on patient’s co-existing

Question 7

Maintenance in anemia of chronic disease:

Answer 7

Maintain high PaO2
Avoid hyperventilation
Maintain high CO
Avoid hypovolemia
Keep patient warm
Maintain Hbg above critical level

Question 8

Emergence/post-op management in anemia of chronic disease:

Answer 8

Keep patient warm
Maintain high PaO2
Period of greatest risk for ischemia/infarction; consider prolonged drug effects

Question 9

Manifestations of folic acid deficiency anemia:

Answer 9

Smooth/thick tongue
Peripheral edema
Liver dysfunction
Mental depression

Question 10

Manifestations of B12 deficiency anemia:

Answer 10

Peripheral neuropathy
Loss of sensation in LEs (proprio/vibration)
Unsteady gait
Memory impairment
Mental depression

Question 11

Anesthetic management of B12/folic acid deficiency anemia:

Answer 11

Avoid regional/PNBs
Avoid N2O (inactivates B12)
Maintain PaO2 to peripheral tissues
Thorough airway exam

Question 12

Special considerations for anesthetic management of thalassemia:

Answer 12

Potential difficult airway d/t maxillary overgrowth
Spinal cord compression - caution w/ positioning
Predisposed to SVT
Sensitive to digitalis
Coagulopathic

Question 13

Complications of iron overload in thalassemia:

Answer 13

Diabetes
Adrenal insufficiency
Liver dysfunction
Hypothyroid/parathyroid
Arrythmias
Heart failure

Question 14

Clinical signs of 20% EBV loss:

Answer 14

Orthostatic hypotension, tachycardia, CVP changes

Question 15

Clinical signs of 40% EBV loss:

Answer 15

Hypotension, tachycardia, tachypnea, diaphoresis

Question 16

Clinical signs of hemorrhagic shock:

Answer 16

SBP

Question 17

Pre-op preparation for aplastic anemia:

Answer 17

Steroid stress dosing
Reverse isolation
Prophylactic abx
Preop sedation

Question 18

Induction considerations for aplastic anemia:

Answer 18

Airway bleeding possible
Avoid nasal intubation
Avoid regional anesthesia
Labile HD response (use ketamine, etomidate, high opioid)

Question 19

Maintenance considerations for aplastic anemia:

Answer 19

Use PEEP to help keep FiO2 below 50%; hyperoxemia will cause bone marrow suppression
Avoid N2O also d/t bone marrow suppression
Normothermia

Question 20

Measures to avoid sickle cell crisis:

Answer 20

Maintain normothermia
Avoid dehydration
Maintain oxygenation
Avoid acidosis
Avoid stasis with proper positioning

Question 21

Pre-op preparation for sickle cell patients:

Answer 21

Pre-op transfusion to Hct > 30%, Hgb S

Question 22

Induction for sickle cell patients:

Answer 22

Avoid hypoxemia and hypovolemia

Use IV lido for smooth induction

Question 23

Emergence and post-op for sickle cell patients:

Answer 23

Continuous hydration
Keep warm
Adequate analgesia
Pulmonary hygiene to prevent post-op respiratory issues that cause acidosis

Question 24

Lab tests indicating DIC:

Answer 24

Rapid decrease in plt count to

Question 25

Treatment of DIC:

Answer 25

Treat underlying cause/trigger!
Platelets
FFP
Low molecular weight heparin
Antithrombin III

Question 26

Peri-op management of coumadin:

Answer 26

Stop coumadin 3-4 days pre-op and either:
IV/SQ heparin or
If INR 2-3, hold 4 doses to allow INR to drop to 1.8

INR should be

Question 27

Emergent reversal of coumadin:

Answer 27

5-8ml/kg of FFP

Question 28

Discuss dilutional thrombocytopenia:

Answer 28

Most common cause of intra-op coagulopathy
Dilution of platelets due to blood/fluid replacement
Treat with 1:1 PRBC:FFP replacement

Question 29

Compensatory physiological mechanisms for dilutional thrombocytopenia:

Answer 29

Release of stored platelets from the spleen (33%)

Release of procoagulant proteins from liver

Question 30

Discuss vitamin K deficiency:

Answer 30

Necessary for production of factors 2, 7, 9 and 10
Deficiency from malnutrition, malabsorption, abx elimination of gut flora, obstructive jaundice
Will see prolonged PT, normal PTT
Tx: daily vit K (takes 6-24 hrs to effect) or FFP (urgent)

Question 31

Discuss hemophilia A:

Answer 31

Absence or severe deficiency of factor 8
Normal platelet count, normal PT, prolonged PTT
Tx with factor 8 infusion or DDAVP
Avoid IM injection and regional, careful during DVL

Question 32

Discuss hemophilia B:

Answer 32

Absence or deficiency of factor 9
Prolonged PTT and normal PT
Tx with factor 9 infusion

Question 33

Discuss von Willebrand’s disease:

Answer 33

Deficient or defective vWF, needed for platelet aggregation

Tx with cryo or DDAVP