Patient with Anemia Flashcards
Retic index >2% or absolute retic count > 100,000 indicates
- There is a good marrow response, so there must be an issue of hemorrhage or hemolysis
CBC provides information about which type of cells?
- Red cells
- White cells
- Platelets
Reticulocytes
- Young red cells that are immediately released from the bone marrow as the end result of erythropoeisis
- Full of RNA
- Appear as polychromasia in blood smear
What do patients with chronic anemia complain that they can hear and why do they hear this?
Hear their heartbeat
- The blood flow out of the heart is turbulent as the heart pumps faster to pump the fewer red cells quicker to exchange oxygen sufficiently
- There is an increased stroke volume and heart rate
- The blood comes out of the heart and up the ascending aorta that is pointed towards the ears and that is how they can hear theit heartbeat
Mean Corpuscle Hemoglobin Concentration (MCHC) may be elevated in what type of diseases?
Spherocytic diseases –> hemolytic
- 36 is normal, but if increases even a small amount, that can indicate presence of a significant number of spherocytes
What are the kidneys response to chronic anemia?
- Kidneys retain salt and water to expand the intravascular volume and patients with compensated, chronic anemia have expanded blood volume
Acute hemorrhage and hypovolemia will trigger
- A reflex vasoconstriction (patients will feel cold and clammy)
Iron deficiency produces a low/high RDW
High RDW because it is a progressive disease and the younger cells will become smaller and smaller
RDW: Normal vs. Widened
- A widened distribution= anisocytosis
RDW
Red cell distribution of width
- Coefficient of variation of the MCV
- How much spread there is in the MCV of all of the different red cells in the patient’s body
- Should be a normal gaussian distribution of red cells
What are the calculated values in a CBC?
- Hematocrit (%)
- MCH
- MCHC
- RDW
What are the 2 ways that anemias may be classified?
- Erythropoietic response (reticulocyte count)
- Red cell size (MCV) and the hemoglobin concentration
If the underlying condition such as malaria or progressive kidney failure causes the anemia, can have further complications such as
Marlarial anemia: Fever will cause more demand on the heart along with the already high demand due to the anemia
Progressive kidney failure: A patient who develops anemia of chronic disease may be more sensitive to the volume overload since they may not be able to excrete the extra volume
Low hemoglobin correlates to
Low O2 delivery that leads to tissue hypoxia, that decreases function in tissues such as the heart, brain, muscles, intestines, etc.
Anemic patients may experience symptoms of tissue hypoxia due to the lack of oxygen delivery to the tissues and these are:
- Fatigue
- Shortness of breath, especially with exertion and eventually even with rest
- Cognitive difficulties
- Ischemic pain (angina or claudication)
- Angina pectoris: chest pain from a lack of oxygen delivery to the myocardium
- Claudication: pain in the leg muscles (calves or glutes) with walked (gets better with rest) –> limping; abdominal pain after eating
Red Cell Indices
- MCV
- MCH
- MCHC
- RDW
What happens to the RDW whenever a person with very low levels of iron starts to take iron?
The RDW will increase because the new cells will not be microcytic while the old ones will be
Why can older patients not tolerate anemia as well as younger patients?
Older patients hearts are not as functional, so they may have angina from the increased heart rate
Low MCV (<80)
- Microcytic anemia
- Problem with hemolgobin synthesis
- Causes: iron deficiency, thalassemia, lead poisoning, anemia of chronic disease, sideroblastic anemias
Which value measures how big the RBCs are?
MCV
Which cells sense low oxygen and what do they do in response?
Renal mesangial cells and they increase synthesis of erythropoietin (EPO) that hopefully increases bone marrow red cell production
If blood volume changes abruptly, the heart rate will increase/decrease
Increase in order to maintain the proper caridac output (Q)
Most symptoms of acute blood loss are related to ________
- Hypovolemia
Symptoms of volume overload in anemic patients:
- Swollen ankles and feet
- This is called “high output heart failure” and is seen in patients with chronic heart failure
Reticulocyte Index
- retic count x (Hct/ideal Hct) x 0.5
- If the bone marrow is working then the retic index should increase as anemia gets worse
Anemia
Decreased hemolgobin/hematocrit below the normal range for gender and age
** Manifestation of a disease and not a final diagnosis
Symptoms of acute hemorrhage are related to hypovolemia and are:
- Hypotension- low BP
- Orthostasis- BP falls and HR rises when the patient stands up and the paint can feel faint when standing
- Syncope- fainting
- Shock- lack of perfusion (oxygen) to vital organs
Patients with chronic anemia have higher/lower levels of 2,3-DPG
- Higher levels that causes rightward shift on the O2 disassociation curve that favors delivery of O2 to tissues
If a person with very small red cells receives a red cell transfusion, what will happen to the RDW value?
It will increase drastically because there are 2 distinct populations of RBCs
The smaller the RDW means
The red cells are more uniform in size
Chronic anemia may lead to
Fluid retention that leads to increased blood volume
Retic index < 2% or absolute retic count < 75,000 suggests
- Problem with red cell production
- Hypoproliferative abnormality
What lab value is the most accurate and reproducible way to describe and monitor anemia?
- Hemoglobin (Hgb or Hb)
What are the directly measured values in a CBC?
- Hemoglobin (Hgb)
- RBC (number of RBCs)
- MCV (measurement of red cell volume in femtoliters)
Why must someone with chronic anemia be monitored when receiving a red cell transfusion?
- To see if they develop CHF and if they do, they need to be put on a diuretic
Absolute reticulocyte count
- retic (%) x RBC
Low blood pressure may be a sign of what in relation to blood volume?
Low blood volume
How does the rate of change of hemoglobin levels affect a person symptomatically?
If someone with a hemoglobin drops from 16 to 13 in a period of 4 hours, then they will have more symptoms than someone who has a steady decrease to a hemoglobin of 4 over the course of years regardless of the hemoglobin being close to normal
It all depends on the rate of change
Hematocrit
- Volume of red cells/ total volume of blood
- Hct= RBC x MCV
- Hct is about 3x the amount of hemoglobin
Which hemoglobin value will make a patient more symptomatic, 4g/dL or 10g/dl?
4 because there is a reduction in the oxygen carrying-capacity
Elevated heart rate may be a manifestation of
Anemia
Hypovolemia
- Decrease in blood volume
In patients with mild thalassemia is the RBC increased/decreased and the MCV small/large?
Increased RBC
Small MCV
What will the RDW be for a person with thalassemia?
Normal because it is not progressive and the cells are uniformly microcytic
High MCV (>100)
- Macrocytic anemia
- Megaloblastic- impairment of DNA synthesis
- Non-megaloblastic- variety of other causes
Macrocytic anemias can be divided into:
- Megaloblastic
- Problem with DNA synthesis
- B12 and folate deficiency are the hallmark causes
- AZT and hydroxyurea can cause this
- Non-megaloblastic
- Elevated reticulocyte counts can increase the MCV since they are larger than mature RBCs
- Liver disease, alcohol, hypothyroidism, myelodisplasia, aplastic anemia
What are the 2 approaches to treating anemia?
- Treat the underlying cause
- Let the patient’s marrow replace the red cells
- Leads to a complete correction of the anemia although it is slower
- Transfusion
How would you treat anemia of someone with leukemia or bone marrow failure?
- Transfusion
How would you treat a vegetarian woman who has been iron deficient for years?
- Give iron supplements
What are the general indications for transfusion?
- Cardiovascular compromise
- CHF
- Fluid backs up into the lungs and hear crackles and sometimes an S3 gallop
- Must give diuretics when transfuse these patients
- Shock
- Patient is cold and clammy as the blood is shunted to the vital organs
- BP is low
- Body quits perfusing the kidneys
- Angina
- CHF
- Hypoproliferative anemia with prolonged recovery period
- If patient has acute leukemia or aplastic anemia, their bone marrow does not work properly
- Given to oncology patients to make them feel better
- Need for surgery to correct source of bleeding
- If someone has iron deficiency from uterine fibroids or colon cancer then need to give iron and transfuse on the way to surgery
- Need for emergent surgery
- Give blood immediately
