Anemias Objectives: Discuss the function of RBC’s, WBC’s, and platelets. Discuss the classification and diagnosis of anemia's Identify lab diagnostics used in the evaluation of anemia Interpret lab diagnostic tests to identify anemia's

Anemia A decrease in the number of RBC’s, or Hgb, or Hct A clinical sign or diagnosis GI bleeding most common reason in adults

Assessment of Hematologic System Health History: Meds, Dietary patterns, Current health problems Presence of decreased energy, fatigue, dizziness, skin changes, easy bruising, Consider nutrition, meds, medical history

Physical Assessment Skin: pallor, jaundice, cyanosis, ecchymoses, petechiae Head and Neck: ulcerations of mouth, oral lesions, lymph nodes

Physical Assessment Respiratory Cardiovascular Resp rate with activity Fatigue, SOB, DOE, PND Cardiovascular JVD Edema Presence of murmurs, gallops, regularity Vitals

Physical Assessment Renal/Urinary Musculoskeletal GI CNS hematuria sp gravity protein Musculoskeletal Bone pain GI Palp spleen or liver GI bleeding CNS cranial nerves neuro checks

Lab Assessment CBC: RBC: Nrl: M. 4.6-6.2/cubic mm F: 4.2-5.4 WBC: Nrl. 4,000-10,000cubic mm Leukocytosis: > 10,000: Leukopenia: < 4,000: Hct: % of RBC in whole blood, nrl: M: 40-54%, F: 38- 47% (varies with age) Hgb. amt of Hgb per 100 ml blood, nrl: M: 13.5-18%, F: 12-16% (varies with age)

CBC RBC Indices: MCV: mean corpusular volume: volume of Hgb in a RBC (size of RBC) ; measured directly (80-100) Average size of RBC Macrocytic Microcytic MCH: mean corpusular Hgb (27-31) Hgb amt. (wgt) in RBC (color) : MCH = Hgb/RBC count Hypochromic Hyperchromic

CBC RBC Indices MCHC: mean corpusular Hgb concentration (32-36G/L) Amt. of Hgb relative to RBC cell size RDW: RBC distribution width Normal value 11-15% Useful with MCV to identify anemia Higher number indicates different cell sizes (anisocytosis) Helpful with IDA

Lab Assessment Platelet Count: for eval of bleeding disorders, bone marrow eval Nrl. : 150-450,000, If inc.: thrombocytosis, If dec: Thrombocytopenia Tests of Coagulation Platelet aggregation PT (prothrombin) eval of extrinsic pathway, Vit K dependant Screens for def of factors I, II, V, VII, X, Coumadin INR: standardization for reporting of PT PTT (partial thromboplastin time) eval of intrinsic and common pathway Screens for defects of factor I, II, V, IX, X, XI, XII IVY bleeding Time

Lab Assessment ESR (erythrocyte sedimentation rate): rate at which RBC’s settle in uncoag blood. Reticulocyte Count: Measure of new blood cells produced in marrow; Precursor to RBC, helps to differentiate anemia r/t bone marrow failure vs. hemorrhage and RBC destruction If inc.: Chronic blood loss If dec.: Inadequate RBC production

Lab Assessment Serum Fe: amount of Fe not part of the RBC, but in circulation Ferritin Level: Total Fe stores (most sensitive for IDA, but not specific) Inc. in inflammation Reliable if low, but not if nrl Fe Binding capacity (IBC): Sites available for binding of Fe

Lab Assessment Transferrin: Protein content of serum that carries Fe If inc.: Fe deficiency If dec.: Anemia, hemorrhage, hemolysis Serum folic acid Schilling Test: 24hr urine for IF deficiency, measures ability of body to absorb ingested B12 from GI tract Gastrin stimulation/ gastrin level

Lab Assessment Bilirubin: to identify if anemia r/t RBC destruction Lead levels: More commonly seen with children Hgb electrophoresis: For Sickle Cell or Thallasemia Bone Marrow Aspiration: ability of marrow to produce nrl cells

Hematologic Disorders Hematologic Disorders: Problems r/t synthesis, function or normal destruction of cells Anemia: deficiency of RBC’s, Hgb, Hct. A clinical sign, can indicate a number of conditions Bleeding Disorders: platelet fx, clotting factor defects

Classification of Anemias Cause Blood Loss Chronic Disease Hemolysis: Hemolytic Underproduction: Hypoproliferative RBC morphology Macrocytic Microcytic Normocytic

Other Classification Hypoproliferative Anemias Hemolytic Anemia Iron Deficiency Pernicious Anemia Folic Acid Deficiency Aplastic Anemia Hemolytic Anemia Sickle Cell

Blood Loss Anemia Acute or chronic S & S: If acute: see more s and s: inc resp, dyspnea, vertigo, inc HR, H/A, restlessness, disorientation Dx: H & H, history Normocytic/normochromic or may result in hypochromic/microcytic if chronic (IDA)

Iron Deficiency Anemia (IDA) Microcytic, hypochromic Microcytic anemia MCV< 80fL Differential includes IDA, thalassemias, anemia of chronic disease, sideroblastic anemia (including lead poisoning) S&S: weakness, pallor, sore & smooth tongue; spoon shape nails, pica, vertigo, palpitations, dysphagia, brittle hair and nails Causes: Most common type Dx: RBC dec, Hgb dec, Fe dec., IBC inc, ferritin dec

IDA Evaluation Screen with CBC Dec. RBC Microcytic RDW shows different cell sizes Commonly assoc. with thrombocytosis Serum Ferritin: if low <30 ug/L (Tefferi, Hanson, & Inwards, 2005)

Anemia Eval – Iron Studies! CBC w diff Serum Iron Ferritin TIBC B12, folate (if MCV increased) Hemoccult cards

IDA Diagnosis Other Labs may be used Transferrin IBC

IDA: Treatment Tx: Diet: Legumes, organ meats, others Meds: Fe salts: ferrous sulfate or ferrous gluconate Consider bioavailability Ascorbic acid may enhance absorption Separate dose from inhibiting substances Increased risk of infection: ferratin thought to sequester bacteria from Fe; supplements circumvent this)

Pernicious Anemia, Vitamin B12 Deficiency Megaloblastic anemia, Macrocytic, or Hypoproliferative Causes: B12 deficiency (from intake or lack of absorption) or lack of IF S & S: weak, listless, pallor, jaundice, glossitis, fatigue, weight loss Neuro symptoms: paresthesias, spastic ataxia, change vibratory sense GI symptoms: inc incidence GI cancers

Pernicious Anemia, Vitamin B12 Deficiency Dx: CBC, B12 levels, antibodies to IF, Schilling test (less commonly used), other tests of anemia Tx: cyclocobalamin (B12) injection, oral B12 Diet: organ meets, green leafy vege, etc

Folic Acid Deficiency Anemia Macrocytic anemia, normochromic (megaloblastic), or Hypoproliferative Causes: poor nutrition, malabsorption, meds Risk factors: Increased requirement, nutrition, meds, absorption S & S: similar to B12 but NO neuro symptoms

Folic Acid Deficiency Anemia Dx: Folic Acid 1 mg per day po Treatment Diet: Organ meats, eggs, green leafy vege Folic acid

Hypoproliferative Anemias: Aplastic Anemia A deficiency of precursor cells r/t dec development of bone marrow Causes: Toxic agents, radiation, infection Assess: signs of bone marrow failure Treatments: blood transfusion, immunosuppressive therapy, splenectomy

Hemolytic Anemias Related to destruction of the RBC: usually hereditary Sickle Cell Anemia Diagnosis made usual lab evaluation for anemia Hgb S, Hgb electrophoresis specific for sickle cell disease

Sideroblastic Anemia Disease in which bone marrow produces ringed, atypical, abnormal erythroblasts (sideroblasts) Body has iron, though it cannot be incorporated into Hgb R/T genetic disorders, toxins, drug-induced, nutritional,

Sideroblastic Anemias Diagnostics Increased ferritin Normal IBC Low Hct MCV normal or low Specific test: Prussian Blue stain of RBC in marrow; shows sideroblasts Required hematology consult for dx

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