1. 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

2. 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

3. 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

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

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

6. 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

7. 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: % (varies with age)
Hgb. amt of Hgb per 100 ml blood, nrl: M: %, F: 12-16% (varies with age)

8. 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

9. 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

10. Lab Assessment
Platelet Count: for eval of bleeding disorders, bone marrow eval
Nrl. : ,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

11. 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

12. 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

13. 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

14. 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

15. 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

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

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

18. 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)

20. 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

22. 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)

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

24. IDA Diagnosis
Other Labs may be used
Transferrin
IBC

27. 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)

29. 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

30. 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

31. 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

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

33. 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

34. 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

35. 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,

36. 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

37. KNOW THIS! Hint, hint…