ANAEMIA

Dr. Kamal M. E. Mubasher

Associate Professor Dept. Of Anaesthesia Faculty of Medicine University of Khartoum

ANAEMIA
A common condition which rarely puts fit patients at increased risk There is no universally accepted minimum haemoglobin concentration The management, if any, must depend on the: Cause Patients overall medical status Surgery being contemplated

DEFINITION The World Health Organization defines anaemia as a haemoglobin (Hb) concentration of less than:
13 gdl-1 in adult men 12 gdl-1 in adult women 11 gdl-1 in children 6 mths to 6 yrs 12 gdl-1 in children 6 to 14 yrs

CAUSES May be divided into three categories:

Defective Red Cell Production Haemolysis

Haemorrhage

PATHOSPHYSIOLOGY
The essential feature of all forms of anaemia is A reduction in the Hb content of blood

Since

Arterial Oxygen Content = Arterial O2 Saturation X Hb Concentration Oxygen Delivery = Arterial O2 Content X Cardiac Output

And

It follows that a fall in Hb concentration will, in the absence of compensatory

mechanisms, be followed by
A Fall In Oxygen Supply To The Tissues

COMPENSATORY MECHANISMS Acute Normovolaemic Anaemia

In otherwise healthy individuals, two mechanisms compensate for the fall in oxygen-carrying capacity: An Increase In Cardiac Output A Reduction In Blood Viscosity

Chronic Anaemia
A third mechanism comes into play: Increased 2,3-diphosphoglycerate (2,3DPG) concentration in the red cells

Shifts the oxygen dissociation to the right

curve

Promotes the release of oxygen to the tissues

CLINICAL FEATURES
Symptoms and Signs include

Dyspnoea on exertion Tachycardia Palpitations Angina

Increased arterial pulse pressure

Capillary pulsation

However, in

mild chronic anaemia

which is well compensated, there may be

no symptoms or signs

Anaemia is poorly tolerated by

patients with CORONARY ARTERY DISEASE or PRE-EXISTING MYOCARDIAL DYSFUNCTION

Such patients, who are often elderly,

may present with CARDIAC FAILURE

PREOPERATIVE ASSESSMENT
In

some surgical patients anaemia is to

be accepted as a feature of the disease for which operation is indicated

In

other surgical patients anaemia is an

unexpected and unrelated finding

revealed only by routine preoperative haematological testing

Routine blood count and blood film examination will disclose:

The severity of the anaemia The type of anaemia, thus suggesting its cause

Classification of causes of anaemia according to red cell morphology Type Cause Hypochromic microcytic Iron deficiency anaemia (reduced MCV, MCH, MCHC) Normochromic microcytic Vitamin B12 or folate deficiency (decreased MCV) alcohol Polychromatic macrocytic Haemolysis (increased MCV) Chronic disease Renal failure Normocytic normochromic Haemorrhage (normal indices) Hypothyroidism Hypopituitarism Marrow aplasia or infiltration Leukoerythroblastic Marrow infiltration.
Renal failure is a common and often unsuspected cause of anaemia. The blood urea or plasma creatinine should always be checked.

FURTHER INVESTIGATIONS
It is always desirable to know the exact cause of any patient's anaemia

IF SURGERY CANNOT BE POSTPONED

Blood should be taken preoperatively so

that investigations may be performed on

a specimen which is undiluted by

transfused blood

CORRECTION OF ANAEMIA What Preoperative Hb Level Is Acceptable ?

There is no Hb conc. which must be met by all pts. in all circumstances

Hb = 10 gdl-1 was generally accepted for many yrs

The degree of anaemia which is acceptable depends on the CARDIAC RESERVES of the patient
Patients in renal failure who are otherwise fit for surgery may safely undergo surgery with Hb conc. as low as 6 gdl-1

A frail old patient with severe coronary artery disease may develop cardiac failure even at a conc. of 10 gdl-1

How May The Patient's Hb Level Be Raised ?

Treatment of the Cause Specific Haematinics Red Cell Transfusion

Treatment of the Cause The ideal solution But Most cases are not amendable to treatment Or The treatment is surgical

Specific Haematinics

Appropriate in specific deficiency states

(iron, vitamin B12 or folic acid) only

Blind haematinic treatment is useless and expensive

Red Cell Transfusion

Only a limited place because:

A moderate degree of anaemia is well

tolerated in otherwise fit pts.

Transfusion has many hazards It is easy to overload the circulation

of normovolaemic anaemic pts.

Preoperative transfusion is certainly indicated in Sickle cell anaemia Severely anaemic patients with cardiac decompensation In whom surgery is urgent For minimization of risks of circulatory overload ..

Transfusion of red cell concentrates Simultaneous administration of diuretic

PERI AND POST-OPERATIVIE MANAGEMENT Aim: TO MAINTAIN OXYGEN DELIVERY An adequate supply of blood must be cross matched Blood lost during the operation should be promptly replaced Particular care should be taken to ensure that: Hypoxaemia never develops The Cardiac Output is not depressed

 Within this framework there is a wide

choice of anaesthetic techniques in

disposal
Virtually no evidence to suggest that

anaemia is associated with increased

morbidity or mortality at elective

surgery

BIBLIOGRAPHY Consensus conference: Perioperative Red Blood Cell Transfusion, Journal of American Medical Association 1988: 260, 2700-2703. Messmer K, Lewis D H, Sunder-Plassman I, Klovrkom W P, Mender N, Holper K: Acute Normovolaemic Haemodilution. European Surgery Research 1972: 4, 55. Nunn J F, Freeman J. Problems Of Oxygenation And Oxygen Transport In Anaesthesia. Anesthesia 1964: 19, 206 Stehling L. Perioperative Morbidity In Anaemic Patients. Transfusion 1989: 29, 375

CROSS REFERENCES

Intraoperative bronchospasm.

Anaesthetic Factors 33: 632

Intraoperative hypotension. Anaesthetic Factors 33: 638

Thankyou