Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K.

Sethi’s EORCAPS 2007

Anemia
ANEMIA IN PREGNANCY • DEFINITION:
Numerical fall in the quantity of RBCs or Hemoglobin
in a unit of blood
• CAUSES:
- Decreased RBC production
PROF R SEHGAL
- Increased destruction of RBC
- Loss from intravascular space
- Increased RBC mass + increased plasma
volume

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

RBC SYNTHESIS NORMAL LEVEL OF Hb/HCT

Bone marrow Humoral feedback EPO
B12, Folate def. Stem Cell
Levels vary with age and gender
Fe, Folate def AGE Hb/HCT
Hb/HCT
Maturing RBC
Cytoplasm Mitochondria Newborn 16/55
Globin Haem 1 month 12/38
Nucleated RBC
3 months 10/30
Reticulocyte
12 months 12/38
RBC Adult male 14/45
Spleen R-
R-E system
Adult female 12/36

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

WHO DEFINITION FOR CH. ANEMIA CLASSIFICATION OF ANEMIAS

AGE Hb gm%
6/12 – 6yrs <10 • Primary / Secondary
6-14 yrs <12 • Chronic / Acute (normovolemic
(normovolemic,,
hypovolemic)
hypovolemic)
Adult male <13
Non pregnant female <12
• Microcytic / Macrocytic / NormocyticM
Pregnant female <11

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

CLASSIFICATION CLASSIFICATION OF ANEMIAS

• Physiological anemia of pregnancy
Pathological:
Pathological:
Plasma volume ↑ 50% • Primary Anemia (Deficiency anemia)
RBC volume ↑ 30% -Iron (hypochromic
(hypochromic,, microcytic)
microcytic)
HCt ↓ 30% -Folic acid, B12 (Normochromic
(Normochromic,, megaloblastic)
megaloblastic)
Hb ↓ 10.5-
10.5-11 gm/dl -Sideroblastic ( hypochromic,
hypochromic, dimorphic)
• Secondary Anemia (Due to chronic disease)
Enhances perfusion of placenta - Chronic endocrine disease ( Thyroid)
- Chronic renal disease
Increases volume in anticipation of blood loss of
childbirth - Hepatic cirrhosis
• Hemolytic anemia
• True or Pathological anemia

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

CLASSIFICATION OF ANEMIAS ANAESTHESIA CONCERNS

HEMOLYTIC ANEMIAS:
• Hereditary red cell defect • Etiology & its functional significance
- Membrane: Hereditary Spherocytosis
• Rate & volume of blood loss
Hereditary Elliptocytosis
- Metabolism: G6PD deficiency
Pyruvate kinase deficiency
• Effect on tissue oxygenation
Oxygen content: HBx1.31xSaO2+0.0034XPaO2
- Hemoglobin: Sickle cell disorder
Oxygen delivery: O2 content X Cardiac output
Unstable hemoglobin
O2 consumption : (CaO2-CvO2) X C.O.
Thalassaemia
Extraction ration : (CaO2 – CvO2) X C.O. /CaO2 X C.O.
• Acquired Membrane defect
Paroxysmal Nocturnal hemoglobinuria
• Effect of anesthesia on Oxygenation
• Extracorpuscular abnormality
Autoimmune - hypersplenism
Hemolytic disease of the
• When to transfuse blood (transfusion trigger)
the newborn
Misc.. Drugs, toxins, infection
infection

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

MINIMUM ACCEPTABLE Hb.

Hb. CASE - 1

• Level at which coronary artery flow is unable to increase any A pregnant patient, at full term, presents
more to provide oxygen to the myocardium
with APH, for emergency LSCS
• Increase in cardiac output Vs increase in myocardial oxygen
consumption

• Concept of Hb 10/30 rule

• Exact level not defined

• Lower level tolerated in chronic anemia

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

ACUTE ANAEMIA : FACTORS AFFECTING

COMPENSATORY MECHANISMS COMPENSATION
• Increased velocity of blood flow • Cardio-
Cardio-pulmonary disease
• Sympathetic stimulation to increase cardiac output
• Left ventricle dysfunction
• Systemic vasoconstriction, Increased venous return
• Tachycardia
• Vasoactive drugs (beta blockers, calcium channel
blockers)
• Increased stroke volume
• Redistribution of blood volume to vital organs
• Atherosclerotic disease
• Water, electrolyte conservation (vasopressin, Corticosteroids)
• Magnitude of loss
• Increased osmotic pressure (increased glucose, lactate, • Oxygen consumption
pyruvate,
pyruvate, phosphate, urea, amino acids from liver) • Anesthesia
• Anerobic metabolism, acidosis, hyperventilation

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

ANAESTHETIC MANAGEMENT
ACUTE HYPOVOLEMIA
• Large bore iv cannula
• Aspiration prophylaxis
CLASS VOL. LOSS SIGN/SYMPTOM
• Left uterine displacement
I <15% mild tachycardia, postural • Oxygen therapy
hypotension
• Urinary catheterization (0.5-
(0.5-1ml/kg/hr)
II 15-
15-30% Mod, tachycardia, ↓ pulse
• Fluid resuscitation: crystalloid vs colloid vs blood
pressure, sweating, anxiety
III 30-
30-40% marked tachycardia, Hypotension,
• No blood if HCT > 25 with normovolemia (Hb/HCT
Hb/HCT value
influenced by fluid vol.)
altered sensorium.
sensorium.
IV >40% Marked tachycardia, hypotension
• Regional not indicated
↓ Pulse pressure • Thiopentone Vs ketamine induction
↓ Urine output • Minimum volatile anesthetics
• Optimize ventilation with high FiO2
Normal BP misleading if patient has PIH • Maintain tissue perfusion with fluids & ionotropes.
ionotropes.

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

ANAESTHETIC MANAGEMENT CASE - 2

• Monitoring: A pregnant young woman at 34 wk of
SpO2, ETCO2, NIBP gestation is admitted for a planned LSCS.
Temperature She is lying comfortably in bed but looks
Urine output very pale.
CVP
Do you think she is anemic?
Blood loss
ECG with ST segment analysis How will you find out?
PCWP for large fluid shift, CRF, LV dysfunction
ABG

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

CHRONIC ANEMIA: SIGNS/SYMPTOM CHRONIC ANEMIA: signs/symptom

Other questions to be asked:

• No symptom • Related to cause
• Fatigue, dyspnoea on exertion, palpitation • Ch. Renal failure, hepatic dis., endocrine dis
• Nausea, loss of appetite, constipation, indigestion • Occupation
• Angina, heart failure, confusion • Diet
• H/O bleeding (DUB, malena,
malena, hematuria etc.) • Past h/o anemia, need for blood transfusion, medication
(salicylate,
salicylate, anticonvulsant, alcohol)
• Family h/o bleeding disorders, splenectomy,
splenectomy, anemia,
early onset gall stones.

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

CHRONIC ANEMIA: signs/symptom IRON DEFICIENCY ANEMIA

• Causes:
Signs of Chronic blood loss
• Pallor Nutritional deficiency
• Glossitis Increased requirement (pregnancy)
• Koilonykia
• Jaundice • Iron stored as Serum ferritin & hemosiderin
• Hepatosplenomegaly Adult male female
• Lymphadenopathy
• Functional cardiac murmur Stores 1000mg 300-
300-500mg
Losses 1mg/day 2mg/day,
• Evidence of cardiomegaly pregnancy 3mg/day
Requirement 12mg 15mg / 30mg

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

IRON DEFICIENCY ANEMIA IRON DEFICIENCY ANEMIA

Differential Diagnosis:
• Effect on mother:
S. Iron Transferrin S Ferritin ↓Fertility
Pica (Bizarre craving for unusual quality or quantity of
foods)
Fe Deficiency ↓ ↑ ↓
Myelodisplasia ↑ ↓ ↑ • Effect on fetus:
Low birth weight (3 fold)
β-Thalassemia N-↑ N-↓ N-↑ Prematurity (2 fold)
Inflamm./tumor
Inflamm./tumor ↓ ↓ ↑ Perinatal mortality
Large placental weight
High ratio of Placenta / Birth weight

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

FOLIC ACID DEFICIENCY FOLIC ACID DEFICIENCY

Effect on fetus
• Co-
Co-factor in nucleic acid synthesis – Premature birth
• Stores limited – Neural tube defect
• Deficiency causes megaloblastic anemia – Cleft palate
• Incidence high in multi, twins,
hyperemesis gravidarum,
gravidarum, alcohol Effect on mother
consumption, smoking – High incidence of abortions

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

CHRONIC ANEMIA
COMPENSATORY MECHANISMS
EFFECT OF ANAESTHESIA
• Increased 2,3DPG, shift of O2 dissociation curve to
right • Severity depends upon agent depth
• Increased extraction ratio • Myocardial depression
• Circulatory adjustments:
Increase in CO by increased stroke vol. • Hypotension
↓Cardiac output
Myocardial hypertrophy ↓ Stroke volume
• Release of erythropoitin ↓ Systemic vascular resistance
• Resp. adjustments:
• ↓ Total body oxygen consumption
decreased physiological shunting in lung
decreased respiratory reserve • ↓ Cerebral, myocardial oxygen demand
tachypnea / hyperventilation
• GIT changes: • Effect of regional not clear
reduced splanchnic blood flow

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Ch. ANEMIA : INVESTIGATIONS Ch. ANEMIA: INVESTIGATIONS

• Hb TLC,DLC • Investigations for primary cause:

• MCV,MCH,MVHC KFT,LFT,TFT, occult blood in stool
• Peripheral blood smear for: • For deficiency anemia, thalassemia
RBC count, size, shape, color S.iron (80mcg/100ml)
Reticulocyte count (if high-
high-hemolysis workup) Iron binding capacity (250-
(250-400dl)
Platelet count S.ferritin assay –M-20-
20-300 F15-
F15-120ng/ul
Hypersegmented polymorphonuclear cells Bone marrow exam to evaluate iron stores
• ECG, ECHO • S. Folate (6-
(6-20mcg/L)
• Stool exam. for ova / cyst • S. B12 (160-
(160-925ng/L)

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

PREOPERATIVE PREPARATION
Ch. ANEMIA: INVESTIGATIONS
• Oral iron (Fe sulphate,
sulphate, gluconate,
gluconate, fumerate,
fumerate,
• Hemolysis workup succinate)
succinate) 200mg tds (60mg elemental iron)
Direct and indirect coombs test Reticulocyte response in 4- 4-5 days.
Direct and indirect bilirubin Hb rise 1-
1-1.5gm % /wk
Lactate dehydrogenase • IM iron dextran,
dextran, sorbitol – better early response
Hepatoglobin level
• IV total dose iron infusion – danger of anaphylaxis
Dose = 0.3 x wt (100-
(100-Hb%)
• Sickledex test
or (deficiency in Hb x 250) + 50% = mg of iron
• Electrophoresis for HbA2 • Oral folic acid 5-
5-15mg
• Erythropoitin
• Genotyping • Blood transfusion

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

BLOOD TRANSFUSION
BLOOD TRANSFUSION
• Depends on gestation, need for LSCS
• Transfusion trigger (intra-
(intra-operative) • <36wks:
Hb.
Hb. 6gm%: hemodilution,
hemodilution, hypothermic bypass, well Hb < 5 gm%
compensated ch.
ch. Anemia with Hb 8g%
Hb.
Hb. 8gm %: expected blood loss> 500ml Hb 5-7 gm% with risk factors (cardiac/
Hb.10gm%: cardiac patients unable to increase CO pulmonary disease, infection)
• >36wks:
• Task force 1996: Hb <6gm%
No uniform transfusion trigger
Vital signs are unreliable Hb 6-8gm% with risk factors
Silent ischemia can occur. • Precautions: give packed cells
diuretics
preferably 48hrs preop

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

PERI-
PERI-OP TRANSFUSION EFFECTS OF TRANSFUSION

Aim to increase volume, Oxygenation • Viscosity increases 33%

• Preop: Hb < 7gm% • Hb increase 1 gm /Unit
• Intraop Hb / blood vol. estimation inaccurate due to • Heart rate decreases 7%
fluid shift • ER no change after 50%
• DO2,VO2, ER estimation require invasive monitoring • More important to
• Measurement not organ specific - Optimize volume status
• Oxygen requirements lower under anesthesia - Optimize cardiopulmonary hemodynamics
• Post Op: - Maintain supranormal O2 delivery by high FiO2,
Increased demand due to fear, pain, shivering fluid volume, ionotropes,
ionotropes, maintain preload.

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

ANAESTHETIC TECHNIQUE SICKLE CELL ANEMIA

• Minimize factors interfering with O2 delivery:
• Valine substituted for glutamic acid
- Low myocardial contractility, cardiac output • Homozygous SS >90% HbS
(careful with volatile aesthetics) Danger of sickling crisis
- Left shift of O2 dissociation curve Autosplenectomy
(hyperventilation , alkalosis, hypothermia) Necrosis of long bones
- Reduced intravascular volume Acute chest syndrome
- Choose technique (GA / RA) Renal papillary necrosis -Inability to concentrate
- Replace loss (Hb
(Hb not above pre op level) urine
• Heterozygous AS 40-
40-60% HbA,30-
HbA,30-40%HbS
• Prevent increase in oxygen consumption No anemia
Renal papillary necrosis, hematuria,
hematuria, scarred kidneys
- reduce post-
post-op pain, fever, fear, shivering. • Sickle Thalassemia HbS+
HbS+ HbA+
HbA+ HbF
• Same as homozygous state

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

SICKLE CELL ANEMIA

SICKLE CELL ANEMIA
• Look for associated disorders
Cardiomyopathy
Congestive heart failure • Monitor pregnancy
Ch. Pulmonary disease Serial determination of HbS
Renal insufficiency Exchange transfusion for cardiac iron disease,
Nephrotic syndrome Stroke, acute chest syndrome, before C. Section
Ch. Liver disease
Elevate Hb>10gm%,
Hb>10gm%, HbS<
HbS< 40%
• Diagnosis:
Hb , HCT
• Folic acid 5mg/day
Reticulocyte count (increased)
• Iron supplement if S ferritin <80-
<80-120pmol/L
Sickle cells, target cells on smear
• Epidural analgesia well tolerated
Microscopic sickle cell test (Na metabisulphite)
metabisulphite) • Avoid hypoxia, hypotension, hypothermia
Hb electrophoresis (HbS
(HbS,, HbA,
HbA, HbF)
HbF) • Counsel patients on therapy with hydroxyurea
Prenatal test of fetus possible

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

THALASSEMIA
SICKLE CELL ANEMIA • Defect in modulation of globin chain synthesis α /β
• α thalassemia –hydrops fetalis
Anesthetic management • β thalassemia - Major/ minor / intermediate
• Risk: precipitation of crisis -infertile, hypogonadism,
hypogonadism, high fetal loss
Marrow, pulmonary infarcts - accumulation of free globin chains-
chains- RBC lysis
• Anesthesia: Favor LA /RA - Repeated transfusions -Secondary hemochromatosis
Avoid hypoxia, hypotension, risk of cardiac failure
acidosis, hypothermia, - prehepatic jaundice
dehydration - hepatosplenomegaly
• Consider exchange transfusion to reduce - Prone to infection
HbS<20
HbS<20--30% - Maintain Hb>10gm/dL,
Hb>10gm/dL, monitor cardiovascular parameters
• Diagnosis: microcytosis,
microcytosis, target cells, electrophoresis, α /β chain
studies
• Prenatal diagnosis possible

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

APLASTIC ANEMIA IMMUNE HEMOLYTIC ANEMIA

• Due to infection, drugs, toxins, immune • Warm Type
mechanism IgG mediated
• Aggravated by pregnancy,
pregnancy, may remit after Coomb’
Coomb’s test +ve
+ve
Antibody interferes with cross matching
pregnancy Treat with steroids
• Early pregnancy – advice termination Delay elective surgery till disease controlled
• Late pregnancy – component transfusion Transfuse 40ml slowly-
• Cold type
slowly-if no reaction, whole unit over 1-
1-3hrs

• Acquired may respond to steroids, IgM mediated

antilymphocyte globulin, bone marrow Less common
Transfuse washed RBCs
transplant Use inline warmer (37degree).
• Pure RBC aplasia from parvovirus infection
• High correlation with thymomas