Anaemia

Question 1

A 61-year-old female is undergoing major abdominal surgery for ovarian malignancy. She has a history of rheumatoid arthritis but is otherwise well. Her preoperative assessment blood test results show a haemoglobin level of 9.0 g/dL.

How do we define anaemia clinically?

Answer 1

• The World Health Organisation has classified anaemia as having a haemoglobin level of <13.0 g/dL (males) and 12.0 g/dL (non-pregnant females).

Question 2

What are the common causes of anaemia?

Answer 2

• Macrocytic anaemia (MCV >96 f):
• Vitamin B12/folate defciency.
• Alcoholic liver disease.
• Drugs e.g. phenytoin.
• Myelodysplasia.
• Normocytic anaemia (normal MCV):
• Acute haemorrhage.
• Anaemia of chronic disease.
• Chronic renal failure.
• Pregnancy.
• Hypothyroidism.
• Microcytic anaemia (MCV <80 f):
• Iron deficiency.
• Thalassaemia.
• Sideroblastic anaemia.

Question 3

What are the risks associated with anaemia during the perioperative period?

Answer 3

• Increased duration of hospital stay.
• Higher incidence of postoperative intensive care requirement.
• Increased postoperative complications e.g. venous thromboembolism,
  wound infections and sepsis.
• Increased likelihood of need for perioperative blood transfusion, and
  subsequent risks.
• Overall increase in morbidity and mortality.

Question 4

What is meant by the term “blood management”?

Answer 4

• Identification and multidisciplinary assessment of patients at risk of perioperative anaemia.
• Strategy that encompasses guidelines and measures that can be used to manage these patients optimally before, during and after their procedure.

Question 5

How can this patient be optimised prior to surgery with regard to her low haemoglobin?

Answer 5

• Identify likely causes of anaemia through investigations (haematinics and red cell morphology).
• Consider agents to improve her haemoglobin level:
• Oral or intravenous iron supplementation (if iron-deficient).
• Erythropoietin.
• Thorough medical and drug history to detect modifiable risk factors for bleeding.
• Optimise the patient’s physiological reserve through optimal nutrition, exercise and lifestyle changes.
• Planning for surgery:
• Senior led care.
• Minimally invasive procedure if possible.
• Strict surgical haemostasis intraoperatively.
• Cell salvage if appropriate.

Question 6

The estimated blood loss from the procedure is 800 mL, and the patient’s postoperative haemoglobin is 7.6 g/dL. She is given one unit of packed red cells in recovery. Five minutes into the transfusion, she feels hot, sweaty and generally unwell. How you do proceed?

Answer 6

• Immediate review and early escalation to seniors if appropriate.
• Stop the blood transfusion while undergoing a rapid ABCDE assessment of the patient to ascertain the cause of her symptoms.
• Check that the packed red cells match the patient’s name and ID band and blood group as per local guidelines.
• Maintain patency of cannula with crystalloid.
• Consider paracetamol if pyrexial.
• Review of notes and observations since transfer into recovery.
• Contact blood lab/consultant haematologist.
• Return the given blood to the lab.
• Blood tests including full blood count, clotting and group and save.
• Conduct other relevant investigations and escalate to appropriate individuals based on initial assessment of the patient.
• Potential causes of the patient’s symptoms include:
• Non-haemolytic febrile transfusion reaction.
• Allergic transfusion reaction.
• Haemolytic transfusion reaction.
• Conditions unrelated to transfusion e.g. sepsis, anaphylaxis, and cardiac event.