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Flashcards in Blood disorders Reduced Deck (59):
1

What are some questions you might want to ask in regards to hematology?

  • Have you ever had a blood problem?
  • Anemia? Leukemia?
  • Any clotting problems?
  • Lots of bleeding from cuts, nosebleeds, surgery, dental work?
  • Have you ever required a blood transfusion?
  • Has a family member/blood relative ever had a serious bleeding condition or clotting problem?

2

What common medications would make you concerned in terms of possible hematological problems?

  • Aspirin/NSAIDS
  • Vitamin E,
  • Ginseng, Gingko, Garlic, Saw Palmetto.
  • How often, how much, and last dose?

3

Anemia Pathology

  1. Can be either Acute or Chronic
    • Acute = Acute blood loss
    • Chronic = Nutritional HemolyticAplasticManifestation of another diseaseAbnormal RBC structure (Sickle cell, Thalassemia)
  2. ​​​Disease state related to
    1. ​abnormal low concentration of hemoglobin (RBCs)
    2. Abnormal structure of hemoglobin
  3. Clinical manifestation of decreased oxygen carrying capacity and  delivery
    1. ​Hemoglobin Defines oxygen carrying capacity
    2. Anemia decreases o2 carrying capacity
  4. ​Care must inclued treatment of the underlying disease as well as the state of anemia
  5. MUST avoid disruption of compensatory mecheanisms

4

Calculation of arterial blood oxygen content

CaO2 = (Hgb x 1.39) SaO2 + PaO2 (0.003)

  • 1.39 = O2 bound to hemoglobin
  • SaO2 = saturation of hemoglobin with O2
  • PaO2 = arterial partial pressure of oxygen
  • 0.003 = dissolved oxygen ml/mmHg/dl
  • Normal O2 capacity = 16-20 mL/dL

5

Compensatory mechanisms for anemia

  1. Increase CO
  2. Increase 2,3-DPG 
  3. Increased P50
  4. Increase plasma volume
  5. Decreased blood viscosity  = increased CO
  6. Decreased SVR
  7. Blood shunting to organs with higher extraction ratios
  8. Kidneys release EPO
  9. RIGHTWARD shift in ox-hem disassociation curve

6

Oxyhemoglobin disassociation curve shifts to the right with:

Think of anything that increases metabolism → RBC will want to drop off Oxygen at the tissues

  • Increased CO
  • Acidosis = Decreased pH
  • Increased 2-3 DPG
  • Exercise
  • Increased temeperature (sepsis)
  • Hgb variants with decreased oxygen affinity (Sickle cell) 
  •  

7

Oxyhemoglobin disassociation curve shifts to the left with:

Think anything that decreases metabolism →tissue does not need as much oxygen

  • Decreased CO2
  • Alkalosis = Increased pH
  • Decreased 2/3 DPG
  • Decreased temperature - hypothermia
  • High oxygen affinity Hgb variants (Fetal Hgb)

(a leftward shift on someone that is dependent on a rightowrd shift may be a problem - we do this from hyperventilation and decreaseing temperature)

8

Changes that could interefere with oxygen delivery to the tissues

  1. Decreased CO
  2. LEFTWARD shft in oxy-heme disassociation curve
    1. Respiratory alkalosis
      1. hyperventilation/decreased PaCO2
      2. Hypothermia
      3. Abnormal Hgb such as fetal hemoglobin and carboxyhemoglobin

9

Anemia Basic Anesthetic management

  1. Know your pts preoperative Hgb and HCT
    • anemia suspected if hemoglobin
      • < 11.5 g/dl (females)
      • < 12.5 g/dl (males)
  2. Hgb and HCT are RELATIVE measuremants

 

 

Treating the underlying cause

10

Anesthesia management and considerations for chronic anemia

Goal =  AVOID disruptions of compensatory mechhanisms that are aimed at maintinging O2 delivery to the tissues! 

  1. Indentify and treat underlying disease if possible
  2. Maximize O2 delivery- High FiO2 
  3. Avoid drug induced decreases in CO
    • consider etomidate induction
    • may want to use high opioid technique
    • hydrate/avoid hypovolemia
    • AVOID propofol, high amounts of IAs, STP
  4. AVOID leftward shifts of the oxyhemoglobin disassociation curve
    • no hyperventilation/respiratory alkalosis
    • no hypothermia
  5. Consder volitile anesthetics may be LESS soluble in plasma
    • may have a faster induction, however, often OFFSET by the fact that these patients have and increased CO

11

Anemia and the decision to transfuse 

Goal of transfusion therapy = Increase O2 carrying capacity and/or correct a coagulation disorder

  • There is NO tranfusion trigger and the decision to transfuse is based on: 
    • The clinical judgment that the oxygen carrying capacity MUST be increased to prevent oxygen  consumtion (VO2) from being greater than oxygen delivery (DO2)
  • A drop in Hgb from 15 to 10 = 33% decrease in arterial oxygen content!
    • it is also manifested by a RIGHT shift in the poxthemoglobin disassociation curve

12

2006 ASA guidelines regurding blood transfusion 

  1. Rarely indicated if Hgb > 10 g/dL  
  2. Almost ALWAYS indicated if Hgb < 6 g/dL
  3. If Hgb is 6-10: transfusion is based on the patients risk for complication and inadequate oxygenation
  4. Use of a transfusion trigger of Hgb is NOT RECOMMENDED
  5. Where apprropriate use of autologous blood, cell save or acute normovolemic hemodilution and measures to decrease blood loss (deliberate hypotension)
  6. Indications for transfusion are more liberal for autologous blood than blood from the blood bank

13

How do you know when to transfuse?

 

  1. You calculate the allowable blood loss for your surgical case
    • ABL = EBV x (patients Hct - Allowable Hct)

​                                               patients Hct

  1. Know that: 
    • 1 unit of RBCs will increase Hct 3-5%;
    • ​​or it will increase Hgb ~1 g/dL

14

Nutritional anemias

  • Iron deficiency
  • Folic acid deficiency
  • B12 deficiency
  • Chronic illness (infections, cancer, RF, DM, AIDS, connective tissue disorders)

15

Iron deficiency anemia- RBCs are? Common causes in adults?

  • Nutritional Anemia
  • Ineffective erythropoesis and Microcytic RBCs
  • In adults, depletion of iron stores is caused by chronic blood loss
    • GI bleed
    • menorrhagia
    • cancer
  • Most common form of nutritional anemia in infants and children

16

B12-def. anemia - RBCs are? May result in? Anesthesia considerations?

Macrocytic (Megaloblastic bone marrow morphology)

B12 deficiency may result in pernicious anemia

  • Bilateral peripheral neuropathy
  • Loss of proprioception/vibratory sensation in lower limbs
  • Decreased deep tendon reflexes
  • Unsteady gait
  • Memory impairment/mental depression

Anesthesia considerations: 

  • Avoid regional blocks (neuropathys)
  • Avoid N2O (binds B12)
  • Maintain oxygenation
  • Emergency correction for imminent surgery is RBC transfusion

17

Causes hemolytic anemias

 

Acquired Hemolytic Anemias

  • Drug induced (High dose PCN, alpha- methyldopa)
  • Disease/infection induced (malaria, epsteen Barr)
  • Sensitization of RBCs (Maternal/fetal)

(particals released durring hemolysis can result in DIC and hypersplenism)

Hereditary hemolytic anemias

  1. Hereditary spherocytosis
  2. Paroxysmal nocturnal hemoglobinuria
  3. Glucose 6 Phospahete dihydrogenase deficiency
  4. Pyruvate Kinase Deficiency

18

Folic acid deficiency anemia- RBCs are? May result in? Anesthesia considerations?

Macrocytic (Megaloblastic bone marrow morphology)

Folic acid deficiency may result in penicious anemia 

  • Smooth tongue (difficult intubation)
  • Hyperpigmentation
  • Mental depression
  • Peripheral edema
  • Liver dysfunction
  • Severely ill patient

Anesthesia considerations: 

  • Thorough airway assessment
  • Have an alternative airway plan in place
  • often have difficult airways d/t tongue texture!

19

Glucose-6-Phosphate dehydrogenase deficiency  What is it? Who does it affect? What should you avoid?

Form of hemolytic anemia

  • Most common enzymopathy; decreased G6PD activity leaves RBCs susceptible to damage by oxidation.
  • Cell membranes have increased rigidity of membranes and there is accelrated RBC clearance
  • Acute and chronic episodes.
  • Most prevalent in: Blacks, Asians, Mediterranean populations

Anesestetic consideratons: 

  • AVOID:  oxidative drugs (LAs, Benzos, Meth. Blue)
  • AVOID:  hypothermia, acidosis, hyperglycemia, infection 

20

Peri-op risks  and concerns for hemolytic anemia

Hemolytic anemia risks:

  • Increased tissue hypoxia
  • Increased infection risk if prior splenectomy
  • Increased risk of venous thrombosis 

To offset these risks preop planning should include:

  • EPO given for 3 days pre-op
  • Consider for transfusion if:
    • Hgb acutely < 8 g/dL or
    • Hgb chronically < 6 g/dL
  • Adequate pre-op hydration and prophylactic RBC transfusions
  • Caution with Methylene Blue - can increase hemolysis!!!

21

Sickle cell anemia patho

Cellular Pathology

  • Inherited Single AA defect in the ß-globin chains
  • Mutant S hemoglobinvaline substituted for a glutamic acid 
  • Hgb aggregates  & forms polymers when there is low O2 concentrations
  • Hemoglobin S has a shorter life span

Sickle cell trait vs. disease

  • trait = heterozygus carriers (asymptomatic)
  • disease = Homozygus (have the disease)

22

Explain a Sickle cell crisis

  • Life threatening
  • Acute vaso-occlusive crisis (Deoxygenation causes Hgb S to form insoluble globulin polymers​)
  • Ischemia and organ infarcts
  • very painful
  • Can cause stroke, renal failure, liver failure, splenic sequestration, PE and acute chest syndrome

23

Periop planning for Sickle cell anemia 

  • O2
  • 12 hours hydration
  • Pre-op exchange transfusons (HCT to 30% Hgb S <30%)
  • Caution with pre-med
    • avoid respiratory  depression that can lead to acidosis
  • USE Regional!
  • AGGRESSIVE pain management
  • Strict aseptic technique, must avoid infections
  • Avoid tourniquets

AVOID ALL SITUATIONS LEADING TO 

  • Hypoxemia
  • Hypovolemia
  • Stasis

24

What are the signs and symptoms of acute chest syndrome and how is it managed?

Signs and symptoms of acute chest syndrome due to pumonary vascular occlusion

  • Pleuritic chest pain
  • dyspnea
  • fever
  • acute pulmonary HTN

Treatment: 

  • Transfuse to Hct 30%
  • give oxygen
  • antibiotics
  • inhaled bronchodilators
  • aggressive pain management

25

Thalassemia major patho and signs and symptoms

  • Inability to form alpah or beta-globin hemoglobin chains

​Signs and symptoms: 

  • Hepatosplenomegaly
  • Dyspnea &orthopnea
  • Infection risk
  • CHF, dysrhythmias
  • Bone malformations (Overgrown maxillae - difficult intubation!!!) 
  • Hemothorax
  • Spinal compression (No epidurals or spinals)
  • Mental Retardation
  • Digitalis sensitivity
  • Increased RBC production
  • Jaundice
  • Iron overload

26

thalassemia 

Perioperative risks and concerns 

 

 

  1. Difficult airway (maxillary deformities), consider awake fiber optic
  2. Complications of iron loading d/t chronic therapy
    1. ​​Arrythmias, CHF, Right heart failure, cardiomyopathy
      • Get an EKG and ECHO
      • also note: VERY sensitive to the effects of digitalis
    2. Adrenal Insufficiency
      • Decreased vasopressor response 
    3. Hemodynamic comprimise with induction agents 
      • ​if low cardiac reserve use cardiac sparing drugs
    4. Diabetes → monitor blood glucose
    5. Liver Dysfunction→ coagulopathy
      • AVOID regional
    6. Hepatosplenomegaly
      1. thrombocytopenia
      2. increased infection risk
    7. Hypothyroid and hypoparathyroid

27

Aplastic anemia is caused by

  1. Bone marrow failure characterized by destruction of rapidly growing cells
  2. Marrow damage from:
    1. Drugs (all kinds)
    2. Radiation
    3. Chemotherapy
    4. Infectious diseases
  3. CBC values extreemly low

28

Aplastic anemia

perioperative risks and concerns

  • Often on immunosuppression
    • may need "stress dose" steroids
  • Reverse isolation
  • Prophylactic antibiotics d/t neutropenia
  • Hemorrhage (GI and intercranial)
  • LV dysfunction due to high output state
  • Difficulty in cross-matching
    • (have had multiple transfusions)
  • Co-existing congenital abnormaliities
    • (Fanconi anemia - peds- cleft palate and cardiac defects)

29

Co-existing congenital abnormalities with aplastic anemia

Fanconi anemia in peds

  • Cleft lip/palate
  • Cardiac defects

30

aplastic anemia

Induction

  • Consider preop transfusion
  • Airway Hemorrhage possible with DVL
  • Avoid nasal intubation
  • Consider Regional if coags allow
  • Will have labile hemodynamic response to induction

31

aplastic anemia

Maintenance

  • PEEP will allow for lower FiO2 
  • Avoid nitrous (immunosupression)
  • Maintain normothermia

32

aplastic anemia

Emergence

  • Extubation and post-op perioid are the periods with greatest oxygen demands
  • Monitor coagulation status

33

Methemoglobinemia

What is it?

What casues it?

 

  1. Formed when iron in Hgb is oxidized from the ferrous to the ferric state (2+ to 3+)
  2. LEFT shift = little oxygen delivery to the tissues
  3. Normal blood level = 1%
  4. At 30-50% methemoglobinemia there will be signs of oxygen deprivation​​BROWN blood
  5. Over 50% can lead to coma and death

Causes: 

  • Nitrate poisoning (SNP)
  • Toxic drug reactions
    • such as from prilocaine (throat spray)

34

Anesthesia considerations for metHgb

  1. Makes the pulse ox inaccurate
    • MetHgb absorbs red and infrared light equally
      • at SaO2 over 85% → true value is underestimated
      • at SaO2 under 85%→ true value is overestimated

(just think the OVER/UNDER RULE!!!)

  1. Toxic Methemoglobinemia requires emergent treatment 
    1. Oxygen
    2. Methylene Blue 1% solution1-2 mg/kg over 3-5 minutes
      • Mary repeat after 30 minutes

35

  • Clinical Signs of acute blood loss

20% acute blood loss:

  • Tachycardia
  • Orthostatic hypotension
  • CVP changes

40% acute blood loss

  • Tachycardia
    • (may have EKG chnages d/t change in O2 carrying capacity)
  • hypotension
  • tachypnea 
  • oliguria
  • acidosis
  • restlessness
  • diaphoresis

36

Acute blood loss

Treatment

  1. Restore intervascualr volume
    • (crystalloids, colloids, blood products)
  2. Monitor Labs
    1. Coagulation
      • CBC (Hgb/HCT, platelets), PT, PTT, INR, fibrinogen
    2. Calcium and potassium 
    3. ABGs (persistant metabolic acidosis reflects hypovolemia and inadequate oxygen delivery to the tissues)
  3. Hemodynamic monitoring
    1. CVP, A-line, +/- PA
    2. do they have adequate urine output? Hematuria?

37

Blood loss

Induction, maintinence and Post op

  1. Induction: Ketamine/Etomidate
  2. Maintinence
    • May too unstable for ANY Inhaled anesthetics 
    • trauma cocktail = scopolamine, benzo, opioid mix
    • Keep warm
    • use pressors sparingly→not treating the problem!
    • watch surgical field for non-clotting blood
  3. Post-operative
    • May need post op ventilation
    • Risk for Pulmonary edema and ARDS

38

Definition massive transfusion

what are consiquences of massive transfusion?

Definition

  • More than 10 units PRBCs in 24 hour period
  • Replacement of at least one blood volume in 24 hours
  • 50% blood volume replacement in 6 hours

Consiquences

  • Hypothermia
  • Volume overload
  • Dilutional coagulopathy
  • Decreased 2,3-dpg
  • Hyperkalemia
  • Citrate toxicity (hypocalcemia)→hypotension
  • Tissue hypoperfusion and lactic acidosis

39

Polycythemia

What is it?

Problem?

Increased Hct and high RBC mass → caused by:

  • dehydration
  • Excess RBC production (polycythemia vera)
  • Chronic hypoxia

Increased blood viscosity poses risk for:

  • Thrombosis leading to CAD, pulm HTN, CNS disorders
  • Hct > 55% is problematic

40

Hemophilia A

Anesthesia considerations

  1. Factor VIII (8 deficiency)
  2. Increased PTT NORMAL PT
    • Severe→ (VIII < 1%) childhood diagnosis  spontaneous hemorrhages; joints, muscles, organs
    • Moderate→ (VIII 1-5%) high bleeding risk in surgery Have less joint bleeding problems
    • Mild  (VIII = 6-30%)adult diagnosisbleeding risk in MAJOR surgery
  3. ​Anesthesia considerations: 
    • Pre-op factor VIII​ →start at 100% then mintain at >50%
    • IV: 50-60 U/kg loading then 25-30 U/kg q8-12 hours
    • E1/2 = 12 hours
    • May need for two weeks post op.
    • DDAVP is also effective at correcting for surg

41

Hemophilia B- Severe, moderate, mild

Congenital Factor IX deficiency

Increased PTT normal PT 

  • Severe (factor IX < 1%)→ severe bleeding
  • Moderate(factor IX = 1-5%)
  • Mild (factor IX = 5-40%)

Anesthesia Considerations

  • GIVE factor IX prior to surgery!!!
  • 7000 Units (70kg)  = 100 U/kg 
  • Half life is 18-24 hours, so 50% of original dose needs to be given every 12-24 hours to keep levels about 50%.
  • Treatment can result in increased thromboembolic events

42

von Wilibrand  disease 

Anesthesia considerations

Von Wilibrand Disease

  • Dysfunctional platelets  (NORMAL plt count)
  • prolonged Bleeding time (>10 minutes)
  • Increased PTT
  • Bleed from mucus membranes
    • epistaxis, bruising, menorrhagia, gingival and GI bleeding

Anesthesia Considerations

  • Avoid messing with the nose (intubation/trumpets)
  • Desmopressin (DDAVP) IV or intranasal
    • IV: 0.3mcg/kg in 30-50ml NS over 10-20 minutes
    • Intrnasal = 300mcg divided between each nostril
    • (can produce tachycardia and hypotension)
  • Cryo for severe bleeding or surgical prophylaxis

43

Compare Labs and Treatment

Hemophelia A, Hemophelia B and von Wilibrand disease

A image thumb
44

Platelet Dysfunction

Causes and Treatment

 

Drugs

  1. Asprin/NSAIDS
    • Inhibits aggregation for life of the platelet
    • bleeding time = 2-3x longer within 3 hours of ingestion
    • 72 hours = returns to normal
    • Aggregation inhibited up to 10 days
  2. Antibiotics
    • Interferes with platelet adhesion and activation
    • Biggest impact on critically ill
  3. Volume expanders
    • dextran = platelet inhibition
    •  hespan = dilutional thrombocytopenis

Other Factors

  1. Hypothermia < 35˚C
  2. Acidosis (pH < 7.3)
  3. Uremea and liver disease

​Treatment

  1. vWF in Cryo
  2. Desmopressin DDVAP
  3. Platelet transfusion

45

Thrombocytopenia

what is it?

signs and symptoms

goals and treatment

  • Low platelet count
  • approximately 1/3 of platelets sequestered in spleen
  • Signs: 
    • Petechial rash
    • nose bleeds
    • GI bleeds
    • bruising
  • Need >50,000 for major surg
  • A six pack of platelets should increase platelets by about 50,000

46

Most common intra-op coagulopathy

  • Dilutional thrombocytopenia or coagulopathy 
    • occurs when blood loss replaced with crystalloid, colloid or PRBCs
    • dilution of platelets and clotting factors
    • occurs with massive transfusion (more than 10 units)
  • Surgical hemorrhage also causes fibrinogen release from hepatic stores

47

Acquired defects in platelet production

  • Radiation
  • Chemo
  • Toxic chemicals
  • Thiazides,
  • ETOH,
  • estrogen
  • Cancer 
  • Viral hepatitis
  • B12/folate deficiency

48

DIC

What is it?

what is it associated with?

Clinical symptoms?

Labs 

Treatmetn

DIC = diseminated intravascular coagulation

  1. Classified as a Consumptive coagulopathy 
    • Bleeding, microemboli, consumption of platelet and clotting factors, fibrin deposits and impaired fibrin degredation
  2. Associated with:
    • sepsis, trauma, cancer, immune disorders
    • OB complications, vascular disorders 
  3. Clinical symptoms d/t thrombosis and bleeding: 
    • microemboli accumulation in the pulmonary system
    • organ damage
  4. ​​​​No single lab test diagnostic
    • ​Rapid decrease in PLT to <50,000
    • Prolonged PT/PTT
    • Presence of split fibrin degridation products 
    • Normal Fibrinogen levels
    • Low plasma Antithrombin III
  5. Treamtment = manage casue and coagualtion process
    • ​PLT, FFP, Fibrinogen, Antithrombin III
    • Heparin (Blocks thrombin and faciltates hemostasis)
    • Hemodynamic and respiratory support

49

Tests of Coagulation

Lab Values 

Clotting factors

A image thumb
50

Vitamin K deficiency

  1. Vitamin K is needed for formation  of factors
    • II, VII, IX, X
  2. Causes:
    • Malnutrition/malabsorbtion
    • Antibiotic induced elimination of intestinal flora
    • Liver Disease/obstrucyive jaundice
  3. Lab profile:
    • Prolonged PT, NORMAL PTT
  4. Treatment:
    • Vitamin K (takes 6-24 hours for effect)
    • FFP for acute bleeding

51

Hypercoagulability Disorder

Causes

Anesthesia considerations

Causes of Hypercoaguability disorders

  • Malignancies, Pregnancies, Oral contraceptives
  • Lupus, Nephrotic syndrome

Anesthesia considerations

  1. Prevent thrombus, PE, DVT, blood clots
    • Early ambulation
    • SubQ heparin
    • Compression devices
    • ASA
    • IVC filter
    • Regional anesthesia is beneficial, but contraindicated if pt on LMWH

52

What is long-term anticoagulation therapy used for

​Long term anticoagulation used for:

  • A-fib, Venous thrombosis and heart valves
  • Hereditary hypercoagulable states
  • Cancer

(Threapy poses a problem at the time of surgery → MUST evaluate the risk of thrombosis with the risk of bleeding)

53

Antiplatelet therapy is indicated periop for what conditions? Which meds are commonly used?

Antiplatelet therapy indicated for: 

  • Pts at high risk for CVA, MI, vascular thrombosis complications

Medication used

  • ASA, PDE inhibitors, ADP receptor antagonists

54

Warfarin

Anesthesia considerations

  • Mechanism
    • Competes with vitamin K  →inhibits formation of vitamin K dependent clotting factors
    • factor II, VII, IX, and X
  • Lab tests: PT/INR
  • Reversal: Vitamin K, FFP, 4 factor PCCs
  • Holding Warfarin prior to surgery:
    • At least 5 days  
    • check INR ONE day preop,
      • if > 1.8→ give 1 mg vitamin K subQ
  • If they are high risk and cannot go without anticoagualtion
    • Start heparin 3 days after stopping warfarin
    • Stop heparin 6 hours prior to surg
    • surgery can be safely performed if INR <1.5
    • (regional??? I wouldn't)

55

Heparin

Anesthesia connsiderations

Mechanism

  • INDIRECTLY inhibits thrombin and Xa by binding to antithrombin III

Lab tests: PTT or ACT

Reversal: Protamine

Complication: HIT (thromboembolic complication)

56

What is P50

  • the partial pressure at which 50% of hemoglobin is saturated 
  • Usually around 26-28%
  • A right shift needs a higher partial pressure to sarurate 50% (left shift = lower PP)

57

Relative partial pressures and oxygen saturation

At 40 mmHg 70% of hemoglobin will be saturated

At 60 mmHg 90% of hemoglobin will be saturated

58

Explain the steep part of the oxyhemoglobin disassociation curve

  • there is a rapid unloading of O2 in response to a small change in the partial pressure of O2

59

Treatment for acute blood loss

  1. Restore intervascualr volume first!!!
    • Colloid
    • crystalloid
    • Blood products (O2 carrying capacity)
  2. Monitor coagulation
    • (blood loss decreases clotting factors)
    • PT, PTT, INR, CBC, PLT
    • If you see oozing in the surgical field CHECK FIBRINOGEN!!! 
  3. Monitor serum calcium and potassium levels
    1. citrate binds to calcium
    2. blood products have high potassium and will have a higher contenct as the cells degrade
    3. Hypotension? may need some calcium!
  4. ABGs
    • persistent metabolic acidosis reflects reflects hypovolemia and decreased oxygen delivery to the tissues