DEFINITION

•The normal range of hemoglobin values -

• adult males is 13.5–17.5 g/dL
• adult females is 12–15 g/dL
•The World Health Organization (WHO) defines
anemia as a hemoglobin level
. <13 g/dL in men
<12 g/dL in women.
 CLINICAL ASSESSMENT

• Iron deficiency anemia is the most common

type of anemia worldwide.
• A thorough gastrointestinal history is
important, looking in particular for symptoms of
blood loss.
• Menorrhagia is a common cause of anemia in
pre-menopausal females, so women should
always be asked about menstrual history.
• A dietary history should assess the intake of iron,
B12 and folate, which may become deficient in
comparison to needs (e.g. in pregnancy or during
periods of rapid growth.
• Past medical history may reveal a disease that is
known to be associated with anemia, such as
- rheumatoid arthritis(anemia of inflammation (AI)
- previous surgery (e.g. resection of the stomach or
small bowel, which may lead to malabsorption of
iron and/or vitamin B12).
• Family history and ethnic background may raise suspicion of
haemolytic anaemias, such as the haemoglobinopathies,
oxidative enzymopathies and membranopathies.

• Pernicious anaemia, an A-I disorder, may also run in families,

but not a/w clear Mendelian pattern of inheritance.

• A drug history may reveal the ingestion of drugs that cause or

worsen blood loss (e.g. anticoagulants, anti-PLT drugs and
anti-inflammatory drugs), haemolysis (e.g. sulphonamides and
anti-malarial drugs) or aplasia (e.g. chloramphenicol,
mercaptopurine).
• On Examination as well as the general physical findings of
anemia, there may be specific findings related to the etiology of
the anemia; for example, a RIF mass due to an underlying caecal
carcinoma.

• Haemolytic anemias can cause jaundice.

• Vitamin B12 deficiency may be a/w neurological signs, including

peripheral neuropathy, dementia.

• Sickle-cell anemia may result in leg ulcers, stroke or features of

pulmonary hypertension.

• Anemia may be multifactorial and the lack of specific symptoms

and signs does not rule out silent pathology.
 REMEMBER Common causes of
ANEMIA
• A - Acute blood loss
• B - BM failure/ infiltration, B12 deficiency
• C - Chronic blood loss (P/V, P/R)
• D - Destruction (Hemolysis)
• E - EPO deficiency (CKD)
• F - Folate deficiency
• G - GI bleed
• H - Hypothyroidism*
• I - Iron deficiency
 Laboratory Tests in Anemia Diagnosis
1. Complete blood count (CBC)
A. Red blood cell count
1. Hemoglobin
2. Hematocrit
3. Reticulocyte count
B. Red blood cell indices
1. Mean cell volume (MCV)
2. Mean cell hemoglobin (MCH)
3. Mean cell hemoglobin concentration (MCHC)
4. Red cell distribution width (RDW)
C. White blood cell count
1. Cell differential
2. Nuclear segmentation of neutrophils
D. Platelet count
E. Cell morphology
1. Cell size
2. Hemoglobin content
3. Anisocytosis
4. Poikilocytosis
5. Polychromasia

II. IRON SUPPLY STUDIES

A. Serum iron
B. Total iron-binding capacity
C. Serum ferritin

III. MARROW EXAMINATION

A. Aspirate
1. M/E ratio
2. Cell morphology
3. Iron stain
B. Biopsy
1. Cellularity
2. Morphology
 GANZONI FORMULA
TOTAL ELEMENTAL IRON TO BE REPLACE
(PARENTERAL)
=
BODY WEIGHT
x
2.4 (TARGET Hb - PATIENT’S Hb)
+
500MG (OR) 1000 mg (FOR STORES)
 PARENTERAL IRON THERAPY
• Intravenous iron can be given to patients who are unable
to tolerate oral iron; whose needs are relatively acute; or
who need iron on an ongoing basis, usually due to
persistent gastrointestinal or menstrual blood loss.

• If a large dose of LMW iron dextran is to be given (>100

mg), the iron preparation should be diluted in 5%
dextrose in water or 0.9% NaCl solution. The iron
solution can then be infused over a 60- to 90-min period.
 ANEMIA IN CKD
• ERYTHROPOIETIN(EPO) is particularly useful in anemias
in which endogenous EPO levels are inappropriately low,
such as CKD or AI.
• Iron status must be evaluated and iron replaced to
obtain optimal effects from EPO.
• In patients with CKD, the usual dose of EPO is 50–150
U/kg three times a week intravenously.
• Hemoglobin levels of 10–12 g/dL are usually reached
within 4–6 weeks if iron levels are adequate.

• Orally bioavailable EPO mimetics such as roxadustat

(usual dose 50 mg PO thrice weekly).
 MEGALOBLASTIC ANEMIA
• Anemia due to cobalamin deficiency or folate
deficiency/ abnormalities of metabolism.

• Treatment
1. Replenishment of body stores should be complete
with six 1000-μg IM injections of
hydroxocobalamin given at 3- to 7-day intervals.

2. For maintenance therapy, 1000 μg

hydroxocobalamin IM once every 3 months is
satisfactory. Because of the poorer retention of
cyanocobalamin, protocols generally use higher and
more frequent doses, for example, 1000 μg IM,
monthly, for maintenance treatment.
• FOLATE DEFICIENCY
• Oral doses of 5–15 mg of folic acid daily.
• The length of time therapy must be continued
depends on the underlying disease.
• It is customary to continue therapy for about
4 months,
 TRANSFUSIONS
• Thresholds for transfusion should be determined
based on the patient’s symptoms.

• In general, patients without serious underlying

cardiovascular or pulmonary disease can tolerate
hemoglobin levels above 7–8 g/dL and do not require
intervention until the hemoglobin falls below that
level.

• Patients with more physiologic compromise may

need to have their hemoglobin levels kept above 11
g/dL.
• Usually, a unit of packed red cells increases
the hemoglobin level by 1 g/dL.

• Blood Components comprise mainly red blood

cell concentrates (RBCCs), platelet
concentrates (PCs), and plasma for transfusion
use (as opposed to plasma for fractionation
into medicinal products such as albumin and
immunoglobulin).
 Transfusion Adverse Reactions: Main
Warning Signs
• Fever (≥38°C)

+1-2°C within 4 h

1. FNHTR (febrile nonhemolytic transfusion

reaction)
2. Anti-HLA immunization and cognate Ag in the
blood product.
3. TRALI (with dyspnea at the forefront)
• +1-2°C within 15 min +/-
Chills
Dyspnea
Hypotension
Digestive disorders
Disseminated intravascular coagulation
Hemoglobinuria

• Transfusion-transmitted bacterial infection

• Hemolysis
• Hypotension (>30 mmHg decrease in
systolic blood pressure)
1. Hemolytic shock
2. Anaphylactic shock
3. Septic shock
4. TRALI (with dyspnea at the forefront)
• DYSPNEA

1. TRALI (within 6 h of transfusion)

2. TACO (within 6 h of transfusion)
3. Severe allergy (immediate; within 4 h)
• HEMOGLOBINURIA
▪ Intravascular hemolysis
• Immunologic
• Mechanical
• Toxic
• Thermic
• RASH

• <2/3 of the body within 2–3 h - Minor allergy

• >2/3 of the body during or within 2–3 h--

Severe allergy

• >2/3 of the body within 5 min Associated with

dyspnea and shock -- Anaphylaxis
• Icterus -- Delayed hemolysis

• New alloantibody -- Allo immunization

• Rash, diarrhea, and fever occurring 2 days to 6

weeks after transfusion – GVHD

• Gum bleeding, purpura 5–12 days after

transfusion -- Post transfusion purpura

• Cardiac, hepatic, and/or renal insufficiency in

frequently transfused patients -- Post
transfusion iron overload.
Thankyou