B18M02L02-Anemia of Acute and Chronic Blood Loss.docx

 ANEMIA OF ACUTE AND CHRONIC BLOOD LOSS MG Alfeche, MD December 2, 21!, 8"m#1"m

BLOCK  18 MODULE 2 LECTURE 2

OUTLINE I.

Overview of Ac Acute an and Ch Chronic Bl Blood Lo Loss II. Acute Blood Loss III. Classication of of An Anemia IV. Hemolytic Anemia A. Non-im Non-immu mune ne Hemol Hemolyti ytic c Ane Anemia mia . !icr !icroa oan"i n"io# o#ath athic ic Hemo Hemolyt lytic ic Anemi Anemia a a. $hro $hrom%o m%otic tic $hro $hrom%o m%ocyt cyto# o#eni enic c &ur#ura '. !acr !acroa oan"i n"io#a o#athi thic c Hemolyt Hemolytic ic Anemia Anemia a. !ar !arch Hemo Hemo"l "lo% o%in inur uria ia %. $raumat raumatic ic Car Cardia diac c Hemo Hemolyt lytic ic Anemia (. Hemo Hemolyt lytic ic ane anemia mia resul resultin tin" " from from a chemical or #hysical a"ent ). Hemol Hemolyti ytic c anem anemia ia resu resutin tin" " from from infectious a"ent B. Immu Immune ne Hem Hemol olyt ytic ic Ane Anemi mia a . Autoim Autoimmu mune ne Hemol Hemolyti ytic c Anemi Anemia a a. *arm arm +eac +eactin tin" " Anti% Anti%odi odies es %. Cryo#a Cryo#athi thic c Hemol Hemolyti ytic c Anemi Anemia a c. Alloi Alloimmu mmune ne Hemol Hemolyti ytic c ,ise ,isease ase of  the New%orn '. ,ru",ru"-ind induc uced ed Hemol Hemolyti ytic c Ane Anemia mia V. Chronic Blood Loss . Chro Chroni nic c I %lee %leedi din" n" '. A%nor A%normal mal Va"inal a"inal Bleed Bleedin" in" VI. Hy#o#roliferative An Anemia . Iron Iron ,ec ,ecie ienc ncy y Ane Anemi mia a '. Anem Anemia ia of +enal enal ,ise ,iseas ase e (. Anemia Anemia of Hy#om Hy#ometa eta%ol %olic ic state state

I.

/i##ed to#ics &aro0ysmal Noctural Hemo"lo%inura II. La%oratory $ests

O$ER$IE% 

BLEEDING & used to descri%e %lood loss # Blood loss inside the %ody 1 I'(er'"l) # Blood loss outside the %ody 1E*(er'"l) 1E*(er'"l) INTERNAL BLEEDING 2 %lood lea/s out throu"h dama"e to a %lood vessel or or"an E+TERNAL BLEEDING & occurs either when %lood e0its3  $hrou"h a %rea/ in the s/in  $hrou"h natural natural o#enin"s3 o#enin"s3 !outh Nose 1Nose %leedin"4 Va"ina 1menstruation4 +ectum 1haemorrhoids5 anal se04

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ACUT ACUTE E BLOO BLOOD D LOS OSS S & A condit condition ion in which which a #atie #atient nt 6uic/l 6uic/ly y loses loses a lar" lar"e e volume volume of circul circulati atin" n" hemo"lo%in

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CHRONIC BLOOD LOSS & A &  A condition wherein the %lood loss develo#s slowly over time and sym#toms may %e %arely noticea%le and "radually worsen

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Normal3 #in/ish s/in7 fast ca#illary rell Anemic3 #ale s/in7 slow ca#illary rell

CASEA '8 year-old colle"e student was %rou"ht to the emer"ency room due to a vehicular accident. • &ertinent &.9.3 ⇒ &ale5 unconscious5 stretcher-%orne ⇒ B&: ;8 "c(e bl4 l33 & failure to com#ensate with the usual mechanism of vascular contraction and chan"es in re"ional %lood @ow #atient remains in su#ine #osition o o #ostural hy#otension o tachycardia

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?@> "c(e bl4 l33  more than ' liters 1avera"e siGed adult4 H/lem0c Shc  o - Confusion - ,ys#nea - ,ia#horesis - Hy#otension - $achycardia Imme40"(e /lme rel"ceme'( o

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si"ns of vascular insta%ility

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ACUTE HEMOL.SIS 2 increased red cell destruction Sm(m3 f m4er"(e "'em0"# ?ati"ue # Loss of stamina # Breathlessness #  $achycardia

%h"( -

"re (he 305'3 f Ac(e G"3(r0'(e3(0'"l Blee40'5 Hy#otension 1systolic B&  8mmH"4 $achycardia 1J'8 %#m4 Orthostatic chan"es in B& Blood or coFee-"round-li/e material in N$ as#irate  I in ori"in  Hematemesis3 vomitin" of %lood  HematocheGia3 fresh %lood from stool 

THREE CLINICAL:ATHO:H.SIOLOGIC STAGES OF ACUTE BLOOD LOSS 19 H.:O$OLEMIA Loss of consciousness Acute renal failure # #

Blood count will not show anemia since H% level is not aFected +elease of vaso#ressin and other #e#tide caused %y %arorece#tors and stretch rece#tors

Hy#ovolemia which #oses a threat #articularly to or"ans that normally have a hi"h %lood su##ly5 li/e the %rain

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and the /idneys7 therefore5 loss of consciousness and acute renal failure are maDor threats HarrisonKs Boo/ of Internal !edicine th edition

29 HEMODILUTION # shift of @uid from the e0travascular to the intravascular com#artment As an emer"ency res#onse5 %arorece#tors and stretch rece#tors will cause release of vaso#ressin and other #e#tides5 and the %ody will shift @uid from the e0travascular to the intravascular com#artment5 #roducin" H9!O,IL$ION thus hy#ovolemia "radually converts to anemia  $he de"ree of anemia will re@ect the amount of %lood lost. If after ( days the hemo"lo%in is5 for e0am#le5 > "-; of those at ris/ with an +h-#ositive5 ABO-com#ati%le fetus5 and ' of these with ABO-incom#ati%le fetus  Ant-, I" readily crosses the #lacenta and leads to a #ositive anti"lo%ulin test and hemolysis of the infant  In ABO haemolytic disease3 themother is usually ty#e O and the fetus is $y#e A or B  Anti-A and Anti-B ordinarily cause mild and rarely severe hemolysis Clinical ?eatures  *ith severe hemolysis5 #rofound anemia leads to hydro#s fetalis 1anasarca caused %y cardiac failure45 and most such features die in utero *ith milder cases3 hemolysis #ersists until incom#ati%le +BCs or the oFendin" I" is  cleared 1Half-life of I"3 ( wee/s4 !ost aFected infants are not Daundiced at %irth due to trans#lacental trans#ort of   %iliru%in enerally with mild disease5 the %iliru%in #ea/s at day ) or  #ost#artum and declines  slowlt thereafter Increased serum %iliru%in-J /ernicterus 1due to de#osition of unconDu"ated %iliru%in in  the %asal "an"lia and cere%ellum If +h-ne"ative3 should %e tested a"ain at '; wee/s "estation %efore +h immuno"lo%ulin  is "iven

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CASE  R.$.5 a ')-year old em#loyee sou"ht consult at the 9.+. due to diGGiness with tea-colored urine • 1S4 fever5 1S4 headache5 1S4 #allor *hat la%oratory tests are you "oin" to re6uestT 

?ollow the @owchart

DRUG#INDUCED IMMUNE HEMOL.TIC ANEMIA # ,ru"s #roduce a #ositive direct anti"lo%ulin test and accelerated red cell destruction Three mech"'03m3 f 4r5#rel"(e4 0mm'l50c 0'r ( re4 cell3 "re rec5'0e419 Ha#tenPC with autolo"ous or  homolo"ous +BCs in the a%sence of dru" As in Autoimmune HA5 these A%s fre6uently react with the +h com#le0  &a"e 1J of 2

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,estruction of +BCs occurs chie@y %y s#lenic se6uestration of I"-coated +BCs

A dru" induces the #atient to #roduce I" warm-reactive autoanti%odies a"ainst +BC selfanti"ens. $hese autoanti%odies react at (>U C5 and the la%oratory ndin"s are indistin"uisha%le from those in *AIHA. Hemolysis is e0travascular and is mediated %y macro#ha"es #redominantly in the s#leen. 

 Me(hl4"#I'4ce4 ;A(0mm'e) Mech"'03m Me(hl4" "'4 rel"(e4 4r53 ;Al4me(, L#4")- (re"(me'( f her(e'30'

An induced inhi%ition of $-su##ressor allowin" uninhi%ited autoanti%ody #roduction %y B cells. ,es#ite dru" withdrawal5 anti%odies may remain for months

A3 $he anti%ody attaches only to the dru"5 which is ti"htly %ound to the red %lood cell 1+BC4 mem%rane 1#enicillin ty#e4 B3 $he anti%ody attaches to a neoanti"en created %y com#onents of %oth the dru" and the +BC mem%rane 16uinidine