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Hematologic Notes

Easy bruising/bleeding
DIC Disseminated intravascular coagulation
o Overview
Can be acute or chronic
o Etiology
Usually occurs when shock causes widespread activation of clotting cascade uses them all up
Sepsis
Trauma and tissue destruction
Massive large vessel coagulation
Malignancy
o S&S
Bleeding diathesis: petechiae, ecchymosis, oozing from wounds and IVs
Diffuse bleeding from all sites IV, wound, catheter, mucous membranes
Thromboembolism
Renal dysfunction AKI
Hepatic dysfunction- jaundice
Resp dysfunction hemoptysis, dyspnea
Shock
CNS involvement: coma, delirium, TIAs
o Workup
Peripheral smear shows microangiopathic hemolytic anemia
Low plts and clotting factors (may be near normal in chronic DIC)
o Management
Treat underlying cause!!
Hemodynamic support
Most coagulopathies are short lived but some pts with severe bleeding may need platelets or FFP transfusions
Thrombocytopenia
o Low platelet count ( <100,000)
o Common causes
Sepsis
H2 blockers
Heparin
Massive transfusion
DIC
Abx
Spurious lab value
o Give DDAVP (demopressin) to help correct platelet dysfunction from uremia, aspirin, or bypass
o Clopidigrel Plavix irreversibly inhibits platelet dysfunction
o Spontaneous bleeding- platelet count <20,000
o Minimum platelet count before surger >50,000

o Prophylactic platelet transfusion <10,000


Transfusion reaction can result in abnormal bleeding
Hemophilias- easy bleeding
Hemophilia A
Hemophilia B
Factor 8 deficient
Factor 9 deficient
Preop- Factor 8 infusion to normal
PTT is elevated
preop levels
PTT is elevated (intrisinc pathway)
Most immediate way to obtain hemostasis pressure (finger)

Von Willebrand factor


Deficient in von Willebrand factor
and Factor 8 (secondary)
DDAVP or cryoprecipitate to
correct

Anemia
Microcytic anemia in a man or postmeno woman is colon cancer until proven otherwise

Anemia is an important concern for the surgical patient throughout the entire surgical process, including the preoperative period, the surgery
itself, as well as the postoperative recovery period. It is estimated that one-third1 to one-half2 of surgical patients may be anemic preoperatively
secondary to the conditions for which they require surgery. After surgery, anemia is even more common, affecting 90% of patients.1,2
Anemia can affect how patients respond to surgery and how quickly they return to health, said Dr. Aryeh Shander, Chief of the Department
of Anesthesiology and Critical Care Medicine, at Englewood Medical Center in Englewood, NJ. Unfortunately, testing for anemia is often
not a top priority during the preoperative period. Anemia is often one of the easiest conditions to diagnose and to treat when it is recognized
early enough before surgery.
Anemia is commonly unrecognized and overlooked by physicians and surgeons because it often exhibits very non-specific symptoms or no
symptoms at all. Detection of anemia is often overshadowed by the myriad of other concerns that need to be addressed when preparing a
patient for surgery.
Preoperative Anemia Screening
While hemoglobin screening is included in standard pre-admission testing, it usually occurs only 3-7 days prior to surgery. This precludes the
opportunity to effectively evaluate and manage the patient who is found to be anemic, and may result in postponement or cancellation of the
surgical procedure. Dr. Shander recommends, Whenever clinically feasible, elective surgery patients should have their hemoglobin level
tested a minimum of 30 days before the scheduled surgical procedure. Preoperative anemia is associated with perioperative risks of blood
transfusion, as well as increased perioperative morbidity and mortality.
Causes of Anemia in Surgical Patients
The causes of preoperative anemia are multifactorial and may include acute or chronic blood loss, poor nutrition, renal insufficiency,
malignancy or chronic disease.3,4 Additionally, some patients may be more susceptible to perioperative anemia than others. Studies have
shown that female patients, those with smaller body surface area, and African American patients are at increased risk.1,5
Untreated bleeding episodes, along with the frequent phlebotomies that are a standard part of postoperative procedure, cause blood loss and
can contribute to anemia during surgery and recovery.4 Postoperative inflammatory response can additionally lead to blunted erythropoietic

response and diminished iron availability, resulting in anemia.3


Causes of Preoperative Anemia

Acute or chronic blood loss


Poor nutrition
Renal insufficiency
Malignancy
Chronic disease

Consequences of Anemia
Anemia should be viewed as a significant clinical condition, rather than simply an abnormal laboratory value.6 In surgical patients, anemia has
been linked to increased postoperative morbidity and mortality.7 Several studies have shown that patients with preoperative anemia have a
higher incidence of allogeneic blood transfusion compounding the problems from anemia which may include a longer hospital stay and an
increased likelihood of dealth after surgery.2,7,8 Patients who are transfused after surgery as a result of anemia are more likely to develop
postoperative infection, require longer periods of mechanical ventilation, and have a greater risk of mortality.9,10
Strategies for Managing Anemia
Blood Transfusions In some circumstances, blood transfusion may be a necessary procedure, but concerns about their risk have restricted
their use. Blood transfusion has many known adverse effects including potential transmission of infectious diseases, allergic and hemolytic
transfusion reactions, and immunomodulation.10,11 Allogeneic blood transfusion should be avoided whenever possible because of these
associated risks and also because transfusion has not been proven to improve postoperative outcomes.12
Blood Conservation Techniques In surgeries with expected high blood loss, strategies to reduce operative blood loss may help prevent
postoperative anemia and may decrease or eliminate the need for allogeneic blood transfusions. These strategies include meticulous surgical
technique, the use of autologous blood, acute normovolemic hemodilution and cell salvage, to name a few.
Erythropoiesis-Stimulating Agents (ESAs) and Iron ESA plus iron therapy can be used to correct preoperative anemia and has been shown to
reduce the need for blood transfusions. In addition to reducing the need for transfusion, management of anemia with erythropoietin and iron
has been shown to accelerate erythropoiesis, Hb recovery, and enhance quality of life and function in surgery patients.13-15
Recognition and treatment of anemia during the preoperative period gives surgeons more options for dealing with the blood lost during
surgery. Comprehensive anemia management can reduce or eliminate the need for perioperative allogeneic transfusions, and provide better
outcomes. According to Dr. Shander, Recognizing and treating anemia before any elective surgery is extremely important, and could be a life
saving intervention.
Fatigue

Systemic responses to surgery

Sympathetic nervous system activation


Endocrine stress response
The classical stress responses (catecholamines, cortisol and glucose) to abdominal surgery such as cholecystectomy

pituitary hormone secretion


insulin resistance
Immunological and haematological changes
cytokine production
The cytokines have a major role in the inflammatory response to surgery and trauma. They have local effects of mediating and maintaining the
inflammatory response to tissue injury, and also initiate some of the systemic changes which occu

acute phase reaction


neutrophil leucocytosis
lymphocyte proliferation

Don't be surprised if you feel very tired when you get home, especially if you've had a major operation or a general anaesthetic.
It's important to move around as soon as possible after surgery and follow your doctor's advice on getting active again. This will encourage
your blood to flow and your wounds to heal, and will build up strength in your muscles. Read about walking for health.