ANEMIA IN CRITICALLY ILL AND

PERIOPERATIF PATIENTS
ARIEF MUNANDAR
INTENSIVIST
 INTRODUCTION
• Anemia is a common condition associated
with criticaaly ill patients.
• WHO defines anemia as a hemoglobin (Hb)
level less than 13 g/dl in men and less than
12 g/dl in women.
• Preoperativ anemia is common,affecting 25%-
75% of patients with an increasing prevalence
in the elderly.
Anesth Analg 2020;130:1364-80)
INTRODUCTION....
• In addition to being the strongest predictor of
perioperativ transfusion, anemia is an
independent risk factor for perioperative
morbidity and mortality, including acute kidney
injury and cardiovascular events.
• Postoperative anemia is markedly
common,occuring in up to 90% of patients
following major surgery, but is often neglected as
an inevitable consequence of perioperative care.
INTRODUCTION....
• Furthermore, it can be used not just before surgery,
but any time anemia is discovered throughout the
perioperative period.
• Anemia evaluation should occur soon after diagnosis.
• Assesment of iron status,storage,and synthetic
capacity should be performed using commonly
available test such as serum iron level,ferritin
level,transferrin saturation,total iron binding capacity
(TIBC),reticulocyte hemoglobin content (CHr),to help
differentiate between anemia state.
INTRODUCTION....
• Carson and colleagues published their study
on a cohort of 300 patients with post
operative hb level not more than 8 g/dl who
do not transfusion and reported that for
every 1 g drop in postoperative hb level below
8 g/dl,the odds of death could increase 2,5
times.

TRANSFUSION 2014;54:2688-2695
 PREVENTING,DIAGNOSING,AND TREATING
ANEMIA
• Proper management of anemia, including its
prevention, requires consideration of the
underlying etiology(s).
• In surgical patients,anemia is typically
multifactorial(eg,blood loss,impaired
erythropoiesis,hemodilution,shortened RBC
life span).
PREVENTING....
• In hospitalized patients,anemia may be the result
of decreased RBC production due to functional
iron deficiency ( ie,conventionally adequate iron
stores with insufficient mobilization to support
erythropoietic needs), immune activation, and
suppressed erythropoiesis. This is often refered
to as anemia of inflammation (AI), or anemia of
chronic disease, and is characterized by elevated
level of hepcidin.
PREVENTING....
• Anemia in critically ill patients result in
significant RBCs transfusions.
• It is apparent that Hb reduction decreases the
amount of oxygen delivered to tissues and
under certain circumstances may result in
tissue hypoxia.
• Oxygen Delivery (D02) = CO X CaO2. CaO2
=(1,36XHbXSaO2+0,03XPaO2) ; CO = SVxHR
TRANSFUSION –RELATED COMPLICATIONS

• Coagulation abnormality (dilutional coagulopathy).

• Biochemical complications : hypocalcemia (citrat
present as anticoagulant acts by binding to the
calcium);hyperkalemia;hypomagnesemia.
• Acid base abnormality,stored blood contains citric
acid as anticoagulant and lactic acid produced from
stored red cells.→ metabolic alkalosis.
• TRALI;TRACO;TRIM
 ETIOPATHOGENESIS OF ANEMIA IN
CRITICALLY ILL PATIENTS
• Loss of red blood cells (RBCs) due to
phlebotomy and bleeding from a surgical
site,trauma,,venous access site,or
gastrointestinal bleed.
• Decreased production of RBCs due to
suppression of bone marrow secondary to
inflammatory cytokines,drugs,functional or
absolute erythropoietin deficiency due to
renal dysfunction.
The Journal of Critical Care Medicine 2016;2(3):109-114
ETIOPATHOGENESIS....
• Nutritional (iron,folic acid,vit B12) deficiency.
• Increased destruction of RBCs (hemolysis) or
RBC precursor in the bone marrow due to
toxins and drugs.
 CONSEQUENCES OF ANEMIA
• Anemia is associated with poor
outcomes,mostly in elderly patients with
chronic disease.
• The body reacts and compensates for anemia
by increasing cardiac out put (increased heart
rate and stroke volume), oxygen unloading
(right shift of the oxyhemoglobin dissociation
curve) and oxygen extraction.
CONSEQUENCES....
• Various studies have shown that anemia is
associated with adverse outcomes in acute
myocardial infarction,chronic kidney
disease,and chronic heart faillure,increased
risk of re-intubation or weaning faillure from
mechanical ventilation.
 CONCLUSION
• Proper management of anemia is consideration of
underlying etiology.
• Considering its multifactorial etiopathogenesis has
an impact on patient morbidity and mortality.
• Therapies for improving the survival rates in the
critically ill patients aim at maintaining adequate
oxygenation of tissues.
• Blood transfusion are associated with various
complication.
TERIMA KASIH