Anemia in Surgery

Anemia in Surgery
Okon E. E. MD
Outline

Introduction
 Composition of blood

Anemia
 Classification

Clinical Effects

Surgical & General hematology

Investigating Anemia

Management

Conclusion/Summary’

References
Introduction

Anemia is defined as a reduced level of circulating Hb

Composition
 Total blood volume – 5.5 litres
 Divided into Plasma & cells

Three main types of cells
 Erythrocytes

Hematocrit
 Leukocytes
 Thrombocytes
Plasma

A protein-rich solution

Carries the blood cells

Transports nutrients, metabolites, antibodies
and other molecules between organs.

All blood cells originate from pluripotent stem
cells in the bone marrow.

Divide lymphoid stem cells and myeloid stem
cells

Erythrocytes
 Transport oxygen via haemoglobin
 Biconcave disc shape
 Contain no nucleus or organelles
 Reticulocytes (immature erythrocytes) contain residual RNA
 Average lifespan is 120 days
 Broken down by macrophages withinthe spleen, liver and bone marrow
 Synthesis stimulated by erythropoietin
Leucocytes

Neutrophils
 Most abundant leucocyte (40–70%)
 Spend 14 days in the bone marrow but have a half-life
of only 7 hoursin the blood

Lymphocytes
 Second most common leucocyte (20–50%)
 Important for specific immune response

Monocytes
 These account for 15% of leucocytes
 Largest leucocyte, mobile phagocytic cell Important in inflammatory reactions.

Eosinophils
 Make up 5% of leucocytes
 Important defence against parasitic infections

Basophils

Thrombocytes
Anaemia

Anaemia is the reduction in the
concentration of circulating haemoglobin
below the expected range for age and sex:
 Adult male: <13 g/dl
 Adult female: <11.5 g/dl

Acute or Chronic

Causes
 Decreased production
 Increased loss
Classification

Size: Microcytic, Normocytic and Macrocytic

Colour: Normochromic or Hypochromic
Microcytic Hypochromic Anemia

Thalassaemia

Iron deficiency
 Malabsorption
 Chronic blood loss, usually gastrointestinal (GI) or
genitourinary (GU) tract
 Decreased dietary intake
 Increased demand
Surgical context

MC Anemia in surgical practice – IDA
 Colon Ca – right colon: fecal occult blood test
 Stomach
Normocytic normochromic

Acute blood loss - Surgical context: trauma, massive GI bleed

Anaemia of chronic disease – Surgical context: Malignant disease
 ACD & IDA may co-exist

Endocrine disease

Malignancy

Haemolytic anaemia

Erythrocyte abnormality:
 Spherocytosis
 Elliptocytosis •
 Glucose-6-phosphatase dehydrogenase (G6PD) deficiency
Normocytic normochromic

Haemoglobin abnormality
 Sickle cell anaemia

Extrinsic factors:
 Disseminated intravascular coagulation(DIC)
 Infections
 Chemical injury
 Sequestration
Macrocytic Anemia

Megaloblastic (interference with DNA synthesis causing morphological abnormalities)
 Folate deficiency
 Vitamin B12 deficiency
 Pernicious anaemia •
 Gastrectomy
 Ileal resection
 Crohn’s disease
 Drugs
 Azathioprine
 Hydroxyurea
 Methotrexate

Non-megaloblastic anaemia
 Liver disease
 Alcohol
 Pregnancy
 Hypothyroidism
 Increased reticulocyte number
Clinical effects of anaemia

A slowly falling haemoglobin level allow for tissue acclimatisation –
Palpitations, angina, ear buzzing

Tachycardia

Asthenia, Lethargy, fatigue

Increased cardiac output

Reticulocytosis

Can anemia be beneficial? Increased blood flow across capillaries:
critical illness
Surgical haematology

Changes in haematology as a response to major surgery
 Leucocytosis (usually due to increase in neutrophil count relative to lymphocytes)
 Relative anaemia:

Chronic illness

Blood loss

Impaired erythropoiesis

Decreased serum iron
 Relative thrombocytosis
 Increased acute phase reactants including erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP)
Investigating anaemia

History
 Acute or chronic blood loss (e.g menorrhagia, per rectal bleedingor change in
bowel habit)
 Insufficient dietary intake of iron and folate (e.g elderly people, poverty,
anorexia, alcohol problems)
 Excessive utilisation of important factors (e.g pregnancy, prematurity)
 Malignancy Chronic disorders (e.g malabsorption states affecting the small
bowel)
 Drugs (e.g phenytoin, antagonises folate)

Investigating Anaemia

Reticulocyte count

Hemolysis - serum bilirubin (unconjugated), urinary
urobilinogen, haptoglobin and haemosiderin

Bone marrow biopsy

TFTs

E,U,Cr

LFTS
Investigating anaemia

Folate levels – Red cell folate levels > Serum folate

Iron studies
 Vitamin C & iron

Investigate for causes of blood loss
 Upper & Lower GI endoscopy
 IVU, Cystoscopy
Management

Emergency Surgery
 Transfusion

Elective surgery – Reversible causes should be corrected
 Mildly anemic – may tolerate GA and sedation
 Profound Anemia – Transfusion & Iron supplementation
 ACD does not respond to hematinics; requires blood transfusion

Blood transfusion requirements for the anemic patient
are very different from those of the patient with acute
blood loss.

During transfusion – caution with circulatory overload
and CCF

Red cell concerntrates should be <14 days as these
have near normal levels of 2,3DPG

Vitamin B12 deficiency – replace

Folate 5mg tab daily
Conclusion

Blood – is composed of Plasma and cells

All blood cells originate from a hematopoietic stem cell.

Major surgery can result in hematologic changes

Anemia is not a diagnosis – Must be classified, investigated and treated
appropraitely

Anemia can be beneficial in critical illness

Transfusion methods differ per patient and red cell concentrates <14
days are preferred
References

Pastest essential revision notes for surgery

Essential Surgical Practice by Sir Alfred
Cushieri

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