SHN.ca

Cha l lenges w i th AnemiaLaura McKenzie-Kerr R.N.

SHN Patient Blood Management Coordinator/ONTraC for SHN

ONTraC Program at SHN

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I am a Registered Nurse and my role is to optimize the elective surgical patient and decrease the need of an allogenic blood transfusion.I have been in this role for 15 years and I have been an employee at SHN for almost 35 years. I am one of 25 ONTraC/Patient Blood Management Coordinators across Ontario. This is a Ministry of Health and Long Term Care funded program.

Objectives of my presentation

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Increase the awareness and the challenges of anemia specifically• Iron Deficiency Anemia• Anemia of Chronic Disease• Hospital Acquired Anemia

Anemia in general …

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• Anemia should be viewed as a serious and treatable medical condition

• Mild pre-operative anemia is an independent risk factor that can increase perioperative morbidity and mortality

• Anemia is an independent risk factor for several un-favorable outcomes including: increase risk of hospitalization/or readmission, prolonged hospitalization (LOS), increased risk of a allogenic blood transfusion, decreased quality of life, contributes to postpartum hemorrhage and post partum depression

Anemia in general …

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- Anemia is an extremely common condition with a disproportionate prevalence in women

- Globally it is estimate 1 in 4 human beings is anemic

- 30% in non pregnant women- 42% in pregnant women across the world- 24% of black women less than 50 years old are

anemic / 3% of white women are anemic

Definition of Anemia

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• Anemia as defined by the World Health Organization is:

oA hemoglobin of less than 120 g/L for women and a hemoglobin of less than 130 g/L for men

• Keep in mind a surgical procedure with moderate or high blood loss will further aggravate the anemia and already depleted iron stores

Common Causes of Anemia

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- Iron Deficiency- Anemia of Chronic Disease / Inflammation (2nd

most common)- Chronic Kidney Disease- Hospital Acquired Anemia- B12 Deficiency Anemia- Thalassemia - Sickle Cell Anemia

Causes of Iron Deficiency Anemia

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• Hemorrhage

• Malabsorption

• Decreased dietary intake

• Increased requirements (pregnancy)

• Chronic Hemolysis

Signs and Symptoms of Anemia

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Exhaustion/fatigue even with sleep / going to bed at 9:30 pm every nightRestless legs, shortness of breath, palpitationsFoggy feeling/difficulty concentrating/studying for exams can be challengingCold hands/feetDizziness especially on sudden movement/black spotsPICA-craving or chewing substances with no nutritional value/dirt, coal, baby powderIce chewing or pagophagia - associated with iron deficiency with or without anemia - cause unclearDry hair and dry nails

Prevalence of Anemia at SHNA snap shot of what is happening across Ontario

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• Total Knees/Total Hip Replacements – 30% of my patients are anemic. This is a mixture of chronic disease, thalassemia, iron deficiency, chronic kidney disease

• Total Abdominal Hysterectomy /Abdominal Myomectomy patients – approximately 90% of my patients have a preop hemoglobin less than 120 g/L

• I am referred patients who are newly diagnosed with colon or gastric cancer who required hemoglobin optimization prior to their surgery

• I have also been involved with patients who are post gastric bypass surgery who require hemoglobin optimization prior to surgery

Prevalence of Anemia at SHN

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• Pregnant patients are referred for hemoglobin optimization prior to delivery

• The risk of iron deficiency increases in pregnancy due to an increase in maternal iron requirements to accommodate the expansion of the maternal red blood cell mass, development of the fetus and placenta and the loss of blood with labor and delivery

• As a result patients were probably anemic prior to pregnancy or become anemic during the pregnancy

• Anemia in pregnancy is defined as a hemoglobin less than 110 g/L

Hot off the Press!

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- Early prenatal anemia exposure may increase risks during pediatric neurodevelopment

- Children born to mothers who had anemia during the first 30 weeks of pregnancy, but not those whose mothers had anemia after 30 weeks of pregnancy, were more likely to develop intellectual disability, autism spectrum disorder and attention-deficit/hyperactivity disorder, compared with those whose mothers didn't have anemia during pregnancy, according to a Swedish study in JAMA Psychiatry. However, researchers found that fewer than 1% of mothers had anemia during early pregnancy.

Anemia and the Pre-op patient

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Early detection and treatment can reduce or eliminate anemia related risks.

From the ONTraC data, we know that the likelihood of receiving a transfusion increases exponentially when the preoperative hemoglobin is below 130 g/L (considered anemic for males).

It is all about the “drop” of hemoglobin with the surgery being performed and there are many strategies used to decrease the amount of blood loss including early assessment for anemia, type of anesthesia planned, use of tranexamic acid, oral iron, iv iron, use of eprex, cell saver and an appropriate transfusion trigger.

Hb (g/dL) <10 <11 <12 <13 >13 >14

Pre-op Hb of 100 g/L has a seven-fold higher likelihood of transfusion than Hb 130 g/L

But need to see patients early enough to effectively correct anemia

Effect of preoperative Hb level on transfusion rate

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Estimated Blood Loss or the “drop”

Surgery Expected and Estimated Blood Loss

Total Knee Replacement 20-30 g/L

Total Hip Replacement 30-40 g/L

Total Abdominal Hysterectomy/ Abdominal Myomectomy 20-40 g/L

Vaginal Delivery Vaginal Delivery less than 500 mLs

C/Section 1000-1500 mLs

Dietary Suggestions to considerNon-heme

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- Cream of Wheat (plain) 25% of your daily iron need

- Cream of Wheat (with brown sugar) 35% of your daily iron need

- One package of Cream of Wheat = 3 cups of raw spinach or one serving of liver

- Prunes/Prune juice- Green Vegetables including spinach, kale,

broccoli, - Beans/ Lentils

Dietary Suggestions to consider

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Heme iron options to consider:

Seal 13.5 to 21.0 mgMoose 4.0 mgWild Duck 7.5 mgChicken 1.0 mgPork 0.5 mg to 1.0 mgSardines 2.0 mgBeef 1.5 mg to 3.0 mg

Anemia Assessment

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Patient history provides a lot of useful informationIs the patient female, small body size, obese, renal disease, diabetic, GI issues, hematuria, blood in stool, endocrine disorders Menstrual cycle and ask what is the flow like, frequency, quality of the periodDiet: any restrictions/issues/concerns/marital statusPast surgeries? Gastric bypass? / Stomach issuesSurgery: What is it and what is the Estimated Blood Loss Medications: prescribed and over the counterOral Iron: What type / how often / when / side effects

Scenario #1

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43 year old female walked into our Emergency Department complaining of feeling tired and weak P 110, BP 125/70 R. 18She was seen by SHN Physician’s AssistantHistory taken by SHN PA : She has regular periods / No bleeding noted in stool / urineDiet – no issues discussed/No surgeriesOn no prescribed medications

Scenario #1

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CBC reveals a normal WBC Hemoglobin of 54 g/LMCV 70 fL (A typical example of Microcytic Anemia with an MCV less than 80 fL)Ferritin done and pendingPA and ER doctor order 3 units of RBC = 9 to 12 hours in the Emergency DepartmentConsultations with Hematology and GastroenterologySHN Charge Technologist Tina Irwin in Transfusion Medicine contacted me to followup regarding order and number of units – we had just started implementing the OTQIP

My discussion with the patient and then the ER Doctor

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Periods: very heavy for first 1-3 days, large clots, accidents happen frequently, pad & tampon every 1-2 hours/24-48 hours (she had no idea that this wasn’t normal) No blood in stool, urineDiet: she ate once a day – trying to lose weight only vegetables and lots of lettuceCurrent vital signs are within her normal limits and pulse is slightly elevatedI went to the ER doctor and discussed with him my information and my concernsI was able to talk him out of 3 units to 2 units. This would take approximately 6 hours for the patient.

My discussion with the ER Doctor

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I said, I think she has Iron Deficiency AnemiaHe was surprised I came up with that diagnosis but he agreed to decrease the transfusion order from 2 to 3 units I went and updated her – she was going to get 2 units of Blood and be in ER for about 6 hours with a repeat CBC. I recommended that she obtain a Gyne referral from her GP as her periods are contributing to her anemia I went back to my desk and about 30 minutes later I checked her labs again and saw that the Ferritin was availableAny Ideas? What do you think happened?

Lab Investigations - Definitions

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Ferritin: is the main protein that stores iron. A ferritin level measures the amount of stored iron.Mean Corpuscular Volume: reflects the average volume of the red blood cell (Hct/RBC). Normal ranges for males and females. MCV is increased in B12 and folate deficiency, reticulocytosis, hyperglycemia, and leukemia. MCV is decreased in iron deficiency anemia. The red blood cell size allows a classification of anemia –microcytic, macrocytic, and normocytic which provides insight to the cause of the anemia

Lab Investigations - Definitions

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Serum Iron: The concentration of iron that is bound to transferrin. Normally, transferrin is about 1/3 bound to iron

Transferrin: a blood protein that transports iron from the gut to the cells. The body makes transferrin in relationship to the need for iron

TSAT: Percent transferrin saturation = serum iron/TIBCx 100

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L a b o ra t o r y I n v e s t i g a t i o n s t o R e v i e w

Laboratory Test Normal ValuesIron DeficiencyAnemia ( IDA)

Microcytic

Anemia of Chronic Disease

(ACD)Normocytic

IDA + ACD

Iron 4-30 umol/L Low Low Low

Transferrin 1.93 -3.60 g/L High Low to normal Low

Ferritin

24-336 ug/L -Men

11-307 ug/L-Women

Low Normal to High> 100 mcg/L Normal to high

TSAT 16.0 -60.0 Low Low Low

MCV/MHC Low Low to normal Low to normal

Anemia of Chronic Disease: Normocytic

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Hemoglobin 100-130 g/L

Normocytic: Mean Corpuscle Value: 80-100 fL

Causes of Normocytic Anemia include: o Nutritional deficiencyo Renal Insufficiencyo Hemolysis (auto/allo)o Primary bone marrow disordero Endocrine disorders

Patient Scenario #2

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- 79 year old woman with a preop hemoglobin of 109 g/L with a normal MCV of 90 fl booked for a knee replacement in 2 weeks

- She is diabetic, takes hypertensive medications and is on thyroid replacement

- I reviewed her diet and she is alone at home/ poor appetite / in too much pain to stand for too long/ husband has just been placed in a NH

- I said I didn’t really like her hemoglobin for her knee replacement / she said the Medical Doctor she just saw didn’t say anything

- I then told her what I expected to happen with her hemoglobin postoperatively and how that can affect her recovery

Anemia of Chronic Disease

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• Typical patients that I see are the patients who have diabetes, thyroid disease and hypertension

• Depending on the labs I may recommend oral iron/diet suggestions

• For these patients I may recommend Eprex to optimize for surgery to target a hemoglobin of 125 g/L for day of surgery

Anemia in the Elderly

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- As women continue to age the frequency of anemia increases to the point that after age 85, about 20% have anemia

- Non-Hispanic black women are 3 times more likely to be anemic as their white counterparts

- Among women residing in nursing homes, approximately 50% are anemic

- Anemia in the elderly is associated with frailty, increased mortality, poor cognition, and decreased physical performance

- It is a potent comorbidity in heart disease and chronic kidney disease

Macrocytic Anemia

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Hemoglobin less than 120 g/L for women and 130 g/L for menMCV > 100 to < 110 mildMCV > 100 markedCauses: Serum B12 deficiency, thyroid disease, alcoholism,

hepatic disease Medications: HIV antivirals, Methotrexate

(RA), Septra, Hydroxyurea Review B12 and Folate and treat accordinglyFor Surgery: Eprex is a consideration depending on the patient’s surgery / history

Hospital Acquired Anemia

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• This is an anemia I see every day • Phlebotomy for diagnostic treatment can result in

iatrogenic anemia and RBC transfusion• 74% of hospitalized patients will develop Hospital

Acquired Anemia• In a study of critically ill patients, almost half of the

variation in the amount of blood transfused was accounted for by diagnostic phlebotomy

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• 95% of patients admitted to the ICU develop anemia by Day 3

• Two separate studies noted that the average daily blood samples in ICU = 41 mL/day and that could be possibly higher

• When reviewing blood use in the Intensive Care at our hospital it is very common to see patients who have been in ICU for over 7 days or so requiring a unit of red blood cells and then again in 5-7 days after that/not actively bleeding/maintaining a hemoglobin around 70-75 g/L

Hospital Acquired Anemia

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Possible strategies to avoid/treat HAA include• Micro-sampling in ICU (has shown to reduce blood

loss by 37-47%• Using a device to return the drawback blood has

been associated with a 50% reduction in diagnostic blood loss

• Order only essential bloodwork and minimize the volume of blood drawn to treat the patient

• Point of Care Testing• Avoid ordering routine daily blood work if there

hasn’t been a change in the patient’s condition

Hospital Acquired Anemia

Following my presentation:

Oral iron / IV iron options will be discussed by Dr. Allison Collins

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R e f e r e n c e s

1. Patient Blood Management – A Toolkit Guide for Hospitals written by Dr. John Freedman

2. Bloody Easy 43. Iron Deficiency Anemia in Women Across the Life

Span written by Dr. A. Friedman, Dr. Chen, Dr. P. Ford, Dr. C. Johnson, Dr. A. Lopez, Dr. A. Shander, Dr. J. Waters.

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