ANEMIA IN PREGNANCY AND ANEMIA IN PREGNANCY AND ITS ANAESTHETIC ITS ANAESTHETIC

IMPLICATIONSIMPLICATIONS

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AnemiaAnemia

Definition:Definition: Quantitative or qualitative reduction of Hb or Quantitative or qualitative reduction of Hb or circulating RBC’s or both.circulating RBC’s or both.

As per WHO, Hb conc. Of <11 gm/dl or Hct < 0.33 in 1st As per WHO, Hb conc. Of <11 gm/dl or Hct < 0.33 in 1st & 3rd trimester. In developing countries, limit brought & 3rd trimester. In developing countries, limit brought down to 10 gm/dl.down to 10 gm/dl.

Incidence = 40 to 60 %Incidence = 40 to 60 %

Normal Level Of Hb/HctNormal Level Of Hb/Hct

AGEAGE

NewbornNewborn

1 month1 month

3 month3 month

12 months12 months

Adult maleAdult male

Adult femaleAdult female

Hb/HctHb/Hct

16/5516/55

12/3812/38

10/3010/30

12/3812/38

14/4514/45

12/3612/36

Levels vary with age and gender

WHO definition for Chronic AnemiaWHO definition for Chronic Anemia

AGEAGE Hb gm%Hb gm%

6/12 - 6 yrs <106/12 - 6 yrs <10

6 - 14 yrs <126 - 14 yrs <12

Adult male <13Adult male <13

Non pregnant female <12Non pregnant female <12

Pregnant female <11/ Hct <33Pregnant female <11/ Hct <33

11stst trimester <11 trimester <11

22ndnd trimester <10.5 trimester <10.5

Severity of AnemiaSeverity of Anemia

ICMR CATEGORIESICMR CATEGORIES Category Severity Hb levels gm %Category Severity Hb levels gm %

1 Mild 10 – 10.91 Mild 10 – 10.9

2 Moderate 7 – 10.02 Moderate 7 – 10.0

3 Severe <7.03 Severe <7.0

4 Very severe <4.0 4 Very severe <4.0

Physiological anemia of pregnancyPhysiological anemia of pregnancy

Blood volume ↑45%Plasma vol ↑55%RBC vol ↑30%HCt ↓30%Hb ↓10.5-11

Physiological anemia of pregnancyPhysiological anemia of pregnancy

↑ ↑ in RBC mass in RBC mass

↑ ↑ demand for iron demand for iron

↓ ↓in total body iron stores in total body iron stores

↓ ↓in serum ferritin levels (28-32 weeks ofin serum ferritin levels (28-32 weeks of

pregnancy)pregnancy)

Criteria for Physiological anemiaCriteria for Physiological anemia

Hb =Hb = 10 gm%10 gm%

RBC = 3.2 million/mmRBC = 3.2 million/mm3 3

PCV = 30%PCV = 30%

Peripheral smear showing normal morphology of RBC Peripheral smear showing normal morphology of RBC with central pallor.with central pallor.

Regulation of Iron Transfer to fetusRegulation of Iron Transfer to fetus

Maternal circulationMaternal circulation ↓↓ Serum transferrin carries FeSerum transferrin carries Fe

Transferrin receptors located on apical Transferrin receptors located on apical surface of placental synctiotrophoblastsurface of placental synctiotrophoblast

↓ ↓Holotransferrin is endocytosedHolotransferrin is endocytosed

↓ ↓Fe is released & apotransferrinFe is released & apotransferrin

↓ ↓Free Fe binds to ferritin in placental cellsFree Fe binds to ferritin in placental cells

↓ ↓Transferred to apotransferrin which enters from foetal sideTransferred to apotransferrin which enters from foetal side

of placenta & exits into fetal circulation.of placenta & exits into fetal circulation.

Pathophysiology

Oxygen Hemoglobin Oxygen Hemoglobin dissociation curve:dissociation curve:

O2 released to the tissues isO2 released to the tissues isaffected by the shape & position affected by the shape & position of ODC which can move either to of ODC which can move either to right or left. Shift is described in right or left. Shift is described in

terms of Pterms of P50 50 – O– O22 tension (Po tension (Po22) at ) at

which Hb is 50%which Hb is 50%

saturated with Osaturated with O22,,

corresponds to 27corresponds to 27 mm Hg.mm Hg.

..

Normal values of oxygen in arterial and Venous bloodNormal values of oxygen in arterial and Venous blood

Oxygen content:Oxygen content: Volume of oxygen carried in 100ml of blood.Volume of oxygen carried in 100ml of blood.

Arterial O2 contentArterial O2 content – – CaOCaO22 = (1.34 x Hb x SaO = (1.34 x Hb x SaO22) + (0.003 x PaO) + (0.003 x PaO22))Venous O2 contentVenous O2 content – – CvOCvO22 = (1.34 x Hb x SvO = (1.34 x Hb x SvO22) + (0.003 x PvO) + (0.003 x PvO22))

..

ParametersParameters Arterial blooodArterial bloood Venous BloodVenous Blood

PoPo2 2 (mm Hg)(mm Hg) 100100 4545

OO22 carried by carried by

Hb/100ml blood(ml)Hb/100ml blood(ml)

20 20 1515

OO22 in solution/100ml in solution/100ml

of blood(ml)of blood(ml) 0.30.3 0.150.15

Oxygen flux:Oxygen flux: Amount of oxygen leaving the left ventricle Amount of oxygen leaving the left ventricle per minute in the arterial blood.per minute in the arterial blood. CO x arterial OCO x arterial O22 sat x Hb conc. X 1.31 sat x Hb conc. X 1.31 Oxygen delivery:Oxygen delivery: Amount of oxygen that reaches theAmount of oxygen that reaches the systemic capillaries each min.systemic capillaries each min. DoDo22 = Q x CaO = Q x CaO22 x 10 (Q = Cardiac output) x 10 (Q = Cardiac output)

Oxygen uptake:Oxygen uptake: Volume of oxygen that leaves the Volume of oxygen that leaves the capillary blood and moves into the tissuescapillary blood and moves into the tissues each min.each min. Measure of oxygen consumption of Measure of oxygen consumption of tissues.tissues. VoVo22 = Q X (CaO = Q X (CaO22 – CvO – CvO22) X 10) X 10

Oxygen extraction ratio:Oxygen extraction ratio: Fraction of oxygen delivered Fraction of oxygen delivered

to the capillaries that is taken up intoto the capillaries that is taken up into

the tissues. the tissues.

Index of efficiency of oxygen.Index of efficiency of oxygen.

OO22ER = VOER = VO22 / DO / DO22

ParametersParameters Absolute RangeAbsolute RangeCardiac outputCardiac output 5 – 6 L/min5 – 6 L/min

OO22 delivery delivery 900 – 1100ml/min900 – 1100ml/min

OO22 uptake uptake 200 – 270ml/min200 – 270ml/min

OO22 extraction ratio extraction ratio 0.20 – 0.300.20 – 0.30

Normal range for oxygen transport parameters

Acute AnemiaAcute Anemia

Blood loss > 20% of blood volume Hypovolemia & hemodynamic instability.

Signs & symptoms of acute Blood lossSigns & symptoms of acute Blood loss

Blood loss %Blood loss % Volume, mlVolume, ml SymptomsSymptoms SignsSigns

<20<20 <1000<1000 RestlessnessRestlessness Mild Mild TachycardiaTachycardia

20-3020-30 1000-15001000-1500 AnxietyAnxiety Tachycardia Tachycardia on exertion & on exertion & ↓ ↓ pulse pressurepulse pressure

30-4030-40 1500-20001500-2000 Syncope on Syncope on sitting or sitting or standingstanding

Tachycardia atTachycardia at

rest, ↑RR,rest, ↑RR,

Syst. Hypoten.Syst. Hypoten.

>40>40 >2000>2000 Confusion, Confusion, shortness of shortness of breathbreath

Marked Marked tachycardia, tachycardia, ShockShock

Compensatory mechanism: Stimulation of adrenergic nervous system & release of

vasoactive hormones. Sympathetic stimulation leading to ↑ CO & HR. Systemic vasoconstriction, ↑ VR and ↑ SV. Redistribution of blood volume to vital organs. Anerobic metabolism, acidosis, hyperventilation. Renal conservation of water & electrolytes.

Factors affecting Compensation: Cardiopulmonary disease Left ventricular dysfunction. Magnitude of loss, oxygen consumption Anaesthesia

Anaesthetic considerations:Anaesthetic considerations:

Management of patient is judged by magnitude of Management of patient is judged by magnitude of hemorrhage and adequacy of volume replacement.hemorrhage and adequacy of volume replacement.

Thiopentone - suitable induction agent for normovolemic Thiopentone - suitable induction agent for normovolemic patients who sustained acute blood loss.patients who sustained acute blood loss.

Ketamine or Etomidate - hypovolemic patients.Ketamine or Etomidate - hypovolemic patients.

Decrease conc. of volatile anaesthetic or infusion rate of Decrease conc. of volatile anaesthetic or infusion rate of agents administered i/v.agents administered i/v.

Regional anaesthesia – not a good option.Regional anaesthesia – not a good option.

Small doses of midazolam can be given.Small doses of midazolam can be given.

Anaesthetic management:Anaesthetic management:SecureSecure 2 large bore cannulas.2 large bore cannulas.Monitor SpO2,ETCO2,NIBP,temp,UO,CVP,ECG.Monitor SpO2,ETCO2,NIBP,temp,UO,CVP,ECG.GA with RSI.GA with RSI.Fluid resuscitation, oxygen by mask, aspiration Fluid resuscitation, oxygen by mask, aspiration prophylaxis.prophylaxis.Send blood for CBC, cross matching, coagulation profileSend blood for CBC, cross matching, coagulation profileArrange adequate blood.Arrange adequate blood.Ensure left uterine placement.Ensure left uterine placement.Transfuse blood if Hb < 7gm % with ongoing blood loss.Transfuse blood if Hb < 7gm % with ongoing blood loss.If coagulation disorder present, give FFP@ 15-20 ml/kg.If coagulation disorder present, give FFP@ 15-20 ml/kg.Prepare for intraop cell salvage if indicated.Prepare for intraop cell salvage if indicated.Regional not indicated.Regional not indicated.

Guidelines for Blood TransfusionGuidelines for Blood Transfusion (By National Institutes (By National Institutes of Health Consensus Conference)of Health Consensus Conference)::Hb > 10gm/dl – transfusion rarely indicated.Hb > 10gm/dl – transfusion rarely indicated.

Hb < 6gm/dl – transfusion almost always indicated.Hb < 6gm/dl – transfusion almost always indicated.

Hb 6 to10gm/dl – decision to transfuse is determined by Hb 6 to10gm/dl – decision to transfuse is determined by patient’s risk for complications of decreased tissue patient’s risk for complications of decreased tissue oxygenation ( pt. with IHD ).oxygenation ( pt. with IHD ).

Preoperative autologous donation in selected patients.Preoperative autologous donation in selected patients.

Intraoperative blood salvage when appropriate.Intraoperative blood salvage when appropriate.

Acute normovolemic hemodilution when appropriate.Acute normovolemic hemodilution when appropriate.

Chronic AnemiaChronic AnemiaIncludes Iron Deficiency Anemia, Thalassemia, sickle cell Includes Iron Deficiency Anemia, Thalassemia, sickle cell

anemia.anemia.Symptoms:Symptoms: No symptom (unless RBC count is very low). No symptom (unless RBC count is very low).

Fatigue, dyspnoea on exertion, palpitation.Fatigue, dyspnoea on exertion, palpitation.Nausea, loss of appetite, constipation, indigestion.Nausea, loss of appetite, constipation, indigestion.Postural hypotension, vertigo, light headedness.Postural hypotension, vertigo, light headedness.Angina, heart failure, confusion.Angina, heart failure, confusion.H/O bleeding (DUB, malena, hematuria).H/O bleeding (DUB, malena, hematuria).

Signs:Signs: Vitals - Vitals - ↑ HR,RR↑ HR,RRGPE - Pallor of skin & mucous membranes, JVP GPE - Pallor of skin & mucous membranes, JVP ↑,↑,

pedal edema, generalised anasarca, pedal edema, generalised anasarca, gglossitis, stomatitis, Koilonychia, mouth soreness.lossitis, stomatitis, Koilonychia, mouth soreness.

Resp. system - TachypnoeaResp. system - Tachypnoea - Basal crepts, if LVF. - Basal crepts, if LVF.

CVS - Tachycardia, strong peripheral pulses with wide CVS - Tachycardia, strong peripheral pulses with wide pulse pressure.pulse pressure. - Functional cardiac murmur (Ejection murmur). - Functional cardiac murmur (Ejection murmur). - Evidence of cardiomegaly, CHF. - Evidence of cardiomegaly, CHF.

Abd. - Jaundice, hepatosplenomegaly.Abd. - Jaundice, hepatosplenomegaly.CNS - altered sensorium.CNS - altered sensorium.

- Mental disturbances (B- Mental disturbances (B12 12 def).def).Edema (Renal failure).Edema (Renal failure).Lower leg ulcers (Sickle cell Anemia).Lower leg ulcers (Sickle cell Anemia).

Compensatory Mechanisms:Compensatory Mechanisms:↑ ↑ 2,3 DPG shift of O2,3 DPG shift of O22Hb dissociation curve to right.Hb dissociation curve to right.↑ ↑ OxygenOxygen ExtractionExtraction ratio.ratio.Circulatory adjustments - Circulatory adjustments - ↑↑ CO by increasing SV. CO by increasing SV.

- myocardial hypertrophy.- myocardial hypertrophy.Release of erythropoietin which stimulates erythroid Release of erythropoietin which stimulates erythroid precursors in bone marrowprecursors in bone marrow to produce RBC’s.to produce RBC’s.

Respiratory adjustments - Respiratory adjustments - ↓ physiological shunting in ↓ physiological shunting in lungs.lungs. - ↓ respiratory reserve.- ↓ respiratory reserve. - tachypnoea,- tachypnoea, hyperventilation.hyperventilation.

GIT - reduced splanchnic blood flow. GIT - reduced splanchnic blood flow.

Lab Investigations:Lab Investigations:1.1. Complete blood countComplete blood count a) RBC count – Hb, Hct.a) RBC count – Hb, Hct. b) RBC indices – MCV,MCH,MCHC, RDW.b) RBC indices – MCV,MCH,MCHC, RDW. c) WBC count c) WBC count - Cell differential- Cell differential - Nuclear segmentation of neutrophils.- Nuclear segmentation of neutrophils.

d) Platelet countd) Platelet count

e) Cell morphologye) Cell morphology

- Cell size- Cell size

- Hb content- Hb content

- Anisocytosis, Poikilocytosis, Polychromasia- Anisocytosis, Poikilocytosis, Polychromasia

2.2. Reticulocyte countReticulocyte count

3.3. Iron supply studies – S.Iron, TIBC, S.Ferritin, Marrow Iron supply studies – S.Iron, TIBC, S.Ferritin, Marrow

4. Marrow examination – aspirate & biopsy4. Marrow examination – aspirate & biopsy

Iron Deficiency AnemiaIron Deficiency Anemia

Most common cause of anemia in pregnancy.Most common cause of anemia in pregnancy.

Stored as S.ferritin & Hemosiderin.Stored as S.ferritin & Hemosiderin.

Adult male Adult femaleAdult male Adult female

Stores 1000mg 300 – 500mgStores 1000mg 300 – 500mg

Losses 1mg/day 2mg/dayLosses 1mg/day 2mg/day

3mg/day(Pregnancy)3mg/day(Pregnancy)

Daily iron requirement Daily iron requirement

2.5mg – early pregnancy.2.5mg – early pregnancy.

5.5mg – from 20 to 22 wks5.5mg – from 20 to 22 wks

6 to 8mg – 32 wks onwards6 to 8mg – 32 wks onwards

Basal Iron 280mgBasal Iron 280mg Transfer to fetus 200-350mgTransfer to fetus 200-350mg For placenta 50-150mgFor placenta 50-150mg Blood loss at delievery 100-250mg Blood loss at delievery 100-250mg Expansion of red cell mass 570mgExpansion of red cell mass 570mg Iron conserved by Amenorrhea 240-480mg Iron conserved by Amenorrhea 240-480mg TOTAL REQUIREMENTTOTAL REQUIREMENT 800-900mg(4-6mg/d) 800-900mg(4-6mg/d) Causes:Causes:

Increased iron demandIncreased iron demandDiminished intake of ironDiminished intake of ironDisturbed metabolismDisturbed metabolismPre-pregnancy health statusPre-pregnancy health statusExcess demandExcess demand

Haematological parameters:Haematological parameters: IDAIDA Normal valuesNormal values

Plasma iron <30 50-150ug/dl Plasma iron <30 50-150ug/dl S.Ferritin <12 14-150ug/lS.Ferritin <12 14-150ug/lTIBC >400 300-350ug/dlTIBC >400 300-350ug/dlTransferrin saturation <15% 30-50%Transferrin saturation <15% 30-50%MCV <75 75-93flMCV <75 75-93flMCH <25 25-36 pgMCH <25 25-36 pgMCHC <30 30-36g/dlMCHC <30 30-36g/dlRBC Protoporphyhrin >200 30-50ug/dl RBC Protoporphyhrin >200 30-50ug/dl

Complications:Complications:

During PregnancyDuring Pregnancy - Pre eclampsia (due to malnutrition or - Pre eclampsia (due to malnutrition or hypoproteinemia)hypoproteinemia) - Intercurrent infection (infection impairs- Intercurrent infection (infection impairs erythropoiesis by BM depression)erythropoiesis by BM depression) - heart failure (at 30-32wks or preg)- heart failure (at 30-32wks or preg) - Preterm labour- Preterm labourDuring labourDuring labour - Uterine inertia - Uterine inertia - PPH- PPH - Cardiac failure- Cardiac failure - shock- shock

PuerperiumPuerperium - Puerperal sepsis - Puerperal sepsis - Subinvolution- Subinvolution - Failing lactation- Failing lactation - Puerperal venous thrombosis- Puerperal venous thrombosis - Pulmonary embolism- Pulmonary embolism

Effects on babyEffects on baby - - Amount of Fe transferred to fetus is Amount of Fe transferred to fetus is uneffected even if mother suffers from IDA.uneffected even if mother suffers from IDA. - increased incidence of low birth.- increased incidence of low birth. - IUD due to severe maternal anoxemia.- IUD due to severe maternal anoxemia.

Folic acid DeficiencyFolic acid DeficiencyFA is cofactor in nucleic acid synthesis and has imp. role FA is cofactor in nucleic acid synthesis and has imp. role in cell division.in cell division.Stores are limited (6-10mg).Stores are limited (6-10mg).Daily requirement is 300-500mg.Daily requirement is 300-500mg.Def. causes Megaloblastic anemia.Def. causes Megaloblastic anemia.High incidence in multigravida, twin pregnancy, High incidence in multigravida, twin pregnancy, hyperemesis gravidarum, alcohol consumption, smoking, hyperemesis gravidarum, alcohol consumption, smoking, malabsorption, antiepileptic drugs.malabsorption, antiepileptic drugs.

Effects on mother:Effects on mother: Incidence of abortion high.Incidence of abortion high.Effects on Fetus:Effects on Fetus: Premature birth, Neural tube defects, Premature birth, Neural tube defects, cleft palate.cleft palate.

ManagementManagement

Prevention:Prevention:

Avoidance of frequent child birth.Avoidance of frequent child birth.

Supplementary Fe therapy (60mg elemental Iron three Supplementary Fe therapy (60mg elemental Iron three times a day).times a day).

Dietary prescription.Dietary prescription.

Adequate treatment for any infection.Adequate treatment for any infection.

Early detection of falling Hb level, levels should be Early detection of falling Hb level, levels should be estimated at 1estimated at 1stst A/N visit, 30 A/N visit, 30thth & finally 36 & finally 36thth week. week.

Pregnancy <30wks

Pregnancy 30-36wks

Pregnancy >36wks

IDA FA def. Oral iron Oral FA

Intolerance orNon-compliance

I/M iron I/V iron

IDA FA def.

Parenteral Oral FA

I/M iron I/V iron

Blood transfusion

PROTOCOL OF SEVERE ANEMIA IN PREGNANCY

Curative:Curative:1.1. ORAL THERAPYORAL THERAPY - - 200mg (60mg elemental iron) 200mg (60mg elemental iron) X 3 times a day.X 3 times a day. WHOWHO – 60mg elemental iron + 250ug FA OD/BD. – 60mg elemental iron + 250ug FA OD/BD. Govt. of India RegimenGovt. of India Regimen – – 100mg Fe + 500ug FA during 2100mg Fe + 500ug FA during 2ndnd half of half of

pregnancy X 100 days.pregnancy X 100 days.Drawbacks:Drawbacks: - Intolerance- Intolerance - Unpredictable absorption rate.- Unpredictable absorption rate. - Non Compliant patient.- Non Compliant patient. - Long time for improvement @ 0.3-1gm/100ml/wk. - Long time for improvement @ 0.3-1gm/100ml/wk.

Response to therapy:Response to therapy:

- Sense of well being.- Sense of well being.

- Increased appetite.- Increased appetite.

- Increase in Hb.- Increase in Hb.

- Reticulocytosis with in 5-10 days.- Reticulocytosis with in 5-10 days.

2.2. PARENTERAL THERAPY-PARENTERAL THERAPY-

Indications:Indications:

- Failure to iron therapy.- Failure to iron therapy.

- Non compliant patient.- Non compliant patient.

- Case seen for the 1- Case seen for the 1stst time during last 8-10 wks time during last 8-10 wks

with severe anemia.with severe anemia.

Advantages:Advantages: - Certainity of admission.- Certainity of admission. - Hb rises @1gm/100ml/wk.- Hb rises @1gm/100ml/wk.I/V Route:I/V Route: Iron Dextran (1ml contains 50mg elemental iron & one Iron Dextran (1ml contains 50mg elemental iron & one ampoule contains 2ml).ampoule contains 2ml).

Total dose infusion – Deficit of iron calculated & total Total dose infusion – Deficit of iron calculated & total amount required to correct deficit is amount required to correct deficit is administered in single setting I/V administered in single setting I/V infusion.infusion.

Elemental Iron Needed (mg) =Elemental Iron Needed (mg) = (Normal Hb - Patients Hb) X Wt(kg) X 2.21 + 1000(Normal Hb - Patients Hb) X Wt(kg) X 2.21 + 1000

Given @10 drops/min X 30 mins (diluted in normal Given @10 drops/min X 30 mins (diluted in normal saline or 5% dextrose).saline or 5% dextrose). If no reaction, If no reaction, ↑ to 40 drops/min.↑ to 40 drops/min.Side effects:Side effects: - Anaphylactoid reaction.- Anaphylactoid reaction. - Chest pain, rigors, chills, fall in BP, dyspnoea,- Chest pain, rigors, chills, fall in BP, dyspnoea, hemolysis.hemolysis. Treatment: Stop infusion.Treatment: Stop infusion. Give antihistaminics, corticosteroids &Give antihistaminics, corticosteroids & epinephrine.epinephrine.I/M Route:I/M Route: Iron Sorbitol Citrate (Jactofer)Iron Sorbitol Citrate (Jactofer) Iron Dextran (imferon) Iron Dextran (imferon) Oral iron should be suspended at least 24 hrs prior to Oral iron should be suspended at least 24 hrs prior to therapy to avoid reaction.therapy to avoid reaction.

Drawbacks:Drawbacks:

- Painful injection (less with jactofer).- Painful injection (less with jactofer).

- Chances of abcess formation & discolouration of skin - Chances of abcess formation & discolouration of skin

over injection site.over injection site.

3.3. BLOOD TRANSFUSIONBLOOD TRANSFUSION - -Transfusion triggers:Transfusion triggers: Task force 1996, 2006 – No uniform transfusion Task force 1996, 2006 – No uniform transfusion triggertrigger Patient factors Type of surgeryPatient factors Type of surgery Preg Preg Elective EmergencyPreg Preg Elective Emergency<36wks > 36wks C/S C/S<36wks > 36wks C/S C/S-Hb -Hb ≤ 5gm% - Hb ≤ 6gm% - with H/O -Always≤ 5gm% - Hb ≤ 6gm% - with H/O -AlwaysWithout CHF without CHF APH,PPH, arrange Without CHF without CHF APH,PPH, arrange -Hb 5-7gm%,if -Hb 6-8gm%,if previous blood.-Hb 5-7gm%,if -Hb 6-8gm%,if previous blood.CHF,hypoxia, CHF,hypoxia, LSCS.CHF,hypoxia, CHF,hypoxia, LSCS.Infections. Infections.Infections. Infections. Hb <8gm%,2 units blood should be arranged.Hb <8gm%,2 units blood should be arranged.

Guidelines for transfusion:Guidelines for transfusion:

Prefer fresh Packed cells.Prefer fresh Packed cells.

Do not repeat tranfusion within 24 hrs.Do not repeat tranfusion within 24 hrs.

Effects of Transfusion:Effects of Transfusion:

↑ ↑ O2 carrying capacity of blood.O2 carrying capacity of blood.

Viscosity increases by 33%.Viscosity increases by 33%.

Hb increases by 1gm/unit.Hb increases by 1gm/unit.

Heart rate decreases by 7%.Heart rate decreases by 7%.

Supplies natural constituents of blood.Supplies natural constituents of blood.

Improvement with in 3 days.Improvement with in 3 days.

Drawbacks:Drawbacks:

Premature labour (blood reaction).Premature labour (blood reaction).

CHFCHF

Transfusion rexn.Transfusion rexn.

Infections: HIV, Hep B etc.Infections: HIV, Hep B etc.

Anaesthetic Considerations:Anaesthetic Considerations:

Etiology & Chronicity of anemiaEtiology & Chronicity of anemia

Pt. overall conditionPt. overall condition

Pt. ability to compensate for Pt. ability to compensate for ↓ O↓ O22 delievery. delievery.

Operative procedure.Operative procedure.

Anticipated blood loss.Anticipated blood loss.

Minimize factors interfering with OMinimize factors interfering with O22 delivery delivery

- low myocardial contractility, CO (careful with - low myocardial contractility, CO (careful with

volatile anesthetic agentsvolatile anesthetic agents

- left shift of ODC (hyperventilation, - left shift of ODC (hyperventilation,

hypothermia, alkalosis) hypothermia, alkalosis)

Prevent increase in O2 consumption (reduce postop pain, Prevent increase in O2 consumption (reduce postop pain, fever, shivering).fever, shivering).

Anaesthetic technique:Anaesthetic technique:Regional anaesthesiaRegional anaesthesia – – Spinal or epidural can be givenSpinal or epidural can be given

Preloading fall in hct by 20% (2lt).Preloading fall in hct by 20% (2lt).

Exacerbate anemiaExacerbate anemia Heart failure.Heart failure.

General anaesthesiaGeneral anaesthesia – –Principle:Principle:a)a) Avoid hypoxia.Avoid hypoxia.b)b) Maintain cardiovascular stability.Maintain cardiovascular stability.c)c) Minimize factors which produce unwanted shift of O2 Minimize factors which produce unwanted shift of O2

dissociation curve. dissociation curve.

SecureSecure 2 large bore cannulas.2 large bore cannulas.Monitor SpO2,ETCO2,NIBP,temp,UO,CVP,ECG.Monitor SpO2,ETCO2,NIBP,temp,UO,CVP,ECG.

Induction:Induction:a)a) Adequate preoxygenation.Adequate preoxygenation.b)b) I/V agents administered slowly.I/V agents administered slowly.

Maintenance:Maintenance:a)a) Ventilation should be maintained to provide Ventilation should be maintained to provide

normocapnia.normocapnia.b)b) Possibility of awareness is to be kept in mind as OPossibility of awareness is to be kept in mind as O2

conc. is increased.conc. is increased.c)c) Mild tachycardia & wide pulse pressure may be Mild tachycardia & wide pulse pressure may be

physiological obtunded by anaesthetic agents.physiological obtunded by anaesthetic agents.d)d) Tissue perfusion judged by blanching ear lobes, nose.Tissue perfusion judged by blanching ear lobes, nose.e)e) Change posture cautiously Change posture cautiously ↓ BP & CO.↓ BP & CO.

Postoperative:Postoperative:

1.1. Extubate relaxant effect worn off.Extubate relaxant effect worn off.

2.2. Monitor vitals, fluid intake/output & respiratory Monitor vitals, fluid intake/output & respiratory parameters for 12 – 24 hrs.parameters for 12 – 24 hrs.

3.3. Oxygen enriched air given by mask. Oxygen enriched air given by mask.

4.4. Prevent shivering.Prevent shivering.

5.5. Hb should be checked postoperatively & transfusion Hb should be checked postoperatively & transfusion accordingly.accordingly.

Management during labourManagement during labour

Adequate oxygenation.Adequate oxygenation.

Avoid sympathetic stimulation and hyperventilation; Avoid sympathetic stimulation and hyperventilation; prevent rightward shift of ODC.prevent rightward shift of ODC.

Decreased blood loss.Decreased blood loss.

Avoid maternal stress, patient can go into CHF.Avoid maternal stress, patient can go into CHF.

Improved uterine blood flow.Improved uterine blood flow.

PPH should be emergently treated. PPH should be emergently treated.

Sickle cell AnemiaSickle cell AnemiaValine substituted for glutamic acid at 6Valine substituted for glutamic acid at 6 thth position on position on ß chain of ß chain of Hb molecule.Hb molecule.Common variants - SS ( sickle cell anemia).Common variants - SS ( sickle cell anemia).

- SA ( sickle cell trait).- SA ( sickle cell trait). - SC ( sickle cell disease).- SC ( sickle cell disease).

Hb SSHb SS Hb SAHb SA Hb SCHb SC

Cell trait Cell trait HomozygousHomozygous HeterozygousHeterozygous Double Double heterozygousheterozygous

HbSHbS 70 – 90%, rest 70 – 90%, rest HbF.HbF.

10 – 40%, 40-10 – 40%, 40-60% HbA.60% HbA.

Very lowVery low

Hb (g/dl)Hb (g/dl) 6 - 96 - 9 13 -1513 -15 9 - 129 - 12

Life expectancyLife expectancy 30 yrs30 yrs normalnormal Slightly Slightly ↓↓

Propensity for Propensity for sicklingsickling

++++++++ + (O+ (O22 falls < falls <

40%)40%)++++

Signs & symtoms of sickle cell disease:Signs & symtoms of sickle cell disease:1.1. Vaso-occlusive complicationsVaso-occlusive complications a) Painful episodesa) Painful episodes b) Acute chest syndromeb) Acute chest syndrome c) Strokesc) Strokes d) Renal insufficienyd) Renal insufficieny e) Splenic sequestratione) Splenic sequestration f) Proliferative retinopathyf) Proliferative retinopathy g) Priapismg) Priapism h) Spontaneous abortionh) Spontaneous abortion i) Bone pains, leg ulcers, Osteonecrosisi) Bone pains, leg ulcers, Osteonecrosis2.2. Complications related to hemolysisComplications related to hemolysis a) Anemia (Hct 15 – 30%)a) Anemia (Hct 15 – 30%) b) Cholelithiasisb) Cholelithiasis c) Acute aplastic episodes c) Acute aplastic episodes

3.3. Infectious complicationsInfectious complications a) Streptococcus pneumonia sepsisa) Streptococcus pneumonia sepsis b) E.coli sepsisb) E.coli sepsis c) Osteomyelitisc) OsteomyelitisFactors favouring Sickling:Factors favouring Sickling: HypoxiaHypoxia AcidosisAcidosis Decrease in body temperatureDecrease in body temperature DehydrationDehydration Circulatory stasisCirculatory stasisInvestigations:Investigations: Hb, Hct, Reticulocyte countHb, Hct, Reticulocyte count Blood filmBlood film Hb electrophoresisHb electrophoresis Sickle cell test (Na metabisulphite)Sickle cell test (Na metabisulphite)

TreatmentTreatment

Acute pain:Acute pain:

a)Fluid replacementa)Fluid replacement

b)Administer opoids & NSAIDS.b)Administer opoids & NSAIDS.

Chronic pain:Chronic pain:

a)Acetaminophen with codienea)Acetaminophen with codiene

b)Fentanyl patchesb)Fentanyl patches

c)NSAIDSc)NSAIDS

Anaesthetic Management:Anaesthetic Management:Goals -Goals -

Avoidance of acidosis due to hypoventilation of lungs.Avoidance of acidosis due to hypoventilation of lungs.Maintenance of optimal oxygenation.Maintenance of optimal oxygenation.Prevention of circulatory stasis (improper body Prevention of circulatory stasis (improper body positioning, use of tourniquets).positioning, use of tourniquets).Maintenance of normal body temperature.Maintenance of normal body temperature.

Preoperative period -Preoperative period - a) Admit to hospital 12 – 24 hrs before surgery toa) Admit to hospital 12 – 24 hrs before surgery to permit optimal hydration with I/V fluids.permit optimal hydration with I/V fluids. b) Correction of any coexisting infection.b) Correction of any coexisting infection. c) Transfuse RBC’s if needed ( keep Hb b/w 9-12c) Transfuse RBC’s if needed ( keep Hb b/w 9-12 gm% & Hct of about 35%, with 60-70% HbA).gm% & Hct of about 35%, with 60-70% HbA).Intraoperative period -Intraoperative period - a) Monitor SpOa) Monitor SpO22,ETCO,ETCO22,NIBP,temp,UO,CVP,ECG,NIBP,temp,UO,CVP,ECG

b) Maintain arterial oxygenationb) Maintain arterial oxygenation c) Hydration.c) Hydration. d) Body temperature.d) Body temperature. e) Replace blood loss when necessary.e) Replace blood loss when necessary. General anaesthesia:General anaesthesia: Preoxygenate for 5 mins before induction to make HbS asPreoxygenate for 5 mins before induction to make HbS as possible is in oxy form.possible is in oxy form. After airway is established, give 30 – 50% inspired oxygen.After airway is established, give 30 – 50% inspired oxygen. Regional anaesthesia:Regional anaesthesia: Maintain oxygenation, ventilation, hypotension.Maintain oxygenation, ventilation, hypotension. Prevent stasis of blood flow. Prevent stasis of blood flow.

Postoperative period –Postoperative period –

a) Maintain oxygenation, hydrationa) Maintain oxygenation, hydration

b) Avoid acidosis & hypothermia.b) Avoid acidosis & hypothermia.

c) Adequate analgesia.c) Adequate analgesia.

d) Incentive spirometry.d) Incentive spirometry.

ThalassaemiaThalassaemiaQuantitative abnormalities of polypeptide globin chain Quantitative abnormalities of polypeptide globin chain synthesissynthesis..

TypeType HbHb Hb Hb electrophoresiselectrophoresis

Clinical Clinical syndromesyndrome

αα-thalassaemia-thalassaemia

1.Hydrops foetalis1.Hydrops foetalis

(deletion of 4 (deletion of 4 αα--genes)genes)

3-10g/dl3-10g/dl Hb Barts(100%)Hb Barts(100%) Fatal in utero Fatal in utero or in early or in early infancyinfancy

2.HbH disease 2.HbH disease (deletion of 3 (deletion of 3 αα--genes)genes)

2-12g/dl2-12g/dl HbH (2%), rest HbH (2%), rest HbA,HbAHbA,HbA2,HbF,HbF

Hemolytic Hemolytic anemiaanemia

3.3.αα-thalassaemia -thalassaemia trait (deletion of 2 trait (deletion of 2 αα-genes)-genes)

10-14g/dl10-14g/dl normalnormal Microcytic Microcytic hypochromic hypochromic bloood picture bloood picture but no anemiabut no anemia

TypeType HbHb Hb-Hb-electrophoresiselectrophoresis

Clinical Clinical syndromesyndrome

ß-ß-thallassaemiasthallassaemias

1. 1. ß-ß-thallassaemiasthallassaemias

Major (Cooley’s Major (Cooley’s anemia)anemia)

<5g/dl<5g/dl HbA(0-50%)HbA(0-50%)

HbF(50-98)HbF(50-98)

Severe cong. Severe cong. Hemolytic Hemolytic anemia,requ BTanemia,requ BT

2. 2. ß-ß-thallassaemiasthallassaemias

IntermediaIntermedia

5-10g/dl5-10g/dl VariableVariable Severe anemia Severe anemia but no regular but no regular BTBT

3. 3. ß-ß-thallassaemiasthallassaemias

minorminor

10-12g/dl10-12g/dl HbAHbA2(4-9%)(4-9%)

HbF(1-5)HbF(1-5)

Usually Usually asymptomaticasymptomatic

Anaesthetic management:Anaesthetic management:

Management depends on severity of Anemia.Management depends on severity of Anemia.

Preoperative evaluation of cardiac & hepatic function Preoperative evaluation of cardiac & hepatic function

in transfusion dependent patients as a risk of Fe toxicityin transfusion dependent patients as a risk of Fe toxicity

or haemochromatosis.or haemochromatosis.

Extramedullary haematopoiesis Hyperplasia of Extramedullary haematopoiesis Hyperplasia of facial bones difficult intubation.facial bones difficult intubation.

Spinal cord compression & massive haemothorax also Spinal cord compression & massive haemothorax also caused by extramedullary haematopoiesis. caused by extramedullary haematopoiesis.

Oxygen CascadeOxygen CascadeDry atmospheric air PODry atmospheric air PO2 = 159 mmHg PO = 159 mmHg PO2= PB x FiO= PB x FiO2,,

760 x .21 = 159760 x .21 = 159

In Humidified air PiOIn Humidified air PiO2 = 149 mmHg PiO = 149 mmHg PiO2 = (PB – 47) x FiO2 = (PB – 47) x FiO2

Alveolar air PAOAlveolar air PAO2= 100 mmHg PAO= 100 mmHg PAO2 = PiO = PiO2 – PACO – PACO2/RQ/RQ

Arterial blood PaOArterial blood PaO2 = 97 mmHg PaO = 97 mmHg PaO2 = 102 – Age/3 = 102 – Age/3

Mixed venous blood PVOMixed venous blood PVO2 = 40 mmHg = 40 mmHg

Cell POCell PO2= 5 to 40 mmHg= 5 to 40 mmHgMitochondria POMitochondria PO2 = 1 to 2 mmHg = 1 to 2 mmHg

PreoxygenationPreoxygenationDenitrogenation.Denitrogenation.

Replacement of the nitrogen volume of the lung Replacement of the nitrogen volume of the lung (upwards of 69% of the FRC) with oxygen to provide a (upwards of 69% of the FRC) with oxygen to provide a

reservoir for diffusion into alveolar capillary blood after reservoir for diffusion into alveolar capillary blood after the onset of apnoea.the onset of apnoea.

Three Methods:Three Methods:

100% O100% O2 via tight fitting mask for 5 mins in a via tight fitting mask for 5 mins in a

spontaneously breathing patientspontaneously breathing patient

10 mins of oxygen reserve10 mins of oxygen reserve

4 vital capacity breaths of 100% O4 vital capacity breaths of 100% O2 over a 30 secs. over a 30 secs.

8 deep breaths in a 60 sec period.8 deep breaths in a 60 sec period.

Oxygen StoresOxygen StoresNormal Oxygen Stores in adults -1500 ml.Normal Oxygen Stores in adults -1500 ml.

(O(O2 remaining in lungs + bound to Hb + dissolved in body fluids)remaining in lungs + bound to Hb + dissolved in body fluids)

Hemoglobin’s high affinity and very limited quantity in Hemoglobin’s high affinity and very limited quantity in solution restricts the availibility of these stores.solution restricts the availibility of these stores.

The oxygen contained within the lungs at FRC becomes The oxygen contained within the lungs at FRC becomes the most important source of oxygen during the period of the most important source of oxygen during the period of apnea, of which 80% is used only.apnea, of which 80% is used only.

Clinical ImportanceClinical Importance Apnea in a patient breathing room airApnea in a patient breathing room air Oxygen content= fiOOxygen content= fiO2(.21) (.21) X FRC(2300 ml)=480 mlX FRC(2300 ml)=480 ml

Metabolic activity =V Metabolic activity =V OO2 ==250ml/min250ml/min

Severe hypoxemia in 90 sec.Severe hypoxemia in 90 sec.

Apnea in a patient breathing 100% O2Apnea in a patient breathing 100% O2 Oxygen content= fiOOxygen content= fiO2(1) (1) X FRC(2300 ml)=2300 mlX FRC(2300 ml)=2300 ml

Metabolic activity =V Metabolic activity =V OO2 ==250ml/min250ml/min

Severe hypoxemia in 7-8 Min.Severe hypoxemia in 7-8 Min.

Pregnant patients- Pregnant patients-

↓↓FRC (15-20%) +↑O2 Consumption(20-40%)FRC (15-20%) +↑O2 Consumption(20-40%)

Rapid desaturation during period of apneaRapid desaturation during period of apnea

Preoxygenation for 3 - 5 Min. Preoxygenation for 3 - 5 Min.

ReferencesReferences1.1. Obstetric Anesthesia- Principles and practice David HObstetric Anesthesia- Principles and practice David H Chestnut 3Chestnut 3rdrd edition edition2. Anaesthesia & Co-existing diseases-Stoelting.2. Anaesthesia & Co-existing diseases-Stoelting.3. Miller’s Anesthesia- Ronald D. Miller 63. Miller’s Anesthesia- Ronald D. Miller 6thth edition. edition.4. Short Practice of Anaesthesia – Churchill Davidson.4. Short Practice of Anaesthesia – Churchill Davidson.5. Textbook of obstetrics- DC Dutta.5. Textbook of obstetrics- DC Dutta.6. The ICU book – Paul. L. Marino.6. The ICU book – Paul. L. Marino.7. Text book of Pathology – Robbins.7. Text book of Pathology – Robbins.

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