Haematology for

Physician Associates

Emily Howard-Wall Physician Associate PA-R

Friday 30th September 2016

Content of lecture

The anaemic patient Iron studies The clotting screen

How to interpret them?

Simple management

strategy of abnormal

results

What’s included in the

screen?

What do the values

mean?

Simple management of

abnormal results.

What is anaemia?

Quick case study

1

Defined as low haemoglobin concentration Males: 130-170g/L Females: 120- 155g/L

Defined by mean cell volume (MCV)

Microcytic <81fL Normocytic 82-99fL Macrocytic >100fL

Various mechanisms lead to anaemia

Blood loss Decreased red cell lifespan (haemolytic anaemia) Impairment of red cell formation Pooling and destruction of red cells in enlarged spleen Increased plasma volume

Symptoms include: dyspnoea on exertion, fatigue, palpitations,

angina, dizziness. Physical signs: pallor, tachycardia, flow murmurs.

* Anaemia

2

Background of haemophilia A and mysathenia gravis Regular medications: intravenous Factor VIII replacement

(administered via long-term central line), Prednisolone 5mg OD Admitted with acute lower back pain and 2-week history of fevers

On examination, he has no focal neurology. There is point

tenderness on palpation of the lumbar spine. Anal tone is normal. Imaging of the lumbar spine (CT and MRI) show discitis at L2/L3

Blood cultures from line: positive for Staphylococcus epidermidis

Bloods: Haemoglobin 85g/L MCV 78fL CRP 150mg/L

* Case study 80-year old African-Caribbean man

3

* Iron studies N.B. serum vitamin B12 and folate levels are normal

Value Units Normal range

Iron

2

μmol/L

135 to 185

Transferrin

2.27

g/L

2.00 to 3.60

Transferrin binding capacity

57

μmol/L

50 to 85

% (transferrin-) iron

saturation

4

%

20 to 50

Ferritin

40

μg/L

30 to 400

4

* Summary of iron handling 6

Recycled iron from haem

Ferritin Transferrin

Red cell synthesis in bone marrow Iron stored as

ferritin e.g. in hepatic Kupffer cells

* Reference table

Iron deficiency Anaemia of

chronic disease

Iron deficiency

and

inflammation

Iron

Transferrin

Transferrin binding capacity

% (transferrin-) iron saturation

Ferritin

5

Normal or

Normal or

“Normal” Normal

* Management

7

1.Check FBC 2.Check iron studies and vitamin B12 and folate 3.If iron deficiency confirmed (remember to look at transferrin and

ferritin too), refer patient for appropriate investigations depending on history e.g. gastro, gynae.

4.Administer oral iron replacement (ferrous sulphate). 5.Repeat iron studies every 3 months to assess response to treatment.

Once serum iron levels have normalised, continue iron replacement for further 3 weeks to replace iron stores.

Summary

Iron deficiency not determined solely by serum iron concentration.

Combination of serum iron, transferrin and ferritin.

Initiate iron replacement, if indicated, as soon as possible.

17

“Their clotting’s a

bit off!”

* The clotting screen

1.

Prothrombin time (PT) or International Normalised Ratio (INR).

3.

Thrombin time (TT)

2.

Activated partial thromboplastin time (APTT)

(4)

(Fibrinogen)

9

The clotting cascade

10

11

* Prolonged PT/INR with normal APTT 12

* Prolonged APTT with normal PT/INR 13

* Prolonged APTT and PT/INR 14

* Prolonged TT with normal or prolonged

APTT and PT/INR

15

* Management

16

1.Depends on clinical presentation or if the patient is actively bleeding

2.Important points of the history:

a) Personal and family history of bleeding

b) Medication history including anticoagulants

c) Liver disease

3.Management of bleeding or correction of abnormal results if needed

Summary

APTT, PT and TT will help to determine where the abnormality is in the

clotting cascade

Causes of derangement can be congenital or acquired

17

Thank you for

listening Any questions?