Anemia; Low hemoglobin, low hematocrit, low red cell count - Cancer Therapy Advisor
Hemoglobin and hematocrit are parts of your red blood cells that are measured in a A normal hemoglobin range is between g/dl, depending on gender. Note that serial measures of Hb/Hct will aid in determining both the degree of the anemia, . count by the ratio of the patient's hematocrit to a normal hematocrit. We initially compared the Hb and Hct values of 46 fresh diagnostic blood samples using our 'in house' The blood samples (n=) were selected to have a wide range of Hct values Manual method Means (% difference).
Assess tempo of anemia. Repeat CBCs should be obtained at appropriate intervals until the patient's Hct and Hb values are stabilized at a level that is compatible with physiological demands. Diagnosis Diagnostic tests For all anemias: Because many therapies--especially erythrocyte transfusions--can interfere with the diagnostic workup, it is generally recommended that, if possible, relevant studies of whole blood, plasma, and serum are obtained prior to initiating therapy.
Minimal initial evaluation for clinically significant anemias includes CBC with red cell indices, and enumeration of both platelets and leukocyte; coagulation studies PT and aPTT ; peripheral blood smear examination; and reticulocyte count. As a practical matter, iron studies iron, transferrin, ferritinnutritional studies folate, vitamin B12and markers of hemolysis [LDH, haptoglobin, bilirubin direct and indirect ] are commonly obtained at the same time.
Tests for markers of hemolysis [LDH, haptoglobin, bilirubin indirect and direct ]. Fibrinogen, D-Dimer or fibrin split products. Red cell enzymes G6PD.
Nutritional studies [iron serum iron, transferrin, ferritinfolate, vitamin B12]. Blood tests for renal and liver function.
Relationship between haemoglobin and haematocrit in the definition of anaemia.
Reticulocyte levels can provide clues to the temporal evolution of the anemia, as well as the adequacy of the marrow response. Uncomplicated, sub-acute and chronic anemias will display a variable elevation in the reticulocyte count; the absence of a reticulocytosis in this setting should prompt a search for a coincident reticulocytopenic condition. As a measure of compensatory marrow erythropoiesis, reticulocyte levels must be corrected for the degree of anemia.
This is done by multiplying the observed reticulocyte count by the ratio of the patient's hematocrit to a normal hematocrit. The resulting number is known as the reticulocyte index RI. Burr cells are commonly observed as an artifact of peripheral smear preparation. Red cell inclusion bodies: Howell-Jolly bodies spherical basophilic bodies comprising nuclear remnants occur in hyposplenic states including post-splenectomy and sickle-cell disease, and less commonly in hemolytic anemias and megaloblastic anemias.
Basophilic stippling persistent RNA is associated with lead intoxication, thalassemia, and conditions characterized by defective heme synthesis.
Hemoglobin and Hematocrit - Clinical Methods - NCBI Bookshelf
Confirming the diagnosis Low and high values for hemoglobin or hematocrit should be confirmed by repeat analysis. There are specific situations in which spurious values for Hb or Hct can be observed, including: If possible, samples should be re-drawn by direct venipuncture.
A similar artifact can arise when samples are drawn from a site that is proximal to an intravenous access site. In this case the clinical laboratory should report a "spun hematocrit" or "packed-cell volume". In many cases agglutination can be reversed by warming the blood sample prior to analysis.
Cold agglutinins do not affect accuracy of spun hematocrit measurements. Abnormal proteins myeloma, cryofibrinogens can interfere with RBC analyses; spun hematocrit measurements are reliable under these conditions. Consider complicating factors [fluid overload, cardiopulmonary compromise, religious objection, immune dysregulatory state hyperhemolysis, post-transfusion purpura ].
Transfusion goals may differ depending upon the degree and chronicity of the anemia, and the extent to which it compromises organ function. Preferred route of administration.
Anemia; Low hemoglobin, low hematocrit, low red cell count
Goal is to provide - mg elemental iron per day. Concern for anaphylactic reactions; most formulations require a 'test' dose. Available as ferric gluconate test dose, followed by mg in ml saline infused over 30 - 60 minutes ; iron sucrose test dose, followed by mg over 60 minutes ; iron dextran test dose, followed by treatment dose.
One unit of transfused blood contains approximately mg of iron. The etiology of vitamin Bdeficient states should always be determined. Schedules for other agents vary widely depending upon the specific condition that is being treated and the patient's underlying medical condition; these pharmaceuticals include steroids and other immunosuppressive agents, intravenous immunoglobulins, replacement hormones, and chemotherapeutic agents.
Refractory cases An attempt should be made to determine the nature of the underlying anemia blood loss, red cell destruction, marrow failure. For refractory cases, consider the possibility that the etiology of the anemia has evolved e. Identify and treat any underlying disorders. Consult a hematological subspecialist to assist with diagnosis and management. Disease monitoring, follow-up and disposition Several conditions can alter the half-life of both normal and transfused red blood cells.
The prognosis of an anemia is largely dictated by the prognosis of the corresponding underlying disorder.
The patient should be continually monitored and supportive care provided while disease-specific therapy is administered. Hct ratio that does not approximate 1: In all cases, laboratory tests should be repeated using samples that are drawn by direct venipuncture not through a vascular access line, and not proximal to an intravenous access site.
Note that automated values for Hb can be affected by lipemia, icterus, cold agglutinin antibodies, and by some abnormal proteins myeloma, cryofibrinogens. Spun hematocrit measurements are generally reliable under all of these conditions.
In many cases the location of hemorrhage may be obvious--or easily deduced--from the patient's history and physical exam: Hemorrhagic anemia can be complicated by qualitative or quantitative platelet defects, and by congenital, acquired, or therapeutic changes in the quantity or activity of blood coagulation proteins.
Destructive Destructive defects can be broadly classified as inherited, mechanical, acquired non-immune, and acquired immune.
Relationship between haemoglobin and haematocrit in the definition of anaemia.
These defects, which result in increased clearance of red cells through a number of different mechanisms, generally result in accelerated destruction of red blood cell progenitors in the marrow ineffective erythropoiesis and shortened half-life of mature erythrocytes in the peripheral circulation hemolysis.
As a group, these disorders are characterized by markers of hemolysis increased LDH and bilirubin, reduced haptoglobin with normal Coombs studies, as well as a compensatory elevation in erythropoiesis can manifest as a reticulocytosis. Mechanical anemias of this type can be traced to defects in normal vascular flow by therapeutic devices artificial heart valves, extracorporeal circulationstructural defects aortic stenosis, renal artery stenosisor several conditions that result in microvascular occlusion.
Electrophoretic mobilities are affected by pH and by the medium in which the test is conducted. Screening tests typically use a hemolysate of anticoagulated blood electrophoresed on cellulose acetate at pH 8.
If necessary, a further electrophoresis in starch gel at pH 6. At that stage, the work will usually be performed by a specialized laboratory.
Hemoglobin electrophoresis will not readily assess situations where there are neutral amino acid substitutions or where the hemoglobin is normal but the constituent chains are not produced in equal numbers thalassemias.
The diagnosis of alpha thalassemia of a mild to moderate degree cannot be made by hemoglobin electrophoresis; the diagnosis of beta thalassemia may be made by inference from an increase in the Hb A2. A standard electrophoresis would look like Figure A standard hemoglobin electrophoresis cellulose acetate, pH 8. Basic Science The molecular weight of hemoglobin is approximately 64, daltons.
The oxygen affinity of hemoglobin is a function of this heme—heme interaction and of pH Bohr effectand is a measure of how many hemoglobin molecules have oxygen bound to them for a given level of oxygen tension. Some are deleterious to the normal function of hemoglobin, whereas others may have relatively normal oxygen affinity and stability. Substitutions in the normal hemoglobin amino acid sequence may result in hemoglobins that have different sub-unit interactions and varying affinities for oxygen.
For example, a substitution of the sixth amino acid on the beta chain causes Hb S, or sickle hemoglobin. Hb S has a lower oxygen affinity and surrenders its oxygen more readily. Hb F, a normal minor hemoglobin constituent, has a higher oxygen affinity.
If the oxygen dissociation curve is abnormal, the body will adjust the hemoglobin level to ensure adequate oxygen distribution to the tissues.
Thus in a rare disease like hemoglobin Hotel Dieu, the difficulty in extracting oxygen from a variant hemoglobin with increased oxygen affinity could result in a lack of oxygen for the tissues tissue hypoxia and a compensatory erythrocytosis.
The smaller fraction of oxygen released from the hemoglobin is thereby offset by the increased number of hemoglobin molecules. Similarly, in sickle cell anemia, the decreased oxygen affinity allows these patients more tissue oxygen at any given hemoglobin level.
Clinical Significance Many anemias are detected by routine laboratory screening performed before the patient is symptomatic. When the patient does have symptoms from an abnormality in the hemoglobin level, the symptoms are often a nonspecific weakness or fatigue.
The only finding on physical examination may be pallor; additional changes in the nail beds such as spooningglossitis red tongueor hepatosplenomegaly enlarged liver or spleen may give a clue to the etiology of the anemia. Symptoms are usually related to the level of hemoglobin, its abruptness of onset and its duration.
A patient with pernicious anemia may feel well at the same level of hemoglobin that would cause severe weakness in a patient with acute gastrointestinal hemorrhage. This is due to volume compensation by plasma and shifts in the oxygen dissociation curve which occur over time. When first confronted with an abnormal hemoglobin or hematocrit level, the next step is to assess the red cell indices see Chapterperipheral smear Chapterand the reticulocyte count Chapter in light of the patient's history and physical examination.
Hemoglobin function, oxygen affinity and erythropoietin.