Commonly missed serious causes of anemia


Anemia is defined as the reduction in red blood cell mass or blood hemoglobin concentration below normal for age and sex. To be Considered when HB ˂9gm/dl with normal TLC & Platelet count. COMMONLY MISSED SERIOUS CAUSES OF ANEMIA -Auto-immune hemolytic anemia (idiopathic or secondary to other diseases as autoimmune diseases, lymphoma, immunodeficiency). -GIT bleeding/ inflammatory bowel disease, celiac disease -Chronic renal failure - Aplastic anemia (not isolated anemia) -Malignancies especially leukemia (not isolated anemia)
H/O Acute or Insidious onset/Accidentally discovered Associated Bleeding from orifices Evidence of Hemolysis: Dark urine/Jaundice Bone or joint pains Prolonged fever, recurrent infections or hospitalization History of other systems affection Family history of similar condition Previous blood transfusions Previous drug or food intake
Potential high risk signs that should be looked for: • Purpura, ecchymosis • Fever • Bone tenderness • Signs of chronic renal failure • Growth failure

  1. Life saving measures if decompensated (i.e. Impaired consciousness, marked tachycardia, gallop, impaired perfusion ‘delayed capillary refill’, RD or dyspnea at rest, metabolic acidosis) - Check airway and breathing, manage accordingly - Put on nasal oxygen even with normal saturation - Insert IV line: 2 lines in shock - Start IV fluids (shock therapy) : if hemorrhage :
  • Keep an IV open with normal saline at a rate 2-5 ml/hr in case of acute hemolysis to make sure the patient is cannulated and that we have access to provide him / her with blood transfusion. - Start inotropes if needed (in severely decompensated, pre or post arrest) - Check for metabolic acidosis and correct if present 2. Arrange for Packed RBC TRANSFUSION (10-15ml/kg) (For further details, check guidelines for transfusion of blood and blood products).
  • Packed RBCs are preferable if the only reason for transfusion is correcting anemia. Whole blood helps in case of acute blood loss/ hypovolemia and FRESH whole blood can provide coagulation factors as well.

➢ Consider immediate transfusion If Hb ≤6gm/dL: with acute hemorrhage – acute hemolysis and decompensated ➢ Consider irradiated blood for neonates, and if leukemia or immunodeficiency is suspected ➢ Consider filtered blood for patients with repeated transfusions or if immunodeficiency is suspected 3. Do post transfusion CBC 4. Repeat transfusion if -1st transfusion was not sufficient to raise Hb above 7g/dl -patient is still decompensated 5. Patients with ongoing hemolysis should have repeated CBC every 12 hrs and repeat blood transfusion with rapid drop of Hb (more than 3g/dl over 12 hrs) till hemolysis stops as evidenced by urine color and steady hb within 12hrs post transfusion. 6. Not followed by Lasix in cases with acute hemorrhage and in acute hemolysis if no signs of volume overload are detected.

Give blood transfusion if patient is compensated with Hb more than 6 gm/dl. ✓ Discharge patients with acute hemolysis before complete clearance of the attack (e.g. no dark urine in a vitally stable child with a steady Hb after 12 hrs of last transfusion) ✓ Discharge patients with acute hemolysis before exclusion of autoimmune causes (if suspicious). ✓ Discharge patients with acute anemia of unknown etiology or in the presences of any of the red flag signs. ✓ Discharge undiagnosed patients with repeated blood transfusion

  1. Full history taking and thorough clinical examination 2. Laboratory assessment: • CBC with differential count and Rtx count. • Blood film • ESR ↑: Malignancy and autoimmune disease as SLE and RA • Virology screening : EBV and CMV IgG and IgM

Discharge and Refer to hematology OPC after stabilization if: ✓ Acute hemolysis with suspected cases of G6PD deficiency and Provide/follow dietary and drug cautions in cases of suspected G6PD deficiency ✓ Diagnosed cases with chronic hemolysis in the absence of other indications of admission. ✓ Undiagnosed cases with isolated anemia of mild severity in the absence of other indications of admission. ✓ Exclude malignancy, aplastic anemia and other indications of hospitalization before discharge general Key points:
• Anemia is NOT a diagnosis but a presentation of disease. Packed RBC transfusion does NOT substitute diagnosis of the CAUSE of anemia. • Because expansion of the intravascular volume can decrease the hematocrit & vice versa, values should be interpreted with the patient’s intravascular status in mind. • Iron deficiency anemia is the most common cause of anemia BUT NOT IN THE ER. • HIGHER Hb Threshold levels for transfusion are to be considered in case of: - Ongoing acute blood loss (hypovolemia may underestimate anemia) or acute hemolysis (levels may drop rapidly) -Neonates (normal levels are higher than older children) -Cases of heart failure, shock requiring inotropic support, hypoxemia or need for significant respiratory support -Congenital cyanotic heart disease -Selected cases of sickle cell disease (e.g. neurological manifestations, VOC not responsive to conservative management and I.V. fluids, patients on chronic transfusion program for primary or secondary prophylaxis of stroke [Obtain Hematologist consultation] -Uremic platelet dysfunction with active bleeding (will probably need dialysis) [obtain Nephrologist consultation].