Chapter 133. Evaluation of Anemia and the Bleeding Patient

Anemia may be chronic and unrelated to the chief complaint, or it may result from acute blood loss as seen in trauma, gastrointestinal bleeding, or other acute hemorrhage. Underlying bleeding disorders must be suspected in patients presenting with spontaneous bleeding from multiple sites, bleeding from nontraumatized sites, delayed bleeding several hours after injury, or bleeding into deep tissues or joints.

The rate of the development of the anemia, the extent of the anemia, the age of the patient, and the ability of the cardiovascular system to compensate for the decreased oxygen-carrying capacity determine the severity of the patient's symptoms and clinical presentation. Patients may complain of weakness, fatigue, palpitations, orthostatic symptoms, and dyspnea with minimal exertion. Patients may have pale conjunctiva, skin, and nail beds. Tachycardia, hyperdynamic precordium, and systolic murmurs may be present. Tachypnea at rest and hypotension are late signs. Use of ethanol, prescription drugs, and recreational drugs may alter the patient's ability to compensate for the anemia.

Patients with bleeding may or may not have an obvious site of hemorrhage. A history of excessive or abnormal bleeding in the patient and other family members may indicate an underlying bleeding disorder. Historical data about liver disease and drug use, such as use of ethanol, aspirin, nonsteroidal anti-inflammatory drugs, warfarin, and antibiotics should be gathered. Mucocutaneous bleeding (including petechiae, ecchymoses, purpura, and epistaxis), gastrointestinal, genitourinary, or heavy menstrual bleeding are features associated with qualitative or quantitative platelet disorders. Patients with deficiencies of coagulation factors often present with delayed bleeding, hemarthroses, or bleeding into potential spaces between fascial planes and into the retroperitoneum. Patients with combination abnormalities of platelets and coagulation factors, such as disseminated intravascular coagulation, present with both mucocutaneous and potential space bleeding.

Acquired hemolytic anemia may be autoimmune or drug-induced. Microangiopathic syndromes include thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS). The classic pentad of TTP is CNS abnormalities, renal disease, fever, microangiopathic hemolytic anemia, and thrombocytopenia. HUS consists of acute nephropathy or renal failure, microangiopathic hemolytic anemia, and thrombocytopenia. Macrovascular hemolysis can be caused by prosthetic heart valves.

A decreased red blood count, hemoglobin, and hematocrit are diagnostic for anemia. The initial evaluation of newly diagnosed anemia should include a complete blood count, review of RBC indices, reticulocyte count, stool hemoccult examination, urine pregnancy test, and examination of the peripheral blood smear. The mean corpuscular volume (MCV) and reticulocyte count can assist in classifying the anemia and can aid in differential diagnosis (Fig. 133-1).

Laboratory studies used to diagnose bleeding disorders can be divided into the following 3 categories: (a) those that test the initial formation of a platelet plug (primary hemostasis); (b) those that assess the formation of crosslinked fibrin (secondary hemostasis); and (c) those that test the fibrinolytic system, which is responsible for limiting the size of the fibrin clots formed (see Table 133-1). A complete blood count with platelet count, prothrombin time, and partial thromboplastin time are the initial studies needed in patients with suspected bleeding disorders. If there is a suspicion for a hemolytic anemia, further studies may be warranted (Table 133-2).

1. Type and crossmatch blood in patients with anemia and ongoing blood loss so that it is available for transfusion, if necessary.

2. Consider immediate transfusion of packed RBCs in symptomatic patients who are hemodynamically unstable and have evidence of tissue hypoxia.

3. Admit patients with anemia and ongoing blood loss for further evaluation and treatment. Admit patients with chronic anemia or newly diagnosed anemia with unclear etiology if they are hemodynamically unstable, hypoxic, acidotic, or demonstrate cardiac ischemia.

4. Consider hematology consultation to assist in evaluation of those patients with anemia of unclear etiology, anemic patients with concomitant abnormalities of platelets and white blood cell counts, and patients with suspected bleeding disorders.