Critical Illness: Hematologic Complications

Susan E. Segreti, MS, MEd, NP-CSyracuse Veterans Administration

Background

Thrombocytopenia

Anemia Neutropenia

• 55,000 ICU patients per day in USA• Incidence of hemorrhage, respiratory failure,

multiple organ system failure, sepsis, and hemodynamic abnormalities

Anemia

• 29% ICU patients anemic with admission• 95% ICU patients develop anemia < 3 days• 30% of critically ill have active bleeding• Stress ulcers lead to GI bleeding (PPIs)• Proinflammatory cytokines cause vasodilatation

and increased permeability in intestinal wall 30% of bleeds in ICU are GI related

• Phlebotomy – 4 draws (41 ml) = 164 cc/day arterial lines > volume/frequency

Destruction

RBC life span = 120 days Intrinsic defect – sickle cell, thalassemia, or

enzyme deficiencies Extrinsic process – hemolysis:

1) transfusions – antibody attacks RBC membrane 2) stasis – enlarged spleen 3) malfunctioning valves 4) rapid infusions of hypotonic solutions 5) mechanical trauma (invasive devices) 6) medications – PCN, sulfa, APAP, procainamide, methyldopa

Production

Erythropoiesis

Production

Erythropoiesis – development of mature RBCs:

• O2 (Hgb) levels signals kidney to erythropoietin

• With critical illness there is a blunted response

• Proinflammatory cytokines also blunt response

Management• Identify the cause• Transfuse – 10/30 rule (tradition)

Hgb < 10 g/dL or Hct < 30% Absence of acute bleeding Hgb < 7.9 g/dL

• Establish iron deficiency ( ferritin/ TIBC)• Caution replacement – iron overload, GI issues,

binding with other drugs• Pseudomonas, Escherichia coli, Salmonella, &

Klebsiella with presence free iron• VA guidelines for Procrit®

Anemia

Neutropenia• WBC – infection/inflammation• Neutrophils – 60-70% WBCs• Kill bacteria• Limited lifespan (13-20 days)• Absolute Neutrophil Count (Segs + Bands x WBC)

100• Neutropenia is ANC < 1500/mcL ANC < 500/mcL – risk of infection

Leukocytosis

• Increased production• May be neutropenic (immature)• What neutrophil is predominant?• Leukemic – acute blast crisis• Bacterial infection – increase in WBC, up to 4x• Stress, trauma, hemorrhage, and hypoxia• Glucocorticosteroids

Leukopenia• Decreased production• Depression of bone marrow• Chemotherapy• Rxs – Bactrim & Zyvox• Sepsis – inflammatory mediators

1. Leukocytosis – neutrophils 2. Leukopenia – consumption, sequestration, and

decreased WBCs 3. APACHE – early identification/intervention

4. Surviving Sepsis Campaign