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Chronic Anemia Treatment & Management

  • Author: Christopher D Braden, DO; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Feb 01, 2016
 

Approach Considerations

EDs rarely treat anemia beyond the emergent needs. Discharging the patient on iron, vitamin B-12, or folate may mask other problems and cloud the correct diagnosis.

Unless cardiopulmonary or cerebrovascular disease is present, transfusion is rarely needed in patients who have chronic anemia with an Hgb greater than 7 g/dL.

The American College of Obstetricians and Gynecologists has guidelines available on the treatment of anemia in pregnancy.[2]

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Emergent Care of Chronic Anemia

Most patients presenting with chronic anemia are not in distress.

Prehospital care most often is initiated for patients in extremis. Attention to ABCs is most appropriate. All such patients should have intravenous (IV) placement, fluid resuscitation, and airway management as necessary.

The initial status and appearance of the patient may hold useful information and should be elicited from prehospital personnel.

Patients with chronic anemia usually do not require intervention in the ED. Ultimate treatment requires investigation into the etiology of the anemia and correction of the underlying cause.

Records of previous hospitalizations or ED visits are invaluable in many aspects of patient management. Such patients frequently have undergone previous workup, and previous Hgb or hematocrit trends indicate the time course of the illness.

Admission considerations

Patients with chronic anemia requiring admission include the following:

  • Patients presenting with hypovolemia, active bleeding, angina, tachypnea, altered mental status, transient ischemic attack (TIA), or exacerbation of congestive heart failure (CHF) [3]
  • Patients who demonstrate a considerable drop in Hgb and hematocrit values when compared with previous values or who have new-onset or worsening pancytopenia
  • Patients with an initial Hgb of less than 10 g/dL or a hematocrit of less than 30%
  • Patients who may not comply with follow-up or those in whom the clinician anticipates the need for an extensive workup

Patients can be admitted to a ward bed, a monitored bed, or an intensive care unit (ICU) bed, depending on their condition.

Go to Anemia and Emergent Management of Acute Anemia for complete information on these topics.

Transfer considerations

Patients with chronic anemia seldom require transfer to another facility for definitive care. Transfers are only acceptable if the patient is hemodynamically stable.

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Transfusions

One conspicuous exception in the treatment of chronic anemia is the use of transfusion therapy. Unless cardiopulmonary or cerebrovascular disease is present, transfusion is rarely needed in patients who have chronic anemia with an Hgb greater than 7 g/dL. Multiple situations that may require transfusion include angina, chronic heart failure, transient ischemic attack (TIA), and signs of tissue hypoxia.

It is important to weigh the risks and benefits of blood transfusion.

Many adverse reactions are associated with transfusion therapy. Most frequently encountered is a febrile nonhemolytic reaction. Patients who have had previous transfusion or patients who are pregnant are at greatest risk. Treatment is supportive with antipyretics. The clinician should maintain a high level of suspicion for a hemolytic reaction, because fever may the first symptom.

Many patients fear infection.[4] Hepatitis C occurs in 1 of 103,000 transfusions, hepatitis B occurs in 1 of 200,000 transfusions, and human immunodeficiency virus (HIV) occurs in 1 of 490,000 transfusions.

In a retrospective study of patients with chronic refractory anemia who were transfusion-dependent for more than 1 year, 10 of the 13 patients had abnormal liver function. The CT Hounsfield units in the liver were proportional to serum ferritin levels and were increased significantly in 11 patients. In the nine patients with serum ferritin >3,500 ng/mL, eight of whom died, skin pigmentation, liver dysfunction, and endocrine dysfunction were observed. Serum ferritin levels did not decrease significantly in the nine patients treated with 15-60 days of iron-chelating therapy.[5]

Graft versus host reaction

The graft versus host reaction is rare but is especially dangerous in patients who are immunocompromised. It carries a mortality rate of greater than 90%. Pathogenesis in this reaction involves donor T lymphocytes attacking host human leukocyte antigens (HLA). High fever, erythematous rash, diarrhea, and abnormal LFTs associated with recent or concurrent transfusion may herald the severe reaction. Symptoms may not appear until 8 days after transfusion, and death occurs in 3-4 weeks.

Using irradiated blood can decrease the incidence of graft versus host reaction and should be considered in all patients deemed immunocompromised, as well as in fetuses receiving intrauterine transfusions, patients receiving units from a blood relative, and patients transplanted with marrow. Care should be taken when transfusing patients with CHF. Preferably, transfusion should occur over 3-4 hours in the sitting position.

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Follow-Up

Patients with chronic anemia most often are treated in the outpatient setting. Clear instructions must be given to the patient regarding proper follow-up.

Consideration of the patient’s financial situation and ability to comply with follow-up care is imperative. The key to minimizing complications from chronic anemia is ongoing reassessment and patient compliance with proposed medical therapy.

All efforts should be made to arrange for follow-up. When all avenues for outpatient evaluation fail, patients should be instructed to return to the ED for reassessment in 2-3 weeks.

Upon discharge, instruct the patient to watch for signs and symptoms of worsening anemia. The patient should be advised to return to the ED if such symptoms develop.

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Consultations

Generally, patients with chronic anemia can be treated on an outpatient basis, and referral to a primary care provider is appropriate.

Consultation with the patient's primary care provider or an available internist should begin in the ED.

Symptomatic patients with an underlying medical condition that requires surgical consultation, such as chronic GI bleeding from colon cancer, should be evaluated by a surgeon in the ED.

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Contributor Information and Disclosures
Author

Christopher D Braden, DO Hematologist/Oncologist, Chancellor Center for Oncology at Deaconess Hospital

Disclosure: Nothing to disclose.

Coauthor(s)

Eric Wilke, MD Medical Director, Traditions Emergency Medicine, College Station Medical Center

Eric Wilke, MD is a member of the following medical societies: American College of Emergency Physicians, Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Roy Alson, MD, PhD, FACEP, FAAEM Associate Professor, Department of Emergency Medicine, Wake Forest University School of Medicine; Medical Director, Forsyth County EMS; Deputy Medical Advisor, North Carolina Office of EMS; Associate Medical Director, North Carolina Baptist AirCare

Roy Alson, MD, PhD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, World Association for Disaster and Emergency Medicine, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Fredrick Melik Abrahamian, DO, FACEP,to the development and writing of the source article.

References
  1. McLennan JD, Steele M. Extent of microcytic anemia among children in a low-income, peri-urban community in the Dominican Republic using different cut-points. J Trop Pediatr. 2015 Apr. 61 (2):86-91. [Medline].

  2. [Guideline] American College of Obstetricians and Gynecologists (ACOG). Anemia in pregnancy. 2008 Jul. [Full Text].

  3. Zittermann A, Jungvogel A, Prokop S, Kuhn J, Dreier J, Fuchs U, et al. Vitamin D deficiency is an independent predictor of anemia in end-stage heart failure. Clin Res Cardiol. 2011 Apr 7. [Medline].

  4. Omar N, Salama K, Adolf S, El-Saeed GS, Abdel Ghaffar N, Ezzat N. Major risk of blood transfusion in hemolytic anemia patients. Blood Coagul Fibrinolysis. 2011 Apr 19. [Medline].

  5. Gao C, Li L, Chen B, Song H, Cheng J, Zhang X, et al. Clinical outcomes of transfusion-associated iron overload in patients with refractory chronic anemia. Patient Prefer Adherence. 2014. 8:513-7. [Medline].

 
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