Chronic Anemia Treatment & Management

In the emergency department (ED), the treatment of anemia rarely extends beyond the emergent needs. Discharging the patient on iron, vitamin B12, or folate may mask other problems and cloud the correct diagnosis. Unless cardiopulmonary or cerebrovascular disease is present, transfusion is rarely needed in patients with chronic anemia whose hemoglobin (Hgb) is greater than 7 g/dL.

The American College of Obstetricians and Gynecologists has guidelines available on the treatment of anemia in pregnancy. ^[7]

Most patients presenting with chronic anemia are not in distress.

Prehospital care most often is initiated for patients in extremis. Attention to ABCs (airway, breathing, circulation) 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. Definitive 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 Hgb or hematocrit trends indicate the time course of the illness.

Admission considerations

Hospital admission is indicated in the following cases:

• Patients presenting with hypovolemia, active bleeding, angina, tachypnea, altered mental status, transient ischemic attack (TIA), or exacerbation of chronic heart failure (CHF) ^[8]

• Patients whose Hgb and hematocrit values have dropped considerably from 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. Transfer is acceptable only if the patient is hemodynamically stable.

Unless cardiopulmonary or cerebrovascular disease is present, transfusion is rarely needed in patients with chronic anemia who have an Hgb greater than 7 g/dL. Situations that may require transfusion include angina, chronic heart failure (CHF), transient ischemic attack (TIA), and signs of tissue hypoxia. When transfusing patients with CHF, care should be taken to avoid circulatory (volume) overload; preferably, transfusion should occur over 3-4 hours, with the patient sitting up.

It is important to weigh the risks and benefits of blood transfusion. Many adverse reactions are associated with transfusion therapy: hemolytic (acute or delayed), febrile non-hemolytic, anaphylactic, simple allergic, septic (from bacterial contamination), transfusion-related acute lung injury (TRALI), and transfusion-associated circulatory overload. ^[9]

Most frequently encountered is a febrile nonhemolytic reaction. Patients who have had previous transfusion or who are pregnant are at greatest risk. Treatment is supportive, with antipyretics. However, fever can also be the first sign of an acute hemolytic reaction, which is more serious, so the clinician should maintain a high level of suspicion. For full discussion of this topic, see Transfusion Reactions.

Many patients fear infection, but the risk is low. ^[10] Transmission of hepatitis C virus occurs in 1 of 103,000 transfusions; of hepatitis B virus, in 1 of 200,000 transfusions; and of human immunodeficiency virus (HIV), in 1 of 490,000 transfusions. For full discussion of this topic, see Transfusion-Transmitted Diseases.

Patients who require repeated transfusions are at risk of iron overload. In a retrospective study of patients with refractory chronic anemia who were transfusion-dependent for more than 1 year, 10 of the 13 patients had abnormal liver function. On computed tomography scans of the liver, Hounsfield unit values (a sensitive indicator of iron overload) 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. The study authors note that although iron chelation therapy is indicated for patients whose serum ferritin is > 1,000 ng/mL, serum ferritin levels did not decrease significantly in the nine patients treated with 15-60 days of iron-chelating therapy. ^[11]

For full discussion of this topic, see Transfusion-Induced Iron Overload.

Transfusion-associated graft versus host disease

Graft versus host disease (GVHD) is a rare adverse transfusion reaction but is especially dangerous in patients who are immunocompromised. It carries a mortality rate of greater than 90%. Transfusion-associated GVHD can occur after transfusion of any blood component, including packed RBCs, that contains viable T lymphocytes. The pathogenesis involves donor T lymphocytes attacking host human leukocyte antigens (HLA). High fever, erythematous rash, diarrhea, and elevated liver enzyme levels during or shortly after transfusion may herald the severe reaction. Clinical manifestations typically occur 5-10 days after transfusion (range, 3-30 days). Death occurs in 3-4 weeks, as a result of infection or hemorrhage due to profound bone marrow failure. ^[12]

Using irradiated blood can decrease the incidence of GVHD and should be considered in all patients deemed immunocompromised (including recipients of allogeneic hematopoietic stem cell transplants), as well as in fetuses receiving intrauterine transfusions, and patients receiving units from a blood relative (because partial HLA matching between donor and recipient increases risk).

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.

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 gastrointestinal bleeding from colon cancer, should be evaluated by a surgeon in the ED.