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Anemia 101 1 Practical Hematology Practical Hematology Anemia 101 1. Anemia 101 2. Blood Loss Anemia Wendy Blount, DVM 3. Hemolysis 4. Non-Regenerative Anemias 5. Transfusion Medicine 6. Polycythemia 7. Bone Marrow Disease 8. Coagulopathy 9. Central IV Lines 10.Leukophilia 11.Leukopenias 12.Splenic Disease DDx Anemia RBC Indices Regenerative Non-Regenerative • MCV – mean corpuscular volume – RBC size • Blood Loss • Secondary Anemia • MCH – mean corpuscular Hb • External bleeding Anemia of inflammatory Dz • MCHC – mean corpuscular Hb concentration – • Internal bleeding Chronic renal disease RBC color intensity • Hemolysis Chronic hepatic disease • Immune mediated Endocrine disease • Microcytic – low MCV • Iron Deficiency • Cold hemagluttinin Dz • Normocytic – anemia with normal MCV • Bone Marrow Disease • Blood parasites Immune mediated • Macrocytic – high MCV Mycoplasma, Babesia, Pure red cell aplasia Cytauxzoon • Hyperchromic – high MCHC • Oxidation – Heinz, Myelodysplasia, Myelofibrosis MetHb Aplasia,Necrosis • Normochromic – anemia with normal MCHC • Heavy metals – Zn, Cu Myelophtisis, neoplasia • Hypochromic – low MCHC (pale RBC) Macrophage proliferation • Hypophosphatemia • Polychromic – more RNA (blue) and often less • Drug Induced Dyscrasia – • Hereditary estrogen, bute, sulfas Hb (orange-red) PK deficiency, PFK • Infection – FeLV, FIV, Ehrlichia, deficiency parvovirus Diagnosis Diagnosis When is anemia significant? • “Anemia” is not a diagnosis • Cats – PCV persistently <20-25% • It’s a symptom • Dogs – PCV persistently <30-35% • Puppies PCV 28-30% and 3-4% reticulocytes • Treating anemia without knowing the diagnosis • St Bernard normal PCV 35-40% doesn’t often work out very well • Sight Hound normal PCV 52-60% Greyhound Borzoi What is the most common treatment for Italian Greyhound Afghan anemia? • Very few anemias require treatment with iron Whippet Basenji** • Iron supplementation will significantly help very Scottish Deerhound Pharoah Hound** few anemias Irish Wolfhound Ibizan** • Contraindicated for anemia of chronic Saluki Rhodesian Ridgeback** inflammatory disease Sloughi 1 Diagnosis Diagnosis When is anemia significant? Symptoms secondary to anemia • Mild Anemia - Cats PCV 20-25%, Dogs 30-35% when to run a CBC • May or may not be a primary problem • Reduced oxygen carrying capacity • Often secondary to chronic inflammation, • Tachypnea, dyspnea, syncope, weakness, confusion malignancy, organ failure, or endocrine disease • hypoxia without cyanosis • Moderate Anemia – Cats PCV 14-19%, Dogs • Pallor PCV 20-29% • Reduced blood volume (blood loss anemia) • Weak peripheral pulses ==>> shock death • Severe Anemia – Cats PCV <13%, Dogs • Pallor, slow CRT (Capillary Refill Time) PCV<20% Related to decreased blood viscosity • Very Severe Anemia – Cats <10%, dogs <13% • Heart murmur Related to underlying disease – pica, Hburia Diagnosis Diagnosis 2 parts of a CBC 2 parts of a CBC • Automated count - EDTA or citrate • Automated count - EDTA or citrate • Should be run within 3 hrs - refrigerate after • Should be run within 3 hrs - refrigerate after • not totally reliable >24 hrs • not reliable >24 hrs • RBC swelling at 6-24 hrs • RBC swelling at 6-24 hrs • inc. PCV & dec. MCHC • inc. PCV & dec. MCHC • Do not run samples with clots in them • Do not run samples with clots in them • Inaccurate automated counts • Inaccurate automated counts • Clog the machine • Clog the machine • If your HCT does not match your patient, • If your HCT does not match your patient, spin a HCT tube (11-15K rpm x 5 min) spin a HCT tube • Blood smear examination - EDTA • Blood smear examination - EDTA Diagnosis Making & Reading the Blood Smear 2 parts of a CBC • Blood smear examination – EDTA • Use good slides with smooth edges • within 30 minutes is best – air dry • Wipe the glass dust off both slides first • Blood smear of any age can still yield valuable information • Let the slide air dry • on all CBCs with significant abnormalities • Avoid the very edge where RBC are • RBC and WBC morphology damaged and distorted • Hemoparasites • Avoid the smear where it becomes thick • capillary blood best yield (ear prick, foot pad) • Read RBC morphology in the monolayer • Inclusions – Dohle bodies, CDV inclusions • I have better luck with a smaller drop of • Differentiate WBC cell lines blood • Sometimes there are cells that the counter can not identify 2 Making & Reading the Blood Smear Making & Reading the Blood Smear • Use good slides with smooth edges • Use good slides with smooth edges • Wipe the glass dust off both slides first • Wipe the glass dust off both slides first • Let the slide air dry • Let the slide air dry Autoagglutination • Avoid the very edge where RBC are • Avoid the very edge where RBC are damaged and distorted damaged and distorted • Avoid the smear where it becomes thick • Avoid the smear where it becomes thick • Read RBC morphology in the monolayer • Read RBC morphology in the monolayer • I have better luck with a smaller drop • I have better luck with a smaller drop Making & Reading the Blood Smear Making & Reading the Blood Smear • Use good slides with smooth edges • Use good slides with smooth edges • Wipe the glass dust off both slides first • Wipe the glass dust off both slides first • Let the slide air dry • Let the slide air dry • Avoid the very edge where RBC are • Avoid the very edge where RBC are damaged and distorted damaged and distorted • Avoid the smear where it becomes thick • Avoid the smear where it becomes thick • Read RBC morphology in the monolayer • Read RBC morphology in the monolayer Feathered• I have Edge better - Don’t luck Read with Morphology a smaller Here drop Monolayer• I have – Read better Morphology luck with Here a smaller drop Making & Reading the Blood Smear Making & Reading the Blood Smear • Use good slides with smooth edges 1. Platelet Estimate – 8-30/HPF (100x) • Wipe the glass dust off both slides first • Platelet clumping at feathered edge Thick Body• – Let Don’t the Read slide Morphology air dry Here • Platelet morphology • Avoid the very edge where RBC are 2. RBC morphology damaged and distorted 3. WBC estimate – 20-50/LPF (10x) dogs, • Avoid the smear where it becomes thick 10-40/LPF (10x) cats • Read RBC morphology in the monolayer • Manual WBC Diff if what you see does not • I have better luck with a smaller drop correlate with the automated count • Count nRBC, but don’t include them in the 100 WBC that you count 3 RBC Morphology RBC Morphology polychromatophil reticulocyte spherocyte K9 RBC feline RBC normal normal regenerative regenerative IV hemolysis (NMB stain) (discocyte) response response schistocyte blister cell helmet cell crenation acanthocyte liver disease schizocyte keratocyte keratocyte echinocyte spurr cell DIC oxidation oxidation artifact burr cell angiopathy metabolic dz dacryocyte leptocyte Splenic dz budding eccentrocyte Mycoplasma Heinz body Howell Target cell DIC, angiopathy, oxidation hepatic dz Mycoplasma oxidation Increased fragmentation haemofelis (NMB stain) Jolly Body (codocyte) IDA, marrow dz regeneration haemofelis nRBC Cases Shelter Cat 5 month DLH cat – tachypnea, lethargy • VetBLUE® ultrasound Shelter Cat Shelter Cat 5 month DLH cat 5 month DLH cat – tachypnea, lethargy – tachypnea, lethargy • VetBLUE® ultrasound • VetBLUE (Bedside Lung US Exam) • Dry lungs • AFAST3 (Abdominal Focused ASessment for Trauma, Triage and Tracking) • Abdominal fluid score 0/4 • Gall bladder and urinary bladder normal • No25% retroperitoneal caval bounce fluid, no pleural Enlarged hepatic fluid, vein no dry lung alveolar-interstitial lung fluid pericardial fluid 4 Attendee, DVM Shelter Cat City TX 5 month DLH cat – tachypnea, lethargy • VetBLUE® (Bedside Lung US Exam) • Dry lungs • AFAST3® (Abdominal Focused ASessment for Trauma, Triage and Tracking) • Abdominal fluid score 0/4 • Gall bladder and urinary bladder normal • No retroperitoneal fluid, no pleural fluid, no pericardial fluid • Caudal vena cava 25% bounce, tree trunk • Chest x-rays Shelter Cat Shelter Cat 15 month DLH cat 15 month DLH cat – tachypnea, lethargy5.1 + 4.0 = 9.1 – tachypnea, lethargy • Skeletal & cranial abdomen • Airways, Lung fields • No abnormalities noted • Great vessels • caudal vena cava somewhat enlarged • Smaller vessels • No abnormalities noted • Cardiac silhouette • Generalized cardiomegaly Shelter Cat Shelter Cat 15 month DLH cat 15 month DLH cat – tachypnea, lethargy – tachypnea, lethargy • Skeletal & cranial abdomen • Airways, Lung fields • Heart Failure?? • No abnormalities noted • no LHF, maybe impending RHF • Great vessels • caudal vena cava somewhat enlarged • Diagnosis • Smaller vessels 3® • No abnormalities noted • TFAST showed dilation of LV & RV, but not LA • Cardiac silhouette • Flea Anemia (PCV 10%) • Generalized cardiomegaly, apex shifted right 5 Shelter Cat Lesson From Shelter Cat • Chronic severe anemia can result in DCM like syndrome in the cat • Usually reversible when anemia treated • VetBLUE® usually much safer than x- rays for dyspneic cat – Allows treatment of pulmonary edema or pleural effusion prior to further diagnostics Diagnosis Diagnosis Severity of Symptoms due to anemia Things that can mask anemia • Rapidity of onset • Dehydration • Severity of Anemia • Acute hemorrhage • Degree of physical activity (cats vs. dogs) • Shock, splenic contraction • Concurrent disease affecting respiratory • Cannot mask a severe anemia exchange • Look at plasma protein • Respiratory disease • Assuming there is no concurrent • Cardiovascular disease hypoprotenemia Pseudoanemia • Mild decrease
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