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Acute Post-Hemorrhagic Anemia
Causes of acute anemia from blood loss are various external injuries (injuries), accompanied by damage to blood vessels, or bleeding from internal organs. Gastrointestinal bleeding, bleeding into the abdominal cavity (rupture of the fallopian tube during ectopic pregnancy), renal, pulmonary (tuberculosis, abscess), uterine, and bleeding from various organs during hemorrhagic diathesis are most commonly observed. In this group, we do not include ultra-acute bleeding that causes instant death, such as bleeding when aortic or cardiac aneurysm is ruptured, etc.
Clinic. The picture of acute post-hemorrhagic anemia in the first moments after blood loss consists of the anemic symptoms and symptoms of collapse. The latter include: “deadly” pallor, dizziness, fainting, frequent pulse-like pulse, drop in body temperature, cold sweat, vomiting, cyanosis, convulsions. In the event of a favorable outcome, these symptoms are replaced by symptoms characteristic of acute anemia itself. As a result of a sharp decrease in the mass of erythrocytes, the respiratory function of the blood decreases and oxygen starvation, hypoxia, develops. The nervous system and sense organs are especially sensitive in this respect. At the slightest movement, adynamia, vertigo; tinnitus, visual disturbances up to complete amaurosis (specific elements of the retina are very sensitive to anoxemia); integuments and visible mucous membranes are very pale, limbs cold; tachycardia and hypotension are noted.
A picture of blood. When assessing the blood picture immediately after blood loss, one should take into account the fact of compensatory intake of blood deposited in the subcutaneous tissue (subpapillary capillaries), muscles, spleen, liver. In addition, it must be remembered that, depending on the amount of blood loss, a more or less significant part of the capillaries reflexively narrows, as a result of which the overall vascular bed size decreases.
The above changes (referred to as reflex vascular compensation phase) lead to the fact that, despite an absolute decrease in erythrocyte mass, digital hemoglobin and erythrocyte values per unit blood volume immediately after blood loss approach the original figures that were before blood loss, and thus , do not reflect the true extent of anemization. It is important for the practitioner to know that anemia due to blood loss is not detected immediately, but after a day or two, when the next one occurs - the hydremic phase of compensation for blood loss, expressed in the abundant flow of tissue fluid (lymph) into the bloodstream, resulting in a vascular bed initial volume. In this phase, which continues for several days depending on the amount of blood loss, there is a progressive uniform decrease in the red blood indices — hemoglobin and red blood cells — without a decrease in the color index. Thus, anemia, especially at first, is of a normochromic nature.
After 4-5 days after blood loss, red blood cells - reticulocytes (the so-called reticulocyte crisis) - appear in large numbers in the blood marrow. This is the bone marrow phase of compensating for anemia, which, as recent research shows, results from an increased erythropoietic activity of the bone marrow after acute blood loss.
In the light of research in recent years, the former idea of the compensatory role of hypoxia as a bone marrow stimulator is replaced by the idea of the role of plasma erythropoietin, the content of which increases in connection with blood loss.
Simultaneously with the regenerative forms of erythrocytes, young forms of leukocytes appear in the blood - stab-nucleated, metamyelocytes, rarely myelocytes, with a total leukocytosis of up to 12,000–20000, occasionally more. Sometimes there is a short-term (within a few days) thrombocytosis (up to 1 000 000 and more).
Already with a single acute blood loss, a transient decrease in plasma iron levels is noted. With sufficient reserves of iron in the depot, the level of iron in the plasma quickly levels out; on the contrary, with depleted depot, the plasma level of iron remains low (sideropenia) and a picture of hypochromic iron deficiency anemia develops.
Post-mortem after major bleeding, the red bone marrow in the flat bones is in a state of increased activity, and the fatty bone marrow in the tubular bones is replaced by red, i.e., hematopoietic bone marrow. With repeated bleeding, extramedullary hematopoiesis may occur in the spleen, liver, lymph nodes and other organs.
A known difficulty is the diagnosis of the underlying disease in case of bleeding from an internal organ, for example, during ectopic pregnancy. In these cases, acute anemia syndrome, supported by laboratory blood tests, serves as a clue that leads the doctor to the correct diagnostic path.
Forecast. The prognosis of acute post-hemorrhagic anemia (in the first moments) depends not only on the amount of blood loss, but also on the rate of blood flow. The most abundant blood loss, even the loss of 3/4 of all circulating blood, does not lead to death, if they proceed slowly, over a number of days. On the contrary, the rapidly occurring loss of 1/4 of the blood volume causes a state of dangerous shock, and the sudden loss of half the blood volume is certainly incompatible with life.
A drop in blood pressure below the critical figure (70-80 mm for systolic pressure) can be fatal due to the developing collapse and hypoxia. As soon as the normal blood supply to the vessels is restored at the expense of tissue fluid, the prognosis for life becomes favorable (if re-bleeding does not occur).
The timing of recovery of a normal blood picture after a single blood loss is very different and depends both on the size of the blood loss itself and on the individual characteristics, in particular, on the regenerative capacity of the bone marrow and the iron content in the body.
If we take the amount of iron in the erythrocyte mass of an organism equal to 36 mg per 1 kg of body weight, then if, for example, 30% of erythrocyte mass is lost, the body will lose 10.8 mg of iron per 1 kg. If you take the monthly intake of nutritional iron in the body equal to 2 mg per 1 kg, then the restoration of the normal iron content, and hence the hemoglobin, will occur in about 5.5-6 months.
Persons weakened or anemic before blood loss, even after a single small bleeding anemiziruyutsya for a longer period. Only energetic therapy can bring their blood-forming organs out of the torpid state and eliminate anemia.
Treatment. First of all, it is necessary to accurately determine the source of bleeding and take measures to eliminate it immediately and prevent re-bleeding.
In certain cases, surgical intervention is indicated - ligation of the bleeding vessel, suturing of the ulcer, gastric resection, removal of the pregnant fallopian tube, etc.
When bleeding occurring with symptoms of pain shock, it is necessary first of all to strive to bring the body out of shock.
Along with the introduction of morphine and cardiovascular agents (strychnine, caffeine, strophanthin, etc.), intravenous infusion of polyglucin, plasma (normal or hypertensive) or other anti-shock fluids is indicated.
Infusion of hypertonic plasma (160 ml) should be made as an urgent measure, so that in the future at the first opportunity to make a transfusion of whole blood.
The effectiveness of plasma injections is determined by the content of hydrophilic colloids in it - proteins, due to which it is isotonic with respect to the plasma of the recipient, which contributes to the long delay of the transfused plasma in the vascular system of the recipient. This is the indisputable advantage of plasma infusion over infusion of salt, the so-called physiological solution. The latter, being administered intravenously, even in large quantities (up to 1 l), is essentially ballast, since it almost does not linger in the bloodstream. Especially it is necessary to caution against the subcutaneous infusion of physiological saline in practice, which does not have any effect on the disordered hemodynamics and only leading to edema of the tissues.
The advantage of plasma infusions lies in the fact that they, as a rule, are not accompanied by a posttransfusion reaction.
The best pathogenetic method of treatment of post-hemorrhagic anemia resulting from acute blood loss is transfusion of whole blood or red blood cell mass. As shown by modern studies, made with the help of radioactive chromium (Сr51) of erythrocytes, the survival rate of transfused erythrocytes is close to physiological terms. The dosage of the transfused blood (erythrocyte mass) and the method of its introduction are determined by three factors: 1) continued bleeding or its cessation, 2) the amount of blood lost, 3) the state of blood pressure.
With a small blood loss, but continued bleeding, whole blood or plasma, preferably fresh, is transferred in a dropwise manner in small hemostatic doses (100-150 ml). If the bleeding has stopped, but the blood loss is large, it is preferable to transfer the erythrocyte mass in a massive dose (not less than 500 ml), and at first the transfusion is performed by a jet method, and later to avoid a reaction, the blood is transfused slowly, preferably by a drip method.
In some cases, with a decrease in systolic pressure of up to 60 mm, the removal of a patient from shock can be achieved by intra-arterial blood or plasma transfusion to 250 ml (V. A. Negovsky, 1956). Blood transfusion is performed in the radial or brachial artery in the direction of the aorta.
The efficiency of blood transfusions is determined at the first moment by an increase in blood pressure, and later - by hematological changes.
In severe anemia as a result of blood loss, when the vital interests of the patient dictate the need for an emergency operation, only transfusions of massive doses of blood (“blood transplantation”) can ensure a successful outcome of the operation.
Blood transfusion during the period of collapse may not lead to the desired goal due to redistribution of blood with the accumulation of the latter in the vessels of the abdominal cavity (the so-called "intravascular" bleeding). In these cases, along with massive blood transfusions produced by the jet method, it is necessary to inject hypertonic blood-substituting liquids.
The best modern blood substitutes possessing simultaneously anti-shock action are dek-countries, polyglukin and syncol.
Dextran is a product of the vital activity of the bacteria Leuconostoc mesenteroides, which synthesize a high-molecular-weight compound of the polysaccharide type from sucrose of the nutrient medium. Currently, two domestic preparations of the dextran type, polyglukin (COLIPK) and syncol (LIPK), have been synthesized.
In clinical practice, a 6% polyglucin solution is used for a 0.85% sodium chloride solution. Possessing a high viscosity (2.3–3.1) and, consequently, a high colloid-osmotic pressure (60–90 mm of H2O), a polyglucin with a molecular weight of about 60,000–90,000 has a high hemodynamic effect, carried out by increasing the volume of circulating blood. due to the influx of tissue fluid in the bloodstream. It has been proven that polyglucin transfusion almost 2 times increases the oxidative processes in the tissues by improving hemodynamic parameters, contributing to the compensation of post-hemorrhagic hypoxia.
Polyglucin lingers in the body for 5-6 days after transfusion, and in the organs of the reticulo-histiocytic system - up to 6-8 weeks.
To obtain a hemodynamic effect: increase in blood pressure, removal of the patient from the state of shock, it is necessary to pour at least 0.5-0.8 l of polyglucin. In case of acute injury with blood loss, polyglucine infusion is initially jetted, controlled by blood pressure. When the systolic pressure rises to 100-110 mm, and the diastolic one up to 50-60 mm, they switch to the drip method, so that in case of a repeated fall in blood pressure, again switch to the jet one. The total dose of the transfused polyglucin solution reaches 1–1.5 l, maximum 2-3 l. Clinical observations, in addition to the high qualities of polyglucin as a plasma substitute, which has antishock effect, have established its reactivity even during transfusion of large doses. This is the invaluable advantage of polyglucin over other blood replacement fluids. Syncol, which is a 6% solution of hydrolyzed dextran in 0.9% sodium chloride solution, possesses similar polyglukes.
If the blood loss and the degree of anemia are small (hemoglobin content is not lower than 8 g%, or 50 units), then it is possible to confine one transfusion of polyglucine (in an amount of at least 0.5 l) in order to bring the patient out of shock. With a sharper degree of anemization (the hemoglobin content is below 8 g%), after the introduction of 0.5–0.7 l of polyglucin it is necessary to switch to blood transfusion. If the patient is abruptly anemic, but is not in a state of shock (systolic pressure is above 110 mm), it is preferable to perform a transfusion of whole blood or red blood cell from the very beginning. Noteworthy is the use of a new drug geleodextran - imferon. Depending on the degree of anemia and the weight of the patient, from 6 to 96 ml of imferon is injected, which corresponds to 0.3-4.8 g of iron.
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