1. ANAEMIA-ITS IMPORTANCE IN GENERAL SURGICAL PRACTICE Dr.R.Selvakumar

2. ANAEMIA- Is it that important to discuss for an hour..? I.S.A-TNLI

3. How much importance we give to anaemia? How do we diagnose anaemia? I.S.A-TNLI

4. When we see 3G and 4G% Hb in the general population… Why do we have to worry? I.S.A-TNLI

5. To answer these questions… knowing some basics is necessary … knowing some basics is necessary I.S.A-TNLI

6. O 2 is carried in blood in 2 forms: 1. Combined with Hb 2. Dissolved in plasma I.S.A-TNLI

7. HOW MUCH O 2 IS DISSOLVED IN PLASMA? Quantity Quantity Importance Importance I.S.A-TNLI

8. What do we achieve in giving O 2 by mask? I.S.A-TNLI

9. IMPORTANCE OF Hb Amount of O 2 carried by Hb Amount of O 2 carried by Hb Reserve O 2 Reserve O 2 Amount of O 2 needed for metabolism Amount of O 2 needed for metabolism I.S.A-TNLI

10. O 2 CONTENT OF BLOOD {Hb X 1.32 X SaO 2 } +{ 0.003 X paO 2 } O 2 FLUX: O 2 content X cardiac output I.S.A-TNLI

11. O 2 CASCADE: airair hu mi di fic at on E n d- ex p g as Al v.g as ArtbloodArtblood C a p bl o o d m it oc h o n d ri a 150mm 100mm 50mm I.S.A-TNLI

12. In nutshell…. What we need is just 2mm of Hg of O 2 at mitochondrial level…… I.S.A-TNLI

13. What will happen if that is not provided? Anaerobic metabolismAnaerobic metabolism Scarcity of ATPScarcity of ATP I.S.A-TNLI

14. If some stupid ATP is not provided why the cell has to die…? Importance of ATP pump I.S.A-TNLI

15. COMPENSATORY MECHANISMS IN ANAEMIA: Can u increase the O 2 content of blood by manipulating the factors involved in the formula? I.S.A-TNLI {Hb X 1.32 X SaO2 } +{ 0.003 X paO2 }

16. COMPENSATORY MECHANISM IN ANAEMIA; TachycardiaTachycardia Cardiac strainCardiac strain Vascular toneVascular tone Increased cardiac outputIncreased cardiac output Associated hypoproteinaemiaAssociated hypoproteinaemia EASY TENDENCY FOR PULMONARY EDEMA I.S.A-TNLI

17. HOW DO WE CORRECT ANAEMIA? Oral and parentral preparationsOral and parentral preparations Blood transfusionBlood transfusion Is there any other way to tackle anemia? I.S.A-TNLI

18. Can we manage without Hb? O 2 content of 100ml of arterial blood= 20ml O 2 content of 100 ml venous blood = 15 ml Tissues need just 5ml of O 2 I.S.A-TNLI

19. Atm.press FiO 2 pIO 2 paO 2 O 2 content Dissolv ed O 2 1atm0.21 150m m 87mm18.7ml0.3ml 1171367321.21.7 211473121823.13.7 312233186425.15.6 Impact of increasing atmospheric pressure I.S.A-TNLI

20. Is there any alternate to Hb? SYNTHETIC O 2 CARRIERS: Perfluoro carbon-Fluosol-DA 1.Perfluoro carbon-Fluosol-DA paO 2 has to be above 300 mm of Hg 2. Perflurooctyl bromide: longer half life 3-4 times more O 2 on the trials 3. Hb based O 2 carriers outdated human RBCs, or bovine RBC increased affinity to O 2 renal toxicity I.S.A-TNLI

21. SYNTHETIC O 2 CARRIERS: 4. Recombinant Hb from E.Coli 5. Recombinant erythropoietin 6. Haemopure: ultrapurified bovine RBC – gluteraldehyde polymerised no croosmatching or typing no transmission of infection increased BP and decreased CI approved in south africa I.S.A-TNLI

22. ROLE OF ERYTHROPOIETIN IN TREATING ANEMIA Recombinant erythropoietin ( rHuEPO)Recombinant erythropoietin ( rHuEPO) 300 units/kg S/C daily for 5 days300 units/kg S/C daily for 5 days Every other day for a minimum of 2 weeksEvery other day for a minimum of 2 weeks Improves the haematocritImproves the haematocrit 36% compared to 31% in placebo36% compared to 31% in placebo I.S.A-TNLI

23. BLOOD TRANSFUSION Role of pre-op transfusionRole of pre-op transfusion How many bottles of blood to be given?How many bottles of blood to be given? I.S.A-TNLI

24. PREOP BLOOD TRANSFUSION.. Packed red cellsPacked red cells Risk of infection,circulatory overload.Risk of infection,circulatory overload. 1 unit increases Hb by 1G%1 unit increases Hb by 1G% ? Quality of the donated blood? Quality of the donated blood ? Quality of storage? Quality of storage ? Simultaneous frusemide administration? Simultaneous frusemide administration I.S.A-TNLI

25. Is there a magic figure of Hb level before submitting the patient for an elective surgery? I.S.A-TNLI

26. If oxygen saturation is good, can you take a patient for surgery with anaemia? I.S.A-TNLI

27. If an ectopic rupture can be taken with a Hb of 3 or 4 g%, Why not a patient with 7 G%? I.S.A-TNLI

28. DANGERS OF ANEMIA-INTRA OP PERIOD May be maskedMay be masked Increased O 2 supply during GA compensatesIncreased O 2 supply during GA compensates Spinal- mild hypotension and vasodilatationSpinal- mild hypotension and vasodilatation compensate compensate I.S.A-TNLI

29. DANGERS OF ANAEMIA – INTRAOP PERIOD Impact of anemia depends on existing organ function vascular status level of atherosclerosis cardiac status…etc I.S.A-TNLI

30. DANGERS OF ANAEMIA – INTRAOP PERIOD Even during a normal course of a well conducted anesthesia and an uneventful Surgery, there may be brief periods of hypotension and hypoperfusion…. The impact of this is aggravated by anemia by anemia I.S.A-TNLI

31. Word of caution: We measure the success of surgery only by looking at the absence of mortality not morbidity. I.S.A-TNLI

32. DANGERS OF ANAEMIA- POSTOP PERIOD Most dangerous periodMost dangerous period All the supports are withdrawnAll the supports are withdrawn Persistent impact of anesthetic drugs and techniquesPersistent impact of anesthetic drugs and techniques Surgical incision,pain all increase O 2 requirementSurgical incision,pain all increase O 2 requirement Even shivering increases it by 200%Even shivering increases it by 200% All these factors resulting in a subtle hypoxaemia I.S.A-TNLI

33. DANGERS OF ANEMIA- LATE POST OP PERIOD Wound healing requires good O 2 supplyWound healing requires good O 2 supply Burst abdomen, wound dehescence, bowel anastamoticBurst abdomen, wound dehescence, bowel anastamotic leak,skin graft failure- all due to reduced O 2 supply leak,skin graft failure- all due to reduced O 2 supply Associated hypoproteinaemia aggravates..Associated hypoproteinaemia aggravates.. I.S.A-TNLI

34. Summarising… The tissues need just 2mm of Hg Oxygen 1.The tissues need just 2mm of Hg Oxygen 2. The O 2 content of the blood can only be increased by maximising Hb. increased by maximising Hb. 3. Body tries to compensate for chronic anemia 4. Immediate preop blood transfusion may not help I.S.A-TNLI

35. Summarising… One unit of preop transfusion improves Hb 5. One unit of preop transfusion improves Hb by 1 g% by 1 g% 6. There is no fixed,magic figure of Hb before any surgery before any surgery 7. Anaemia may not kill a patient intra operatively. 8. The most dangerous period is the post op period I.S.A-TNLI

36. CONCLUSION: DON’T TAKE ANEMIA LIGHTLY IT IS A SILENT KILLER. IT IS A SILENT KILLER. I.S.A-TNLI

37. Dr.R.Selvakumar Assistant professor, Madurai Medical College,Madurai THANK YOU