Treatment of acute posthemorrhagic anemia in children

Treatment of a patient with acute blood loss depends on the clinical picture and the amount of blood loss. All children who are clinically or anamnestic data are expected to be hospitalized for blood loss of more than 10% of BCC.

The volume of circulating blood and the parameters of hemodynamics should be evaluated immediately. It is extremely important to repeatedly and accurately determine the main indicators of central hemodynamics (heart rate, blood pressure and their orthostatic changes). A sudden increase in heart rate may be the only sign of recurrence of bleeding (especially with acute gastrointestinal bleeding). Orthostatic hypotension (a decrease in systolic blood pressure> 10 mm Hg and an increase in heart rate> 20 bpm in the transition to an upright position) indicate moderate blood loss (10-20% BCC). Arterial hypotension in the supine position indicates a large blood loss (> 20% BCC).

It is generally accepted that in acute blood loss, hypoxia occurs in a child after losing> 20% of BCC. Children, in view of the lower affinity of hemoglobin for oxygen than in adults, can compensate for hemorrhage in a number of cases, and at a level of Hb <70 g / l. It is necessary to solve the problem of transfusion for each child individually, taking into account, in addition to blood loss, hemodynamics and red blood parameters such factors as the ability to compensate for a decreased oxygen function, the presence of co-morbidities,

Treatment of the patient begins with both an immediate stop of bleeding, and the withdrawal of the child from shock. In the fight against shock, the main role is played by the restoration of BCC blood substitutes and blood components. The volume of blood loss should be replaced by erythrocyte mass or (in its absence) whole blood of small (up to 5-7 days) storage periods. Transfusion of crystalloid (Ringer's solution, 0.9% NaCl solution, lactasol) and / or colloid (reopolyglucin, 8% solution of gelatin, 5% albumin solution) of blood substitutes must precede blood transfusion, which allows to restore BCC, to stop microcirculation disorders and hypovolemia. It is advisable to initially introduce a 20% glucose solution (5 ml / kg) with insulin, vitamin B ₁₂ and cocarboxylase (10-20 mg / kg). The rate of administration of blood substitutes in conditions of stopped bleeding should be at least 10 ml / kg / h. The volume of transfused blood-substituting solutions should exceed (approximately 2-3 times) the volume of erythrocyte mass.

When reconstructing BCC blood substitutes, it is necessary to ensure that the hematocrit is not less than 0.25 l / l in connection with the danger of development of hemic hypoxia. Transfusion of erythrocyte mass compensates for erythrocyte deficiency and relieves acute hypoxia. The dose of blood transfusion is chosen individually depending on the amount of blood loss: 10-15-20 ml / kg of mass, if necessary and more. Restoration of hemodynamics, including central venous pressure (up to 6-7 mm Hg), is an indicator of the adequacy and effectiveness of infusion-transfusion therapy for acute blood loss.

Indications for transfusion of erythrocyte mass in acute blood loss are:

1. acute hemorrhage> 15-20% BCC with signs of hypovolemia, not suppressed by transfusions of blood substitutes;
2. operational blood loss> 15-20% BCC (in combination with blood substitutes);
3. postoperative Ht <0.25 l / l with clinical manifestations of anemia (Ht <0.35 l / l, Hb <120 g / l) in severe restrictive diseases (artificial lung ventilation);
4. Ht <0.25 l / l Hb <80 g / l with clinical manifestations of anemia, active bleeding;
5. iatrogenic anemia (<5% BCC) as a result of taking blood samples for laboratory tests (Ht <0.40-0.30 l / l).

Indications for blood transfusions: acute massive blood loss, open heart surgery. It must be remembered that with blood transfusion the risk of transmission of viral infections (hepatitis, cytomegalovirus, HIV), sensitization is great.

Newborns with acute posthemorrhagic anemia and hemorrhagic shock require intensive care. A newborn in a state of shock should be placed in a kuvez or under a source of radiant heat to maintain body temperature at 36.5 ° C, and provided with inhalations of oxygen-air mixtures.

Indications for blood transfusion in newborns are:

1. anemia with contractile heart failure (1 ml / kg body weight, slowly for 2-4 hours); repeated transfusions if necessary;
2. Hb <100 g / l with symptoms of anemia;
3. Hb <130 g / l in children with severe respiratory diseases;
4. Hb <130 g / l at birth;
5. loss of BCC 5-10 %.

For transfusion use erythrocyte mass (not more than 3 days of preservation), which in the amount of 10-15 ml / kg of body weight is injected slowly (3-4 drops per minute). This leads to an increase in the hemoglobin level of 20-40 g / l. In case of severe anemia, the required amount of erythrocyte mass for transfusion is calculated according to the Nyburt-Stockman formula:

V = m (kg) x deficiency of Hb (g / l) x OCK (ml / kg) / 200, where V is the required quantity of erythrocyte mass, 200 is the usual level of hemoglobin in erythrocyte mass in g / l.

For example, a child with a body weight of 3 kg has anemia with a hemoglobin level of 150 g / l, which means that hemoglobin deficiency is 150-100 = 50 g / l. The required amount of erythrocyte mass is 3.0 x 85 x 50/200 = 64 ml. At very low hemoglobin levels in a child, the desired level of Hb, which is determined by hemoglobin deficiency, is 130 g / l.

Indications for transfusion of erythrocyte mass in children older than the first days of life are hemoglobin levels below 100 g / l, and in children older than 10 days - 81-90 g / l.

To avoid complications of massive blood transfusion (acute heart failure, citrate intoxication, potassium intoxication, homologous blood syndrome), the total volume of blood transfusion should not exceed 60% of the BCC. The remaining volume is replenished with plasma substitutes: colloid (reopolyglucin, 5% albumin solution) or crystalloid (Ringer's solution, 0.9% NaCl solution). If a child who is in posthemorrhagic shock is unable to urgently perform blood transfusion, then they begin treatment with plasma substitutes, since the mismatch of the volume of circulating blood and the capacity of the vascular bed must be eliminated immediately. Limit of hemodilution in the first hours of life is considered to be a hematocrit of 0.35 l / l and an amount of red blood cells of 3.5 x 10 ¹² / l. When this boundary is reached, replenishment of BCC should be continued with blood transfusions.

The effectiveness of therapy for acute posthemorrhagic anemia is judged by normalizing the color and temperature of the skin and mucous membranes, increasing systolic blood pressure to 60 mm Hg. Restoration of diuresis. At laboratory control: the level of Hb 120-140 g / l, hematocrit 0.45-0.5 l / l, CVP within 4-8 cm of water. Art. (0.392-0.784 kPa), bcc above 70-75 ml / kg.

A patient with acute posthemorrhagic anemia needs a bed rest. The child is warmed and given a plentiful drink.

According to the indications, cardiovascular agents are prescribed, drugs that improve microcirculation.

At the end of the acute period, a full-fledged diet is prescribed, enriched with proteins, trace elements, vitamins. Considering the depletion of iron stores, iron treatment is prescribed.