Neobook — clinical reference

The aetiology of anaemia in palliative care patients may be multifactorial and can result in significant distressing symptoms, such as:

Dyspnoea
Postural hypotension
Oedema
Anorexia
Headache
Fatigue
Exacerbation of angina
Impaired concentration
Low mood
Loss of libido

Major causes of anaemia in the palliative care setting include:

Anaemia of chronic disorders
Malnutrition or malabsorption
Acute and chronic haemorrhage
Marrow failure or suppression
Haemolysis (may be encountered with chronic lymphocytic leukaemias, non – Hodgkin’s lymphoma and various adenocarcinomas)
Congenital anaemia

Assessment

Take a detailed history including:

history of current illness,
other chronic illnesses,
any symptoms, related to the cause or effects of anaemia

Examination:

to assess for possible causes of anaemia
to assess clinical severity of anaemia

Investigations:

should be considered in the light of the most likely cause of anaemia
should be appropriate for the patient’s condition
should be undertaken to guide the most appropriate management
May include; full blood count, iron studies, vitamin B12, folate, Coomb’s test, and rarely, bone marrow studies.

Explanation to patient and family

Explain the likely causes of tiredness and the options for treatment. Involve the patient and family in decisions regarding treatment, in particular the options to administer a blood transfusion, explaining the likely benefits and burdens of the transfusion and the probable time that it will provide relief of symptoms. Repeated blood transfusions may become a burden to the patient, may not be providing benefit and may not be appropriate for the stage of illness

Management

Correct reversible causes:

Chronic haemorrhage:
- Control bleeding if possible
- Limit drawing of blood to only necessary blood tests that will improve management
- Consider iron supplements if haemorrhage has led to iron deficiency
- Consider blood transfusion for symptomatic anaemia
Acute Haemorrhage:
- Consider the patient’s stage of illness and prognosis
- After assessment, if appropriate, resuscitate
- Institute appropriate measures to prevent recurrence
- If the haemorrhage is considered a terminal event, manage the patient’s and family’s distress appropriately - non-pharmacological and pharmacological)
Marrow Failure
- Consider blood transfusions, while these are still of clinical benefit to the patient.
Chronic Haemolysis
- Immune haemolysis may respond to steroids (e.g., prednisone 0,5 – 1,0 mg/kg)
- Microangiopathic, haemolytic anaemia responds poorly to any treatment unless the tumour can be removed
- Hypersplenism may be treated by surgical resection or radiation to the spleen
Keep the patient and family informed. Involve them in the decision-making process. Carefully explain the cause of the anaemia and go through the therapies available and the advantages and disadvantages of interventions.

Blood transfusion

Blood transfusion should be considered in a patient who has distressing symptoms attributable to anaemia, in whom no other treatment is feasible, and for whom a favourable outcome of the transfusion is expected. A transfusion may not be indicated if the patient’s poor functional status is due to the worsening illness as a transfusion will not improve these symptoms. Typically these patients have a very limited prognosis and symptomatic support is required.
Each unit of packed cells should raise the Hb in adults by 1g/dl.
In treating anaemia in palliative care, packed cells are preferable to whole blood.
Complications include:
- Volume overload
- Febrile Non-haemolytic Transfusion Reaction
- Mild allergic Reaction
- Acute Haemolytic Transfusion Reaction/ ABO Incompatibility
- Hypersensitivity/Anaphylaxis
- Transfusion related acute lung injury (TRALI)
- Bacterial contamination
- Iron overload as a long term complication of numerous blood transfusions as may be required in marrow failure

Iron overload is not a problem until about 50 to 75 units have been transfused, so this complication is rarely seen in the palliative care setting.

Transmission of infections through blood transfusion is minimal, due to careful screening of blood to be used for transfusion. In the palliative care setting, the advantages usually outweigh this risk.

Review assessment and management

It is important to regularly review the patient’s status and responses to interventions such as blood transfusions. At some stage in the progression of terminal illness, the blood transfusions will no longer achieve the desired effects of alleviating symptoms. It will then be necessary to explain to this to the patient and family.

Other interventions; such as steroids or haematinics, may become redundant as the patient’s condition deteriorates and should be stopped if there is no benefit. It is always important to discuss this with the family first

Involve the interdisciplinary team

All members of the team are available to support the family and the patient, through each phase of the illness. It is especially important, when transfusions are no longer effective. The patient and family need to know that the team is not “giving up”. The treatment is being tailored to the patient’s condition and care is always being given.

Referral to appropriate services

Refer patients for a surgical consult if surgical treatment to prevent anaemia is appropriate.
Referral or consultation as required for any of the severe acute blood transfusion reactions.

Anaemia and Blood Transfusions

Drugs mentioned