Anaemia

Re: Anaemia

sarah mason — Thu, 07 Jul 2011 12:09:30 GMT

Do they have money to rule out Addisons, can present as lethargy and melena. Also do the red blood cell indices give you any more information? BSAVA manual of clin path has a good chapter on these.

Re: Anaemia

HMC — Wed, 06 Jul 2011 15:40:47 GMT

[quote user="Kate Richardson"]Possible coagulopathy causing low grade git haemorrhage and the transfusion provided clotting factors and platelets as well as rbcs? [/quote]

I was just about to say that.

Re: Anaemia

Kate Richardson — Wed, 06 Jul 2011 14:00:01 GMT

[quote user="Joyce Whitehead"] I have spoken to them this morning, and oddly, since the transfusion, no melaena. Not quite sure what to make of this.[/quote]

Possible coagulopathy causing low grade git haemorrhage and the transfusion provided clotting factors and platelets as well as rbcs? Did you do clotting times prior to the transfusion? Although normal times wouldn't rule out angiostrongylus, so worth treating for this anyway I guess.

With regards to when to transfuse, I think it is a combination of how the animal is clinically, how quickly it has become anaemic, and how low the pcv is, and whether there is likely to be ongoing loss, so I don't have a magic figure that i use.

Re: Anaemia

Joyce Whitehead — Wed, 06 Jul 2011 12:55:02 GMT

Thanks for all the replies - especially Martin, I was having a low day I think. No history of odd meds, owners are sensible and keen to help. I have spoken to them this morning, and oddly, since the transfusion, no melaena. Not quite sure what to make of this. I am going to resample her to see how she is post transfusion (probably tomorrow), and change onto omeprazole then.

She is (not surprisingly) bouncing around since the transfusion. Steroids obviously would be my first choice if not getting anywhere, except for the gut issues, as I too have seen lots of spaniels with IMHA. By the way, platelet count was confirmed by the lab as ok.

To answer the question about how low before transfusing, I think I have only transfused dogs under 15, but mainly toward the 10-12 mark. It is surprising how they can be keeping up a fairly reasonable existence with such a low blood count really!

It's a waiting game isn't it. It seems to have been anaemia week here, as we had another profoundly anaemic dog on Monday with a very enlarged liver - biopsied and come back as malignant histiocytosis top of the list - grim.

Re: Anaemia

Kate Richardson — Wed, 06 Jul 2011 12:36:31 GMT

All these extra investigations may/may not be helpful, but if you have melaena and you are sure it is melaena ie you have seen a sample not just taken owners word for it, then surely it's the most likely cause of the anaemia? Why subject the dog to more invasive testing at this point in time? If the dog is ok otherwise, why not treat with gut protectants (omeprazole and antepsin) and see if the meleana resolves and the pcv increases/remains stable/doesn't drop again? Is there any history of the owner giving her any medications such as ibuprofen- sometimes you need to specifically ask the question.

Re: Anaemia

Martin Atkinson — Wed, 06 Jul 2011 11:08:07 GMT

Lungworm is now top of my list of differentials for anaemias without obvious cause. EPO injections can stimulate RBC production if the marrow is intact and buy you some more time.

Re: Anaemia

Mark Holmes — Wed, 06 Jul 2011 10:47:38 GMT

Just out of interest how low do you go with PCV before looking to transfuse? The reason I say this is I currently have a little dog with what appears to be IMHA. PCV 14%, quiet but alert. Smear looks regenerative. Marked clumping on the slide. I am always cautious about burning the first transfusion and making any future requirements more complicated. Just started dex so would hopefully expect PCV to increase over the next few days anyway and I am tempted to wait it out at present but there has been a dramatic fall in PCV overnight frm 25% yesterday evening.

Re: Anaemia

Laurence Webb — Wed, 06 Jul 2011 09:38:46 GMT

You can get IMHA that attacks erythrocytes within the marrow so you get an apparently non-regnerative peripheral blood picture although the marrow is working furiously away. This is more common in Springers. I'd agree with Martin's idea of a reduced price repeat marrow aspirate and get a core biopsy at the same time too. Even if you don't have to use it it's nice to have a backup (I started to do this after having a couple of non-diagnostic aspirates and being advised to get core biopsies by the lab). Worth pointing out to the owners that knackered marrow may not yield anything on aspirate so it's not technique that may be to blame for non-diagnostic samples)

Assuming the platelets are functioning OK that doesn't account for the GIT bleeding though. Did the external lab verify the platelet count on the smear as fragmented rbc can confuse automated machines into thinking they're platelets. Have you checked buccal bleeding time to see if the platelets are working OK?

Consider lungworm as that can cause strange blood/coagulation disorders.

After that I guess your onto a tumour hunt or getting the preds out which would be my choice if funds are limited

Re: Anaemia

Martin Jones — Wed, 06 Jul 2011 09:26:20 GMT

Your general approach has been impeccable - most of your current stress levels are to do with trying to get an answer off limite means (!). Don't beat yourself up so.

Had a similar case recently, with an ex-colleague's (nurse) retriever, although admittedly that had a reasonably regenerative anaemia. A fine balancing act between trying to get the answer and trying to protect the owner, a good friend. We never really did come up with anything definitive, despite two goes at lymph node biopsy, but eventually the C-word became obvious and we let him go.

My two penn'orth would be to second the move onto omeprazole, and to discuss perhaps a reduced-fee second go at marrow biopsy - good for your stress and anxiety, good for well-motivated owners; the lab may well already have said something about being willing to look at another sample either FOC or at a reduced rate. Whilst at the position for a biopsy, having a quick look round the abdo would be a good idea also. I think ex-laps are often regarded as major, major undertakings, but are often quicker, cheaper and better value than a number of technological investigations.

Chin up, you've bought yourself some time with the transfusion, ruled out a few things and gone down the right avenues. But if you get an inconclusive or useless answer from any investigation, what would be the point of NOT repeating the test? The problem and the differential haven't gone away, so not repeating simply suggests that there was no point in the first place.

As ye seek, so shall ye find.

Re: Anaemia

Joyce Whitehead — Wed, 06 Jul 2011 08:05:10 GMT

Yes, blood smear sent with first sample to external lab after in house sample done, and no abnormal cells. I do feel this dog may have some mass somewhere, but nothing is palpable or visible. The dog is still on cimetidine at present, and there was a total of 10days between first sample (PCV18) to transfusion (PCV 12) so no regeneration in that time, which seems odd if it is just a gut ulceration issue.

I have offered the owners referral so they are considering that, as no insurance means costs have to be looked at carefully. Thanks for the suggestions so far though.

Re: Anaemia

Busybee — Tue, 05 Jul 2011 21:43:05 GMT

Have you done a blood smear at all? I would certainly be concerned about something (ulcer/mass) beyond the stomach, but also consider iron-deficiency anaemia in conjunction.

Re: Anaemia

Kate Richardson — Tue, 05 Jul 2011 13:28:56 GMT

What meds is she on now? If this is due to melaena then I would put her on sucralfate and change cimetidine to omeprazole, plus covering antibiotics as there is breach of the gut mucosa. If the melaena doesn't resolve, then ex lap and biopsy probably indicated, probably ultrasound abdomen first? Interesting she is not regenerating though unless it was still at pre-regenerative stage which I think is still feasible at 3 days, but odd as it sounds like chronic blood loss not acute.