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Critical issues in hematology: anemia, thrombocytopenia, coagulopathy, and blood product transfusions in critically ill patients ReedE. Drews, MD a,b, * a Department of Medicine, Division & 8230; Evaluating anemia Given the 120-day lifespan of a normal RBC, acquired anemias that are due toR BC underproduction generally develop and progress slowly over weeks to months.In contrast,anemias that are due to bleeding or hemolysis generally occur rapidly over days to weeks; the tempo of anemia development depends on the pace of bleeding or hemolysis in relation to RBC production.Knowing patients histories of anemia throughout& 8230;

Anemia, thrombocytopenia, and coagulopathy are commonly encountered when caring for critically ill patients [1-3] . Pursuing structured evaluations of these hematologic problems is essential to their successful management. Certain clinical circumstances warrant blood product administration, but clinicians must balance potential benefits of transfusions against the risks. For example, red blood cell (RBC) transfu- sionincreasesred cell mass; this maybe indicated to expand intravascular volume in bleeding or to enhance oxygen delivery in unstable angina or myocardial infarction, but it may offer uncertain benefits, or even harm, in other clinical scenarios [4,5] . Platelet transfusion can diminish bleeding inpatients who have thrombocytopenia or impaired platelet function, but it is contraindicated in thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) or typeIIheparin-induced thrombocytopenia (HIT). In these settings, platelet transfusion can fuel thrombosis and worsen clinical signs and symptoms [6,7] . Fresh frozen plasma (FFP) infusion in coagulopathy pro- videsportionsof all clotting factors that are required for adequate hemostasis [8] . Prothrombin complex concentrates (PCC) [9] or recombinant activated factor VII (rFVIIa) [10] , that are administered in small volumes, may prove better than FFP when coagulo- pathiesrequire quick intervention (as in life-threaten& 8230;. RDW isapoorsurrogate for reviewing the peripheral blood smear, because it lacks specific information about aberrantRBC morphologies (eg, spherocytes, schistocytes, bite cells, spur cells). Ideally, clinicians should examine the peripheral blood smear for mor- phologicfeatures of RBCs, WBCs, and platelets that may provide important clues to the cause of the patient& 8217;shematologic disorder. Various blood chemistries help to refine or confirm diagnostic possibilities suggested by the complete blood count, reticulocyte count, and peripheral blood smear. Ferritin, folate, and cobalamin levels indicate the adequacy of body stores of iron and vitamins that are required for hematopoiesis. Serum iron levels and total iron binding capacity (TIBC) supplement inter- pretationof ferritin levels that might be confounded by inflammatory cytokines in acute and chronic disease [11,12] . In inflammatory states, cytokines increase serum ferritin levels by as much as threefold. Hence, if serum ferritin levels divided by 3 are 20 or less, cli- niciansshould suspect concomitant iron deficiency in patients who have inflammatory states [13]

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