Hello Ivo

We had treated a mild women, with Hb 3,8, who works at 1400 meters, only asthenia, treated with 3 grams of IV iron (plus C and B6 vitamins). No EPO. She arose above 11,8 in five weeks with transfusion. She is not JW. She had a gastric ulcer Forrest II.

We will be glad to collaborate with you

Best regards

Hello

I observed a young vegan man with 40 g/L (the use of SI units is recommended) without severe subjective symptoms. After transfusion in ER, he refused any therapy

Dear collegues, thank you for sharing your experience with me.

I didn's say, but I added to iron B12, folate and oxygen therapy. The final diagnosis was "menorrhagia". Faecal occult blood test and screening for celiac disease was negative but in my opinion an in-depth study with EGD should be mandatory.

I treated without transfusion three more cases (no JW) 

1. Hb 4.8 g/dL 50 years old : heavy menstrual bleeding. After 26 days and FCM 2 g Hb 10.9

2. Hb 5.0 g/dL 42 years old male : colon cancer. 9.9 after 30 days (2 g FCM)

3. Hb 4.8 g/dL. 50 Y.O. Female: Malabsorption after biliopancreatic diversion. 10.4 after 20 days and 12.2 after 41 days (FMC 2 g)

In this days I am managing with FCM an 47 years old man that refuses transfusion (but not for religious reasons) after trauma. Today Hb is 4.6 g/dL.

 Best regards

I think that after restoring of both RBCs count and HB level as well as the timing for the transfused RBCs clearance an accurate evaluation of anaemia characteristic should be performed such as  MCV, MCHC (spherocytosis?) and HB variants. Even the evaluation of reticulocytes count could be informative: an increase of these despite HB level in normal range  may indicate a chronic loss rather than a defect of production.   After this path only, invasive procedures might  be considered 

Dear Antonio,

thank you for your suggestions!

Reticulocytes was 2.84% at diagnosis with a peak of 17.3% at +7 day.

At last visit Hb 11.9 -  MCH 28.1 - MCHC 30.9 and reticulocytes 0.71

Best regards

Dear Ivo

based on our data (Hb119; mch 28.1, mchc 309 and reticulocytes 0.71%) I calculated RBC count (4,23), Hct (38.5), MCV (91) and reticulocytes count (30,000). So, if we could exclude the residual presence of transfused RBC (check the instrumental RBC histogram for a double population) it is possible to rule out the thalassemic trait (MCV) as well as the spherocytosis (MCHC). Regarding the possibility of intestinal bleeding I remember you that the immunological FOC test are appropriate for the not-digested human haemoglobin only (from bowel) while for the research of the digested haemoglobin from the stomach it is appropriate the use "old guaiac test". Finally, in my opinion the reticulocytes count could be too low: check for ferritin level.

Good job .Antonio

Dear Antonio,

thank you again.

Maybe I was not clear, but the girl was not transfused.

Speaking of "old guaiac test", the problem is just the term "old": in the lab of my hospital this test is abandoned for years

Best regards

Ivo

Estimado Ivo Beverina, tuve un caso por déficit nutricional (Paciente comía más vómito provocado por ella: Bulimia) con valores hematológicos parecidos a vuestra paciente, pero de 14 años, un dato que te puede parecer interesante y que está en la Quinta edición de Guyton Fisiologia Medica Humana. La mujer pierde 15 mg de Hierro elemental cada día que menstrua, (Imaginemos cuanto perdera en una menorragia).si no se hace profilaxis ingiriendo hierro o aumentando el consumo de alimentos ricos en Hierro, tendrá anemia toda mujer que no tome esa precaución. A la Srta la tratamos con Hierro Maltosato IM 4 ampollas (1 ampolla cada 4 días) y luego ingesta oral de Hierro maltosato 50 mg con ácido Folico 5 mg diarios por un mes. La cual si no es aplicada con técnica en Zeta deja manchas en la piel donde se administró.  Disculpa que te escriba en Español. (Luego haré la traducción) 

Estimado Jorge Luis, gracias por compartir esto conmigo su experiencia interesante! 

(si he cometido algunos errores, es culpa del traductor de google...)

No os preocupeis Estimado Ivo. Éxitos en la presentación de vuestro caso.

Hi Ivo

sorry for mistake I had understood that it had been made transfusions. The contribution of Jose Luis is interesting because a nutritional aetiology  can't be excluded in a young girl (bulimia?) without a collaborative action from the  patient in the collection of clinical history.

Dear Jorge Luis

Intramuscular Iron must be "avoided" (forbiden)

The risks, disconfort, need of continuous dose (ten or more administration) 

New IV iron presentation allow us to give almost need dose in one, maximum two, doses.

Un abrazo

José Antonio

Dear Ivo and Antonio

Iron deficit anaemia are hypo regenerative anaemia. The corrected reticulocytes count must be very low. After correct iron administration, a retyculocites peak can be seen from fifth day. The maximum peak is usually observed two weeks laters. After this moment till one month later, as the same grade than anaemia is corrected the retyculocites count is decreasing.

The maximum hb value is found several weeks after. It depend how deep (severe) was the anaemia.

Best regards

Dear José Antonio,

 I entirely agree with you!

The attachement is the correlation graph for my series of 165 pts (at the end they will be around 200 and more). Data are similar to your study published on Bloodtransfusion in 2016.

Best regards

Dear all

this interesting discussion demonstrated that the sharing of experiences between Colleagues represents a tool for improving ours knowledge  as well as the quality of ours profession. Thanks to all

Antonio

Thank you Antonio for your words!

I know Ivo from ten years ago or more, but only I see him once a year (some minutes) at NATA Meetings. We are always encouraging him to publish his nice experience. We always share problems and limitations of work almost alone!

We must share experience, but it must be publish! 

Vamos IVO!

Best regards

VAMOS IVO!!

Estimados Ivo y Jose 

José Antonio García-Erce

De acuerdo contigo. El caso que expuse ocurrió hace 8 años, dos años después de que inició el gobierno socialista, hubo escasez de medicinas, solo tenia Hierro maltosato IM, el padre de la niña había trabajado como supervisor en una empresa farmacéutica, fue despedido y jubilado por tener Insuficiencia Renal Crónica y realizarse hemodiálisis. La paciente hizo un cuadro de bulimia (se alimentaba y provocaba vómito sin que lo vieran sus familiares y anorexia, veía su imagen distorsionada frente al espejo, todo inició porque el hermano de ella le decía gorda, cara de chancho, etc. Estatura 1.40 mts. Antes=peso 60 Kg cuando la vi 45Kg; esto empezo 7 meses antes de que sea llamado por teléfono por el papá debido a que había presentado un síncope, indicandole acuestala y levanta las piernas de la niña  y llevarla a urgencias. El padre decidió no llevarla, le indicamos una infusión azucarada de manzanilla (no había desayunado, hipoglucemia?), se sintió un poco mejor y se le solicitó Biometría Hemática Completa, plaquetas, Hierro sérico, Ferritina, Transferrina,  Glucosa (cuyo resultado fue 75mg/dL) con los datos anteriormente expuestos de Hb y Htc. Con la legislación actual una opinión (El Hierro IM debe evitarse o prohibida, no lo tomes a mal es una observación) puede ser tomada por un abogado e iniciarse un juicio, como en el caso narrado y la penalización pagar USD 200 mensuales aproximadamente medio sueldo básico, por dos años, (los esquemas de tratamiento evolucionan de acuerdo a los estudios y el avance de la ciencia, pero no se pueden usar muchas veces por cuestiones económica o no haber las herramientas necesarias, entonces habrá que usar lo que se tiene a mano y lo que se conoce, en su momento es útil  el Fe IM) Veamos ahora costos: Una ampolla de Ferrum maltosato cuesta Un dólar por 4=USD 4, más un dólar la puesta IM Jeringuilla USD 0,10 x 4 (Enfermera bien capacitada técnica en Zeta)= USD4,40 es decir un total de 8,40 dólares. Una Ampolla de Hierro IV FCM costaba USD 12 (Ahora USD 3???) Una solución salina de 100 mL cuesta USD 0,90 Un equipo de Venoclisis USD 0,70 + Jeringuilla USD 0,10 más USD 200 del Hematolog@ por realizar el procedimiento = Antes Costo Total Fe IV USD 213,70. Costo actual USD 204,70. La paciente: Esperando un trasplante renal, falleció el padre  de  Ella; fue sometida a un régimen nutricional y tratamiento con psicóloga (No le cobre por mi ejercicio profesional ni un centavo), quiso estudiar medicina, se retiro luego del primer año y empezo Nutrición y Dietetica becada, se graduo, se caso, ahora es madre y mantiene un regimen saludable de alimentación y Trabaja en una institución que se encarga de los problemas alimentarios y tratar sobrepesos. No tomeis a mal mi narración , pero es mi vivencia.

Dear Ivo and Jose

José Antonio García-Erce

Agree with you. The case I exposed occurred 8 years ago, two years after the socialist government began, there was a shortage of medicines, only had Hierro maltosato IM, the father of the girl had worked as a supervisor in a pharmaceutical company, was dismissed and retired to have Chronic Renal Insufficiency and hemodialysis. The patient made a clinical picture of bulimia (she fed and caused vomiting without her relatives saw) and anorexia, she saw her image distorted in front of the mirror, everything started because her brother said fat, face of pig, etc. Stature 1.40 m Before I weighed 60 kg when I saw it 45 kg, it started 7 months before it was called by the father because he had had a syncope, indicating that he was lying down and lifting the girl's legs and taking her to the emergency room. (She had not breakfast, hypoglycemia?), He felt a little better and requested for a Complete blood count, Platelets, Serum Iron, Ferritin, Transferrin, Glucose (which resulted in 75mg / dL) With the above information of Hb and Htc. With the current legislation an opinion (El Hierro IM should be avoided or prohibited, do not take it wrong away, is an observation) can be taken by a lawyer and initiated a Legal judgment, as in the case narrated and the penalty pay USD 200 monthly approximately half basic salary, for two years, (treatment schemes evolve according to studies and the advancement of science, but can not be used many times by issues economic or not have the necessary tools, then a MD have to use what he had at hand and what is known, Fe IM is useful at the time Let us now see costs: A Ferrum maltosate ampoule costs One dollar for 4 = USD 4 , Plus a dollar  every IM Shot Syringe USD 0.10 x 4 (Well trained Nurse in Zeta technique) = USD4.40 ie a total of $ 8.40. An IV Iron Amp FCM cost USD 12 (Now USD 3 ???) A 100 mL saline solution costs USD 0.90 A Venoclysis Unit USD 0.70 + Syringe USD 0.10 plus USD 200 Hematolog @ The procedure = Before Total Cost Fe IV USD 213.70. Current cost USD 204,70. The patient : Waiting for a kidney transplant her father passed away; She was submitted to a nutritional regimen and treatment with a psychologist ( I does not charge her for my professional practice a penny), she wanted to study medicine, she retired after the first year and began Nutrition and Dietetics, graduated, married, now She is mother and maintains a healthy diet of food and works in an institution that is in charge of food problems and treat overweight. excuse me do not take wrong my story , but it is my experience.

De acuerdo con todos, No os conozco, es interesante conversar nuestras experiencia.

Estimado IVO pública tu experiencia: Correlations Hb IV recovery FCM. 

Buena semana a todos.

Querido Jorge Luis

Siento que mis palabras/mis opiniones hayan podido herir sensibilidades o puedan llegar crearte problemas. No es el foro para hablar de política, pero siento y lamento que cualquier régimen liberticida, que bajo una bienintencionada pero malinterpretada búsqueda de una justicia social a través de la igualdad, llega a poner en peligro hasta la salud de sus ciudadanos -que llegan a perder su condición por la de súbditos-. 

Yo también he llegado a administrar hierro IM en el siglo pasado, a pacientes jóvenes con anemias graves (Hb inferiores a 5 g/dL), pero la experiencia acumulada con casi todos los hierros ev disponibles en Europa desde 2000, con varios cientos de pacientes (quizás miles) tratados en múltiples escenarios, patologías y diagnósticos, me permiten afirmar que puede ser uno de los grandes avances seguros y efectivos para mejorar la calidad de vida de nuestros pacientes médicos y quirúrgicos.

Mucha suerte, a tu disposición

Saludos

José Antonio

Hola a todos, 

Estimado IVO, pensando en vuestro caso tratado con  hierro, folato, vitamina B12 y Oxigenoterapia Recordaba un párrafo que leí en una Hematologia (No recuerdo si es la Hematologia de Williams o una hematología pediátrica de Osky): Que en las anemias graves, se debe suministrar al paciente Oxígeno 7 a 10 Lts por minuto, lo cual satura la poca hemoglobina que se encuentra y entra el O2 en disolución saturando la fase líquida de la sangre, es exactamente como quien realiza una transfusión de urgencia, Esto como apoyo a porque la oxigenaste.

Dear IVO, thinking of your case treated with iron, folate, vitamin B12 and oxygen therapy I remembered a paragraph that I read in a hematology (I do not remember if it is Williams Hematology or Osky's Pediatric Hematology) :  in severe anemia, supplying the patient with Oxygen 7 to 10 Lts per minute, which saturates the little hemoglobin that is and enters the O2 in solution saturating the liquid phase of the blood, it is exactly like doing an emergency transfusion, this in support of because the oxygenate your patient.  Please public your experience and work, and then send to us your publicatión.

Dear José Antonio,

I remember...NATA Congress, Lisbon 2008! 9 years ago.

I know...publish or perish..

In these years I actually did a lot of studies but I didn't publish them. Thank you  for your exhortation! I'm just writing an article on plasma appropriateness (presented at NATA Congress in Florence)

Dear Jorge Luis,

as you pointed out, the dissolved oxygen in the blood is very important in these cases and is often used in JW with life-threatening anaemia.

Dear Antonio,

I agree with you. It's exciting for me sharing knowledges.

If you are interested, you can find me (and my group voted in Patient Blood management ) on Twitter (@PbmOvestMi), Facebook (@PbmOvestMi) and LinkedIn ( www.linkedin.com/in/ivo-beverina-78385377 )

Best regards to everybody!

Dear Jorge

In our classical "blood saving protocols" we give iv iron, plus B vitamins, EPO sc if Hb under 13 g/dL preoperative, "restrictive transfusion criteria", "one by one" ("Only One" in Italy, actually), but we add "oxiygen supply the firs 48 hours after surgery"!

Wonderful protocol! You start very early with iron and others drugs! 

An answer...Is Epo so cost effective to be used as a standard therapy for all patients?

Kind regards

At Spain, YES!

We have national discounts over 80-85% EPO cost!

Also we have biosimilars of alpha-EPO.

And also, if you give IV iron, rarely more than two EPO doses are need!

In our hip fractures, we usually give an unique EPO dose (

Very easy in Spain, I agree!