Successful management of profound anemia in upper GI bleed without blood transfusion: a case report.

A 22-year-old male Jehovah’s Witness was referred to a MedStar hospital with a bloodless medicine and surgery program from a hospital where transfusion was the only treatment option offered to him. His hemoglobin upon admission was 3.7. He was evaluated by the bloodless medicine and surgery team and was found to be profoundly iron deficient (ferritin level 1mg/ml, transferrin saturation 3%). Iron repletion and other supportive therapy corrected his anemia and he was discharged from the hospital with a hemoglobin level of 7.6; one week after discharge his hemoglobin was 10.3.

One of the “pillars” – the key principles – of bloodless medicine and surgery is managing anemia appropriately without blood transfusion. Much has been learned about how well the human body adapts to anemia, so that even profound anemia is shown to be survivable.

The case of “Brian Chen” well illustrates this principle. Other key principles of bloodless medicine and surgery will be highlighted throughout the case report.

A 22-year-old male Jehovah’s Witness with two prior episodes of coffee-ground emesis and extreme pallor was evaluated at a MedStar hospital where no bloodless protocol or program was available. Before the care team was aware that the patient was a Witness, they recommended blood transfusion. When they learned that the patient was a Witness, they promptly transferred him to the care of the Bloodless Medicine and Surgery Program at Georgetown University Hospital.

A first priority in bloodless medicine and surgery is to identify and stop any active bleeding. This strategy is highlighted in the document “Clinical Strategies for Managing Acute Gastrointestinal Hemorrhage and Anemia Without Blood Transfusion”. This strategy sheet advises:

Clinical Action Alerts:

• Patients who present with active upper or lower gastrointestinal (GI) bleeding represent a high-risk medical emergency that requires immediate aggressive intervention.
  
• The management priorities are to support the circulation and simultaneously identify and arrest the source of bleeding.
  
• Determination of the severity of bleeding should be based on the estimated magnitude of the initial hemorrhage and the rate of current bleeding. This can be ascertained from the history and physical examination, hemodynamic status, presenting symptoms, and endoscopic findings.
  
• In the bleeding patient, initial assessment can take place during resuscitation.

Mr. Chen’s evaluation upon admission to GUH revealed:

One month prior to admission, Mr. Chen experienced diarrhea and vomiting and thought the illness was likely due to a stomach virus. These symptoms appeared to resolve, but two weeks later, he experienced severe back pain. He took 200 mg of Tramadol, a mild narcotic, over 10 hours to help ease the pain. He then had an episode of coffee-ground emesis on the following day. Mr. Chen regularly took duloxetine for his chronic back pain and, in addition to this, had been taking about 600mg of ibuprofen, four times a day, for about a year.

• 22-year-old male with a history of scoliosis currently on Cymbalta.
• History of a prior lower gastrointestinal bleed approximately eight years ago.
• Presented to ED at an outside facility and with two prior episodes of coffee-grounds emesis. First episode was on Sunday prior to admission. After the episode on Sunday he reported no recurrence on the following day. However, two days later on Tuesday, which was the day of presentation to the outside facility, he experienced another episode of coffee-grounds emesis.
• Approximately two-to-three weeks prior to admission he had a gastrointestinal illness including diarrhea and some nausea. He denied any history of coffee-ground emesis at that time. He also denied any history of change in the color or consistency of his stools. He denied any black tarry stools.

• Blood pressure 99/50
• Pulse 127
• Extreme pallor and fatigue.
• Very thin male with pale conjunctivae.
• Oropharynx was clear.
• Pupils were equally round and reactive to light.
• Tachycardic, normal S1, S2. Presence of a flow murmur throughout.
• Lungs were clear to auscultation bilaterally. No wheezes or rhonchi.
• Abdomen was soft, was non-distended, non-tender to palpation with normoactive bowel sounds.
• Pulses were +2 throughout and no evidence of calf tenderness or lower extremity edema.
• Neurologic examination: He was appropriately conversant, moving all four extremities. Strength was 5/5 throughout.

By the time the patient was admitted to the ICU, his hemoglobin had dropped to 3.1. Despite this very low level of hemoglobin, his condition was stable; he showed no signs of confusion as he would have in the presence of lack of oxygen to the heart and brain. He showed signs of compensatory mechanisms due to his very low  hemoglobin. His pulse was elevated to 170-180. He showed no signs of active bleeding such as bloody stool. In view of his history of coffee-ground emesis, the care team suspected an upper GI problem. Taking these factors into consideration, the care team focused on stabilizing him, monitoring his vital signs every hour, and requested endoscopy and hematology consults (the latter because of his low platelet count).

The endoscopist did not agree to an exploratory procedure due to the patient’s very low hemoglobin. Although the risks of endoscopy are very low, since the patient had no buffer in case of an adverse event, endoscopy was postponed.

The hematology report came back negative for bone marrow disease. Lab tests revealed that Mr. Chen’s ferritin level was 1/mg/ml and transferrin saturation was 3%. These indicators of profound iron deficiency, along with the patient’s long- and short-term use of medications known to potentially cause bleeding as a side effect, were crucial for developing the treatment plan. As he did not show signs of active bleeding, the care team decided to wean the patient off his pain medications and administered folate, B12, IV iron, EPO and a PPI. He was given a single shot of 1000 micrograms of vitamin B12 and one 250 mg dose of IV iron daily for six consecutive days. He responded well to this protocol and his hemoglobin began to rise, indicating that his reticulocyte production was normal.

Within a few days it was clear that Mr. Chen’s urgent issues were being addressed effectively. His pallor, energy, and mood improved, and his hemoglobin continued to rise. It may require 24-48 hours for a patient to respond to iron supplementation, and the hemoglobin level may plateau and then suddenly jump. Mr. Chen’s hemoglobin at discharge was 7.6; one week after discharge it was 10.3, confirming the appropriateness and effectiveness of the treatment plan. Follow-up endoscopy after his discharge revealed eosinophil enteritis, a chronic auto-immune system disease that causes GI illness.

At most healthcare facilities, this patient would have been given a blood transfusion immediately. It has happened more than once that a patient in his condition has been told that without a transfusion they would die. In addition to violating the patient’s conscientious stand, blood transfusion would have raised the patient’s hematocrit only temporarily, and would have exposed the patient to the risks of transfusion without addressing the underlying issues of extreme iron-deficiency anemia and iatrogenic bleeding. Tolerating this otherwise stable patient’s low hemoglobin until the underlying cause of his anemia could be diagnosed and addressed led to optimal care.

No measures were taken by the bloodless care team that the first hospital could not have provided, had they been trained in bloodless medicine and surgery.