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An accident during a recent surgery to repair a ruptured artery -- which was a problem from a catheter accident months earlier while getting an angiogram -- caused significant blood loss. I got two transfusions. I found out that there is a huge spread between the standard of HMGlobin high enough to send you home from the hospital and HMG high enough for well being and vigor. I have given up on finding a way to get an additional transfusion. I was discharged at HMG = 9.2. Minimum for an adult male is considered anywhere between 13.5 or 14.0 depending on who you believe. In two weeks it went up to 10.7. While I am no longer afraid to walk across a room without holding on to something I am still a long way from the stamina this 77 YO cardiac arrest survivor is used to. I had been going to a workout 2x/week and doing a 30 mile bike ride 1x/week. No way in my current condition! Takes a lot out of me to walk the dogs a few hundred feet.
Yes, I have been back to the ER and they ran all sorts of tests and found nothing but low HMG.
I had been heavily supplementing my iron but bloodwork told me I went over and needed to cut back.
Before these medical mishaps I never had low HMG.
I am guessing I have a month + to go. It has been 3 weeks now.
It is hard to be patient when surgical mishaps are 100% responsible for my current weakness and an additional transfusion would undoubtedly be a big boost but nobody will give me one.
Anyway, appreciate others' experiences and encouragement! Any hints other than maximum safe iron level to restore HMG ?
People with heart problems can get into trouble with too low or too high blood volumes. They don't handle volume overload and in many cases the split the unit of blood in half and transfuse very slowly. They are hesitant in over doing it with transfusions. Your hemoglobin is going up and it isn't an issue in blood production. It was an incident of blood loss and that is over I presume. One would expect your hemoglobin to get back to pre-incident range at the the present increase. Some elderly have age related anemia due to a decrease production of red blood cells.
Once again, a WARNING to all readers about taking Fe supplements-- NEVER take them unless you have been diagnosed by a doctor, he has investigated why you became Fe-deficient and has then prescribed the Fe pills...The reason: the routine, yearly blood test often shows that you are anemic if you have developed some sort of illness that hasn't otherwise become evident yet. The astute doc will follow up on that anemia and finding your illness early, give you a better chance of recovery...If you had been taking Fe pills, that may cover up the anemia, it won't be apparent on the blood test and your disease will progress until it shows itself at a more serious stage.
In regards the OP's problem-- the cause of the anemia is obvious-- bleeding. No mystery. The treatment was a transfusion first because the anemia was so bad, and the pt has cardiac problems. Once the Hb level was back up to an acceptable level, oral Fe replacement was recommended-- the risks of more transfusions, like hepatitis etc too great compared to the benefit at this point for this pt....A Hb of 10 or so is good enough for govt work here, with the pt being sedentary during his recovery....
Don-- your continued fatigue/malaise is most likely due to the psychological and hormonal stress of your recent experience more than to the effect of a low Hb level. All sorts of illnesses &/or surgeries can "take something out of you" (no pun intended). Pts frequently have such complaints after a major surgery, then one day- a few days, maybe even a few weeks later, they suddenly feel "normal" again.
BTW- you can take too much Fe-- follow up with more blood tests. Once the Hb & Hct levels are normal again, you will be told to stop the pills.
Once again, a WARNING to all readers about taking Fe supplements-- NEVER take them unless you have been diagnosed by a doctor, he has investigated why you became Fe-deficient and has then prescribed the Fe pills...The reason: the routine, yearly blood test often shows that you are anemic if you have developed some sort of illness that hasn't otherwise become evident yet. The astute doc will follow up on that anemia and finding your illness early, give you a better chance of recovery...If you had been taking Fe pills, that may cover up the anemia, it won't be apparent on the blood test and your disease will progress until it shows itself at a more serious stage.
In regards the OP's problem-- the cause of the anemia is obvious-- bleeding. No mystery. The treatment was a transfusion first because the anemia was so bad, and the pt has cardiac problems. Once the Hb level was back up to an acceptable level, oral Fe replacement was recommended-- the risks of more transfusions, like hepatitis etc too great compared to the benefit at this point for this pt....A Hb of 10 or so is good enough for govt work here, with the pt being sedentary during his recovery....
Don-- your continued fatigue/malaise is most likely due to the psychological and hormonal stress of your recent experience more than to the effect of a low Hb level. All sorts of illnesses &/or surgeries can "take something out of you" (no pun intended). Pts frequently have such complaints after a major surgery, then one day- a few days, maybe even a few weeks later, they suddenly feel "normal" again.
BTW- you can take too much Fe-- follow up with more blood tests. Once the Hb & Hct levels are normal again, you will be told to stop the pills.
Good luck with your problem.
The definition of "an acceptable level" for hemoglobin seems to be not so low as to be life-threatening with no regard for quality of life for the next month or two. According to the Cleveland Clinic below 13.5 is severely deficient. I was discharged at 9.2. I am used to a good exercise program and being forced to be sedentary is not quality of life for me.
I am fully aware iron can be overdone. I have temporarily stopped the iron supplements per bloodwork. Iron is going to be checked again on the 12th. With the guidance of bloodwork I aim to keep my iron levels high but not excessive.
I will reinstate iron supplementation based on blood work and probably continue moderate iron supplementation after HMG is eventually stabilized per the recommendation of my gastroenterologist who found iron borderline low before the whole history of mishaps.
I don't think the weakness is psychosomatic. I was fully expecting to feel better with the fistula repaired. But any placebo effect from that was apparently overwhelmed by the poor hemoglobin level. I don't think I was out of breath and light-headed simply standing up to put my pants on for reasons of psychology and hormones.
What statistics I have been able to find on transfusions state the risk of acquiring HIV or hepatitis are next to nothing.
The definition of "an acceptable level" for hemoglobin seems to be not so low as to be life-threatening with no regard for quality of life for the next month or two. According to the Cleveland Clinic below 13.5 is severely deficient. I was discharged at 9.2. I am used to a good exercise program and being forced to be sedentary is not quality of life for me.
I am fully aware iron can be overdone. I have temporarily stopped the iron supplements per bloodwork. Iron is going to be checked again on the 12th. With the guidance of bloodwork I aim to keep my iron levels high but not excessive.
I will reinstate iron supplementation based on blood work and probably continue moderate iron supplementation after HMG is eventually stabilized per the recommendation of my gastroenterologist who found iron borderline low before the whole history of mishaps.
I don't think the weakness is psychosomatic. I was fully expecting to feel better with the fistula repaired. But any placebo effect from that was apparently overwhelmed by the poor hemoglobin level. I don't think I was out of breath and light-headed simply standing up to put my pants on for reasons of psychology and hormones.
What statistics I have been able to find on transfusions state the risk of acquiring HIV or hepatitis are next to nothing.
The 10 g% hemoglobin is the clinical threshold limit for action based on the clinical state of the patient. Those with compromised cardiac function and cardiovascular state can exhibit symptoms under 10 g% while those without such history can go down pretty low before exhibiting symptoms. One can exhibit symptoms when losing 2 units of blood loss and again that might be more noticeable in those compromised.
The infusion of one unit of blood supposedly increased the hemoglobin 1 g%. Your estimated Hgb after the hemorrhage would be estimated to be around 7 g%. One should transfuse at least 2 units of blood when deciding to infuse blood or not. If one loses 1 unit of blood then that is like donating blood and one does not transfuse just one unit of blood.
One does not want to volume overload (TACO) a person with compromised circulatory problems that could end up causing fluid in the lungs. A Hgb over 10 g% is not an indication for transfusion. A hemoglobin of 13.5 is not considered as severe anemia. There is anemia present but the grading of anemia and the clinical threshold for transfusion are slightly different.
I didn't comment on the iron because I knew something was missing there and not all the information was being presented.
The blood utilization committees reviews all of the transfusions performed and clinical information to see if the blood is being utilized appropriately or not. Doctors may be contacted and warned about their transfusion practices. Transfusion practices and guidelines are clearly outlined. There can be fatal outcome transfusion reactions unrelated to ABO incompatibility. TRALI, transfusion related acute lung injury is the leading cause of death involving transfusions.
It is unclear what is causing your symptoms which seem to imply cardiogenic or circulatory rather than simply oxygenation of the blood.
The 10 g% hemoglobin is the clinical threshold limit for action based on the clinical state of the patient. Those with compromised cardiac function and cardiovascular state can exhibit symptoms under 10 g% while those without such history can go down pretty low before exhibiting symptoms. One can exhibit symptoms when losing 2 units of blood loss and again that might be more noticeable in those compromised.
The infusion of one unit of blood supposedly increased the hemoglobin 1 g%. Your estimated Hgb after the hemorrhage would be estimated to be around 7 g%. One should transfuse at least 2 units of blood when deciding to infuse blood or not. If one loses 1 unit of blood then that is like donating blood and one does not transfuse just one unit of blood.
One does not want to volume overload (TACO) a person with compromised circulatory problems that could end up causing fluid in the lungs. A Hgb over 10 g% is not an indication for transfusion. A hemoglobin of 13.5 is not considered as severe anemia. There is anemia present but the grading of anemia and the clinical threshold for transfusion are slightly different.
I didn't comment on the iron because I knew something was missing there and not all the information was being presented.
The blood utilization committees reviews all of the transfusions performed and clinical information to see if the blood is being utilized appropriately or not. Doctors may be contacted and warned about their transfusion practices. Transfusion practices and guidelines are clearly outlined. There can be fatal outcome transfusion reactions unrelated to ABO incompatibility. TRALI, transfusion related acute lung injury is the leading cause of death involving transfusions.
It is unclear what is causing your symptoms which seem to imply cardiogenic or circulatory rather than simply oxygenation of the blood.
The severe weakness symptoms happened after a fistula, which I acquired through a catheter accident in my groin when getting an angiogram, was repaired. I went to the ER and received all kinds of tests. Cat scan, ultrasound, bloodwork, I was continuously monitored, chest x-ray. EKG. I was told all these tests were normal, while for some reason they did not mention low hemoglobin. Two doctors from the same practice as the surgeon who repaired the fistula came to the hospital and looked at the groin site and said everything was fine there. That night I was told I would be admitted for overnight and further testing done the next day and they were determined to get to the bottom of what was wrong. The further testing the next day never happened, and I was no longer being continuously monitored. That next day I was taken aback when a doctor came in and said I was discharged and no wonder I felt like crap with low hemoglobin. As the hemoglobin has gone up my symptoms have improved but I have a long way to go.
Unless I am mistaken the Cleveland Clinic has an excellent reputation, hardly fly-by-night quacks. I quote: "At what level is hemoglobin dangerously low?
Normal hemoglobin levels are different for men and women. For men, a normal level ranges between 14.0 grams per deciliter (gm/dL) and 17.5 gm/dL. For women, a normal level ranges between 12.3 gm/dL and 15.3 gm/dL. A severe low hemoglobin level for men is 13.5 gm/dL or lower. For women, a severe low hemoglobin level is 12 gm/dL."
Last checked my hemoglobin was at 10.7 which is considerably below the 13.5 threshold so well into "severe low" if we are to believe the Cleveland Clinic.
The severe weakness symptoms happened after a fistula, which I acquired through a catheter accident in my groin when getting an angiogram, was repaired. I went to the ER and received all kinds of tests. Cat scan, ultrasound, bloodwork, I was continuously monitored, chest x-ray. EKG. I was told all these tests were normal, while for some reason they did not mention low hemoglobin. Two doctors from the same practice as the surgeon who repaired the fistula came to the hospital and looked at the groin site and said everything was fine there. That night I was told I would be admitted for overnight and further testing done the next day and they were determined to get to the bottom of what was wrong. The further testing the next day never happened, and I was no longer being continuously monitored. That next day I was taken aback when a doctor came in and said I was discharged and no wonder I felt like crap with low hemoglobin. As the hemoglobin has gone up my symptoms have improved but I have a long way to go.
Unless I am mistaken the Cleveland Clinic has an excellent reputation, hardly fly-by-night quacks. I quote: "At what level is hemoglobin dangerously low?
Normal hemoglobin levels are different for men and women. For men, a normal level ranges between 14.0 grams per deciliter (gm/dL) and 17.5 gm/dL. For women, a normal level ranges between 12.3 gm/dL and 15.3 gm/dL. A severe low hemoglobin level for men is 13.5 gm/dL or lower. For women, a severe low hemoglobin level is 12 gm/dL."
Last checked my hemoglobin was at 10.7 which is considerably below the 13.5 threshold so well into "severe low" if we are to believe the Cleveland Clinic.
Sorry about the confusion. Several different things here at play and I will try and explain some although I don't know anyone else anywhere that would call all values below 13.5 g% as severe. What do they consider as mild anemia and what do they consider as moderate anemia? I think that is a typo. Everybody would treat a severe anemia. Everybody else uses this.
Grading of anemia, according to the National Cancer Institute, is as follows:
"Mild: Hemoglobin 10.0 g/dL to lower limit of normal
Moderate: Hemoglobin 8.0 to 10.0 g/dL
Severe: Hemoglobin 6.5 to 7.9 g/dL[1]
Life-threatening: Hemoglobin less than 6.5 g/dL"
Those are the ones that we all pretty much recognize and use.
Those values apply to a person who is hemodynamically stable and not actively bleeding. If a person were to start bleeding all of a sudden one would not see a low Hgb. It takes hours before the Hgb drops to reflect the bleeding. The better indicator is the visible blood loss as a way of knowing a loss of blood and another way is the blood pressure drop either as a result of blood loss outside of the body or inside of the body. he blood pressure drop tells us how much blood to give.
There are blood transfusion triggers based on the blood pressure in a hemorrhaging patient. In all other hemodynamically stable patients not actively bleeding then the above ranges apply.
Based on that scoring of mild, moderate, and severe ranges one can guess the amount of blood needed to replace based on the one unit 1 g% increase.
As far as clinical thresholds for blood transfusion there are differences around the world. There might be some variances here and there.
This is an article about Sweden,
"Transfusion of red blood cells (RBC) is performed daily in hospitals around the world [1]. Blood transfusions, however, can be associated with multiple disadvantages due to potential adverse events, high costs and limited availability [2, 3]. For many decades, the arbitrary threshold for RBC transfusion was set at a hemoglobin (Hb) level of < 100 g/L and a hematocrit of < 30% [4–6]. The results from the TRICC trial, supporting the restriction of RBC transfusions in specific patient populations, has led to a rethinking [7]. Hence, lower Hb thresholds of 60–80 g/L have been suggested in most patients [7–11]. At present, a broad variety of different transfusion guidelines are available [12–15]. They all emphasize that not only Hb levels, but also patient-related factors (e.g. age, comorbidities, risk of cardiac ischemia) and heterogeneity of anemia (acute versus chronic) should be considered in the decision to transfuse."
The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence).
Recommendation 2:
The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence).
Recommendation 3:
The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence).
Recommendation 4:
The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence).
The top two recommendations are stronger will the lower 3 and 4 are weak to very weak stregnth in the evidence.
So what you are asking for is one go by Recommendation 4 and that is it should be based on your symptoms and hemoglobin. There is very low quality evidence for that.
Sorry about the confusion. Several different things here at play and I will try and explain some although I don't know anyone else anywhere that would call all values below 13.5 g% as severe. What do they consider as mild anemia and what do they consider as moderate anemia? I think that is a typo. Everybody would treat a severe anemia. Everybody else uses this.
Grading of anemia, according to the National Cancer Institute, is as follows:
"Mild: Hemoglobin 10.0 g/dL to lower limit of normal
Moderate: Hemoglobin 8.0 to 10.0 g/dL
Severe: Hemoglobin 6.5 to 7.9 g/dL[1]
Life-threatening: Hemoglobin less than 6.5 g/dL"
Those are the ones that we all pretty much recognize and use.
Those values apply to a person who is hemodynamically stable and not actively bleeding. If a person were to start bleeding all of a sudden one would not see a low Hgb. It takes hours before the Hgb drops to reflect the bleeding. The better indicator is the visible blood loss as a way of knowing a loss of blood and another way is the blood pressure drop either as a result of blood loss outside of the body or inside of the body. he blood pressure drop tells us how much blood to give.
There are blood transfusion triggers based on the blood pressure in a hemorrhaging patient. In all other hemodynamically stable patients not actively bleeding then the above ranges apply.
Based on that scoring of mild, moderate, and severe ranges one can guess the amount of blood needed to replace based on the one unit 1 g% increase.
As far as clinical thresholds for blood transfusion there are differences around the world. There might be some variances here and there.
This is an article about Sweden,
"Transfusion of red blood cells (RBC) is performed daily in hospitals around the world [1]. Blood transfusions, however, can be associated with multiple disadvantages due to potential adverse events, high costs and limited availability [2, 3]. For many decades, the arbitrary threshold for RBC transfusion was set at a hemoglobin (Hb) level of < 100 g/L and a hematocrit of < 30% [4–6]. The results from the TRICC trial, supporting the restriction of RBC transfusions in specific patient populations, has led to a rethinking [7]. Hence, lower Hb thresholds of 60–80 g/L have been suggested in most patients [7–11]. At present, a broad variety of different transfusion guidelines are available [12–15]. They all emphasize that not only Hb levels, but also patient-related factors (e.g. age, comorbidities, risk of cardiac ischemia) and heterogeneity of anemia (acute versus chronic) should be considered in the decision to transfuse."
The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence).
Recommendation 2:
The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence).
Recommendation 3:
The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence).
Recommendation 4:
The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence).
The top two recommendations are stronger will the lower 3 and 4 are weak to very weak stregnth in the evidence.
So what you are asking for is one go by Recommendation 4 and that is it should be based on your symptoms and hemoglobin. There is very low quality evidence for that.
I have abandoned hope for an additional transfusion despite my belief it would make me feel significantly better. The purpose of the original post was to get a handle on how long it might take to get my hemoglobin up to a normal range and what can I do to expedite this besides managing my iron level?
I have abandoned hope for an additional transfusion despite my belief it would make me feel significantly better. The purpose of the original post was to get a handle on how long it might take to get my hemoglobin up to a normal range and what can I do to expedite this besides managing my iron level?
There's a lack of full context which is why I concentrated on one discrete point and that was transfusion criteria.
You might have symptoms that you associate with a low hemoglobin. My impression as well as yours is that when your hemoglobin gets back to what it was then you will feel better.
That answer as to how long is dependent on why you are taking iron and why your doctor said your iron levels were low within a context of seeing a GI doctor.
If you iron was low then that would indicate a chronic blood loss or problems in iron absorption. If you are having a negative iron balance then it will take longer to get back to normal if you do get back to your previous hemoglobin levels.
Blood work can give more precise information as to the type of anemia. Normally blood loss anemia is associated with normal red blood cells. Iron deficiency anemia has small pale red blood cells and oval shaped.
There's a big difference between acute onset anemia and chronic anemia associated with iron deficiency. The urgency in treatment is different. With chronic anemia the body adopts and reduces symptoms because the nature of the blood makes it more efficient in oxygen exchange.
One can extrapolate what the hemoglobin was when you left the hospital and the next time you had the hemoglobin checked. That change over that time will give you an estimate. I don't remember the numbers now but I think it was a gram change in a month? If your iron stores were depleted (ferritin) then one likes to see a substantial increase well within the ferritin reference range within 6 months.
There's a lot of information missing to give definitive answers about how long.
There's a lack of full context which is why I concentrated on one discrete point and that was transfusion criteria.
You might have symptoms that you associate with a low hemoglobin. My impression as well as yours is that when your hemoglobin gets back to what it was then you will feel better.
That answer as to how long is dependent on why you are taking iron and why your doctor said your iron levels were low within a context of seeing a GI doctor.
If you iron was low then that would indicate a chronic blood loss or problems in iron absorption. If you are having a negative iron balance then it will take longer to get back to normal if you do get back to your previous hemoglobin levels.
Blood work can give more precise information as to the type of anemia. Normally blood loss anemia is associated with normal red blood cells. Iron deficiency anemia has small pale red blood cells and oval shaped.
There's a big difference between acute onset anemia and chronic anemia associated with iron deficiency. The urgency in treatment is different. With chronic anemia the body adopts and reduces symptoms because the nature of the blood makes it more efficient in oxygen exchange.
One can extrapolate what the hemoglobin was when you left the hospital and the next time you had the hemoglobin checked. That change over that time will give you an estimate. I don't remember the numbers now but I think it was a gram change in a month? If your iron stores were depleted (ferritin) then one likes to see a substantial increase well within the ferritin reference range within 6 months.
There's a lot of information missing to give definitive answers about how long.
I was taking a moderate dose of iron before this whole mess because gastro doc said my iron was just slightly low. This is the first time I have heard that in my 77 years. Scheduling an endoscopy to check for gastric bleeding keeps getting postponed because of all the other mess but that is what the gastric doc is concerned about. I have suffered from ulcerative colitis but it is currently in remission. After the ER visit I ramped up the iron to 65 mg pure elemental iron 2x/day. This shot the iron higher than it should be so stopped. Iron will be checked again tomorrow and supplementation adjusted or postponed as appropriate. Extrapolating from increase to 10.7 a while back I guess I have a month to 6 weeks to go. This is all confounded with getting out of shape due to lack of exercise since before 12-20. I should be cleared for working out and bike rides by the surgeon who repaired the fistula on 1-18. This can only help although I anticipate the riding and workouts initially will be far from what they were before the whole mess.
I will do my best to be patient.
Is there anything else I can to help the recovery process? I guess not.
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