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November 23, 2020

No Bad Blood—Surviving Severe Anemia Without Transfusion

Author Affiliations
  • 1Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
  • 2MedStar Institute for Quality and Safety, MedStar Health, Columbia, Maryland
  • 3MedStar Georgetown University Hospital, Washington, DC
JAMA Intern Med. 2021;181(1):7-8. doi:10.1001/jamainternmed.2020.6560

A 51-year-old female Jehovah’s Witness with a history of uterine fibroids traveled from her home country of Colombia to the US for a 2-month visit to assist her daughter in caring for her newborn baby. Soon after arriving in the US, she experienced heavy vaginal bleeding that continued for 2 weeks. She developed dyspnea with exertion, chest pain, and fatigue. She went to an urgent care center for evaluation and was found to have a hemoglobin level of 4.6 g/dL (range, 11.0-14.5 g/dL; to convert to g/L, multiply by 10.0); she was then referred to a local hospital for further care. The patient recalled that on a recent laboratory test, her hemoglobin level was 14 g/dL.

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4 Comments for this article
A pretty straightforward case
Alexandre Mello de Azevedo, MD | Private practice
I have treated several patients with iron-deficiency anemia as severe as this patient's without resorting to blood transfusion, even when they have no religious objection to the procedure.  The truly complicated situations involving Jehova's Witnesses are the anemias that are not caused by nutrient deficiencies, like those caused by rapidly progressive hematologic malignancies infiltrating the bone marrow, or severe auto-immune hemolysis that is hard to control in an unstable patient (e.g. elderly, with severe coronary or cerebrovascular disease). Transfusing a patient with iron deficiency will always be something to be avoided.
Bloodless Management
Innocent Okoawo, MBBS, PGDA, DFM(MCN, FMAS | Safehands Specialists’ Hospital for Bloodless Medicine and Surgery Lagos, Nigeria
Excellent article highlighting the need for better understanding of non-blood medical management. We manage several cases like this without hyperbaric oxygen having come to understand the molecular adjustments to low tissue oxygen.
A very instructive article!
Nathaniel Usoro, MD | University Hospital
This is exemplary evidence-based care, no doubt influenced positively by the bloodless medicine program in the center. Evidence-based medicine is the integration of best evidence from current research with patient preferences/values and clinical expertise/resources to address clinical issues in a timely fashion (Sackett, 2000).

Bloodless medicine programs have demonstrated over and over again that transfusion avoidance is associated with improved outcomes, better patient satisfaction, and better clinician satisfaction too. Bloodless medicine should be the standard of care rather than an advocacy.

This is truly a very instructive article!
Standard of Care
Ben Park, MD | Physician Group Practice
I recently managed an elderly woman with a hemoglobin of 4.4 with in office iron infusions. Her only symptoms were exertional dyspnea that resolved once her iron levels were restored. I engaged her in shared decision making. After she understood her options she chose outpatient iron infusions. She got a great outcome that was professionally satisfying and protected her from potential COVID exposure at the hospital.

She had the lowest hemoglobin I have treated with outpatient iron infusions. I have treated other patients with hemoglobins in the 5s.