Urgent: anyone know about blood transfusions?

[IJustHadToLookHavingReadTheBook]

Hi all

Apologies for putting this in chat- I'm doing it for traffic.

My sister is 35 and in hospital after coming in through A&E three nights ago with a chest infection. Shes been poorly for weeks and had three lots of oral antibiotics. She's been treated with IV antibiotics now and is getting better on that score but she's severely anaemic. This is an ongoing and chronic issue- she takes high doses of iron and has done for ~10yrs but investigations have proven that she just absorbs iron very poorly and seemingly the period of illness she's had (it started with covid back in Feb) has made this worse.

She's got a HG level of 7.9 currently. That's down from 8.2 on Tuesday but has been consistently 7.9 for two days. No active bleeding anywhere, lots of checks and tests done and they're confident of that. Two A&E doctors felt she should be transfused and recommended this - one originally via ambulatory care and then the second wanted her to have it through the hospital ASAP. This was further compounded by a severely high pulse- 120 at rest, 150 when moving. That's calmed down a bit now, but she's still consistently got a pulse of 90-100. No previous history of this.

After 24hrs of being pushed around to find a bed we have been told this morning that she actually doesn't qualify for a transfusion because they don't transfuse until under 7. This is totally at odds with what the A&E doctors have said but I can see on googling that those are the guidelines. I don't know what her hematocrit is (or what a hematocrit is!) but from what I can gather 30% is the number below which that shouldn't be. They're now saying she may qualify for iron injections today before they discharge.

I feel very strongly that my sister needs a transfusion. She's a level of pale I've never seen her (or an alive human!) and I think they're just trying to get out of the expense/aggravation of transfusion. She's very weak and breathless. Even an iron infusion would be better than nothing.

I'm trying to put together a case and gather info, but I'm a history teacher rather than a doctor so would appreciate any help.

Thanks in advance.

Can you get in touch with PALS?

no one on here can really advise you because the decision is based on more than just the numbers. She has at least 2 things going on that will be contributing to how she's feeling, the raised pulse etc and the only people who can decide where the balance of risk and benefit lie are the people who can see her and interpret the results in context. It's not at all beyond the realms of possibility that a blood transfusion isn't needed though, particularly given the chronic nature of the anaemia (and it should be remembered that transfusions are not risk free so there has to be some significant benefit to giving one).

I don't understand the numbers you've given, my recent FBC listed my HG as 135 g/L.

Are you not in the UK?

If iron injections/supplements will bring her Hb to a satisfactory level then that’s what should happen.

She has a chest infection which could be contributing to her poor appearance, breathlessness and tachycardia.

Her anaemia appears to chronic and not deteriorating at a significant pace so the best option IME is to treat the infection as a priority.

I had a transfusion recently due to anaemia. I was told the cut off was 8. I was 7.6. I'd been shovelling in iron tablets

I had a transfusion as a stop gap and was told I'd be referred for an iron infusion the next week but then was told no.
My GP tried to help so I got an appointment for an infusion 6 weeks after the transfusion.
I knew I couldn't wait that long as I felt so ill. So I paid for a private infusion. Worth every penny!

May I ask, is the number you've written your folate level or HG?

@TomatoSandwiches HB it should be over 115.
Even after my transfusion it only got to 96

Thank you 🙂

I know you are trying to help her but you need to talk to the doctors not gather evidence on the internet. Your sister has an infection, that could well influence her pulse. And she's chronically unwell and anaemic which is why she's pale. A blood transfusion is not risk free and can have implications for future care. Has she had any pulmonary rehab push Covid? Breathlessness is multi factorial. Can somebody go in and ask to speak to a doctor about her whole condition, not just the possible transfusion. It's common that doctors seeing a patient first will describe what may be done, then when more info is gathered eg that she's not actively bleeding that plan changes.

Can I just say - as someone who has had a blood transfusion - I'm discovering in a subsequent pregnancy that I have strange antibodies in my blood from having previously had a blood transfusion. I do think it should be a last resort. Have they tried an iron transfusion first?

For those questioning the figures, it is different units. Some hospitals would say 7.6 for example but the hospital up the road would say 76 for the same result. OP, I would be fighting this based on the fact that she is clearly symptomatic from her low Hb. If someone is walking around totally fine with that level it's totally different to someone who is significantly tachycardic. Sounds like she really needs it to me. Iron injections take time to work she needs something ASAP.

Transfusion is a last resort for many reasons. Not least because there are frequently shortages of supply, but also it’s not the simple solution - there’s lots of risks involved in pumping someone else’s blood into your body.

The clinical team will look at less risky and potentially easier ways first before they opt for the transfusion.

My friend is a transfusion specialist. It's a last resort because the risk is much higher than most people know. Its a poorly understood area even by clinicians.

Listen to the specialist. A&E are generalist in most things (specialist in emergency medicine). I know you want the best for your sister and you are not a clinician.

Agree with this and I've had lots of transfusions due to a blood disorder I have.
I now have to carry a card at all times as I have platelet antibodies in my blood and a transfusion of blood that is just the same type (like A or B etc) could kill me.
The last transfusion I had, had to come from a matched donor from the other end of the country.

I would risk saying that the reason they arent doing a transfusion is because she has held steady and they probably hope the HB will increase in the next few days.
Like PP have said, there are risks with transfusions.

I just wanted to update on this in case anyone else is ever in this position and needs advice.

After looking at the Nice Guidelines for transfusion and a few other bits and pieces for anaemia and bleeding etc. we asked about the possibility of a gastric bleed- she has acid reflux and has done since her pregnancies. Because she takes a large amount of oral iron her stools are always black, so had there been a gastric bleed it would have been hard to obviously see.

This wasn't taken hugely seriously at first, but then one doctor latched onto it and she subsequently went for an endoscopy which found a bleeding ulcer.

She's now been transfused with blood and iron infusions and is feeling and looking much better. The ulcer will be treated by gastro who she's seeing tomorrow.

Lesson being: even if there's no clear bleeding, maybe there is!

I hope your friend recovers quickly @IJustHadToLookHavingReadTheBook Glad to hear that the issue has now been identified and that treatment is underway.

Doctor here. We don’t usually transfuse unless Hb <70 (old fashioned term would be 7.0). Unless you have ischaemic heart disease then if it’s <80. Obviously there are exceptions.

Sounds like your sister might benefit from an iron infusion. Also maybe a repeat referral to haematology if impacting upon her quality of life. Transfusions have risks that can be serious so if her Hb is 79 (don’t know why you were told 7.9 that’s a very old school way of looking at things) then the benefits of a transfusion will not outweigh the risks plus we don’t have a limitless supply of blood products.

Just seen about the ulcer! Good that they looked into it. Very unusual at her age. She’s lucky it was found!