Parenteral Iron Therapy for the Treatment of Acute Surgical Blood Loss

 Drs. Nichelle Hocking-Brown, Ambre Olsen, Jeanette Harrington
       University of Iowa
       Iowa City, Iowa

Aim: To report our experience with IV iron therapy in the management of acute postoperative blood        loss in the stable patient.
Case 1:   38 yo P3 POD# 8 s/p TAH/BSO for benign disease presented with abdominal pain and a hematocrit of 20. CT revealed two large pelvic hematomas. Pt strongly declined the blood transfusion. IV iron therapy administered. Four weeks later hct was 36.
Case 2:   42 yo P2 in course of Burch RPU lost 2 liters of blood.  Vitals stable and visiting professor suggested parenteral iron instead of blood transfusion. Pt did well and no transfusion was required
Discussion:   Parenteral iron therapy was used effectively to overcome acute anemia from surgical blood loss. Barriers to use include the fear of adverse reactions.  Serious adverse reactions occur rarely. In a recent study on its safety, no patients had an anaphylactoid reaction. Recent changes in the formulation will likely lower the adverse reaction rate even further. 
  Parenteral iron therapy is effective. The earliest hematologic evidence of response to treatment is an increase in reticulocytes. The maximum reticulocyte count occurs within 5-10 days. The hct corrects within 4-8 weeks. 
 While blood transfusion results in an immediate correction of anemia and is the treatment of choice in the unstable patient, transfusion is not without risks. HIV, Hepatitis B and C, CMV, HTLV, and bacterial infections can all be contracted through blood. The risk of HIV is currently 1:200,000 – 1: 2,000,000 per unit transfused and the risk of hepatitis is 1:30,000 – 1:250,000 per unit transfused. One half of blood recipients who contract Hepatitis B develop symptoms. About one half of those who contract Hepatitis C develop a chronic form and many of them go on to develop significant liver dysfunction, including cirrhosis and cancer. 
  Clearly, oral iron therapy is also effective. Side effects including stomach irritation and constipation may lead to noncompliance. 
  The question is whether parenteral or oral iron raises the hematocrit faster. A recent study on postpartum anemia demonstrated an average increase in hct on day 14 after parenteral vs. oral iron to be 9.2 vs. 8.0, respectively. The role of erythropoietin combined with parenteral iron therapy is also showing promise to correct anemia and merits further investigation.