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Thread: Low HB / Hemoglobin count....how low can you go?

  1. #1
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    Question Low HB / Hemoglobin count....how low can you go?

    How low of an HB count is life threatening?










    Hello again!

    I posted this question last year....unfortunately I have not received an answer:

    Hi , does anyone know how low of an HB count is considered Life Threatening in Children/Teens, if possible with a Internet link? Our Doctor (recommended by the Liason committee) claims that an HB under 6 is life threatening, he also doesnt believe in EPO. Our son has Leukemia / ALL, and was forced blood against his wishes. His HB was at 5,1 / Heartbeat 120 / Platelets over 100,000 at the time he had no infection. He was still able to go to the restroom, was up and around, still eating(alot), and he could still carry a conversation. I should add that this is a doctor in Germany and in Germany parents have no real legal rights to minors that are in hospital care. We try to work together to a certain degree...Why do doctors use the magical number (HB) 7 when they start giving blood transfusions, to nonwitness children? It would be really nice if someone could help me out. Thank you!

    I have now a new question....my son continues the fight against ALL, he ist now 17 and once again the question of how low can a doctor go before he gives him a blood transfusion? Right now his HB is at 2,5 (we are now in another hospital that works better with Witnesses and gives him EPO once a week), Heartbeat when asleep/resting about 110, when going to the restroom about 135, Oxygen level between 95-100%, Blood pressure is approx. 80/40 it varies (it depends what he is doing, watching TV, talking or sleeping). He has had a low HB level since about 6 days...unfortunately it keeps dropping! So far no signs that it is going to increase...so can anyone help me?? If all his vital signs are still ok, is there a reason to help keep the doctor from transfusing?? What risks is the doctor taking?? Are there any articles I could read that might help?? Let me put it this was...this is ground breaking working here in this hospital...no child has ever been allowed to have such a low HB without a blood transfusion!! Can someone help me?? Thank you

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  3. #2
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    Hello!
    The level of hemoglobin that is life-threatening would depend on the condition of the patient himself. In adults, anemia in the the presence of comorbid diseases like coronary disease (ischemia) or cerebrovascular disease (stroke) will definitely result in aggravation of the heart disease because an increase in heart rate (body's compensation for anemia) increases oxygen consumption by the heart. Thus chest pain will result. In children, who are otherwise normal (without heart disease) do tolerate severe anemia better than adults do. At which level? We can't really say.

    Clinical reports/studies that I have come across:
    1. Weiskopf conducted a study on human tolerance of anemia (adults) by doing ANH (withdrawing blood to a low Hgb level and giving fluids to maintain normovolemia). They found that at hemoglobin of 6 g/dL and below, the neurological tests were less accurate than when Hgb was higher and improved when patient's blood was reinfused. At lower Hgb levels, regional (organ level) blood flow was compromised even when global (taking the whole body) oxygen supply was normal.
    2. Case report in Anesthesia and Intensive Care, (don't remember the journal issue) of an adult JW who underwent surgery and bled to a Hgb of 1.4 g/dL. Part of the management was using intermittent exposure to hyperbaric chamber to increase oxygen supply to body cells/tissues while iron and EPO were given. Patient survived.
    3. In subSaharan Africa where blood screening tests are lacking or not reliable, their transfusion trigger is 4 g/dL.
    4. A study in children (not sure if by Weiskopf also) using ANH also where lowest Hgb was 5 g/dL. There was no adverse event.

    However, at 2.5 g, possibility of heart failure may occur. I would suggest that your son be kept in an absolute bed rest with a bedside commode, while medications to increase Hgb are given. Exerting effort by ambulating to the toilet will push heart to failure.

    I hope your attending physicians/pediatricians can give the best management to your son.
    Angelina A. Gapay, MD

  4. #3
    [QUOTE=
    I have now a new question....my son continues the fight against ALL, he ist now 17 and once again the question of how low can a doctor go before he gives him a blood transfusion? Right now his HB is at 2,5 (we are now in another hospital that works better with Witnesses and gives him EPO once a week), Heartbeat when asleep/resting about 110, when going to the restroom about 135, Oxygen level between 95-100%, Blood pressure is approx. 80/40 it varies (it depends what he is doing, watching TV, talking or sleeping). He has had a low HB level since about 6 days...unfortunately it keeps dropping! So far no signs that it is going to increase...so can anyone help me?? If all his vital signs are still ok, is there a reason to help keep the doctor from transfusing?? What risks is the doctor taking?? Are there any articles I could read that might help?? Let me put it this was...this is ground breaking working here in this hospital...no child has ever been allowed to have such a low HB without a blood transfusion!! Can someone help me?? Thank you[/QUOTE]

    Your son is clearly a fighter! Children & adolescents are not little adults when it comes to anemia. Brain function is impacted before cardiac performance is impaired. I heard in a recent lecture by Dr. Aryeh Shander, who is probably the most well-respected figure in bloodless care in the United States, that he has used a Gameboy (a type of video game) to assess cognitive function at bedside in an anemic teenage boy. His patient scored so well when his hemoglobin dropped precariously low that no other doctor would challenge his decision not to transfuse.

    A hemoglobin of 2.5 is definitely low, but I have had two small children walk in to my office with hemoglobins of 3.0. I also provided convalescent care for a little boy some years ago whose hemoglobin dropped to 1.6 during a stay in the PICU in New Haven, Connecticut. He eventually left the hospital in good spirits.

    Are there articles? Here are a couple to start with:

    Newton CR, Marsh K, Peshu N, Mwangi I. Blood transfusions for severe anemia in African children. Lancet. 1992;340:916-917. The authors describe 8 children with hemoglobin levels below 3 that were treated without transfusion.

    Frankel LS, Damme CJ, Van Eys JV. Childhood cancer and the Jehovah’s Witness faith. Pediatrics. 1977;60:916-921
    In summarizing their experience treating childhood cancer in children of the Jehovah’s Witness faith, the authors concluded, “It is interesting to note that in all the cases presented, none of the children, whether they lived or died, had a significant change in outcome as a result of withholding transfusion therapy."
    Joseph T. Malak, MD

  5. #4
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    I have a question on how high does the hgb/hct have to be before open heart surgery can be done on a bloodless medicine patient?

  6. #5
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    that is really useful information, thanks J. Malak and Dr gapay,

    Why is there a risk of Heart Failure Dr Gapay?

  7. #6
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    A normal heart usually compensates for acute severe anemia by increasing the cardiac output and heart rate/minute (among other physiologic mechanisms); and for a chronic demand for increased work load by increasing the size of the heart muscles (hypertrophy). Walking through a distance, say, from the bedroom to the kitchen, would produce an increase workload on the heart because the muscles and other tissues of the body would need oxygen. Thus, we see this as an increase in the heart rate. When the physiologic increase in cardiac (heart) output is unable to keep up with the demand for maintenance of oxygen delivery, congestive heart failure occurs.
    Angelina A. Gapay, MD

  8. #7
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    no blood

    Continue to fight for your son. Remember as the parent Jehovah holds us responsible, and takes "absolutely no blood" seriously. You have that right as a parent.

    bj

  9. #8
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    Hello again, my son continued having a low hb of approx. 2,9-2,5 for a period of 7 days! He was not transfused!!!!!! A lot of doctors would come by to see this miracle!! They are taught in Medical school that no one can survive under a HB of 6 and if they do they have brain damage or heart problems. And my son has survived... 8 months later he has almost fully recovered (still a bit tired), his HB is at 16,6 even though he is still taking Chemo tabletts and he has no side afffects from having had a low HB!! A month ago he was "rock climbing", something he hadnt done in 18 months!! We are very happy & proud to have helped him in his fight against blood transfusions!!

  10. #9
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    Thanks for the post.
    Hi guys, Im a newbie. Nice to join this forum.

  11. #10
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    Smile

    Quote Originally Posted by Ihavehope View Post
    Hello again, my son continued having a low hb of approx. 2,9-2,5 for a period of 7 days! He was not transfused!!!!!! A lot of doctors would come by to see this miracle!! They are taught in Medical school that no one can survive under a HB of 6 and if they do they have brain damage or heart problems. And my son has survived... 8 months later he has almost fully recovered (still a bit tired), his HB is at 16,6 even though he is still taking Chemo tabletts and he has no side afffects from having had a low HB!! A month ago he was "rock climbing", something he hadnt done in 18 months!! We are very happy & proud to have helped him in his fight against blood transfusions!!
    It's the good news like this that makes us all feel good. Whether pioneering bloodless surgery, cancer treatment or after-care, when everything has been done that can be done without the use of blood and the patient shows a recovery that is sustainable, we can only rejoice. To top it all, knowing that we haven't compromised our faith gives us the strength we need to carry on.
    Thanks for updating us on this.

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