Major surgery in patients refusing blood transfusion poses a maximum challenge for Patient Blood Management (PBM). At the same time kinetics of erythropoietic regeneration as influenced by therapeutic measures can be studied without parameters being changed by transfusion. We have analysed the anemia development and erythropoetic regeneration in a Jehova"s witness requiring urgent surgery.

A 77yrs old male was admitted with respiratory decompensation due to tracheal compression (giant struma nodosa) requiring tracheotomy and hypertensive pulmonary edema. In need of clinical stabilisation thyreoidectomy was postponed. The course was complicated by pneumonia. Anemia management was implemented only stepwise: hemoglobin (Hb) monitoring; diagnostic anemia workup; substitution of documented deficits and (iv) erythropoetin stimulation with i.v. iron support. Routine methods were applied for clinical chemistry, iron parameters, folate, vitamin B12 and erythropoetin. Erythrocyte parameters were assessed with an Sysmex XN-9000. Due to comorbidities a Hb-concentration of ≥8g/dl was considered desirable.

At admission renal failure was manifest; Hb-concentration (Hb-c) was 13,2g/dl [13,5-16,9] dropping at day+8 to 9,2 and 7,5 after surgery. At this time reticulocytopenia (38/nl) was manifest. Folate deficiency was objectivated (2,2ng/ml [3,9-26,9]) and substitution implemented. Reticulocytes only slightly increased (73/nl). The Hb-c was unstable (fluctuating fluid balance). Epoetin alfa (Erypo®FS 100IU/kg b.w. 3 times weekly) together with Iron-sucrose (FerMed®) were started. Within 5 days, reticulocyte numbers increased. The Hb-c dropped further to 7,1g/dl and then started to rise (7,9 at day +11 after start epoetin; 9,7 day+16; 13,0 day+27) while reticulocytosis was operative (124/nl day+5, 213 day+16, 287 day+27).

Our case illustrates the dynamic of anemia development with delayed erythropoiesis support, as well as the kinetics of regeneration upon adequate utilisation of therapeutic tools. Reticulocyte counts are most valuable for estimating how anemia develops. In face of upcoming surgery erythropoiesis support has to be established forward-looking to the expactable development or aggravation of anemia. Therapeutic pragmatism is preferable to diagnostically based step-by-step decision making.

The authors declare, that there are no conflicts of interest in relation to this work.