Do You Chew Ice? You May Be Anemic, and This May Present a Serious Risk to Your Health

Iron-Rich Foods

Eating iron-rich foods is one way for many people to avoid being anemic. There are two types of food which may be sources of iron. Food derived from plants is a source of nonheme iron. Food derived from animals is a source of heme iron.

Heme iron is more easily absorbed by the body. In the picture above, the whole wheat bread and kidney beans are sources of nonheme iron. The clam and egg are sources of heme iron. A more complete list of iron-rich foods may be found at the Cleveland Clinic site: Iron-rich Foods and Anemia

Ice
If you crave ice, maybe you should see your doctor, because chewing ice can be a symptom of anemia. According to the Mayo Clinic, pagophagia (ice-chewing) is often associated with iron deficiency, with or without anemia. I learned this the hard way.

felix_w on Pixabay*

There was a time when my freezer couldn't keep up with my appetite for ice cubes. I took to buying Slurpies (an ice drink) from 7-Eleven. My craving for ice was truly insatiable. It wasn't until I went in for emergency surgery that my significant anemia was revealed. Surgery had to be postponed for 24 hours because I needed a blood transfusion.

Paulbr75 on Pixabay

Adverse Outcomes for Patients with Anemia

A 2020 article in Lancet explains that preoperative anemia in a patient facing elective surgery, "is associated with poor outcomes." The importance of addressing anemia in the pre-surgical patient is highlighted in another article, this one published by SABM, the Society for the Advancement of Blood Management. According to SABM, anemia increases the risk of "morbidity and mortality" in the surgical patient.

Defining Anemia
There does not seem to be unanimity in the cut-off points for anemia in different sources. The Mayo Clinic cites a 'normal' range of hemoglobin concentrations at 13.5 to 17.5 grams g/dL for men and 12.0 to 15.5 g/dL for women.

The Pallor of Anemia, on the left (Hand with the Ring)

Image credit:James Heilman, MD. Used under CC 3.0 license.

The journal Lancet describes anemia as hemoglobin concentrations at "130 g/L for men and 120 g/L for women". These values are the equivalent of 13-14.2 g/dL fo men and 11.6-12.3 g/dL for women. While the upper ranges of normal differ between Lancet and the Mayo Clinic, the lower ranges are pretty close, so the cut-off for anemia would not vary significantly.

Transfusions Are Not the Solution

An article published in the journal Surgery asserts that "an overwhelming amount of evidence suggests that perioperative (time around surgery) blood transfusion can be associated with adverse surgical outcomes". A curious finding in this article is that patients who were at low-risk for transfusion complications had a ten-fold increase in adverse post-operative outcomes if they received transfusions within 72-hours of the operation. However, patients who were assessed to be at high risk, did not see their post-operative outcomes increase after transfusion.

Hazen Sise & Dr Norman Bethune with the Canadian Blood Transfusion Ambulance, 1938

Image credit: Imperial War Museum. Used under CC 4.0 license

Multiple sources suggest that the decision to transfuse an anemic patient before surgery cannot be based on one fact alone. If there is not enough time (as would be the case in an emergency) to raise iron levels gradually before surgery, doctors have to consider several factors before deciding whether or not to transfuse.

Thermometer Indicating Fever

Image credit: Menchi. Used under CC 4.0 license

Guidance issued by the JPAC (Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee) states: "Clinical factors, as well as the degree of anaemia, must always be considered when making the decision to transfuse."

Returning to my particular case as an example: there was an underlying condition which caused the doctor to refer me for surgery. There were complicating factors. Anemia was just one of them. This likely raised the likelihood that I would receive a transfusion.

Fortunately I seem to have come out of the surgery and the transfusion without complication. This incident occurred more that thirty years ago. Not everyone has the same good outcome.

Some adverse events associated with transfusions, according to the Royal Children's Hospital in Melbourne:

*Fever and chills
*Mild allergic reaction (occurs in about 1%)
*Severe allergic reaction (anaphylaxis)
*Acute haemolytic reactions (usually caused by transfusing incompatible blood types)
*Bacterial contamination
*Transfusion related acute lung injury (usually occurs 2 to 8 hours later)
*Hypothermia
*Citrate toxicity
*Delayed haemolysis (patient develops antibodies to red blood cells)

Image credit:Foxtrot620. CC license 4.0

Although I did not have an adverse outcome from the transfusion, there was a moment of panic from the medical staff as my first bag of blood was initiated. Hives started to appear here and there, quite consistently. The nurse assumed I had an allergic reaction to the blood. She changed the bag. More hives. It then occurred to her that I was also receiving intravenous antibiotics--an antibiotic to which I had a known allergy. Oops!! She switched antibiotics and after that there were no problems with my infusions. (In U.S. hospitals, medication errors number about 1 out of every 854 inpatient deaths.)

Avoiding Blood Transfusions
An article published in Hospital Healthcare Europe discusses the desirability of limiting transfusions and at the same time acknowledges the necessity of using transfusions in certain circumstances. Besides the cutoff thresholds for assessing anemia and the importance of considering the overall clinical picture, there's the issue of blood dilution caused by fluid infusion.

If medical staff assesses hemoglobin concentration, that concentration may be artificially reduced if large amounts of fluids are introduced intravenously. This is often the case during surgery. A physician interprets the artificially low hemoglobin concentration as anemia and needlessly transfuses, thus complicating the recovery outlook for the patient.

Red Blood Cells Pictured in Three Different States

Image credit: Zephyris. CC license 3.0 An excerpt from the caption under this: "Three conditions are shown: hypertonic..., isotonic (...appear normal), and hypotonic..."

Procedures to Avoid Transfusion During and After Surgery

There are four established procedures that may allow a surgeon to avoid instituting a transfusion:

Autologous TransfusionPerhaps the most well-known of transfusion sparing procedures, preoperative autologous donation (PAD) involves storing your own blood in advance of surgery. One of the reasons this procedure has fallen out of favor among some medical professionals is that the blood often is not used and therefore is wasted. Another reason is that there seems to be an increased likelihood of receiving a transfusion if an autologous blood supply is at hand. Also, according to the BJA (British Journal of Anesthesia), there's a risk of clerical error in collecting, storing and reinfusing the blood. Also a risk of bacterial contamination.

Here's a YouTube video showing the process of autologous blood collection:

Intraoperative Hemodilution This involves removing a small amount of blood, one or two pints, before surgery and replacing that blood in the patient with acellular fluid (crystalloid and/or colloid replacement fluid). There does not exist universal endorsement of this procedure in the medical community. A 2002 article, from the journal Anesthesiology, describes a "lack of efficacy in reducing the need for allogenic (person to person) transfusions and postoperative bleeding." However, other articles assess the procedure more positively. A 2020 article in the Journal of Clinical Anesthesiology, considers intraoperative hemodilution during the time of COVID-19 to be a life saver. Not only is blood scarce during the pandemic, but there is the possibility of COVID-19 shedding in allogenic transfusions.

Blood Salvage This involves exactly what it sounds like: blood is captured during surgery, and even may be collected from the site of incision. This 'salvaged' blood may be reintroduced to the patient after the procedure. This may eliminate or reduce the need for an allogenic transfusion.

Treating Anemia in advanceThis approach doesn't work in an emergency situation. In cases of elective surgery, the type of anemia should be assessed. Iron deficiency anemia is the most common. According to the Cleveland Clinic: eating foods rich in iron, iron supplements and taking vitamin C (to increase iron absorption) should be implemented. Another route to increasing iron preoperatively is to introduce iron intravenously. A January 2021 article published in BioMed Central suggests that the virtues of this intervention are not certain: "randomized controlled trials (RCT) investigating this efficacy for IV iron are small, limited, and inconclusive."

An Iron Supplement Marketed in the Nineteenth Century

CC license 4.0

Conclusion

I began this post by asking if you like to chew ice. And then I asserted that if you do, perhaps you should be checked for anemia. Anemia is a condition many of us don't take seriously. I certainly did not at one time. Even some doctors tend to be casual about moderate anemia. I write this blog in the hope that some readers might pay more attention to this quite common condition. Common especially in women and the elderly.

Being anemic can be very consequential. Besides presenting a risk during surgery, there are other effects of anemia I have not addressed here. It can damage your organs, can cloud your thinking. and can actually shorten your life. If you are one of the fortunate whose anemia is not caused by a pathology, do yourself a favor and try to improve your status.

Some Sources Used in Writing This Blog

1.https://my.clevelandclinic.org/health/diseases/14621-iron-rich-foods-and-anemia
2.https://www.sciencedirect.com/science/article/abs/pii/S0039606015003268
3.https://www.sabm.org/wp-content/uploads/2018/08/Anemia-in-the-Pre-Surgical-Patient.pdf
4.https://www.sciencedirect.com/topics/medicine-and-dentistry/hemodilution
5.https://sabm.org/
6.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7169263/
7.https://pubmed.ncbi.nlm.nih.gov/26032824/
8.https://professionaleducation.blood.ca/en/transfusion/publications/transfusion-related-acute-lung-injury-trali
9.https://www.beaconhealthsystem.org/library/faqs/craving-and-chewing-ice-a-sign-of-anemia/
10.https://oklahoman.com/article/2926087/chewing-ice-could-be-sign-of-iron-deficiency-anemia
11.https://www.transfusionguidelines.org/transfusion-handbook/7-effective-transfusion-in-surgery-and-critical-care/7-1-transfusion-in-surgery
12.https://www.ncbi.nlm.nih.gov/books/NBK225187/
13.https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014-0229-8
14.https://www.uptodate.com/contents/surgical-blood-conservation-preoperative-autologous-blood-donation
15.https://pubmed.ncbi.nlm.nih.gov/19181341/
16.https://www.beaconhealthsystem.org/library/faqs/craving-and-chewing-ice-a-sign-of-anemia/
17.https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31539-7/fulltext
18.https://www.mayoclinic.org/tests-procedures/hemoglobin-test/about/pac-20385075
19.https://www.dynamed.com/approach-to/anemia-in-adults-approach-to-the-patient
20.https://www.rch.org.au/bloodtrans/adverse_effects/Adverse_effects_of_transfusion/
21.https://hospitalhealthcare.com/latest-issue-2017/haemodilution-and-avoidable-blood-transfusions/
22.https://academic.oup.com/bjaed/article/6/5/192/337094
23.https://pubmed.ncbi.nlm.nih.gov/10172465/
24.https://www.uptodate.com/contents/surgical-blood-conservation-acute-normovolemic-hemodilution
25.https://pubs.asahq.org/anesthesiology/article/97/2/367/40182/Intraoperative-Low-volume-Acute-Normovolemic
26.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7225706/
27.https://www.surgeryencyclopedia.com/A-Ce/Blood-Salvage.html
28.https://my.clevelandclinic.org/health/articles/14568-oral-iron-supplementation
29.https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-021-01579-8
30.https://my.clevelandclinic.org/health/diseases/3929-anemia
31.https://www.cedars-sinai.org/health-library/diseases-and-conditions/a/overview-of-anemia.html
32.https://www.hopkinsmedicine.org/Press_releases/2006/09_13_06.html
33.https://www.lifeexpectancy.org/articles/anemia.pdf
34.https://emedicine.medscape.com/article/198475-overview

Illustration at the top of the blog a collection of Pixabay Pictures:
kidney beans
whole wheat bread
eggs
clams

Thank you for reading my blog

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