›Serum iron > 90 µmol/l (500 µg/dL)
›Hemodynamic instability or shock
›Altered mental status
›Metabolic acidosis with elevated anion gap
›Ingestion > 60 mg/kg elemental iron with clinical symptoms
›IV infusion dosing (preferred in shock)
›Initial: 1000 mg IV at rate not exceeding 15 mg/kg/hour
›Subsequent: 500 mg IV every 4-12 hours at rate not exceeding 125 mg/hour
›Maximum: 6000 mg in 24 hours
›IM dosing (non-shock patients, rare)
›Initial 1000 mg IM, then 500 mg IM every 4-12 hours
›Maximum 6000 mg in 24 hours
›Monitoring and endpoints
›Vin rose urine color indicates active chelation of free iron
›Resolution of urine color indicates reduction in free iron
›Clinical improvement and resolution of acidosis
›Continue until hemodynamic stability and metabolic normalization
›Duration caution
›Prolonged infusion > 24 hours associated with ARDS risk
›Avoid extended continuous infusion without reassessment
›Adverse effects
›Hypotension with rapid infusion
›Increased susceptibility to Yersinia enterocolitica infection
›ARDS with high-dose prolonged infusion
›Contraindications
›Severe renal disease: dose adjustment and monitoring required
›Anuria: accumulation risk
›Fluid resuscitation
›Normal saline 20 mL/kg IV bolus for hypotension
›Repeat as needed to restore perfusion
›Reassess after each bolus
›Vasopressors for refractory shock
›Norepinephrine 0.01-0.5 mcg/kg/min IV infusion
›Titrate to MAP > 65 mmHg
›GI hemorrhage management
›Packed red blood cells for hemoglobin < 70 g/L with active bleeding
›Transfuse to hemoglobin 70-90 g/L
›Fresh frozen plasma for coagulopathy with active bleeding
›INR > 1.5 with hemorrhage
›GI surgery or endoscopy for refractory bleeding
›Hepatic failure management
›N-acetylcysteine consideration if hepatotoxicity develops
›150 mg/kg IV over 1 hour loading dose
›50 mg/kg IV over 4 hours, then 100 mg/kg IV over 16 hours
›Evidence limited but used empirically in iron-induced hepatic failure
›Liver transplantation evaluation
›Definitive treatment for fulminant iron-induced hepatic failure
›King's College criteria for transplant listing
Monitoring during treatment
›Serial laboratory monitoring
›Serum iron every 4-6 hours during deferoxamine therapy
›Electrolytes and renal function every 8-12 hours
›LFTs daily if hepatotoxicity concern
›CBC for hemorrhage surveillance
›Hemodynamic monitoring
›Continuous cardiac monitoring for arrhythmia
›Urine output > 0.5 mL/kg/hour target
›Arterial line for accurate BP monitoring in shock
›Imaging surveillance
›Repeat KUB after whole bowel irrigation
›CT abdomen if perforation or late obstruction suspected