Does a patient with severe anemia (hemoglobin level of 74 g/dL) require a blood transfusion?

Transfusion Decision for Hemoglobin 74 g/dL (7.4 g/dL)

Yes, a patient with hemoglobin of 74 g/dL (7.4 g/dL) generally requires blood transfusion, particularly if symptomatic or if cardiovascular disease is present. 1, 2

Primary Transfusion Threshold

• The standard transfusion threshold for most hospitalized patients is 70 g/dL (7 g/dL), making a hemoglobin of 74 g/dL borderline but still within the range where transfusion is commonly indicated 1, 2
• The American Association of Blood Banks strongly recommends transfusion for hospitalized adults when hemoglobin is less than 70 g/L, and 74 g/L is just above this threshold 1
• For critically ill patients requiring mechanical ventilation, transfusion should be considered at hemoglobin levels below 70 g/dL 3, 2

Clinical Assessment Factors That Mandate Transfusion at 74 g/dL

Transfuse immediately if any of the following are present:

• Cardiovascular disease or acute coronary syndrome: Use a higher threshold of 80 g/dL (8 g/dL) for these patients 1, 2, 4
• Symptoms of inadequate tissue oxygenation: tachycardia (heart rate >110 beats/min), tachypnea, dyspnea, chest pain, orthostatic hypotension, or altered mental status 1, 2
• Signs of end-organ ischemia: ST changes on ECG, decreased urine output, elevated lactate, or reduced mixed venous oxygen saturation 2
• Active or ongoing blood loss: surgical drains, gastrointestinal bleeding, or visible blood loss 2
• Hemodynamic instability: despite fluid resuscitation 2

Transfusion Protocol

• Administer single units of packed red blood cells in the absence of active hemorrhage 3, 1, 2
• Reassess clinical status and hemoglobin level after each unit before administering additional units 1, 2
• Each unit typically increases hemoglobin by approximately 10 g/L (1 g/dL) 1, 2
• Target post-transfusion hemoglobin of 70-90 g/dL for most patients 1, 2

Special Population Considerations

Patients with Cardiovascular Disease

• Use a transfusion threshold of 80 g/dL (8 g/dL) rather than the standard 70 g/dL 1, 2, 4
• At 74 g/dL, these patients should receive transfusion even if asymptomatic 2

Critically Ill Patients

• A restrictive transfusion strategy (70 g/dL threshold) is appropriate for mechanically ventilated patients without cardiovascular disease 3, 2
• No benefit has been demonstrated for liberal transfusion strategies (targeting hemoglobin >100 g/dL) 3, 1

Chronic Kidney Disease

• Target hemoglobin should be 110-120 g/dL long-term with erythropoiesis-stimulating agents, but acute transfusion is still needed at 74 g/dL 2

Critical Pitfalls to Avoid

• Do not delay transfusion at 74 g/dL if the patient has cardiovascular disease or symptoms, as compensatory mechanisms may be failing 1
• Avoid liberal transfusion strategies (transfusing to hemoglobin >100 g/dL), which provide no benefit and may increase complications including transfusion-associated circulatory overload, infections, and thromboembolism 1, 2
• Do not use hemoglobin level alone as the transfusion trigger; assess for hemorrhagic shock, hemodynamic instability, signs of inadequate oxygen delivery, and acuity of anemia 2
• Avoid overtransfusion: once hemoglobin reaches 70-90 g/dL, reassess before giving additional units 1

Post-Transfusion Management

• Follow transfusions with intravenous iron supplementation when appropriate, especially if iron deficiency contributed to the anemia 3, 4
• Investigate and treat the underlying cause of anemia, as transfusions do not correct the underlying pathology and have no lasting effect 3, 1
• Consider erythropoiesis-stimulating agents for patients with chronic kidney disease or cancer-related anemia after acute stabilization 3, 2