How should I manage an adult patient with a hemoglobin level of 70 g/L (7 g/dL)?

Management of Hemoglobin 70 g/L (7 g/dL)

For a hemodynamically stable adult patient with hemoglobin of 70 g/L (7 g/dL), transfusion is generally indicated unless the patient has no cardiovascular disease and is completely asymptomatic. 1, 2

Initial Assessment Priority

First, assess hemodynamic stability—if the patient shows any signs of shock, hemorrhage, or hemodynamic instability, transfuse immediately regardless of the hemoglobin number. 2, 3 Signs requiring immediate transfusion include:

• Symptomatic hypotension or persistent tachycardia unresponsive to fluids 2, 4
• Evidence of inadequate oxygen delivery: chest pain, ST-segment changes on ECG, altered mental status, severe dyspnea 2, 4
• Active bleeding or hemorrhagic shock 2, 3
• Elevated lactate, low mixed-venous oxygen saturation, or oliguria 2, 3

Transfusion Decision Algorithm for Stable Patients

For patients WITHOUT cardiovascular disease:

• At Hb 7 g/dL, transfusion is recommended 1, 2
• This represents the threshold where restrictive transfusion strategies begin 1, 2
• If completely asymptomatic and hemodynamically stable, you may observe closely, but transfusion is reasonable 2, 3

For patients WITH cardiovascular disease (CAD, heart failure, peripheral vascular disease):

• Transfusion is clearly indicated at Hb ≤8 g/dL 1, 2
• At 7 g/dL, these patients should be transfused even if asymptomatic 2, 4
• The FOCUS trial established this higher threshold for cardiovascular patients 1

For patients with acute coronary syndrome:

• Transfusion should be considered at Hb <8 g/dL, especially if symptomatic 2, 4
• Avoid liberal strategies targeting Hb >10 g/dL, which provide no benefit 2, 4

Transfusion Protocol

Administer one unit of packed red blood cells at a time, then reassess clinical status and hemoglobin before giving additional units. 1, 2 This single-unit approach:

• Reduces unnecessary blood product exposure 2, 3
• Allows clinical reassessment after each unit 1, 2
• Each unit typically raises hemoglobin by 1-1.5 g/dL 2, 5
• Lower pre-transfusion hemoglobin is associated with greater hemoglobin rise per unit 5

Critical Pitfalls to Avoid

Never use hemoglobin level alone as the transfusion trigger—you must incorporate intravascular volume status, evidence of shock, duration and acuity of anemia, and cardiopulmonary reserve. 2, 3 The traditional practice of automatically ordering "2 units of PRBCs" is outdated and potentially harmful. 2

Do not transfuse to achieve Hb >10 g/dL—liberal transfusion strategies increase complications without improving outcomes: 1, 2, 3

• Higher rates of transfusion-related acute lung injury (TRALI) 2, 3
• Increased nosocomial infections and multi-organ failure 2, 3
• Transfusion-associated circulatory overload (TACO) 2
• No mortality benefit demonstrated 1, 2

Evidence Quality and Strength

The restrictive transfusion strategy (Hb <7 g/dL threshold) is supported by Level 1 evidence from multiple high-quality randomized controlled trials, including the landmark TRICC trial. 1, 2, 3 The AABB 2012 guidelines provide strong recommendations with high-quality evidence for restrictive strategies in most hospitalized patients. 1

The key distinction is that at exactly 7 g/dL, you are at the threshold—not clearly above it—making transfusion appropriate for most patients, particularly given that acute anemia is less well-tolerated than chronic anemia. 2, 4