An 80-year-old man fell at home and sustained a hip fracture. On the day after repair, physical therapy team members notice that the patient's post-operative hemoglobin is 8.6 g/dL. They recommend a blood transfusion, which may allow the patient greater participation in rehabilitation and a more rapid recovery.
The patient's admitting ECG showed evidence of an old inferior myocardial infarction. At that time, his pre-operative hemoglobin was 11.5 g/dL. Two years ago, he experienced pedal edema and dyspnea with exertion requiring diuretics for presumed mild congestive heart failure.
The patient is currently resting comfortably and has no chest pain or pressure, dyspnea, or fatigue. His blood pressure is 130/84 mm Hg and pulse is 84/min and regular. Oxygen saturation is 97% on room air. Jugular venous pressure is normal. The lungs are clear to auscultation. There is a grade 2/6 systolic murmur along the upper left sternal border. There is trace pedal edema bilaterally to the shin.
Repeat hemoglobin is 8.5 g/dL and mean corpuscular volume is 89 fL.
Which of the following is the most appropriate step in management of this patient's low hemoglobin?

Question

An 80-year-old man fell at home and sustained a hip fracture.  On the day after repair, physical therapy team members notice that the patient's post-operative hemoglobin is 8.6 g/dL.  They recommend a blood transfusion, which may allow the patient greater participation in rehabilitation and a more rapid recovery.
The patient's admitting ECG showed evidence of an old inferior myocardial infarction.  At that time, his pre-operative hemoglobin was 11.5 g/dL.  Two years ago, he experienced pedal edema and dyspnea with exertion requiring diuretics for presumed mild congestive heart failure.
The patient is currently resting comfortably and has no chest pain or pressure, dyspnea, or fatigue.  His blood pressure is 130/84 mm Hg and pulse is 84/min and regular.  Oxygen saturation is 97% on room air.  Jugular venous pressure is normal.  The lungs are clear to auscultation.  There is a grade 2/6 systolic murmur along the upper left sternal border.  There is trace pedal edema bilaterally to the shin.
Repeat hemoglobin is 8.5 g/dL and mean corpuscular volume is 89 fL.
Which of the following is the most appropriate step in management of this patient's low hemoglobin?

Quizplus · Accepted Answer

11ec193a_96d2_399d_853d_89dd388a8770_MD0002_00 Studies show that in most asymptomatic patients, restrictive blood transfusion (eg, transfusion for hemoglobin <7-8 g/dL) may be associated with lower mortality and infection rate compared to liberal blood transfusion (eg, transfusion for hemoglobin <10 g/dL). This includes postoperative surgical patients and those with stable cardiovascular disease. Liberal transfusion can be considered in symptomatic patients with myocardial ischemia or orthostatic hypotension/tachycardia unresponsive to fluids (Choice D). (Choice A) Erythropoietin is typically not recommended for treatment of anemia in patients with coronary artery disease or heart failure as it has limited efficacy and may be associated with an increased risk for venous thromboembolism. Empiric therapy with iron is also unlikely to benefit this patient as his mean corpuscular volume is normal and he does not have a documented iron deficiency. (Choice C) Though packed red blood cells can be transfused one unit at a time in hemodynamically stable patients who are not actively bleeding, this patient does not require a blood transfusion given the aforementioned reasons. (Choice E) There is no evidence supporting the use of blood transfusion to maintain a hemoglobin >12 g/dL. Educational objective: Most asymptomatic patients should not receive a red blood cell transfusion if their hemoglobin is >7-8 g/dL. This includes postoperative surgical patients and those with stable cardiovascular disease. Patients with symptoms (eg, myocardial ischemia or orthostatic hypotension/tachycardia unresponsive to fluids) may benefit from blood transfusion to maintain a hemoglobin >10 g/dL. __________ References: Red blood cell transfusion: a clinical practice guideline from the AABB. (http://www.ncbi.nlm.nih.gov/pubmed/22751760) Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. (http://www.ncbi.nlm.nih.gov/pubmed/22513904)

An 80-Year-Old Man Fell at Home and Sustained a Hip