The physician managed this case reflexively rather than reflectively. Although the patient had severe anemia, her symptoms
Many physicians believe that if the hemoglobin level is less than 8 gm/dL, it must be increased immediately, especially if it is extremely low and the patient is elderly (and therefore supposedly frail). That is not true, however. Patients in their 70s often tolerate hemoglobin levels as low as 3 or 4 gm/dL. The body has a variety of mechanisms to compensate, especially when the anemia develops gradually. Since compensation is better in some patients than others, management decisions should always be made on a case-by-case basis.
Physicians first should ask whether the anemia is an immediate threat to the patient, then whether it is possible to reverse the condition without transfusion. One can avoid a transfusion with this strategy. A serious omission in this case was the failure to examine the blood smear. This should be done immediately for any patient with severe anemia or pancytopenia. A smear examination might have saved this patient an unnecessary blood transfusion.
Another important omission was the failure to repeat the CBC in the hospital before transfusion. A blood count that shows severe anemia should always be repeated, for two reasons. First, to make sure that the first reading was correct. This is particularly important if the reading will be the basis for transfusion. Second, to provide some information about the course of the condition. For example, if this patient's hemoglobin level had fallen from 5.4 to 4.4 gm/dL during the hour or two that it took to travel from the office to the hospital, it would have suggested rapid progression. When symptoms are sufficiently worrisome to warrant a transfusion, start with one unit of blood. Give a second unit if the symptoms do not resolve. Only severe symptoms or active bleeding justify immediate administration of multiple units. In this case, the order for three units was another indication that the patient's physician was practicing medicine by numbers. Because each unit raises the hemoglobin level by about 1 gm/dL, the apparent objective was to raise the level to 8 gm/dL. It should be remembered, however, that each unit raises the risk of a transfusion reaction or disease transmission.
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