1. Is that Hemoglobin High Enough? COPYRIGHT © 2014, ALL RIGHTS RESERVED From the Publishers of

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3. Copyright © 2014 Dear Consult Guys: I need your advice regarding the practice style of one of our newest physician hires. He joined us in 2012 after completion of his residency and now does most of the care of our hospital patients. While he seems to be excellent I have a major gripe with his management of our seriously ill patients in the ICU. My complaint relates to his management of our ICU patients and postoperative patients who are anemic. Based on my training (I began practice 25 years ago) I’ve been liberal regarding the approach to anemia in our ICU and postoperative patients. I think that a Hgb as close to 10 gm/dl really helps to maximize oxygen delivery. Our newest associate’s approach to blood transfusion is much more restrictive. He seems to tolerate a Hgb as low at 7 g/dL in the ICU patient and 8 g/dL in the post operative patient. I think that his approach is wrong and may even be dangerous. By the end of this year we’ll have to decide whether or not to give him a long term contract. What do you guys think? A.B. Corncob General Medical Assoc Dear Consult Guys: I need your advice regarding the practice style of one of our newest physician hires. He joined us in 2012 after completion of his residency and now does most of the care of our hospital patients. While he seems to be excellent I have a major gripe with his management of our seriously ill patients in the ICU. My complaint relates to his management of our ICU patients and postoperative patients who are anemic. Based on my training (I began practice 25 years ago) I’ve been liberal regarding the approach to anemia in our ICU and postoperative patients. I think that a Hgb as close to 10 gm/dl really helps to maximize oxygen delivery. Our newest associate’s approach to blood transfusion is much more restrictive. He seems to tolerate a Hgb as low at 7 g/dL in the ICU patient and 8 g/dL in the post operative patient. I think that his approach is wrong and may even be dangerous. By the end of this year we’ll have to decide whether or not to give him a long term contract. What do you guys think? A.B. Corncob General Medical Assoc

4. A Difference of Opinion How high should Hgb be in the ICU and postoperative patient? LIBERAL (higher Hgb goals)  Hgb 10-12 RESTRICTIVE (transfusion approach)  Hgb 7-9 Doesn’t the LIBERAL approach deliver more O2 to the tissues and improve outcome? Copyright © 2014

5. Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365:2453-62.

6. Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999;340:409-417.

7. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB* Restrictive transfusion in hospitalized stable patient  Transfuse if Hgb < 7-8 Restrictive transfusion in hospitalized patient with CV disease  Transfuse if symptomatic or Hgb < 8 Transfusion decisions guided by symptoms and Hgb No data for guide in hospitalized stable ACS patient Copyright © 2014

8. Liberal or Restrictive Transfusion in High-Risk Patients after Hip Surgery Patients > age 50  Known or at risk for cardiovascular disease  Hip fracture surgery Liberal: transfuse if Hgb< 10 Restrictive: transfuse if anemia symptoms or Hgb<8 No difference in:  Mortality  Morbidity  Functional capacity at 60 days postop Copyright © 2014

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