No transfusion or further diagnostic testing is necessary for this patient with postoperative anemia and cardiovascular disease. He had a considerable decline in hemoglobin level, but this is consistent with the amount of blood loss noted in surgery (1200 mL). Moreover, this degree of blood loss after multilevel spine fusion is not atypical. Multiple studies have demonstrated that a conservative approach to perioperative blood management is as good as or superior to a liberal approach (such as maintaining a hemoglobin level of >10 g/dL [100 g/L]). This approach has been demonstrated even in patients with known cardiac disease or risk factors for cardiac disease. Current guidelines recommend transfusing red blood cells if a patient has symptoms attributable to anemia or a hemoglobin level less than 7 to 8 g/dL (70-80 g/L).

Intravenous iron is typically indicated in patients who are unable to take oral iron or unable to take in adequate amounts of oral iron in the presence of ongoing chronic blood loss, and in patients with kidney failure and anemia. However, this patient with mild anemia and likely normal iron stores may not require iron therapy for postoperative anemia and does not have a clear indication for parenteral iron if therapy were needed.

Transfusion of one unit of packed red blood cells (pRBCs) is not indicated because the patient does not have a clear indication for transfusion. If transfusion were indicated, the number of units administered should be based upon the target hemoglobin level and if active blood loss is present. One unit of pRBCs usually raises the hemoglobin level by 1 g/dL (10 g/L).

A frequent practice of clinicians is to order no less than two units of pRBCs at a time. This is based on the erroneous assumption that “more is better,” and that the transfusion risks of giving two units is no greater than for one unit. Such practices result in unnecessary depletion of the blood supply and double the risk of transfusion adverse effects because each unit carries its own potential for complications.