The most appropriate management of this patient's anemia is to not transfuse. This patient is hemodynamically stable with no evidence of active bleeding. The decision to transfuse erythrocytes should be based on hemodynamic parameters, the acuity of anemia, coexisting medical problems, and ongoing blood loss. In patients with critical illness, restricting blood transfusions for a hemoglobin of less than 7 g/dL (70 g/L) significantly reduces cardiac events, rebleeding, bacterial infections, and total mortality as compared with a less restrictive strategy allowing transfusion at higher hemoglobin levels. Four critical care organizations (the American College of Chest Physicians, the American Thoracic Society, the Society of Critical Care Medicine, and the Association of Critical Care Nurses) recommend avoiding transfusion of erythrocytes in nonbleeding, hemodynamically stable patients with a hemoglobin concentration greater than 7 g/dL (70 g/L). Because this patient's hemoglobin is above the recommended threshold and he is hemodynamically stable with no clinical findings suggesting the need for increased oxygen-carrying capacity, transfusion is not indicated.

The recommendation to avoid transfusion in nonbleeding, hemodynamically stable patients has been included in the Choosing Wisely Campaign, an initiative of the American Board of Internal Medicine Foundation to encourage physicians, patients, and other health care agencies to consider the risks and benefits of medical tests and procedures, noting that all tests may not be necessary and some, in fact, may cause harm. Part of the initiative is to help physicians be better stewards of finite health care resources.

The erythropoiesis-stimulating agents (ESAs) should be considered for patients with chronic kidney disease (CKD) and symptomatic anemia attributable to erythropoietin deficiency when the hemoglobin level is less than 10 g/dL (100 g/L). Before attributing anemia to CKD, it is important to exclude other causes. Iron deficiency is common in patients with CKD. ESAs are associated with an increased risk of thrombotic and cardiovascular events as well as increased blood pressure and are generally not an appropriate intervention for a critically ill patient.