Anaemia (Inpatient) 🩸
Inpatient anaemia and transfusion. When to transfuse, thresholds, iron, and when to refer for NCHDs on the ward.
🔍 Context
- Establish baseline Hb if known (GP letters, previous discharge).
- Acute drop vs chronic anaemia: symptoms (dizziness, breathlessness, chest pain, fatigue), rate of fall, and haemodynamic impact.
- Cause: bleeding (overt or occult), chronic disease, nutritional (iron, B12, folate), haemolysis, renal (EPO), drug-related.
📋 When to transfuse (adults)
- Restrictive strategy is standard: transfuse when Hb <70 g/L in stable patients, or <80 g/L if symptomatic or at risk (e.g. acute coronary syndrome, ongoing bleeding).
- Consider symptoms and comorbidities: symptomatic at higher Hb (e.g. chest pain, SOB, pre-existing IHD or heart failure) may warrant transfusion at 70–80 g/L; discuss with senior.
- Major haemorrhage: follow local major haemorrhage protocol; don’t wait for Hb before giving blood if clinically indicated.
🧪 Investigations
- FBC: Hb, MCV (microcytic / normocytic / macrocytic), reticulocytes.
- Film comment if requested or if haemolysis/suspected B12/folate deficiency.
- Iron studies if microcytic or unclear: ferritin, TIBC, transferrin saturation.
- B12 and folate if macrocytic or relevant history.
- Renal function (CKD → consider EPO), LFTs if chronic disease.
- Group and save / crossmatch if transfusion likely.
💊 Non-transfusion management
- Iron deficiency: oral iron (e.g. ferrous sulfate 200 mg OD–BD); IV iron (e.g. ferric derimaltose, ferinject) if oral not tolerated, malabsorption, or need rapid rise – check local protocol.
- B12/folate: replace as per cause and local guidance. Caution when both are low: replace B12 first (or ensure B12 is replete) before giving folate; giving folate alone in B12 deficiency can precipitate or worsen subacute combined degeneration of the cord.
- Treat cause: stop bleeding, treat underlying disease; involve gastroenterology if occult GI bleed.
📞 When to refer
- Haematology: uncertain cause, suspected haemolysis, possible haematological malignancy, complex or refractory anaemia.
- Gastroenterology: suspected GI bleed for endoscopy.
- Transfusion: discuss with senior or haematology if unusual request, refusal, or special requirements.