Level 1 of 6Core
Severe anaemia: transfusion and treating the cause
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- Ask first: bleeding or chronic anaemia? Acute blood loss is a resuscitation problem in which the first haemoglobin is meaningless — whole blood leaves the body and until plasma refill over hours the residual concentration is near-normal. Chronic severe anaemia is a diagnostic problem: the patient is fully compensated and more likely to be killed by over-enthusiastic transfusion than by the anaemia itself.
- Cardiovascular signs are more dependable than pallor: tachycardia, wide pulse pressure with a bounding pulse, and a soft ejection systolic flow murmur; pallor of conjunctivae, palmar creases and tongue is insensitive, especially in poor lighting and pigmented skin. A severely anaemic patient cannot become cyanosed — central cyanosis needs more than 40 g/L of reduced haemoglobin, unattainable at a total of 50 g/L.
- Know the bands and the red flags: WHO grades severe anaemia below 80 g/L in adults (below 70 g/L in children under 5); treat below 70–80 g/L as severe, below 50 g/L as life-threatening. Red flags whatever the haemoglobin: systolic BP below 90 mmHg, heart rate above 110/min, capillary refill beyond 3 seconds, urine below 0.5 mL/kg/h, respiratory rate above 24/min, breathlessness at rest, altered mental state or syncope.
- Children compensate then crash: blood pressure is maintained until 30–40% of blood volume is lost — hypotension is late and near-terminal; act on tachycardia, cool peripheries, prolonged capillary refill and altered consciousness. A child with haemoglobin below 40 g/L and deep sighing (acidotic) breathing is in immediate danger — classically severe falciparum malaria. Sickle baseline is 60–80 g/L, and that number alone is not an indication for anything.
- Look for the signs that name the cause: koilonychia, angular cheilosis, glossitis and pica (iron deficiency); lemon-yellow tinge, beefy tongue and posterior column signs (B12 deficiency); jaundice, splenomegaly, dark urine and leg ulcers (haemolysis); petechiae, bruising and fever (marrow failure); a rapidly enlarging tender spleen in a sickle child (splenic sequestration). In the elderly the presentation is falls, confusion, functional decline, worsening heart failure or new angina.
- Draw the diagnostic bloods BEFORE the first unit runs: ferritin, B12, folate, reticulocytes, blood film, LDH, haptoglobin and direct antiglobulin test all become uninterpretable once donor cells circulate — take them at the same venepuncture as the group-and-save. The reticulocyte count is the single most informative test: above 100 × 10⁹/L means bleeding or haemolysis; low or inappropriately normal means the marrow is not responding.
Manage now— do this, in order
- Resuscitate before you analyse, and stop the bleeding — a shocked bleeding patient is managed as haemorrhagic shock without awaiting a haemoglobin, and no volume of transfused blood substitutes for control of the source. High-flow oxygen if shocked, breathless or in chest pain; shocked patient supine with legs elevated, overloaded patient upright; keep the patient warm — hypothermia impairs coagulation.
- Access: two large-bore cannulae, 16 G or 14 G in an adult; in a shocked child in whom access fails quickly use an intraosseous needle — blood may be given by that route.Doctor / Nurse
- Crystalloid is a bridge, not a treatment: warmed 0.9% sodium chloride or Ringer's lactate 500 mL IV over 15 minutes in an adult, 10 mL/kg in a child, then reassess — repeated large boluses dilute red cells and clotting factors, and in febrile African children with severe anaemia they worsen outcome. Blood is the fluid for blood loss.Doctor / Nurse
- Transfuse for physiology, not a number — one unit at a time in the non-bleeding patient: stable non-bleeding adult below 70 g/L targeting 70–90 g/L; cardiovascular disease or older post-surgical blood-loss anaemia below 80 g/L targeting 80–100 g/L; massive active haemorrhage — transfuse regardless of the haemoglobin. One unit raises the haemoglobin by ~10 g/L; if it does not, the patient is still bleeding or still haemolysing. Never prescribe two units reflexively — circulatory overload is the commonest cause of transfusion-related death.Doctor / NurseNot available at your setup — Blood & blood products.
- Give the unit safely: over 90 minutes to 2 hours in a stable adult, completed within 4 hours of leaving controlled storage; in chronic anaemia, heart failure or frailty one unit over 4 hours with furosemide 20–40 mg IV (child 0.5–1 mg/kg IV). Children: 10–15 mL/kg over 3–4 hours raises the haemoglobin ~20–30 g/L; with cardiac failure give 5 mL/kg slowly under furosemide cover. Observations at baseline, at 15 minutes — when haemolytic and anaphylactic reactions declare themselves — hourly, and at completion; bedside identity checking is the single most important safety step.Doctor / NurseNot available at your setup — Blood & blood products.
- Major haemorrhage — balanced components: red cells : FFP : platelets 1:1:1 (or 4:4:1); FFP 15–20 mL/kg; platelets kept above 50 × 10⁹/L (above 100 with intracranial bleeding); fibrinogen above 1.5 g/L (2 g/L in obstetric haemorrhage). Tranexamic acid 1 g IV over 10 minutes then 1 g IV over 8 hours as early as possible in traumatic and obstetric haemorrhage (child 15 mg/kg, max 1 g, then 2 mg/kg/h). Watch hourly for hypothermia, citrate hypocalcaemia (calcium gluconate 10% 10 mL IV over 10 minutes; child 0.5 mL/kg, max 20 mL), hyperkalaemia and dilutional coagulopathy.Doctor / NurseNot available at your setup — Blood & blood products, Coagulation (PT/INR).
- Treat the cause — nutritional anaemias are cured by the missing nutrient, not by blood: ferrous sulphate 200 mg orally (about 65 mg elemental iron) once to three times daily, continued 3 months after the haemoglobin normalises (child 3–6 mg/kg/day elemental iron); hydroxocobalamin 1000 µg IM, 6 doses 2–3 days apart, then 1000 µg every 3 months for life; folic acid 5 mg orally daily for about 4 months. Never give folic acid alone when B12 status is unknown — the count corrects while cord degeneration progresses; if the patient cannot wait, give both.
- If a reaction occurs, stop the transfusion, keep the vein open through a new giving set, recheck identity, and return the unit with a fresh sample. TACO (dyspnoea + hypertension + raised JVP within 6 h): sit upright, oxygen, furosemide 20–40 mg IV (child 0.5–1 mg/kg) — restart only after diuresis. TRALI (hypoxia + fever + bilateral infiltrates + NORMAL JVP within 6 h): oxygen and ventilatory support, no diuretic, never restart. Anaphylaxis: adrenaline 0.5 mg IM (1:1000) every 5 minutes as needed (child over 12 years 0.5 mg, 6–12 years 0.3 mg, 6 months–6 years 0.15 mg), plus chlorphenamine 10 mg IV and hydrocortisone 200 mg IV — never restart.Doctor / Nurse
| Situation | Transfuse below | Target |
|---|---|---|
| Stable non-bleeding adult | 70 g/L | 70–90 g/L |
| Cardiovascular disease / older post-surgical | 80 g/L | 80–100 g/L |
| Massive active haemorrhage | any Hb | — |
| One unit of packed cells | raises Hb ~10 g/L | child 10–15 mL/kg → ~20–30 g/L |
Refer / escalate
Refer or transfer urgently any patient with shock, ongoing uncontrolled bleeding, haemoglobin below 50 g/L, chest pain or ischaemic ECG change, high-output failure, pancytopenia with fever, suspected haemolysis with a difficult crossmatch, or a child with haemoglobin below 40 g/L and acidotic breathing — and move them before the blood bank, endoscopy or marrow examination you lack becomes urgent.
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