Case 7 (9/08/2013): Management Commentary

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… This 112 year-old male was admitted with shortness of breath and was placed on broad spectrum antibiotic coverage. The hemoglobin on admission is 11.4 gm/dL and declined to 8.3 gm/dL, 78 hours post-admission. The patient was transfused one unit PRBC, 96:16 hours post-admission. The post-transfusion hemoglobin was 12.4 gm/dL, 100:41 hours post-admission. The patient expired 20 hours and 49 minutes post-transfusion.

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Given the advanced patient age, tube feeding and (advanced) dementia should the patient be considered for palliative (end-of-life) care? Even though the patient presented with anemia, iron studies were not performed until 15 hours post-admission. As a general rule, anemia studies (including reticulocyte count) should be performed as soon as possible so that treatment may start sooner than later; however, if the patient is not going to be treated aggressively, what If any diagnostic studies should be performed? The patient received IV iron 100 mg x 3 days, beginning 44 hours post-admission, in the face of somewhat low iron levels and ferritin. Occult blood testing was not performed.

The key question in this case is: Does a patient with extremely advanced age (112) and 8.3 gm/dL hemoglobin due to anemia benefit from PRBC transfusion? Was this patient harmed by PRBC transfusion? The patient did not benefit from PRBC transfusion in this case. The post-transfusion hemoglobin rose 4.1 gm/dL post 1 unit PRBC. The height and weight of the patient are unknown, but the patient is assumed to be small and frail. Perhaps the normal blood volume in the patient is small so that one unit of PRBC caused significantly higher post-transfusion hemoglobin than would be expected in a normal adult patient. Alternatively the pre-transfusion hemoglobin is spuriously low, in which case the physician treated a laboratory value, rather than the patient. There is likely little outcome data for transfusion in centigenarian patients.

Conclusion: This PRBC transfusion was critiqued as “Avoid” because the pre-transfusion hemoglobin exceeded 8 gm/dL, the patient is 112 years old with frail health and not likely to benefit from aggressive therapy, and is perhaps a better candidate for end-of-life care rather than acute hospitalization.

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