Two clinical cases—one obstetric and one surgical—illustrate how structured P-PBM strategies can support survival and recovery from profound anaemia when allogeneic blood transfusion is not used.
By Angelina A. Gapay, MD, FPSA (Department of Anesthesiology, Divine Word Hospital, Tacloban City, Philippines)
Severe anaemia remains one of the most difficult challenges in perioperative and obstetric medicine. In many settings, red blood cell transfusion is still viewed as the default response when haemoglobin falls sharply. Yet transfusion is not always available, not always acceptable to patients, and not always the safest or most sustainable option. Patient Blood Management (PBM), as endorsed by the World Health Organization, offers a patient-centred and evidence-based framework that shifts the focus from transfusion alone to the optimisation of physiology, haemostasis, and recovery.
The principles of PBM become especially relevant when caring for patients who decline allogeneic blood transfusion. In such situations, clinicians must move quickly from a product-based mindset to a physiology-based strategy: control bleeding, restore and preserve red cell mass, reduce avoidable blood loss, optimise oxygen delivery, and protect organ function.
These two cases, one obstetric and one surgical, show how a structured PBM approach can support recovery from life-threatening anaemia even under highly adverse circumstances.
Case 1: Life-Threatening Postpartum Anaemia in a Jehovah’s Witness
A 32-year-old primigravid Jehovah’s Witness at 38–39 weeks’ gestation presented in labour with persistent anaemia despite oral iron throughout pregnancy and several doses of intravenous iron sucrose before admission. She was markedly undernourished, weighing only 42.5 kg, and complained of dizziness and hunger. On assessment, she had additional complications including urinary infection, pre-eclampsia, azotaemia, low FT3, and laboratory findings suggestive of evolving medical complexity rather than isolated iron deficiency alone. Peripheral smear showed mostly normocytic, normochromic red cells with a few microcytic cells and slight thrombocytosis.
On hospital day 4, she underwent vacuum-assisted vaginal delivery of a 2.3 kg baby, complicated by cervical and vaginal lacerations with haemorrhage. Bleeding control included repair of the lacerations, tranexamic acid, colloid and crystalloid resuscitation. Her haemoglobin then fell dramatically to 3.4 g/dL. At that stage she developed tachycardia and dyspnoea, but despite repeated efforts by the clinical team, she declined allogeneic transfusion in keeping with her beliefs.
Management then shifted fully to PBM. She received repeated doses of intravenous iron sucrose, erythropoietin, intravenous vitamin B12, folic acid, oxygen, nutritional support, and strict limitation of phlebotomy. Ivabradine was used for tachycardia. Her course was further complicated by ascites, pleural effusion, severe peripheral oedema, marked hypoalbuminaemia, and ultrasound evidence of liver and renal parenchymal disease. After discussion with her family, she accepted albumin and diuretic management. Despite this degree of physiological insult, her haemoglobin rose to 6.0 g/dL by postpartum day 8 and to 9.0 g/dL by hospital discharge on day 18. The report also notes severe leukocytosis and later thrombocytosis during recovery, both of which improved as haemoglobin recovered. Long-term follow-up revealed that she eventually required dialysis, underscoring how medically fragile this patient already was at presentation.
Case 2: Severe Postoperative Anaemia in an Elderly Surgical Patient
A 78-year-old man with chronic alcoholism and a history of low anterior resection for rectal adenocarcinoma after radiotherapy. He presented for repair of a large incisional hernia with loss of domain. Preoperatively, his nutritional status was optimised and his haemoglobin was 14.6 g/dL, with no major comorbidity apart from mild liver parenchymal disease.
He underwent mesh hernioplasty, but four hours later developed postoperative bleeding after an episode of retching. Initial measures, including tranexamic acid, vitamin K, and pressure over the wound, did not control the bleeding, and he returned to theatre six hours after surgery for haemostasis of ruptured fascia. Intraoperative hypotension was managed with hydroxyethyl starch and acetate Ringer’s solution. Postoperatively, haemoglobin fell first to 9.0 g/dL and then to 6.5 g/dL within six hours. He was placed on high-flow oxygen and started on intravenous iron sucrose.
His postoperative course then became far more complex. He developed acute kidney injury with hyperkalaemia and supraventricular tachycardia, both of which responded to treatment. Later, bowel perforation and recurrent bowel leaks required further operations. On postoperative day 8, while another leak was being observed, haemoglobin dropped further to 4.8 g/dL. Rather than rushing into ineffective or physiologically harmful decisions, the team used PBM principles to create time for recovery: ongoing oxygen therapy, intravenous iron to a cumulative dose of 1,200 mg, erythropoietin, vitamin B12, folic acid, parenteral nutrition, antimicrobials, hydration, incentive spirometry, chest physiotherapy, physical therapy, gastrointestinal bleed protection, and deep vein thrombosis prevention.
Remarkably, despite profound anaemia, pneumonia, renal injury, and four surgeries within two weeks, the patient remained sufficiently stable to continue recovery without allogeneic transfusion. By the time of the fourth surgery on postoperative day 13, pneumonia and acute kidney injury had resolved and haemoglobin had increased to 7.1 g/dL. He was discharged after six weeks in hospital, haemodynamically stable, with a haemoglobin of 10.4 g/dL.
| Variable | Case 1 Postpartum Haemorrhage | Case 2 Surgical Case |
| Patient profile | 32-year-old primigravid Jehovah’s Witness; severe malnutrition and multisystem illness | 78-year-old male; Jehovah’s Witness post major abdominal surgery; preoperatively optimised |
| Clinical trigger | Vacuum-assisted delivery with lacerations and severe haemorrhage | Postoperative bleeding requiring re-exploration and haemostasis |
| Lowest haemoglobin | 3.4 g/dL | 4.8–6.0 g/dL |
| Intravenous iron | Iron sucrose 200 mg every other day (Day 1–9), total 1,000 mg | Iron sucrose: 200 -300 mg daily ×3 days → 100 mg (Day 5), total 1,200 mg |
| Erythropoietin | 4,000 IU ×2 doses, then 10,000 IU ×3 doses (alternate days) | Single dose 6,000 IU |
| Adjunct haematinics | Vitamin B12 and folic acid | Vitamin B12 and folic acid |
| Post-discharge iron therapy | Oral iron for 1 month | Sucrosomial iron OD ×20 days |
| Bleeding management | Surgical repair + tranexamic acid. No factor concentrates (unavailable). CCT | Reoperation + tranexamic acid + vitamin K. No factor concentrates (unavailable). CCT |
| Physiological optimisation | Oxygen therapy, ivabradine, fluid management, strict phlebotomy restriction, nutritional support | High-flow oxygen, haemodynamic support, physiotherapy, infection control |
| Complications | Pre-eclampsia, renal and hepatic dysfunction, ascites, pleural effusion; later dialysis | Acute kidney injury, pneumonia, bowel perforation/leaks, multiple surgeries |
| Haemoglobin at discharge | 9.0 g/dL (Day 18) | 10.4 g/dL (~6 weeks) |
| Follow-up Hb | Not reported | 13.4 g/dL after additional oral iron optimisation |
| Length of stay | 18 days | ~6 weeks |
| Outcome | Survival with chronic renal sequelae | Survival with full haematologic recovery |
CCT, Conventional Coagulation Tests.
What These Cases Teach Us
These two cases show that when allogeneic blood is declined or cannot be used, clinicians are not powerless. PBM provides a practical framework for action.
First, both cases highlight that severe anaemia should be understood as a dynamic physiological state. The key question is not only “What is the haemoglobin?” but also “Is bleeding controlled? Is oxygen delivery being supported? Are we minimising further blood loss? Are we stimulating erythropoiesis? Are we protecting the heart, lungs, kidneys, and brain while recovery takes place?”
Second, both cases demonstrate that haemoglobin recovery is rarely the result of a single intervention. What made the difference was the coordinated use of multiple PBM measures: haemostatic control, oxygen support, iron replacement, erythropoietin, vitamins, nutritional therapy, minimisation of phlebotomy, and treatment of complications such as infection, renal dysfunction, and respiratory compromise.
Third, these reports remind us that patient autonomy and clinical excellence must go together. Caring for patients who decline transfusion is not about doing less. It is about thinking more clearly, acting earlier, and applying PBM more rigorously.
The Broader Message for Practice
For anaesthesiologists, obstetricians, surgeons, intensivists, and multidisciplinary teams, these cases reinforce a broader truth: PBM is not merely a transfusion-reduction programme. It is a strategy for safer, more thoughtful, and more resilient care. When applied well, it can help clinicians navigate some of the most demanding scenarios in modern medicine, including profound anaemia, ongoing physiological stress, and complex comorbidity, while still respecting patient values.
In that sense, the most important lesson from these two cases is not simply that both patients survived. It is that survival was made possible by replacing reflexive dependence on transfusion with deliberate, multimodal, physiology-driven care.
Take-Home Messages
- Severe anaemia should be managed as a physiological emergency, not simply as a transfusion trigger.
- PBM can support survival even in profound anaemia through coordinated, multimodal care.
- Rapid control of bleeding, minimisation of iatrogenic blood loss, and active support of oxygen delivery are central to success.
- Iron, erythropoietin, vitamin supplementation, nutritional support, and careful organ support may create the time needed for endogenous haemoglobin recovery.
- Respect for patient autonomy does not preclude high-quality care. It demands a structured and proactive PBM response.
References
1. World Health Organization. Patient blood management and clinical use of blood. Geneva: WHO; 2021.
2. Shander A, et al. Recommendations from the International Consensus Conference on Anemia Management in Surgical Patients. Anesth Analg. 2021;132:1368–1390.
3. Shakur-Still H, et al. Tranexamic acid for post-partum haemorrhage: what, who and when. Lancet. 2017;389:2105–2116.
4. Carson JL, et al. Clinical trials of red blood cell transfusion thresholds: an updated systematic review and meta-analysis. Lancet. 2016;387:127–136.
5. Spahn DR, et al. Patient blood management: recent advances and future directions. Lancet. 2019;393:123–134.
