In this episode of Hospital Medicine Unplugged, we plug into evidence-based blood transfusion—who really needs blood, how much, and when a “top-up” quietly harms more than it helps.

We start with the big pivot: why modern practice has moved to a restrictive transfusion strategy (Hb <7 g/dL for most hemodynamically stable adults) and what the RCTs and Cochrane data actually show. We walk through nuanced thresholds for cardiac and orthopedic surgery, preexisting cardiovascular disease, ICU patients, kids, and hematologic/oncologic populations, and flag key exceptions like GI bleeding and brain injury, where the rules bend.

Then we zoom out to the menu of components: RBCs for oxygen delivery, platelets for thrombocytopenia, plasma for true coagulopathy, cryo/fibrinogen for hypofibrinogenemia, and whole blood in massive hemorrhage. We hammer home indications beyond “just the number”—symptoms, hemodynamics, rate of Hb drop, volume status—and when NOT to transfuse: mildly abnormal INRs, “just-in-case” platelets, and procedure prophylaxis that doesn’t move bleeding risk.

Massive hemorrhage gets its own sprint: what actually defines a massive transfusion, when to trigger an MTP, why balanced 1:1:1 resuscitation (RBC:plasma:platelets) improves hemorrhage control, and how to layer in TXA, calcium, fibrinogen replacement, and viscoelastic testing (TEG/ROTEM) without drowning the patient in crystalloid.

We unpack the dark side of blood: TACO, TRALI, acute and delayed hemolytic reactions, TA-GVHD, alloimmunization, and iron overload—and how restrictive thresholds, leukoreduction, irradiation, careful dosing, and slower infusion rates slash those risks. You’ll get a practical mental checklist for “this patient is getting worse during transfusion—now what?”

Zooming up to the system level, we build a patient blood management (PBM) toolkit: Choosing Wisely-aligned thresholds, single-unit RBC default with “transfuse 1, then reassess,” EMR best-practice alerts, audit-and-feedback reports, and multidisciplinary transfusion committees that actually change culture and save thousands of units (and dollars).

We close on ethics and patient-centered care: informed consent that’s real, not scripted, transfusion decisions in frail or terminally ill patients, and caring for Jehovah’s Witness and other transfusion-refusing patients using IV iron, ESAs, cell salvage, hemostatic agents, and meticulous blood conservation—respecting autonomy while still practicing high-value medicine.

Restrictive, thoughtful, system-aware, and patient-centered—this episode is your playbook to give blood when it heals, withhold it when it harms, and always know why you’re hanging that unit.