1. Clinical Presentation

Anemia in the intensive care unit (ICU) often presents with subtle hemodynamic and oxygenation changes rather than the classic symptom of fatigue. Clinicians should recognize compensatory signs that may signal a falling hemoglobin level and impending tissue hypoxia.

Key Signs and Symptoms

• Hemodynamic Instability: Tachycardia (a heart rate more than 20% above the patient’s baseline) and new or worsening hypotension that is unresponsive to fluid challenges.
• Worsening Oxygenation: An increased requirement for supplemental oxygen (FiO₂) or the sudden development of lactic acidosis despite stable ventilatory settings.
• Respiratory Distress: New or worsening dyspnea, particularly in patients on minimal ventilator support or during spontaneous breathing trials.
• Organ-Specific Manifestations: Signs of end-organ ischemia, such as angina in patients with known coronary artery disease, altered mental status, or oliguria indicating acute kidney injury.

2. Laboratory Assessment

A systematic laboratory evaluation is crucial to distinguish between different anemia subtypes. This involves integrating complete blood count (CBC) indices, reticulocyte parameters, iron studies, and inflammatory markers to build a complete picture of the underlying pathophysiology.

3. Advanced Diagnostics

Imaging and bone marrow examination should be reserved for patients with refractory anemia or atypical presentations where the initial workup is inconclusive.

Bleeding-Source Imaging

If gastrointestinal (GI) bleeding is suspected as the primary cause of anemia, imaging can help locate the source. It is critical to first stabilize the patient’s hemodynamics and correct any significant coagulopathy before proceeding with invasive procedures.

• Endoscopy (EGD/Colonoscopy): The gold standard for diagnosing and potentially treating upper or lower GI bleeding.
• CT Angiography: A non-invasive option with a sensitivity of approximately 85% for detecting active arterial bleeding at rates greater than 0.3 mL/min.

Bone Marrow Biopsy

A bone marrow biopsy is rarely needed for the initial diagnosis of ACI but should be considered in specific scenarios:

• Persistent, unexplained anemia after 7–10 days of targeted therapy.
• Suspicion of an underlying hematologic malignancy or marrow infiltration.
• Pancytopenia or other cytopenias accompanying the anemia.

In classic ACI, the biopsy typically reveals erythroid hypoplasia (a reduced number of red blood cell precursors) with adequate iron stores visible on Prussian blue staining, confirming iron sequestration.

4. Classification and Severity Scoring

Accurate classification of the anemia subtype is essential for guiding therapy. Furthermore, hemoglobin transfusion triggers should be adjusted based on the patient’s clinical stability and specific comorbidities.

Anemia Subtypes in the ICU

• Absolute Iron Deficiency: Characterized by depleted iron stores. Lab findings include ferritin <30 µg/L, TSAT <20%, and Ret-He <29 pg.
• Functional Iron Deficiency: Iron stores are adequate, but iron is sequestered and unavailable for use by the bone marrow due to inflammation. Lab findings include ferritin >100 µg/L, low Ret-He (<29 pg), and high CRP.
• Pure Inflammation-Driven Anemia (ACI): A state of severe inflammation causing bone marrow suppression, with normal/high ferritin and a blunted reticulocyte response, even with adequate iron.

Hemoglobin Transfusion Thresholds

• Stable ICU Patients: A restrictive transfusion strategy is recommended, with a hemoglobin threshold of <7 g/dL.
• High-Risk Patients: A more liberal threshold of <8 g/dL should be considered for patients with active cardiovascular disease, acute coronary syndrome, or evidence of end-organ ischemia.

Severity and Risk Stratification

The severity of a patient’s underlying critical illness correlates directly with the severity of their anemia and their need for transfusions. Higher scores on prognostic models like SOFA (Sequential Organ Failure Assessment) or APACHE II (Acute Physiology and Chronic Health Evaluation II) can help contextualize the urgency of anemia management and guide monitoring frequency.

5. Diagnostic and Initial Management Algorithm

A stepwise approach ensures timely, targeted intervention while promoting blood product stewardship and avoiding the risks of over-transfusion.