In the high-stakes realm of extracorporeal membrane oxygenation (ECMO), every decision can have profound consequences—from initiation to termination. Management controversies persist throughout the entire course. Beyond patient selection, timing, anticoagulation, potential complications, and other challenges, one of the frequently debated issues remains the haemoglobin threshold for transfusion of packed red blood cells (PRBC). Amid conflicting evidence and evolving practice, this editorial challenges the clinician to critically reassess both the available data and clinical dogma, and demand clearer guidance for our most critical patients.