Casey A Cable1, Seyed Amirhossein Razavi2, John D Roback3, David J Murphy1. 1. Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA. 2. Department of Surgery, Emory University School of Medicine, Atlanta, GA. 3. Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA.
Abstract
OBJECTIVES: To critically assess available high-level clinical studies regarding RBC transfusion strategies, with a focus on hemoglobin transfusion thresholds in the ICU. DATA SOURCES: Source data were obtained from a PubMed literature review. STUDY SELECTION: English language studies addressing RBC transfusions in the ICU with a focus on the most recent relevant studies. DATA EXTRACTION: Relevant studies were reviewed and the following aspects of each study were identified, abstracted, and analyzed: study design, methods, results, and implications for critical care practice. DATA SYNTHESIS: Approximately 30-50% of ICU patients receive a transfusion during their hospitalization with anemia being the indication for 75% of transfusions. A significant body of clinical research evidence supports using a restrictive transfusion strategy (e.g., hemoglobin threshold < 7 g/dL) compared with a more liberal approach (e.g., hemoglobin threshold < 10 g/dL). A restrictive strategy (hemoglobin < 7 g/dL) is recommended in patients with sepsis and gastrointestinal bleeds. A slightly higher restrictive threshold is recommended in cardiac surgery (hemoglobin < 7.5 g/dL) and stable cardiovascular disease (hemoglobin < 8 g/dL). Although restrictive strategies are generally supported in hematologic malignancies, acute neurologic injury, and burns, more definitive studies are needed, including acute coronary syndrome. Massive transfusion protocols are the mainstay of treatment for hemorrhagic shock; however, the exact RBC to fresh frozen plasma ratio is still unclear. There are also emerging complimentary practices including nontransfusion strategies to avoid and treat anemia and the reemergence of whole blood transfusion. CONCLUSIONS: The current literature supports the use of restrictive transfusion strategies in the majority of critically ill populations. Continued studies of optimal transfusion strategies in various patient populations, coupled with the integration of novel complementary ICU practices, will continue to enhance our ability to treat critically ill patients.
OBJECTIVES: To critically assess available high-level clinical studies regarding RBC transfusion strategies, with a focus on hemoglobin transfusion thresholds in the ICU. DATA SOURCES: Source data were obtained from a PubMed literature review. STUDY SELECTION: English language studies addressing RBC transfusions in the ICU with a focus on the most recent relevant studies. DATA EXTRACTION: Relevant studies were reviewed and the following aspects of each study were identified, abstracted, and analyzed: study design, methods, results, and implications for critical care practice. DATA SYNTHESIS: Approximately 30-50% of ICU patients receive a transfusion during their hospitalization with anemia being the indication for 75% of transfusions. A significant body of clinical research evidence supports using a restrictive transfusion strategy (e.g., hemoglobin threshold < 7 g/dL) compared with a more liberal approach (e.g., hemoglobin threshold < 10 g/dL). A restrictive strategy (hemoglobin < 7 g/dL) is recommended in patients with sepsis and gastrointestinal bleeds. A slightly higher restrictive threshold is recommended in cardiac surgery (hemoglobin < 7.5 g/dL) and stable cardiovascular disease (hemoglobin < 8 g/dL). Although restrictive strategies are generally supported in hematologic malignancies, acute neurologic injury, and burns, more definitive studies are needed, including acute coronary syndrome. Massive transfusion protocols are the mainstay of treatment for hemorrhagic shock; however, the exact RBC to fresh frozen plasma ratio is still unclear. There are also emerging complimentary practices including nontransfusion strategies to avoid and treat anemia and the reemergence of whole blood transfusion. CONCLUSIONS: The current literature supports the use of restrictive transfusion strategies in the majority of critically ill populations. Continued studies of optimal transfusion strategies in various patient populations, coupled with the integration of novel complementary ICU practices, will continue to enhance our ability to treat critically illpatients.
Authors: Andrew Rhodes; Laura E Evans; Waleed Alhazzani; Mitchell M Levy; Massimo Antonelli; Ricard Ferrer; Anand Kumar; Jonathan E Sevransky; Charles L Sprung; Mark E Nunnally; Bram Rochwerg; Gordon D Rubenfeld; Derek C Angus; Djillali Annane; Richard J Beale; Geoffrey J Bellinghan; Gordon R Bernard; Jean-Daniel Chiche; Craig Coopersmith; Daniel P De Backer; Craig J French; Seitaro Fujishima; Herwig Gerlach; Jorge Luis Hidalgo; Steven M Hollenberg; Alan E Jones; Dilip R Karnad; Ruth M Kleinpell; Younsuck Koh; Thiago Costa Lisboa; Flavia R Machado; John J Marini; John C Marshall; John E Mazuski; Lauralyn A McIntyre; Anthony S McLean; Sangeeta Mehta; Rui P Moreno; John Myburgh; Paolo Navalesi; Osamu Nishida; Tiffany M Osborn; Anders Perner; Colleen M Plunkett; Marco Ranieri; Christa A Schorr; Maureen A Seckel; Christopher W Seymour; Lisa Shieh; Khalid A Shukri; Steven Q Simpson; Mervyn Singer; B Taylor Thompson; Sean R Townsend; Thomas Van der Poll; Jean-Louis Vincent; W Joost Wiersinga; Janice L Zimmerman; R Phillip Dellinger Journal: Crit Care Med Date: 2017-03 Impact factor: 7.598
Authors: Ludhmila A Hajjar; Jean-Louis Vincent; Filomena R B G Galas; Rosana E Nakamura; Carolina M P Silva; Marilia H Santos; Julia Fukushima; Roberto Kalil Filho; Denise B Sierra; Neuza H Lopes; Thais Mauad; Aretusa C Roquim; Marcia R Sundin; Wanderson C Leão; Juliano P Almeida; Pablo M Pomerantzeff; Luis O Dallan; Fabio B Jatene; Noedir A G Stolf; Jose O C Auler Journal: JAMA Date: 2010-10-13 Impact factor: 56.272
Authors: Howard L Corwin; Andrew Gettinger; Timothy C Fabian; Addison May; Ronald G Pearl; Stephen Heard; Robert An; Peter J Bowers; Paul Burton; Mark A Klausner; Michael J Corwin Journal: N Engl J Med Date: 2007-09-06 Impact factor: 91.245
Authors: Rajendra H Mehta; Shubin Sheng; Sean M O'Brien; Frederick L Grover; James S Gammie; T Bruce Ferguson; Eric D Peterson Journal: Circ Cardiovasc Qual Outcomes Date: 2009-10-06
Authors: Vipul Jairath; Brennan C Kahan; Alasdair Gray; Caroline J Doré; Ana Mora; Martin W James; Adrian J Stanley; Simon M Everett; Adam A Bailey; Helen Dallal; John Greenaway; Ivan Le Jeune; Melanie Darwent; Nicholas Church; Ian Reckless; Renate Hodge; Claire Dyer; Sarah Meredith; Charlotte Llewelyn; Kelvin R Palmer; Richard F Logan; Simon P Travis; Timothy S Walsh; Michael F Murphy Journal: Lancet Date: 2015-05-05 Impact factor: 79.321
Authors: Filomena R B G Galas; Juliano P Almeida; Julia T Fukushima; Eduardo A Osawa; Rosana E Nakamura; Carolina M P D C Silva; Elisângela Pinto Marinho de Almeida; Jose Otavio Costa Auler; Jean-Louis Vincent; Ludhmila A Hajjar Journal: J Cardiothorac Surg Date: 2013-03-26 Impact factor: 1.637
Authors: Patricia Wischmann; Raphael Romano Bruno; Bernhard Wernly; Georg Wolff; Shazia Afzal; Richard Rezar; Mareike Cramer; Nadia Heramvand; Malte Kelm; Christian Jung Journal: Eur Heart J Open Date: 2022-06-15
Authors: Matthew A Warner; Andrew C Hanson; Phillip J Schulte; Nareg H Roubinian; Curt Storlie; Gabriel Demuth; Ognjen Gajic; Daryl J Kor Journal: J Intensive Care Med Date: 2022-02-01 Impact factor: 2.889