Indian Journal of Critical Care Medicine

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 23 , ISSUE S3 ( September, 2019 ) > List of Articles


Red Blood Cell Transfusion Thresholds in Critically Ill Patients

Jose Chacko, Gagan Brar

Keywords : Anemia, Blood transfusion, Critical illness, Hemoglobin

Citation Information : Chacko J, Brar G. Red Blood Cell Transfusion Thresholds in Critically Ill Patients. Indian J Crit Care Med 2019; 23 (S3).

DOI: 10.5005/jp-journals-10071-23248

License: CC BY-NC 4.0

Published Online: 01-12-2019

Copyright Statement:  Copyright © 2019; The Author(s).


Anemia of multifactorial etiology is common among critically ill patients and several arbitrary transfusion thresholds have been proposed. Transfusion of red blood cells has been well established to increase morbidity and even mortality among critically ill patients. Several randomized controlled studies have evaluated the use of a restrictive compared to a more liberal transfusion strategy in the critically ill. A transfusion threshold of 7 g/dL appears to be generally safe, especially in the younger age group without significant comorbidities. Besides, a restrictive transfusion strategy reduces the incidence of transfusion-related complications. However, the decision to transfuse needs to be individualized depending on the clinical situation, balancing putative benefits against possible complications.

PDF Share
  1. Walsh TS, Garrioch M, Maciver C, Lee RJ, MacKirdy F, McClelland DB, et al. Red cell requirements for intensive care units adhering to evidence-based transfusion guidelines. Transfusion. 2004;44:1405–1411. doi:10.1111/j.1537-2995.2004.04085.x
  2. Carson JL, Noveck H, Berlin JA, Gould SA. Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion. Transfusion. 2002;42:812–818. doi:10.1046/j.1537-2995.2002.00123.x
  3. Weiskopf RB, Viele MK, Feiner J, Kelley S, Lieberman J, Noorani M, et al. Human cardiovascular and metabolic response to acute, severe isovolemic anemia. JAMA. 1998;279:217–221. doi:10.1001/jama.279.3.217
  4. Hill GE, Frawley WH, Griffith KE, Forestner JE, Minei JP. Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a meta-analysis. J Trauma. 2003;54:908–914. doi:10.1097/01.TA.0000022460.21283.53
  5. Taylor RW, Manganaro L, O'Brien J, Trottier SJ, Parkar N, Veremakis C. Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient. Crit Care Med. 2002;30:2249–2254. doi:10.1097/00003246-200210000-00012
  6. Corwin HL, Gettinger A, Pearl RG, Levy MM, Abraham E, MacIntyre NR, et al. The CRIT Study: Anemia and blood transfusion in the critically ill-current clinical practice in the United States. Crit Care Med. 2004;32:39–52. doi:10.1097/01.CCM.0000104112.34142.79
  7. Hébert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G A, et al. Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care. N Engl J Med. 1999; 340:409–417.
  8. Carson JL, Stanworth SJ, Alexander JH, Roubinian N, Fergusson DA, Triulzi DJ, et al. Clinical trials evaluating red blood cell transfusion thresholds: An updated systematic review and with additional focus on patients with cardiovascular disease. Am Heart J. 2018;200:96–101. doi:10.1016/j.ahj.2018.04.007
  9. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:801–810. doi:10.1001/jama.2016.0287
  10. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–1377. doi:10.1056/NEJMoa010307
  11. Napolitano LM. Anemia and Red Blood Cell Transfusion. Crit Care Clin. 2017;33:345–364. doi:10.1016/j.ccc.2016.12.011
  12. Holst LB, Haase N, Wetterslev J, Wernerman J, Guttormsen AB, Karlsson S, et al. Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock. N Engl J Med. 2014;371:1381–1391. doi:10.1056/NEJMoa1406617
  13. Robertson CS, Hannay HJ, Yamal J-M, Gopinath S, Goodman JC, Tilley BC et al. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. JAMA. 2014;312:36–47. doi:10.1001/jama.2014.6490
  14. Walsh TS, Boyd JA, Watson D, Hope D, Lewis S, Krishan A, et al. Restrictive Versus Liberal Transfusion Strategies for Older Mechanically Ventilated Critically Ill Patients: A Randomized Pilot Trial. Crit Care Med. 2013;41:2354–2363. doi:10.1097/CCM.0b013e318291cce4
  15. Salisbury AC, Amin AP, Reid KJ, Wang TY, Masoudi FA, Chan PS, et al. Hospital-acquired anemia and in-hospital mortality in patients with acute myocardial infarction. Am Heart J. 2011;162:300–309.e3. doi:10.1016/j.ahj.2011.05.021
  16. Leal-Noval SR, Rincón-Ferrari MD, García-Curiel A, Herruzo-Avilés A, Camacho-Laraña P, Garnacho-Montero J, et al. Transfusion of blood components and postoperative infection in patients undergoing cardiac surgery. Chest. 2001;119:1461–1468. doi:10.1378/chest.119.5.1461
  17. Hajjar LA, Vincent JL, Galas FR, Nakamura RE, Silva CM, Santos MH, et al. The TRACS Randomized Controlled Trial. JAMA. 2010;304:1559–1567. doi: 10.1001/jama.2010.1446.
  18. Murphy GJ, Pike K, Rogers CA, Wordsworth S, Stokes EA, Angelini GD, et al. Liberal or restrictive transfusion after cardiac surgery. N Engl J Med. 2015;372(11):997–1008. doi: 10.1056/NEJMoa1403612.
  19. C David Mazer, Richard P Whitlock, Dean A Fergusson, Judith Hall, Emilie Belley-Cote, Katherine Connolly, et al. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery. N Engl J Med. 2017;377(22):2133–2144. doi:10.1056/NEJMoa1711818
  20. Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365(26):2453–2462. doi: 10.1056/NEJMoa1012452. Epub 2011 Dec 14.
  21. Fominskiy E, Putzu A, Monaco F, Scandroglio AM, Karaskov A, Galas FR, et al. Liberal transfusion strategy improves survival in perioperative but not in critically ill patients. A meta-analysis of randomised trials. Br J Anaesth. 2015 Oct;115(4):511–519. doi: 10.1093/bja/aev317.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.