Question 13

Outline your approach to the transfusion  of red blood cells in the critically ill patient.

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College Answer

A sophisticated and broad response is expected for this very common clinical issue.. Clinical Practice Guidelines were issued by NH&MRC (and Australian Society of Blood Transfusion) in 2001.

Strategies should be in place to deal with prevention: minimise blood loss (sampling, other losses, management of anticoagulation, etc.), to supply appropriate haematinics; and to individualise transfusion based on subgroups.   In general ICU patients and in elective surgery recent studies suggest benefit associated with the choice of a transfusion threshold of 70 g/L (as opposed to 100g/L), and there seems to be no harm in choosing 80 g/L as opposed to 90 g/L in patients after coronary artery bypass grafting.   These levels may be too low for uncorrected ischaemic heart disease (? >100 g/L may be better).  In the setting of acute blood loss, earlier transfusion should be considered, based on estimated blood volume lost and haemodynamics (e.g. >1000 mL or 250 mL/hr). 

 Other controversial issues include prophylactic use of erythropoeitin, routine use of filters/leukodepletion of red cells prior to transfusion, reinfusion of autologous blood (e.g. drain tubes after cardiac surgery), and the approach to those patients unwilling to be transfused.   A strategy should also be in place to deal with the potential complications associated with a massive transfusion (e.g. coagulopathy).


The topic of transfusion in critical illness is covered elsewhere.

This answer is based not on the (gradually phased out) 2011 NHMRC guidelines, but on the more recent series of practice guidelines issued by the National Blood Authority of Australia, specificallythe Critical Care Module (4).

In brief:

  • Use judgement, rather than a numerical haemoglobin goal
  • Employ a restrictive transfusion strategy:
    • aim for a Hb of 70-90 g/L in all patients;
    • aim for a Hb 80-100 g/L in patients with an acute coronary syndrome
  • Don't use EPO
  • Use cell salvage where possible

Evidence for this:

1999 TRICC study:

  • no 30-day mortality difference but a significant in-hospital mortality difference (22% vs 28%) which favoured the restrictive transfusion strategy.

2012 Cochrane meta-analysis:

  • 19 trials involving a total of 6264 patients
  • Restrictive transfusion strategies were associated with a statistically significant reduction in hospital mortality (RR = 0.77)
  • Restrictive transfusion strategies did not appear to impact the rate of adverse events compared to liberal transfusion strategies


Goodnough, Lawrence T., Jerrold H. Levy, and Michael F. Murphy. "Concepts of blood transfusion in adults." The Lancet 381.9880 (2013): 1845-1854.


Spahn, Donat R., and Lawrence T. Goodnough. "Alternatives to blood transfusion." The Lancet 381.9880 (2013): 1855-1865.


There is also a rescinded document from the NHMRC (2001) which has been used to guide practice:Clinical Practice Guidelines on the Use of Blood Components.


To some extent this document has been superceded by the Australian and New Zealand Society of Blood Transfusion GUIDELINES FOR THE ADMINISTRATION OF BLOOD PRODUCTS.


The Patient Blood Management Guidelines from the National Blood Authority of Australia is another series of documents worth looking at - it contains several important modules which have been reviewed and which act as successors to the 2001 NHMRC guidelines.


Treleaven, Jennie, et al. "Guidelines on the use of irradiated blood components prepared by the British Committee for Standards in Haematology blood transfusion task force." British Journal of Haematology 152.1 (2011): 35-51.


Aoun, Elie, et al. "Transfusion‐associated GVHD: 10 years’ experience at the American University of Beirut—Medical Center." Transfusion 43.12 (2003): 1672-1676.


Heddle, Nancy M., and Morris A. Blajchman. "The leukodepletion of cellular blood products in the prevention of HLA-alloimmunization and refractoriness to allogeneic platelet transfusions [editorial]." Blood 85.3 (1995): 603-606.


Sharma, R. R., and Neelam Marwaha. "Leukoreduced blood components: Advantages and strategies for its implementation in developing countries."Asian journal of transfusion science 4.1 (2010): 3.


Dzik, Walter H. "Leukoreduction of blood components." Current opinion in hematology 9.6 (2002): 521-526.


Corwin, Howard L., and James P. AuBuchon. "Is leukoreduction of blood components for everyone?." JAMA 289.15 (2003): 1993-1995.


Blajchman, M. A. "The clinical benefits of the leukoreduction of blood products."Journal of Trauma-Injury, Infection, and Critical Care 60.6 (2006): S83-S90.


Rosenbaum, Lizabeth, et al. "The reintroduction of nonleukoreduced blood: would patients and clinicians agree?." Transfusion 51.12 (2011): 2739-2743.


Bilgin, Y. M., L. M. van de Watering, and A. Brand. "Clinical effects of leucoreduction of blood transfusions." Neth J Med 69.10 (2011): 441-450.


Australian Red Cross - Blood Service Policy on "The Age of Red Cells"


Hess, John R. "Red cell changes during storage.Transfusion and Apheresis Science 43.1 (2010): 51-59.


Bennett-Guerrero, Elliott, et al. "Evolution of adverse changes in stored RBCs."Proceedings of the National Academy of Sciences 104.43 (2007): 17063-17068.


Hébert, Paul C., et al. "A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care." New England Journal of Medicine340.6 (1999): 409-417.


Carson, Jeffrey L., Paul A. Carless, and Paul C. Hébert. "Outcomes using lower vs higher hemoglobin thresholds for red blood cell transfusion." Jama 309.1 (2013): 83-84.


Carson, Jeffrey L., Paul A. Carless, and Paul C. Hebert. "Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion." Cochrane Database Syst Rev 4 (2012).