Recommendations or guidelines for red blood cell transfusion are available. The Red Blood Cell (RBC) 2023 Transfusion Association for the Advancement of Blood & Biotherapies (AABB) International Guidelines have been published. They appear in the Journal of the American Medical Association (JAMA) and aim to describe recommendations “for [the] use of RBC transfusion in adults and children.”
The authors explained that the guidelines for red blood cell transfusion answer two questions,
- “[f]or hospitalized, hemodynamically stable adult patients, should clinicians transfuse with a restrictive strategy (typical hemoglobin level <7-8 g/dL) vs. a liberal strategy (typical hemoglobin level <9-10 g/dL)?
- For hospitalized, hemodynamically stable pediatric patients (a) without congenital heart disease (infancy to 16 years), should clinicians transfuse with a restrictive strategy (hemoglobin level <7-8 g/dL) vs a liberal strategy (hemoglobin level <9-10 g/dL); and (b) with congenital heart disease, should clinicians transfuse with a restrictive vs. liberal strategy based on the cardiac lesion?”
They noted that the recommendations are based on values and preferences that include, “[a]void the adverse effects after RBC transfusion (high value), [c]onserve resources related to RBC transfusions (high value) to ensure blood is available for individuals who need it most, [and] refer the demonstrated benefits of a restrictive transfusion policy despite the remaining possibility of a small increase in mortality.”
The guidelines for red blood cell transfusion were developed from conducting a systematic review of 45 randomized controlled trials (RCTs) with more than 20,000 adults. “The systematic reviews included RCTs in which the transfusion groups were assigned based on a clear transfusion threshold, described as the hemoglobin concentration or hematocrit level required before RBC transfusion. Outcomes in adults included 30-day mortality, nonfatal myocardial infarction, pulmonary edema or congestive heart failure, stroke, thromboembolism, acute kidney injury, infection, hemorrhage, mental confusion, proportion of patients with an allogeneic or autologous RBC transfusion, hemoglobin concentration (postoperative or discharge), number of RBC units transfused, and quality of life.”
For adults, the guidelines for red blood cell transfusion included:
- “[f]or hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive RBC transfusion strategy in which the transfusion is considered when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence).
- For hospitalized adult patients, the panel suggests a restrictive RBC transfusion strategy in which transfusion is considered when the hemoglobin concentration is less than 7 g/dL in those with hematologic and oncologic disorders (conditional recommendation, low certainty evidence).”
The guidelines for red blood cell transfusion for children were:
- “[f]or critically ill children and hospitalized children at risk of critical illness who are hemodynamically stable and without a transfusion-dependent hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy in which a transfusion is considered when the hemoglobin level is less than 7 g/dL compared with one of less than 9.5 g/dL (strong recommendation, moderate certainty evidence).
- The international panel suggests considering a transfusion threshold for hemodynamically stable children with congenital heart disease that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence).”
The authors also explained that, “[g]iven the findings indicating the safety of restrictive thresholds, new trial designs should focus on the safety of lower transfusion thresholds (e.g., 5-6 g/dL), incorporation of physiologic parameters, and the conduct of health economic analyses. They concluded that, “[o]ur panel recommends restrictive transfusion strategies, typically with a threshold of 7 g/dL for both adult and pediatric patients. The panel recognizes important additional considerations, including signs, symptoms, comorbid conditions, and patient values and preferences, that will differ between patients. The recommendation is strong, based on moderate certainty evidence for most patients, but conditional, based on lower certainty evidence subgroups that include hematologic and oncologic disorders in adults and cyanotic cardiac condition in infants.”
In the U.S., someone requires a blood transfusion every two seconds. more than 11.5 million pints of red blood cells were collected and more than 10 million were transfused according to data in the most recent data in National Blood Collection and Utilizations Survey Report. The most recent statistics regarding blood donation are available in the America’s Blood Centers U.S. Blood Donation Statistics and Public Messaging Guide. Designed for blood centers, media, and anyone who is generally interested in the current state of blood donations and utilization, this guide is the first of its kind designed to provide the latest look at America’s blood supply and its donors.
Citation: Carson, J.L., Stanworth, S.J., Guyatt, G., et al. “Red Blood Cell Transfusion 2023 AABB International Guidelines.” JAMA. 2023.