Grade A Recommendation Restrictive transfusion (7.0g/dL) threshold in critical care.
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Author info
Posted By:	Gordon S. Doig
E-Mail:	Gordon.Doig@EvidenceBased.net
Posted Date:	March 5, 2003
Title:	Restrictive transfusion (7.0g/dL) threshold in critical care.
PubMed Resource Link:	Click here to repeat the Medline search used to develop this EBR.
Evidence-based Recommendation
Best level of evidence
	Well conducted Level I RCT
Target Population
	ICU patients expected to stay in the unit longer than 24 hours with a hemoglobin of 9.0g/dL or less within 72 hours of admission and considered to be euvolemic.
Purpose
	To reduce exposure to blood products and reduce the total amount of blood products used. May also reduce hospital discharge mortality, compared to a liberal transfusion strategy, from 28.1% to 22.2% (p=0.05)
Exclusion criteria
	Patients with active blood loss, defined as a decrease in the hemoglobin concentration of 3.0 g/dL in the preceding 12 hours or a requirement for at least 3 units of pRBCs during the same period. Patients with chronic anemia, defined as a hemoglobin of less than 9.0 g/dL on at least one occasion more than one month before hospital admission. Pregnancy.
Recommendation
	Transfusion should be given when the hemoglobin drops below 7.0g/dL with the aim of maintaining hemoglobin levels between 7.0g/dL and 9.0g/dL.
Potential harm
	Although a detailed sub-group analysis failed to demonstrate any harms associated with this restrictive transfusion approach in patients with cardiac disease, clinical judgement should be used with regards to the management of patients with severe cardiac disease.
Development Information
Date EBR last updated
	March 5, 2003
Literature source and search terms
	Medline was searched from 1966 to March 5, 2003 using the Therapy Clinical Queries filter, with emphasis on Sensitivity, crossed with key transfusion MeSH terms and filtered for studies performed in the ICU. This resulted in the following search statement: ("erythrocyte transfusion"[MeSH Terms] OR red blood cell transfusion[Text Word]) AND (critical* OR intensive* OR intensive care OR intensive care units OR "intensive therapy" OR critically ill OR critical illness OR critical care) AND (randomized controlled trial [PTYP] OR drug therapy [SH] OR therapeutic use [SH:NOEXP] OR random* [WORD])
Study selection
	83 abstracts were retrieved and hand searched for randomized controlled trials evaluating the impact of transfusion triggers on clinically meaningful outcomes in critically ill patients.
References
	A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999;340(6):409-416 (Level I) Is a low transfusion threshold safe in critically ill patients with cardiovascular disease? Crit Care Med 2001;29(2):227-234 (Level II - a priori sub-group analysis from a Level I trial)
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