Grade A Recommendation
Restrictive transfusion (7.0g/dL) threshold in critical care.
This review may be edited
Author info
Posted By: Gordon S. Doig
E-Mail: gdoig@med.usyd.edu.au
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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    Restrictive transfusion (7.0g/dL) threshold in critical care.

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