Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Nov 21;330(19):1852-1861.
doi: 10.1001/jama.2023.20737.

Red Blood Cell Transfusion in the Intensive Care Unit

Senta Jorinde Raasveld  1 , Sanne de Bruin  1 , Merijn C Reuland  1 , Claudia van den Oord  1 , Jimmy Schenk  1   2 , Cécile Aubron  3 , Jan Bakker  4   5   6 , Maurizio Cecconi  7 , Aarne Feldheiser  8 , Jens Meier  9 , Marcella C A Müller  1 , Thomas W L Scheeren  10 , Zoe McQuilten  11 , Andrew Flint  11   12 , Tarikul Hamid  13 , Michaël Piagnerelli  14 , Tina Tomic Mahecic  15 , Jan Benes  16 , Lene Russell  17   18   19 , Hernan Aguirre-Bermeo  20 , Konstantina Triantafyllopoulou  21 , Vasiliki Chantziara  22 , Mohan Gurjar  23 , Sheila Nainan Myatra  24 , Vincenzo Pota  25 , Muhammed Elhadi  26 , Ryszard Gawda  27 , Mafalda Mourisco  28 , Marcus Lance  29 , Vojislava Neskovic  30 , Matej Podbregar  31 , Juan V Llau  32 , Manual Quintana-Diaz  33 , Maria Cronhjort  34 , Carmen A Pfortmueller  35 , Nihan Yapici  36 , Nathan D Nielsen  37 , Akshay Shah  38 , Harm-Jan de Grooth  1 , Alexander P J Vlaar  1 ; InPUT Study Group
Collaborators, Affiliations

Red Blood Cell Transfusion in the Intensive Care Unit

Senta Jorinde Raasveld et al. JAMA. .

Erratum in

Abstract

Importance: Red blood cell (RBC) transfusion is common among patients admitted to the intensive care unit (ICU). Despite multiple randomized clinical trials of hemoglobin (Hb) thresholds for transfusion, little is known about how these thresholds are incorporated into current practice.

Objective: To evaluate and describe ICU RBC transfusion practices worldwide.

Design, setting, and participants: International, prospective, cohort study that involved 3643 adult patients from 233 ICUs in 30 countries on 6 continents from March 2019 to October 2022 with data collection in prespecified weeks.

Exposure: ICU stay.

Main outcomes and measures: The primary outcome was the occurrence of RBC transfusion during ICU stay. Additional outcomes included the indication(s) for RBC transfusion (consisting of clinical reasons and physiological triggers), the stated Hb threshold and actual measured Hb values before and after an RBC transfusion, and the number of units transfused.

Results: Among 3908 potentially eligible patients, 3643 were included across 233 ICUs (median of 11 patients per ICU [IQR, 5-20]) in 30 countries on 6 continents. Among the participants, the mean (SD) age was 61 (16) years, 62% were male (2267/3643), and the median Sequential Organ Failure Assessment score was 3.2 (IQR, 1.5-6.0). A total of 894 patients (25%) received 1 or more RBC transfusions during their ICU stay, with a median total of 2 units per patient (IQR, 1-4). The proportion of patients who received a transfusion ranged from 0% to 100% across centers, from 0% to 80% across countries, and from 19% to 45% across continents. Among the patients who received a transfusion, a total of 1727 RBC transfusions were administered, wherein the most common clinical indications were low Hb value (n = 1412 [81.8%]; mean [SD] lowest Hb before transfusion, 7.4 [1.2] g/dL), active bleeding (n = 479; 27.7%), and hemodynamic instability (n = 406 [23.5%]). Among the events with a stated physiological trigger, the most frequently stated triggers were hypotension (n = 728 [42.2%]), tachycardia (n = 474 [27.4%]), and increased lactate levels (n = 308 [17.8%]). The median lowest Hb level on days with an RBC transfusion ranged from 5.2 g/dL to 13.1 g/dL across centers, from 5.3 g/dL to 9.1 g/dL across countries, and from 7.2 g/dL to 8.7 g/dL across continents. Approximately 84% of ICUs administered transfusions to patients at a median Hb level greater than 7 g/dL.

Conclusions and relevance: RBC transfusion was common in patients admitted to ICUs worldwide between 2019 and 2022, with high variability across centers in transfusion practices.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Cecconi reported receiving personal fees from Edwards Lifesciences, GE Healthcare, and Directed Systems outside the submitted work. Dr Feldheiser reported receiving personal fees from Baxter and Medtronic outside the submitted work. Dr Scheeren reported serving as senior medical director for Edwards Lifesciences (Garching, Germany). Dr McQuilten reported receiving grants from Australian National Blood Authority and National Health and Medical Research Council during the conduct of the study. Dr Flint reported receiving grants from the Australian National Blood Authority and Blood Synergy (Monash University) during the conduct of the study. Dr Piagnerelli reported receiving grants from Centre Federal d'Expertise Belge–KCE grant for COVID-19 study outside the submitted work. Dr Gurjar reported receiving royalties for edited books (Manual of ICU Procedures and Textbook of Ventilation, Fluids, Electrolytes and Blood Gases) from the publisher Jaypee Brothers Medical Publishers (Pvt) Ltd, New Delhi. Dr Pfortmueller reported receiving grants from Orion Pharma, Abbott Nutrition International, B Braun Medical AG, CSEM AG, Edwards Lifesciences Services GmbH, Kenta Biotech Ltd, Maquet Critical Care AB, Omnicare Clinical Research AG, Nestle, Pierre Fabre Pharma AG, Pfizer, Bard Medica SA, Abbott AG, Anandic Medical Systems, Pan Gas AG Healthcare, Bracco, Hamilton Medical AG, Fresenius Kabi, Getinge Group Maquet AG, Dräger AG, Teleflex Medical GmbH, GlaxoSmithKline, Merck Sharp and Dohme AG, Eli Lilly and Co, Baxter, Boehringer Ingelheim, Aseptuva, Astellas, AstraZeneca, CSL Behring, Novartis, Covidien, and Nycomed outside the submitted work; the funds were paid into departmental funds and no personal financial gain applied. Dr Nielsen reported receiving personal fees from Adrenomed outside the submitted work. Dr Vlaar reported receiving personal fees from a Vidi grant (ZonMW: 09150172010047). No other disclosures were reported.

Figures

Figure.
Figure.. Median Hemoglobin (Hb) Level Before Red Blood Cell (RBC) Transfusion in Patients Undergoing Transfusion During Intensive Care Unit (ICU) Stay
For patients with multiple RBC transfusions, the mean of the pretransfusion Hb level across different transfusions was calculated. In panels A and B, the dotted vertical line at 7 g/dL represents the current guideline for RBC transfusion. Approximately 84% of ICUs transfused their patients at a median Hb level above 7 g/dL.
See this image and copyright information in PMC

References

    1. Free RJ, Sapiano MRP, Chavez Ortiz JL, Stewart P, Berger J, Basavaraju SV. Continued stabilization of blood collections and transfusions in the United States: findings from the 2021 National Blood Collection and Utilization Survey. Transfusion. 2023;(January):1-11. doi: 10.1111/trf.17360 - DOI - PMC - PubMed
    1. Bosboom JJ, Klanderman RB, Zijp M, et al. Incidence, risk factors, and outcome of transfusion-associated circulatory overload in a mixed intensive care unit population: a nested case-control study. Transfusion. 2018;58(2):498-506. doi: 10.1111/trf.14432 - DOI - PubMed
    1. Mazer CD, Whitlock RP, Fergusson DA, et al. ; TRICS Investigators and Perioperative Anesthesia Clinical Trials Group . Restrictive or liberal red-cell transfusion for cardiac surgery. N Engl J Med. 2017;377(22):2133-2144. doi: 10.1056/NEJMoa1711818 - DOI - PubMed
    1. Murphy GJ, Pike K, Rogers CA, et al. ; TITRe2 Investigators . Liberal or restrictive transfusion after cardiac surgery. N Engl J Med. 2015;372(11):997-1008. doi: 10.1056/NEJMoa1403612 - DOI - PubMed
    1. Ducrocq G, Gonzalez-Juanatey JR, Puymirat E, et al. ; REALITY Investigators . Effect of a restrictive vs liberal blood transfusion strategy on major cardiovascular events among patients with acute myocardial infarction and anemia: the REALITY randomized clinical trial. JAMA. 2021;325(6):552-560. doi: 10.1001/jama.2021.0135 - DOI - PMC - PubMed

Publication types