Review

. 2025 Feb;167(2):477-489.

doi: 10.1016/j.chest.2024.09.016. Epub 2024 Sep 26.

Red Blood Cell Transfusion in Critically Ill Adults: An American College of Chest Physicians Clinical Practice Guideline

Affiliations

¹ Critical Care Medicine Division and Pulmonary Medicine Division, Integrated Hospital-Care Institute, Cleveland, OH; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH. Electronic address: cozyata@ccf.org.
² Division of Pulmonary and Critical Care Medicine, Department of Medicine, Salem Hospital/Massachusetts General Brigham, Salem, MA; American College of Chest Physicians, Glenview, IL.
³ Bruyere Research Institute, University of Ottawa, Ottawa, ON, Canada.
⁴ Population Health Research Institute, Hamilton, ON, Canada.
⁵ Department of Critical Care and Pulmonary Medicine, Lexington Veterans Affairs Healthcare System, Lexington, KY.
⁶ Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
⁷ Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI.
⁸ American College of Chest Physicians, Glenview, IL.
⁹ Department of Medicine, McMaster University, Hamilton, ON, Canada.
¹⁰ Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH.
¹¹ Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Section on Hematology and Oncology, Department of Medicine, Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC.
¹² Wilmington Health and MICU, Novant New Hanover Regional Medical Center, Wilmington, NC.
¹³ Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN.
¹⁴ Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
¹⁵ Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI.

PMID: 39341492
PMCID: PMC11867898
DOI: 10.1016/j.chest.2024.09.016

Review

Red Blood Cell Transfusion in Critically Ill Adults: An American College of Chest Physicians Clinical Practice Guideline

Angel O Coz Yataco et al. Chest. 2025 Feb.

. 2025 Feb;167(2):477-489.

doi: 10.1016/j.chest.2024.09.016. Epub 2024 Sep 26.

Authors

Affiliations

¹ Critical Care Medicine Division and Pulmonary Medicine Division, Integrated Hospital-Care Institute, Cleveland, OH; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH. Electronic address: cozyata@ccf.org.
² Division of Pulmonary and Critical Care Medicine, Department of Medicine, Salem Hospital/Massachusetts General Brigham, Salem, MA; American College of Chest Physicians, Glenview, IL.
³ Bruyere Research Institute, University of Ottawa, Ottawa, ON, Canada.
⁴ Population Health Research Institute, Hamilton, ON, Canada.
⁵ Department of Critical Care and Pulmonary Medicine, Lexington Veterans Affairs Healthcare System, Lexington, KY.
⁶ Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
⁷ Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI.
⁸ American College of Chest Physicians, Glenview, IL.
⁹ Department of Medicine, McMaster University, Hamilton, ON, Canada.
¹⁰ Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH.
¹¹ Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Section on Hematology and Oncology, Department of Medicine, Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC.
¹² Wilmington Health and MICU, Novant New Hanover Regional Medical Center, Wilmington, NC.
¹³ Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN.
¹⁴ Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
¹⁵ Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI.

PMID: 39341492
PMCID: PMC11867898
DOI: 10.1016/j.chest.2024.09.016

Abstract

Background: Blood products frequently are administered to critically ill patients. Considering recent trials and practice variability, a comprehensive review of current evidence was deemed essential to offer pertinent guidance to critical care practitioners. This American College of Chest Physicians (CHEST) guidelines panel examined the literature on RBC transfusions among critically ill patients overall and specific subgroups, including patients with gastrointestinal bleeding, acute coronary syndrome (ACS), cardiac surgery, isolated troponin elevation, and septic shock, to provide evidence-based recommendations.

Study design and methods: A panel of experts developed six Population, Intervention, Comparator, and Outcome questions addressing RBC transfusions in critically ill patients and performed a comprehensive evidence review. The panel applied the Grading of Recommendations, Assessment, Development, and Evaluations approach to assess the certainty of evidence and to formulate and grade recommendations. A modified Delphi technique was used to reach consensus on the recommendations.

Results: The initial search identified a total of 3,082 studies, and after the initial screening, 38 articles were reviewed. Among them, 23 studies met inclusion criteria, comprising 22 randomized controlled trials and one cohort study. Based on the analysis of these studies, the panel formulated two strong and four conditional recommendations. The overall quality of evidence for recommendations ranged from very low to moderate.

Conclusions: In most critically ill patients, a restrictive strategy was preferable to a permissive approach because it does not increase the risk of death or complications, but does decrease RBC use significantly. Data from critically ill subpopulations also supported a restrictive approach, except in patients with ACS, for whom favoring a restrictive approach could increase adverse outcomes.

Keywords: GI bleed; acute coronary syndrome; cardiac surgery; critically ill; red blood cell; sepsis; septic shock; transfusion.

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Conflict of interest statement

Financial/Nonfinancial Disclosures None declared.

Figures

**Figure 1**
Suggested approach to RBC transfusion in critically ill patients. Hgb = hemoglobin; PRBC = packed RBC.

See this image and copyright information in PMC

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References

1. Vincent J.L., Jaschinski U., Wittebole X., et al. Worldwide audit of blood transfusion practice in critically ill patients. Crit Care. 2018;22(1):102. - PMC - PubMed
1. Free R.J., Sapiano M.R.P., Chavez Ortiz J.L., Stewart P., Berger J., Basavaraju S.V. Continued stabilization of blood collections and transfusions in the United States: Findings from the 2021 National Blood Collection and Utilization Survey. Transfusion. 2023;63(suppl 4):S8–S18. - PMC - PubMed
1. Raasveld S.J., de Bruin S., Reuland M.C., et al. Red blood cell transfusion in the intensive care unit. JAMA. 2023;330(19):1852–1861. - PMC - PubMed
1. United Kingdom Blood Services. Effective transfusion in surgery and critical care. In Norfolk D, ed. Handbook of Transfusion Medicine. 5th ed. United Kingdom Blood Services website. Accessed July 1, 2024. https://www.transfusionguidelines.org/transfusion-handbook/7-effective-t...
1. Hebert P.C., Wells G., Blajchman M.A., et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340(6):409–417. - PubMed

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Red Blood Cell Transfusion in Critically Ill Adults: An American College of Chest Physicians Clinical Practice Guideline

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Red Blood Cell Transfusion in Critically Ill Adults: An American College of Chest Physicians Clinical Practice Guideline

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Conflict of interest statement

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