Transfusion of Red Blood Cells in Hospitalized Patients

Sponsoring Organization: Association for the Advancement of Blood & Biotherapies (AABB)

Background

This guideline updates the 2016 AABB guideline on red blood cell (RBC) transfusions (JAMA 2016; 316:2025). It is based on a systematic review using the GRADE framework to rate strength of recommendations and the quality of supporting evidence.

• Applying recommendations for transfusion is highly individualized and depends on many factors besides the hemoglobin level — for example, associated signs and symptoms, rate of hemoglobin drop, volume status, hemodynamic stability, patients' preferences and values, and other clinical variables.
• Clinicians should consider RBC transfusion only when expected benefits outweigh harms.
• The most common per-unit adverse events associated with RBC transfusion are transfusion-associated circulatory overload (1 in 125), febrile reactions (1 in 161), and allergic reactions (1 in 345).
• In the U.S., transfusion-associated transmission of HIV and hepatitis B and C viruses occurs in fewer than 1 per million transfusions.

Key Recommendations

• For hemodynamically stable hospitalized adults, a restrictive transfusion strategy of RBC transfusion when hemoglobin concentration is <7.0 g/dL is recommended (strong recommendation, moderate-certainty evidence).
• Some subgroups of patients might benefit from a slightly higher transfusion threshold. Consider RBC transfusion for patients undergoing cardiac surgery when hemoglobin concentration is <7.5 g/dL; consider transfusion for patients with cardiovascular disease or those undergoing orthopedic surgery when hemoglobin concentration is <8.0 g/dL.
• A restrictive transfusion strategy of RBC transfusion when hemoglobin concentration is <7.0 g/dL also is recommended for hospitalized adults with hematologic and solid-organ malignancies (conditional recommendation, low-certainty evidence).
• Due to lack of evidence, no specific recommendation is made for or against a restrictive or liberal transfusion strategy for patients hospitalized with acute myocardial infarction.