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Thresholds for red blood cell transfusion in adults

Thresholds for red blood cell transfusion in adults
Condition Hemoglobin threshold for transfusion
Symptomatic patient (eg, myocardial ischemia, hemodynamic instability) 10 g/dL*[1]
Hospitalized patient
Preexisting coronary artery disease 8 g/dL*
Acute coronary syndromes, including acute MI 8 to 10 g/dL¶[2]
ICU (hemodynamically stable) 7 g/dL*[3,4]
Gastrointestinal bleeding (hemodynamically stable) 7 g/dL*[5,6]
Orthopedic surgery 8 g/dL*[1]
Cardiac surgery 7.5 g/dL*[7,8]
Ambulatory outpatient
Oncology patient in treatment 7 to 8 g/dL
Palliative care setting As needed for symptoms; hospice benefits may vary
These thresholds are not a substitute for direct assessment of the patient and clinical judgment. Refer to UpToDate topics on red blood cell transfusion and specific clinical settings for further details. Hospitalized patients with heart failure are an especially challenging case because there are no data from large randomized trials, and the improvement in oxygenation from transfusion must be balanced against the risks of worsening heart failure due to the volume of the transfused blood. The authors generally use a threshold of 7 to 8 g/dL in this population, erring on the side of a higher hemoglobin level in those who are expected to be able to better tolerate the volume load. In patients who do not fit into these clinical subgroups, we recommend that transfusion based on the location of care (ICU versus other) or the similarity of their underlying disease to those patient groups where data are available. In most cases, a 7 or 8 g/dL threshold is appropriate.
MI: myocardial infarction; ICU: intensive care unit.
* Based on results from clinical trial(s). Some experts may use different values. As an example, in individuals with gastrointestinal bleeding, it is often difficult, if not impossible, to estimate what the nadir hemoglobin will be, and some experts recommend a transfusion threshold of 8 g/dL[6].
¶ There are no large clinical trials yet performed in this setting. These recommendations are based on the authors' opinions.
References:
  1. Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011; 365:2453.
  2. Ducrocq G, Gonzalez-Juanetey JR, Puymirat E, et al. 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; 325:552.
  3. Hébert PC, Wells G, Blajchman MA, 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; 340:409.
  4. Lacroix J, Hebert PC, Hutchison JS, et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007; 356:1609.
  5. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368:11.
  6. Barkun AN, Almadi M, Kuipers EJ, et al. Management of nonvariceal upper gastrointestinal bleeding: Guideline recommendations from the International Consensus Group. Ann Intern Med 2019; 171:805.
  7. Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA 2010; 304:1559.
  8. Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or liberal red-cell transfusion for cardiac surgery. N Engl J Med 2017; 377:2133.
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