Critical Care Societies Collaborative – Critical Care

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Released January 28, 2014

Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 g/dL.

Most red blood cell transfusions in the ICU are for benign anemia rather than acute bleeding that causes hemodynamic compromise. For all patient populations in which it has been studied, transfusing red blood cells at a threshold of 7 g/dL is associated with similar or improved survival, fewer complications and reduced costs compared to higher transfusion triggers. More aggressive transfusion may also limit the availability of a scarce resource. It is possible that different thresholds may be appropriate in patients with acute coronary syndromes, although most observational studies suggest harms of aggressive transfusion even among such patients.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

This document was prepared as an initiative of the Critical Care Societies Collaborative, which includes the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society and the Society of Critical Care Medicine. Each of these four societies was invited to nominate up to three members to join the taskforce. The final taskforce included 10 members representing all four societies and the disciplines of internal medicine, surgery, anesthesiology, emergency medicine and critical care nursing. Taskforce members initially proposed 58 items for consideration. The taskforce evaluated each item on five criteria (evidence, prevalence, cost, relevance, innovation), and agreed to narrow the list to 16 items. The taskforce debated the conceptual merits of these 16, and selected nine in which to pursue in-depth evidence reviews and consultations with external content experts. Taskforce members then independently scored each item on a scale from 1-9, rating each item on its overall impact as well as on each of the five criteria. The five items with the best mean overall scores were retained in the “penultimate” list. The taskforce then reviewed and edited the wording of items on the penultimate list, and submitted it to the 4 societies’ executive committees. The executive committees sought feedback from additional experts in the field, debated the items, and provided written comments to the taskforce. The taskforce deliberated and incorporated these suggestions where appropriate to create the final list, resolving any conflicts through discussion. All four societies endorsed the final list.

Members of the taskforce were: Scott D. Halpern, MD, PhD (Chair), Deborah Becker, PhD, RN, J. Randall Curtis, MD, MPH, Robert Fowler, MD, Robert Hyzy, MD, Jeremy M. Kahn, MD, MSc, Lewis Kaplan, MD, Nishi Rawat, MD, Curtis Sessler, MD and Hannah Wunsch, MD, MSc.

The disclosure and conflict of interest policies for the American Association of Critical Care Nurses, American College of Chest Physicians, the American Thoracic Society and the Society of Critical Care Medicine can be found at www.accn.org, www.chestnet.org,www.thoracic.org and www.sccm.org respectively.

Sources

Corwin HL, Gettinger A, Pearl RG, Fink MP, Levy MM, Abraham E, MacIntyre NR, Shabot MM, Duh MS, Shapiro MJ. The CRIT Study: anemia and blood transfusion in the critically ill – current clinical practice in theUnited States. Crit Care Med. 2004;32(1):39–52.

Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, Nemo G, Dragert K, Beaupre L, Hildebrand K, Macaulay W, Lewis C, Cook DR, Dobbin G, Zakriya KJ, Apple FS, Horney RA, Magaziner J; FOCUS Investigators. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Eng J Med. 2011;365(26):2453–62.

Hajjar LA, Vincent JL, Galas F, Nakamura RE, Silva CM, Santos MH, Fukushima J, Kalil Filho R, Sierra DB, Lopes NH, Mauad T, Roquim AC, Sundin MR, Leão WC, Almeida JP, Pomerantzeff PM, Dallan LO, Jatene FB, Stolf NA, Auler JO Jr. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA-JAMA. 2010;304(14):1559–67.

Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Eng J Med. 1999;340(6):409–17.

Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló C, Muñiz E, Guarner C. Transfusion strategies for acute upper gastrointestinal bleeding. N EngJ Med. 2013;368:11–21.

Chatterjee S, Wetterslev J, Sharma A, Lichstein E, Mukherjee D. Association of blood transfusion with increased mortality in myocardial infarction. JAMA.2013;173:132–39.