American Society of Anesthesiologists

View all recommendations from this society

Released October 12, 2013

Don’t administer packed red blood cells (PRBCs) in a young healthy patient without ongoing blood loss and hemoglobin of ≥6 g/dL unless symptomatic or hemodynamically unstable.

The hemoglobin transfusion threshold used in multiple studies has varied from 6.0 to 10.0 g/dL. The optimal hemoglobin/hematocrit criterion for transfusion remains controversial in several clinical settings. Nevertheless, compared with higher hemoglobin thresholds, a lower hemoglobin threshold is associated with fewer red blood cell units transfused without adverse associations with mortality, cardiac morbidity, functional recovery or length of hospital stay. Hospital mortality remains lower in patients randomized to a lower hemoglobin threshold for transfusion versus those randomized to a higher hemoglobin threshold.

The decision to transfuse should be based on a combination of both clinical and hemodynamic parameters.

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

The list started as an academic project of Onyi C. Onuoha, M.D., M.P.H A review of the literature and practice guidelines as approved by the American Society of Anesthesiologists (ASA) was performed to identify an evidence-based list of activities to question within the field of anesthesiology. A multi-step survey of anesthesiologists in both the academic and private sector and ASA Committees of Jurisdiction was performed to generate a “Top 5 List” list of preoperative and intraoperative activities. The final list was endorsed by the ASA and accepted for the Choosing Wisely® campaign. We believe that developing strategies whereby all stakeholders in the perioperative team are involved in the implementation is a means in which anesthesiologists could be engaged in the efforts to reduce over-utilization of low value, non-indicated medical services evident in the U.S. health system today.

ASA’s disclosure and conflict of interest policy can be found at


American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Practice guidelines for perioperative blood transfusion and adjuvant therapies. Anesthesiology. 2006 Jul;105(1):198–208.

Carson JL, Carless PA, Hebert PC. Outcomes using lower versus higher hemoglobin thresholds for red blood cell transfusion. JAMA. 2013;309(1):83–4.

Carson JL, Patel MS. (2013). Is there an optimal perioperative hemoglobin level? In L. Fleisher, Evidence-based practice of anesthesiology (3rd ed., pp. 155–163). Philadelphia (PA): Elsevier Saunders.

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