American Society for Clinical Laboratory Science

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Released June 10, 2020

Do not transfuse red blood cells as the sole intervention for expansion of circulatory volume unless deemed necessary for patients experiencing severe hemorrhage.

The Canadian Transfusion Requirements in Critical Care (TRICC) trial was the first to investigate a liberal versus restrictive approach to red blood cell (RBC) transfusions. The trial included a total of 838 hemodynamically stable, critically ill patients who had a hemoglobin (Hgb) concentration less than 9 g/dL (adult transfusion trigger 7–8 g/dL). The trial defined two categories for the study, a “liberal” approach that required allogeneic RBC transfusions for patients with Hgb less than 10 g/dL and a “restrictive” approach for patients with a Hgb concentration less than 7 g/dL. Patients were randomly divided between both study groups and were evaluated at 30 days. There was no significant mortality difference. The trial also noted a significantly better survival rate among patients less than 55 years old within the restrictive group; including in particular less acutely ill patients. Subsequent studies have shown that clinically stable patients may benefit more from a restrictive approach by reducing the percentage of patients exposed to allogeneic RBCs. It is not recommended to transfuse RBCs as the sole intervention for volume expansion. The World Health Organization recommends volume-expanding solutions such as crystalloids or colloids to expand fluid volume. These promote blood circulation through vital organs and tissues. RBC transfusions should be used to treat conditions such as severe hemorrhage that otherwise lead to significant mortality. Recent evidence for blood transfusions suggests that a restrictive transfusion approach is safer and as effective as a liberal approach for post-operative stable patients, normovolemic critically ill-patients with a hemoglobin transfusion trigger of 7–8 g/dL and patients with clinical symptoms of anemia. The exception to the restrictive approach is comprised of patients with clinically significant cardiovascular conditions. Blood products carry the risk of transmitted infectious diseases and adverse effects of blood transfusion (e.g. immunosuppressive complications).

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

George Fritsma, MS, MLS (ASCP), and the late Cindy Johns, MS, MLS (ASCP) hosted a plenary presentation “Enhancing Laboratory Communication to Reduce Extra-analytical Errors” at the ASCLS Clinical Laboratory Educators’ Conference in Boston in February 2017. Their talk referenced the ABIMF Choosing Wisely initiative. Subsequent discussions resulted in the ASCLS Board of Directors appointing a Choosing Wisely task force that evolved to a standing committee. The committee is composed of ASCLS members representing all medical laboratory science disciplines.

The committee collaborated with respective ASCLS Scientific Assemblies in developing and reviewing recommendations, which the Board of Directors reviewed and accepted for publication. The recommendations were subsequently reviewed in collaboration with the ASCP Test Utilization Steering Committee prior to submission.



American Society for Clinical Laboratory Science (ASCLS) recommendations were developed under the leadership of ASCLS’s Choosing Wisely Committee and the ASCLS president and executive vice president. The Committee examined numerous options based on evidence available through an extensive review of  the literature and member proposals. Subject matter experts from the ASCLS Scientific Assemblies reviewed and recommended approval of their respective recommendations, which are subsequently approved by the ASCLS Board of Directors. The recommendations were subsequently reviewed in collaboration with the ASCP Test Utilization Steering Committee prior to submission.


American Cancer Society. Alternatives to Blood Transfusions.

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Carson JL, Triulzi DJ, Ness PM. Indications for and Adverse Effects of Red-Cell Transfusion. New England Journal of Medicine; 2017; 377:1261-1272.

Hébert 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. New England Journal of Medicine. 1999;340(6):409-417.

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World Health Organization. Clinical Transfusion Practice: Guidelines for Medical Interns.