======Transfusion Guidelines=======

=====Packed Red Blood Cells=====




^  Condition  ^  Hemoglobin Threshold  ^
^ Symptomatic patient (eg, myocardial ischemia) | 10 g/dL <sup>1,2</sup> |
^ Hospitalized patient ^^
| Preexisting coronary artery disease | 8 g/dL <sup>2</sup> |
| Acute coronary syndromes | 8 to 10 g/dL <sup>2,3</sup> |
| Intensive care unit (hemodynamically stable) | 7 g/dL <sup>4,5</sup> |
| Gastrointestinal bleeding (hemodynamically stable)  | 7 g/dL <sup>6</sup> |
| Non-cardiac surgery | 8 g/dL* <sup>1</sup> |
| Cardiac surgery | 7.5 g/dL* <sup>7,8</sup> |
^ Ambulatory outpatient ^^
| Oncology patient in treatment | 7 to 8 g/dL |
| Palliative care setting | As needed for symptoms; hospice benefits may vary |


  - 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.
  - Carson JL, Brooks MM, Abbott JD, et al. Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease. Am Heart J 2013; 165:964.
  - Cooper HA, Rao SV, Greenberg MD, et al. Conservative versus liberal red cell transfusion in acute myocardial infarction (the CRIT Randomized Pilot Study). Am J Cardiol 2011; 108:1108.
  - 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.
  - Lacroix J, Hebert PC, Hutchison JS, et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007; 356:1609.
  - Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368:11.
  - Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA 2010; 304:1559.
  - Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or liberal red-cell transfusion for cardiac surgery. N Engl J Med 2017; 377:2133.
  - 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.

[[https://jamanetwork.com/journals/jama/article-abstract/2569055|AABB 2016 Guidelines]]
  * Recommendation #1: restrictive transfusion
    * Most patients: 7 (strong recommendation, moderate evidence)
    * Orthopedic surgery, cardiac surgery, pre-existing CVD: 8 (strong recommendation, moderate evidence)
    * 7 likely comparable to 8, but RCT evidence not available for all categories
    * These do not apply to patients with ACS, severe thrombocytopenia (treatment for hematologic or oncologic reasons at risk for bleed), or chronic transfusion-dependent anemia) due to insufficent evidence
  * Recommendation #2: RBC units can be from any time within licensed period rather than fresh RBC units (strong recommendation, moderate evidence)
  * "One is better than two": transfuse one unit at a time

[[http://success.redcross.org/success/file.php/1/TransfusionPractices-Compendium_3rdEdition.pdf|Red Cross, 3E 2017]]
  * Restrictive > liberal transfusion
  * Cardiac surgery: 7.5-8 (TITRe2)
  * General Critical Care:
    * in healthy adults, adequate O2 at Hgb 6-7, consider transfusion after adequate IVF in critically ill trauma patients if Hgb < 7; consider TXA if anemia due to ongoing blood loss
    * restrictive RBC transfusion (Hgb <7-8) for stable hospitalized patients (TRICC: 7 vs 8, normovolemic critically ill; similar 30d mortality, but fewer RBCs; TRISS for septic shock: Hgb 7 was safe)
  * Cardiovascular disease
    * 2012 AABB: consider transfusing at Hgb < 8 or when clinically significant symptomatic anemia
    * FOCUS trial: pre-existing cardiac disase or CV risk factors: restrictive (Hgb 8 or symptoms) non-inferior after hip surgery (higher MI, but lower mortality)
    * ACS: data unclear, no recommendations for or against
  * Upper GIB: restrictive (7) better than liberal (9) for 45-day mortality and further bleed, predominantly in cirrhosis and CPT-A or B disease.
  * Pediatric Critical Care
  * Chronic Anemia:
    * Asymptomatic: Treat underlying condition (B12, folate, ESA, iron)
    * Symptomatic: minimize symptoms and risks, usually required at <6, but such low threshold only for healthiest/most stable
    * Patients awaiting chemo or radiation therapy: when Hgb > 12 due to ESAs, M&M great and could be associated with ESAs; not advised for cancer patients receiving myelosuppresive agents for hematologic or lymphoid malignancies. Consider transfusing at <10.
  * Sickle cell disease:
    * Preoperative prophylaxis, taransfuse to 10
      * SCD with Hgb > 8.5 on hydroxyurea with high-risk surgery: consult SCD specialist
      * Not on hydroxyurea or transfusion therapy and may have higher Hgb S and high risk for hyperviscosity: avoid transfusion to Hgb > 10
    * Severe, symptomatic ACS
    * Acute splenic sequestration
    * Acute stroke
    * Hepatic sequestration
    * Intrahepatic cholestasis
    * Multisystem organ failure
    * Aplastic crisis
    * Symptomatic anemia
    * Previous clinically overt stroke