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. 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.
3. 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.
4. 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.
5. Lacroix J, Hebert PC, Hutchison JS, et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007; 356:1609.
6. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368:11.
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.
9. 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.

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

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