Red Blood Cell Transfusion: 2023 AABB International Guidelines

Jeffrey L Carson¹, Simon J Stanworth^2,3,4,5, Gordon Guyatt⁶, Stacey Valentine⁷, Jane Dennis⁸, Sara Bakhtary⁹, Claudia S Cohn¹⁰, Allan Dubon¹¹, Brenda J Grossman¹², Gaurav K Gupta¹³, Aaron S Hess¹⁴, Jessica L Jacobson^15,16, Lewis J Kaplan¹⁷, Yulia Lin¹⁸, Ryan A Metcalf¹⁹, Colin H Murphy²⁰, Katerina Pavenski²¹, Micah T Prochaska²², Jay S Raval²³, Eric Salazar²⁴, Nabiha H Saifee²⁵, Aaron A R Tobian²⁶, Cynthia So-Osman^27,28, Jonathan Waters²⁹, Erica M Wood³⁰, Nicole D Zantek¹⁰, Monica B Pagano³¹

¹Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
²Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.
³NHSBT, Oxford, United Kingdom.
⁴Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.
⁵Department of Transfusion Medicine, NHS Blood and Transplant, Oxford, United Kingdom.
⁶Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, Hamilton, Ontario, Canada.
⁷Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester.
⁸Cochrane Injuries Group, London School of Hygiene and Tropical Medicine, London, United Kingdom.
⁹Department of Laboratory Medicine, University of California, San Francisco.
¹⁰Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis.
¹¹Patient partner.
¹²Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri.
¹³Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
¹⁴Departments of Anesthesiology and Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison.
¹⁵Department of Pathology, New York University Grossman School of Medicine, New York.
¹⁶NYC Health + Hospitals/Bellevue, New York, New York.
¹⁷Department of Surgery, Division of Trauma, Surgical Critical Care and Surgical Emergencies, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
¹⁸Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
¹⁹Department of Pathology, University of Utah, Salt Lake City.
²⁰Pathology Associates of Albuquerque, Albuquerque, New Mexico.
²¹Department of Laboratory Medicine and Pathobiology, University of Toronto and St Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada.
²²Department of Medicine, University of Chicago, Chicago, Illinois.
²³Department of Pathology, University of New Mexico, Albuquerque.
²⁴Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, Texas.
²⁵Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, Washington.
²⁶Department of Pathology, Johns Hopkins University, Baltimore, Maryland.
²⁷Department of Unit Transfusion Medicine (UTG), Sanquin Blood Bank, Amsterdam, the Netherlands.
28Department Hematology, Erasmus Medical Center, Rotterdam, the Netherlands.
²⁹Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
³⁰Department of Haematology, Monash Health, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia.
³¹Department of Laboratory Medicine and Pathology, University of Washington, Seattle.

PMID: 37824153 DOI: 10.1001/jama.2023.12914

Abstract

Importance:
Red blood cell transfusion is a common medical intervention with benefits and harms.

Objective:
To provide recommendations for use of red blood cell transfusion in adults and children.

Evidence review:
Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed.

Findings:
For adults, 45 randomized controlled trials with 20 599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence).

Conclusions and relevance:
It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.