2023 AABB International Guidelines for Red Blood Cell Transfusion

The 2023 AABB International Guidelines for red blood cell (RBC) transfusion were recently published in a JAMA Theme Issue on Blood, Bleeding and Transfusion. The updated guidelines were commissioned through the AABB Clinical Transfusion Medicine Committee and were developed in collaboration with and are endorsed by the International Society of Blood Transfusion, International Collaboration for Transfusion Medicine Guidelines, the Society of Critical Care Medicine, the European Blood Alliance, and the Society for the Advancement of Patient Blood Management.

Published evidence evaluated for adult RBC transfusion included 45 randomized controlled trials (RCTs) with 20,599 participants comparing restrictive transfusion thresholds, typically 7-8 g/dL hemoglobin, with liberal transfusion thresholds of 9-10 g/dL hemoglobin. Literature examined for pediatric RBC transfusion included seven RCTs with 2,730 participants comparing a range of restrictive and liberal transfusion thresholds.

Recommendations

“Recommendation 1: For hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive RBC transfusion strategy in which the transfusion is considered when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Remark: In accordance with the restrictive strategy threshold used in most of the trials for subgroups of patients, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for patients undergoing orthopedic surgery or those with preexisting cardiovascular disease.

Recommendation 2: For hospitalized adult patients, the panel suggests a restrictive RBC transfusion strategy in which transfusion is considered when the hemoglobin concentration is less than 7 g/dL in those with hematologic and oncologic disorders (conditional recommendation, low certainty evidence).

Recommendation 3: For critically ill children and hospitalized children at risk of critical illness who are hemodynamically stable and without a transfusion-dependent hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy in which a transfusion is considered when the hemoglobin level is less than 7 g/dL compared with one of less than 9.5 g/dL (strong recommendation, moderate certainty evidence).

Recommendation 4: The international panel suggests considering a transfusion threshold for hemodynamically stable children with congenital heart disease 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).”

These recommendations may not apply to all individual patients, and clinicians should consider other parameters such as patients’ symptoms, signs, comorbid conditions, and rate of bleeding in the decision to transfuse RBCs.

Reference:

1.      Carson JL, Stanworth SJ, Guyatt G, et al. Red Blood Cell Transfusion 2023 AABB International Guidelines. JAMA. 2023; 330(19):1892-1902.