Red blood cell transfusion - 2023 AABB international guidelines
The AABB commissioned and funded updated red blood cell transfusion guidelines through the AABB Clinical Transfusion Medicine Committee, published in JAMA in October 2023.
The recommendations were developed in collaboration with experts in RBC transfusion from, 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.
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate levels of evidence and strength of recommendations. They were based on 45 randomised controlled trials with 20,599 adult participants and 7 randomised controlled trials with 2,730 paediatric participants that compared restrictive haemoglobin-based transfusion thresholds with liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes.
The guidelines do not address transfusion in preterm neonates.
Note that for an Australian audience, we have converted g/dL to g/L in the recommendation statements from these guidelines, reproduced below.
Recommendation 1: for hospitalised adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the haemoglobin concentration is less than 70 g/L (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 75 g/L for patients undergoing cardiac surgery and 80 g/L for those undergoing orthopaedic surgery or those with preexisting cardiovascular disease.
Recommendation 2: for hospitalised adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the haemoglobin concentration is less than 70 g/L (conditional recommendations, low certainty evidence). There were insufficient trial data to inform recommendations in outpatient transfusion management.
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 hypoxaemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the haemoglobin concentration is less than 70 g/L (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: 70 g/L (biventricular repair), 90 g/L (single-ventricle palliation), or 70 to 90 g/L (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence).
The guideline group concluded, ‘It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient’. Refer to the full text article for further important insights, including the range of considerations important to good transfusion practice, and comparison with other international guidelines.
“These international guidelines incorporate the latest evidence and are a welcome addition to the National Blood Authority Patient Blood Management guidelines” says Dr James Daly, Medical Director, Pathology Services at Australian Red Cross Lifeblood. “The evidence was also used to update our Red cell transfusion resource for adult, haemodynamically stable, non-bleeding inpatients, available on our website.”
Carson JL, Stanworth SJ, Guyatt G, et al. Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA. Published online October 12, 2023. doi:10.1001/jama.2023.12914