Red Blood Cell Transfusion in Critically Ill Adults: An American College of Chest Physicians Clinical Practice Guideline

Angel O Coz Yataco; Israa Soghier; Paul C Hébert; Emilie Belley-Cote; Margaret Disselkamp; David Flynn; Karin Halvorson; Jonathan M Iaccarino; Wendy Lim; Christina C Lindenmeyer; Peter J Miller; Kevin O'Neil; Kathryn M Pendleton; Lisa Vande Vusse; Daniel R Ouellette

doi:10.1016/j.chest.2024.09.016

Red Blood Cell Transfusion in Critically Ill Adults: An American College of Chest Physicians Clinical Practice Guideline

Chest. 2024 Sep 26:S0012-3692(24)05272-3. doi: 10.1016/j.chest.2024.09.016. Online ahead of print.

Authors

Affiliations

¹ Critical Care Medicine Division and Pulmonary Medicine Division, Integrated Hospital-Care Institute, Cleveland, OH; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH. Electronic address: [email protected].
² Division of Pulmonary and Critical Care Medicine, Department of Medicine, Salem Hospital/Massachusetts General Brigham, Salem, MA; American College of Chest Physicians, Glenview, IL.
³ Bruyere Research Institute, University of Ottawa, Ottawa.
⁴ Population Health Research Institute, ON, Canada.
⁵ Department of Critical Care and Pulmonary Medicine, Lexington Veterans Affairs Healthcare System, Lexington, KY.
⁶ Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
⁷ Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI.
⁸ American College of Chest Physicians, Glenview, IL.
⁹ Department of Medicine, McMaster University, Hamilton, ON, Canada.
¹⁰ Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH.
¹¹ Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Section on Hematology and Oncology, Department of Medicine, Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem.
¹² Wilmington Health and MICU, Novant New Hanover Regional Medical Center, Wilmington, NC.
¹³ Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN.
¹⁴ Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
¹⁵ Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI.

PMID: 39341492
DOI: 10.1016/j.chest.2024.09.016

Abstract

Background: Blood products frequently are administered to critically ill patients. Considering recent trials and practice variability, a comprehensive review of current evidence was deemed essential to offer pertinent guidance to critical care practitioners. This American College of Chest Physicians (CHEST) guidelines panel examined the literature on RBC transfusions among critically ill patients overall and specific subgroups, including patients with gastrointestinal bleeding, acute coronary syndrome (ACS), cardiac surgery, isolated troponin elevation, and septic shock, to provide evidence-based recommendations.

Study design and methods: A panel of experts developed 6 Population, Intervention, Comparator, and Outcome questions addressing RBC transfusions in critically ill patients and performed a comprehensive evidence review. The panel applied the Grading of Recommendations, Assessment, Development, and Evaluations approach to assess the certainty of evidence and to formulate and grade recommendations. A modified Delphi technique was used to reach consensus on the recommendations.

Results: The initial search identified a total of 3,082 studies, and after the initial screening, 38 articles were reviewed. Among them, 23 studies met inclusion criteria, comprising 22 randomized controlled trials and 1 cohort study. Based on the analysis of these studies, the panel formulated 2 strong and 4 conditional recommendations. The overall quality of evidence for recommendations ranged from very low to moderate.

Conclusions: In most critically ill patients, a restrictive strategy was preferable to a permissive approach because it does not increase the risk of death or complications, but does decrease RBC use significantly. Data from critically ill subpopulations also supported a restrictive approach, except in patients with ACS, for whom favoring a restrictive approach could increase adverse outcomes.

Keywords: GI bleed; acute coronary syndrome; cardiac surgery; critically ill; red blood cell; sepsis; septic shock; transfusion.

Publication types

Practice Guideline