Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care* Lena M. Napolitano, MD; Stanley Kurek, DO; Fred A. Luchette, MD I. STATEMENT OF THE PROBLEM Red blood cell (RBC) transfusion is common in critically ill and injured pa- tients. Many studies (Table 1) (1– 6) have documented the widespread use of RBC transfusion in critically ill patients and the data from these studies from diverse locations in Western Europe, Canada, the United Kingdom, and the United States reveal remarkably similar findings, with approximately 40% of patients receiving RBC transfusions, with a mean of 5 RBC units transfused per patient, and a pre- transfusion hemoglobin (Hb) of 8.5 g/dL. RBC transfusions are utilized to treat hemorrhage and anemia as well as to improve oxygen delivery to tissues. Blood transfusion is clearly indicated for the treatment of hemorrhagic shock, partic- ularly in patients who have reached crit- ical oxygen delivery. Independent of the mechanism of injury, hemorrhagic shock consistently represents the second lead- ing cause of early deaths among the in- jured, with only central nervous system injury consistently more lethal. However, most RBC transfusions in the intensive care unit (ICU) (90% in the CRIT Trial in the United States) are used for the treatment of anemia (Anemia and Blood Transfusion in Critical Care [ABC 1 ] and Anemia and Blood Transfusion in the Critically Ill [CRIT 2 ] trials). The efficacy of RBC transfusion in hemodynamically stable trauma and critically ill patients with anemia has not been demonstrated in most clinical settings. Historically, the decision to transfuse has been guided by an Hb concentration, “transfusion trig- ger.” A reevaluation of this practice has been prompted by the growing recognition of transfusion-related complications, such as transfusion-related infections and im- munosuppression, studies that demon- strate RBC transfusion may be associated with worse clinical outcomes and most ev- idence documenting lack of efficacy. Although recent data suggested that critically ill patients in general can toler- ate anemia to an Hb level of 7 g/dL, con- cerns have been raised that this level of anemia may not be well tolerated by cer- tain critically ill or injured patients, such as those with preexisting coronary, cere- brovascular, and pulmonary disease. Fi- nally, some clinicians retain the belief that certain conditions may require higher Hb concentrations, such as acute respiratory distress syndrome (ARDS), sepsis and multiple organ failure (MOF), traumatic brain injury and cerebrovascu- lar diseases. A number of prior guidelines regard- ing the indications for RBC transfusion have been published (Table 2) including the following: 1. American College of Physicians. Prac- tice Strategies for Elective RBC Trans- fusion (7). 2. Practice Guidelines for Blood Compo- nent Therapy; American Society of An- esthesiologists 1996 (8). 3. Practice Guidelines for perioperative blood transfusion and adjuvant thera- pies: an updated report. American So- ciety of Anesthesiologists 2006 (9). 4. National Institutes of Health Consen- sus Conference on Perioperative RBC Transfusion (10). 5. Perioperative blood transfusion for elec- tive surgery. A national clinical guide- line. Scottish Intercollegiate Guidelines Network; initially published in 2001, up- dated in 2004 (11, 12). 6. Guidelines for RBC and plasma trans- fusion for adults and children. Report of the Canadian Medical Association Expert Working Group, 1997 (13). 7. Guidelines for Transfusion in the Trauma Patient—SOP for Clinical Care 2006 (14). 8. Perioperative Blood Transfusion and Blood Conservation in Cardiac Sur- gery: The Society of Thoracic Sur- geons and The Society of Cardiovascu- lar Anesthesiologists Clinical Practice Guideline, 2007 (15). None of these guidelines specifically addresses the issue of RBC transfusion in critically ill and injured adult patients. This guideline reviews the evidence re- garding RBC transfusion in adult trauma and critical illness. It will not address issues related to neonates and children. Questions 1. What are the risks and benefits of RBC transfusion in critically ill and injured patients? 2. What are the indications for RBC transfusion? During resuscitation, during hospitalization? *See also p. xxx. From the For the EAST Practice Management Workgroup and The American College of Critical Care Medicine Taskforce of the SCCM. The EAST Practice Management Workgroup: Gary L. Anderson, DO; Michael R. Bard, MD; William Brom- berg, MD; William C. Chiu, MD; Mark D. Cipolle, MD, PhD; Keith D. Clancy, MD; Lawrence Diebel, MD; Wil- liam S. Hoff, MD; K. Michael Hughes, DO; Imtiaz Munshi, MD; Donna Nayduch, RN, MSN, ACNP; Rovin- der Sandhu, MD; Jay A. Yelon, MD. The American College of Critical Care Medicine Taskforce of the SCCM: Howard L. Corwin, MD; Philip S. Barie, MD; Samuel A. Tisherman, MD; Paul C. Hebert, MD, MHSc. The authors have not disclosed any potential con- flicts of interest. For information regarding this article, E-mail: lenan@med.umich.edu; lenan@umich.edu Copyright © 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e3181b39f1b Objective: ●●●. (Crit Care Med 2009; 37:000 – 000) KEY WORDS: transfusion; red blood cell transfusion; blood; anemia; hemorrhage; critical care; trauma 1 Crit Care Med 2009 Vol. 37, No. 11