Blood transfusion: Less is more

In the current issue of JAMA, published October 12, Carson et el have updated red blood cell (RBC) transfusion guidelines by AABB (American Association of Blood Banks). Based on review of 31 randomized clinical trials (RCTs) performed in a variety of different clinical settings involving more than 12 587 patients.


Main recommendations

  1. Transfusion  not indicated until the hemoglobin level is  7g/dL  for hospitalized adult patients who     are hemodynamically stable, including critically ill patients
  2. For patients undergoing orthopedic surgery or cardiac surgery and with preexisting cardiovascular disease, transfusion threshold is Hb of 8gm/dl(You may be wondering why 8 ? The RCTs involving these patients used 8 as their level for some reason!)
  3. No need to  limiting patients (including neonates) to transfusion of only fresh RBCs (storage length: <10 days)


NO recommendations

  1. No recommendation for or against a liberal or restrictive transfusion threshold in patients with acute coronary syndrome.
  2. No recommendation for a transfusion threshold in patients treated for hematological or oncological disorders and for those with severe thrombocytopenia who are at risk of bleeding or for those with chronic transfusion–dependent anemia.


Why important

RBC transfusion is associated with significant adverse effects


Adverse Event Approximate Risk Per-Unit

Transfusion of RBCs

Febrile reaction 1:60
Transfusion-associated circulatory overload 1:100
Allergic reaction 1:250
Transfusion-related acute lung injury 1:12 000
Hepatitis C virus infection 1:1 149 000
Hepatitis B virus infection 1:1 208 000 to 1:843 000
Human immunodeficiency virus infection 1:1 467 000
Fatal hemolysis 1:1 972 000



Current RCTs on which these guidelines are based did not show increased transfusion related adverse events in liberal strategy group as seen in other observational studies.



  1. Carson  JL, Guyatt  G, Heddle  NM,  et al.  Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA. doi:10.1001/jama.2016.9185
  2. Carson  JL, Grossman  BJ, Kleinman  S,  et al.  Red blood cell transfusion. Ann Intern Med. 2012;157(1):49-58.





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