Red Blood Cell Transfusion in the Intensive Care Unit
Jorinde Raasveld, Sanne de Bruin, Merijn C. Reuland, Claudia van den Oord, Jimmy Schenk, Cécile Aubron, Jan Bakker, Maurizio Cecconi, Aarne Feldheiser, Jens Meier, Marcella C.A. Müller, Thomas Scheeren, Zoe McQuilten, Andrew W. J. Flint, Tarikul Hamid, Michaël Piagnerelli, Tina Tomić Mahečić, Jan Benes, Lene Russell, Hernán Aguirre-Bermeo, Konstantina Triantafyllopoulou, Vasiliki Chantziara, Mohan Gurjar, Sheila Nainan Myatra, Vincenzo Pota, Muhammed Elhadi, Ryszard Gawda, Mafalda Mourisco, Marcus D. Lancé, Vojislava Nešković, Matej Podbregar, Juan V. Llau, Manual Quintana‐Diaz, Maria Cronhjort, Carmen A. Pfortmueller, Nihan Yapıcı, Nathan D. Nielsen, Akshay Shah, Harm‐Jan de Grooth, Alexander P. J. Vlaar, InPUT Study Group, Alisa M. Higgins, Ary Serpa Neto, K. Brady, Erica M. Wood, Alexis Poole, Tony Trapani, Meredith Young, Jamie Cooper, Paul Secombe, Graham Reece, Prashanti Marella, David Brewster, Alan Rashid, Ruwan Suwandarathne, Raman Azad, Jonathan Barrett, Elisha Turner, Amber‐Louise Poulter, Lixian Chen, Vishwanath Biradar, Christina Whitehead, Sandra Peake, Alexis Tabah, Stephanie O’Connor, Michael C. Reade, Guido Janssen, Richard McAllister, Katherine Elizabeth Triplett, David Bowen, Hergen Buscher, John P. Santamaria, Dinesh Parmar, Paul Power, Craig French, Matthew Mac Partlin, Md Motiul Islam, Injamam Ull Haque, A. de Anta Román, Lionel Haentjens, Višnja Ikić, Slavica Kvolik, Robert Bojčić, Kazimir Juričić, Martin Duksa, Lukáš Bílek, I Satinský, Jan Zatloukal, Lene Russell, Morten H. Bestle, Christian S. Meyhoff, Ana Maria Diaz-Medina, Verónica Llumiquinga, Hernán Aguirre-Bermeo, Heinert Enmanuel Gonzabay-Campos, Mohamed Elbahnasawy, Xavier Chapalain, Charlène Le Moal, Pierre-Yves Egreteau, Yoann Launey
Abstract
Importance: Red blood cell (RBC) transfusion is common among patients admitted to the intensive care unit (ICU). Despite multiple randomized clinical trials of hemoglobin (Hb) thresholds for transfusion, little is known about how these thresholds are incorporated into current practice. Objective: To evaluate and describe ICU RBC transfusion practices worldwide. Design, Setting, and Participants: International, prospective, cohort study that involved 3643 adult patients from 233 ICUs in 30 countries on 6 continents from March 2019 to October 2022 with data collection in prespecified weeks. Exposure: ICU stay. Main Outcomes and Measures: The primary outcome was the occurrence of RBC transfusion during ICU stay. Additional outcomes included the indication(s) for RBC transfusion (consisting of clinical reasons and physiological triggers), the stated Hb threshold and actual measured Hb values before and after an RBC transfusion, and the number of units transfused. Results: Among 3908 potentially eligible patients, 3643 were included across 233 ICUs (median of 11 patients per ICU [IQR, 5-20]) in 30 countries on 6 continents. Among the participants, the mean (SD) age was 61 (16) years, 62% were male (2267/3643), and the median Sequential Organ Failure Assessment score was 3.2 (IQR, 1.5-6.0). A total of 894 patients (25%) received 1 or more RBC transfusions during their ICU stay, with a median total of 2 units per patient (IQR, 1-4). The proportion of patients who received a transfusion ranged from 0% to 100% across centers, from 0% to 80% across countries, and from 19% to 45% across continents. Among the patients who received a transfusion, a total of 1727 RBC transfusions were administered, wherein the most common clinical indications were low Hb value (n = 1412 [81.8%]; mean [SD] lowest Hb before transfusion, 7.4 [1.2] g/dL), active bleeding (n = 479; 27.7%), and hemodynamic instability (n = 406 [23.5%]). Among the events with a stated physiological trigger, the most frequently stated triggers were hypotension (n = 728 [42.2%]), tachycardia (n = 474 [27.4%]), and increased lactate levels (n = 308 [17.8%]). The median lowest Hb level on days with an RBC transfusion ranged from 5.2 g/dL to 13.1 g/dL across centers, from 5.3 g/dL to 9.1 g/dL across countries, and from 7.2 g/dL to 8.7 g/dL across continents. Approximately 84% of ICUs administered transfusions to patients at a median Hb level greater than 7 g/dL. Conclusions and Relevance: RBC transfusion was common in patients admitted to ICUs worldwide between 2019 and 2022, with high variability across centers in transfusion practices.