At what hemoglobin (HGB) level is erythrocyte infusion indicated?

From the Guidelines

Erythrocyte infusion is generally indicated when hemoglobin levels fall below 7 g/dL in most stable, hospitalized patients, as supported by the most recent and highest quality study 1.

Key Considerations

• The decision to transfuse should not be based solely on hemoglobin levels but should consider the patient's clinical status, symptoms of anemia, ongoing blood loss, and comorbidities.
• Transfusion may be warranted at higher hemoglobin levels if the patient is symptomatic or hemodynamically unstable.
• For patients with cardiovascular disease, a higher threshold of 8 g/dL may be considered, as suggested by previous guidelines 1.

Administration and Goals

• When administering transfusions, each unit of packed red blood cells typically raises hemoglobin by approximately 1 g/dL in an average-sized adult.
• The goal is not to normalize hemoglobin but to alleviate symptoms and reduce risks associated with anemia while avoiding unnecessary transfusions.
• Unnecessary transfusions carry risks including transfusion reactions, infection transmission, and iron overload with repeated transfusions.

Evidence Summary

• The American College of Chest Physicians clinical practice guideline from 2024 1 recommends a restrictive RBC transfusion strategy over a permissive RBC transfusion strategy, with a hemoglobin threshold of 7 to 8 g/dL.
• Previous studies and guidelines, such as those from the AABB 1 and Critical Care Medicine 1, also support a restrictive transfusion strategy, with consideration for individual patient factors and symptoms.

From the Research

Erythrocyte Infusion Indications

• Erythrocyte infusion, also known as red blood cell transfusion, is indicated at a hemoglobin (HGB) level of less than 7 g/dL for hospitalized adult patients who are hemodynamically stable 2, 3, 4.
• A restrictive transfusion strategy with a threshold of 7-8 g/dL is recommended for most patient populations, including those with critical illness, sepsis, gastrointestinal bleeding, and trauma 2, 5, 3.
• For patients undergoing cardiac surgery, a threshold of 7.5 g/dL may be considered, while those undergoing orthopedic surgery or with preexisting cardiovascular disease may have a threshold of 8 g/dL 3, 4.
• The decision to transfuse should be based on the patient's clinical context, symptoms, and preferences, rather than a specific HGB threshold alone 5, 3, 4.

Special Considerations

• Patients with acute coronary syndrome, severe thrombocytopenia, or chronic transfusion-dependent anemia may require different transfusion thresholds, but the evidence is limited 2, 4.
• Critically ill children and those at risk of critical illness may have a transfusion threshold of less than 7 g/dL, while those with congenital heart disease may have a threshold based on the cardiac abnormality and stage of surgical repair 3.
• The storage duration of red blood cells does not appear to affect clinical outcomes, and standard-issue blood can be used for transfusions 4.