Is blood transfusion indicated in patients with sepsis?

Blood Transfusion in Sepsis

In patients with sepsis, red blood cell transfusion should only occur when hemoglobin falls below 7.0 g/dL, targeting a hemoglobin range of 7.0-9.0 g/dL, once tissue hypoperfusion has resolved. 1

Restrictive Transfusion Strategy

The Surviving Sepsis Campaign guidelines provide a strong recommendation (grade 1B) for restrictive transfusion thresholds in septic patients. 1 This approach is supported by high-quality evidence from the TRISS trial, which demonstrated that a restrictive strategy (hemoglobin <7.0 g/dL) is safe and does not increase mortality compared to liberal transfusion strategies. 2, 3

Key principle: Transfuse only when hemoglobin drops below 7.0 g/dL and target 7.0-9.0 g/dL. 1, 2

Critical Exceptions Requiring Higher Thresholds

Consider transfusion at higher hemoglobin levels (potentially 8.0-9.0 g/dL or higher) in the following specific circumstances: 1, 2

• Active myocardial ischemia or acute coronary syndrome 1, 2
• Severe hypoxemia 1, 2
• Active hemorrhage 1, 2
• Documented ischemic coronary artery disease 1, 2

These exceptions are based on the physiologic rationale that these patients may not tolerate anemia as well, though definitive evidence in septic patients is limited. 2

Important Timing Consideration

The restrictive threshold applies only AFTER tissue hypoperfusion has resolved. 1 During active resuscitation with ongoing tissue hypoperfusion, clinical judgment regarding transfusion should incorporate hemodynamic parameters, lactate levels, and evidence of ongoing shock beyond just the hemoglobin value. 2

Practical Transfusion Approach

• Administer RBC transfusions as single units and reassess hemoglobin levels before giving additional units to minimize unnecessary exposure. 2
• Do not use hemoglobin level alone as the trigger—base decisions on intravascular volume status, evidence of shock, duration and extent of anemia, and cardiopulmonary parameters. 2
• Do not assume RBC transfusion will improve tissue oxygenation or facilitate weaning from mechanical ventilation, as evidence does not support these assumptions. 2

Risks of Transfusion in Sepsis

Blood transfusion in septic patients carries significant risks that support the restrictive approach: 2, 4, 5

• Increased nosocomial infection rates, particularly concerning in immunocompromised or post-transplant patients 2
• Independent risk factor for multi-organ failure and systemic inflammatory response syndrome 2
• Transfusion-related acute lung injury (TRALI), a leading cause of transfusion-associated mortality 2
• Observational data shows increased 90-day and 180-day mortality associated with low-grade RBC transfusions in septic patients 5
• Higher morbidity scores and longer ICU stays in transfused septic patients 4

Management of Other Blood Products

Fresh frozen plasma (FFP): Do not use FFP to correct laboratory coagulation abnormalities in the absence of active bleeding or planned invasive procedures (grade 2D). 1, 2, 6 FFP transfusion typically fails to correct prothrombin time in nonbleeding patients with mild abnormalities. 1, 6

Platelets: Transfuse prophylactically based on specific thresholds: 1, 7, 6

• <10,000/mm³ in the absence of apparent bleeding
• <20,000/mm³ if significant bleeding risk exists
• ≥50,000/mm³ for active bleeding, surgery, or invasive procedures

Erythropoietin: Do not use erythropoietin as a specific treatment for anemia in sepsis (grade 1B), as it shows no effect on clinical outcomes. 1, 2

Antithrombin: Do not administer antithrombin for treatment of septic shock (grade 1B), as phase III trials showed no mortality benefit and increased bleeding risk. 1, 6

Common Pitfalls to Avoid

• Do not transfuse based solely on a hemoglobin threshold without assessing clinical status, including resolution of tissue hypoperfusion and presence of extenuating circumstances. 1, 2
• Avoid liberal transfusion strategies that expose patients to unnecessary risks without mortality benefit. 2, 5
• Do not correct coagulation abnormalities prophylactically in nonbleeding patients, as this provides no benefit and increases transfusion-related risks. 2, 6