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Transfusion Trigger – New AABB Guidelines for Adults and Children

November 10, 2023

Written by Clay Smith

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For hemodynamically stable adults and children, 7g/dL is the best transfusion trigger, with a few exceptions.

Liberal or conservative? At least transfusion triggers are clear
Transfusion of PRBCs can be life saving, but it also comes with risks. Volume overload is 1 in 125, febrile reaction 1 in 160, allergic reaction 1 in 345, transfusion associated lung injury 1 in 1,250, anaphylaxis 1 in 5,000, and infection from hepatitis B, hepatitis C, or HIV are all 1 in >1,000,000. We also need to conserve blood resources. So, what is the ideal transfusion trigger for hemodynamically stable, hospitalized adults and children?

This was a systematic review of 45 RCTs with 20,599 adults as well as 5 RCTs plus 2 additional pediatric trials with 2,730 children. The simplest answer: 7g/dL is the best transfusion trigger for both children and adults (strong recommendation, moderate certainty evidence).

Here are the exceptions:

  • Use a trigger of 7.5 g/dL for adult patients undergoing cardiac surgery; 8 g/dL for patients undergoing orthopedic surgery or preexisting cardiovascular disease.
  • For children with congenital heart disease, transfusion triggers depend on the cardiac anomaly and stage of repair: “7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence).”

How will this change my practice?
This affirms my practice. It’s nice that the trigger is the same for kids and adults. This is solid evidence, which was largely at very low risk of bias. It’s about as good as it gets. Bear in mind, this guideline deals with hemodynamically stable, hospitalized adults and children and does not speak to massive transfusion or unstable patients.

Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA. 2023 Oct 12. doi: 10.1001/jama.2023.12914. Online ahead of print.

What are your thoughts?