Transfusion decision making (TDM) in the critically ill requires consideration of: (1) anemia tolerance, which is linked to active pathology and to physiologic reserve, (2) differences in donor RBC physiology from that of native RBCs, and (3) relative risk from anemia-attributable oxygen delivery failure vs hazards of transfusion, itself. Current approaches to TDM (e.g. hemoglobin thresholds) do not: (1) differentiate between patients with similar anemia, but dissimilar pathology/physiology, and (2) guide transfusion timing and amount to efficacy-based goals (other than resolution of hemoglobin thresholds). Here, we explore approaches to TDM that address the above gaps.
Key points
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A transfusion is indicated when O 2 delivery fails to meet metabolic need (or failure is impending).
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Additionally, the risk and impact of O 2 delivery failure should exceed the risk and impact of harm anticipated from transfusion.
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Transfusion should be appropriately sequenced with other interventions (based on principles of integrative physiology, potential morbidity, likelihood to optimize O 2 delivery, and context specific to individual patient trajectories).
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Once the decision to transfuse has been made, clinicians should use a titrated approach to administering red blood cells to maintain the risk of transfusion as low as is reasonably achievable while monitoring for resolution of anemia intolerance and improvement in O 2 delivery.
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