The American College of Chest Physicians released updated clinical practice guidelines for red blood cell transfusion in critically ill adults. 

The guidelines, published in CHEST, provide evidence-based recommendations for red blood cell (RBC) transfusion strategies across various patient populations. Guidelines include: 

• Critically Ill Patients: A restrictive RBC transfusion strategy (hemoglobin [Hb] 7-8 g/dL) is recommended over a more permissive approach (Hb 8.5-10 g/dL) (strong recommendation, moderate certainty of evidence).
• Acute Gastrointestinal Bleeding: A restrictive transfusion strategy is recommended for this population (strong recommendation, moderate certainty of evidence).
• Acute Coronary Syndrome (ACS): The guidelines suggest against using a restrictive transfusion strategy for ACS (conditional recommendation, low certainty of evidence).
• Cardiac Surgery: In the perioperative setting, a restrictive transfusion strategy is suggested (conditional recommendation, moderate certainty of evidence).
• Isolated Troponin Elevation: For critically ill patients with isolated serum troponin elevation without evidence of myocardial ischemia, a restrictive strategy is suggested based on expert opinion (conditional recommendation, very low certainty of evidence).
• Septic Shock: The guidelines recommend against adding permissive RBC transfusion thresholds to standard care in patients with septic shock (conditional recommendation, low certainty of evidence).

The panel developed six clinical questions using the Population, Intervention, Comparator, and Outcome (PICO) format. A comprehensive literature review was conducted using MEDLINE, Embase, and Cochrane databases, with data updated through January 2024. The quality of the evidence was evaluated using the GRADE framework, and outcomes were reported as risk ratios (RRs) for dichotomous data and mean differences for continuous outcomes.

The study looked at the financial impacts of transfusions and determines that RBC unit costs in U.S. hospitals averaged $207, with administrative and labor costs increasing the total to $1,183. A restrictive strategy reduced RBC usage by 50%, saving costs by 33%.

The guidelines exclude recommendations for patients with hemodynamic instability due to acute hemorrhage, neurological injuries, or trauma. Further research is encouraged for subpopulations such as those with sickle cell disease, heart failure, or chronic kidney disease.

The guidelines emphasize the need for additional data on restrictive strategies in younger, high-risk cardiac surgery patients, and other underrepresented groups in sepsis trials.

None of the authors reported conflicts of interest.