Table III.

Summary of the most recent recommendations and clinical guidelines on red blood cell transfusion thresholds from national or international scientific societies.

Society, year of publication	RBC transfusion threshold	Clinical setting	Grading of evidence1	Ref.
College of American Pathologists, 1998	Hb level <6 g/dL	Acute anaemia in surgical and non-surgical patients	NA	33
Society of Critical Care Medicine (SCCM), 2009	Hb level <7 g/dL	Critically ill patients	NA	34,35
American Academy of Family Physicians, 2011	Hb level <7 g/dL	The threshold for transfusion of RBC should be a Hb level of 7 g/dL in adults and most children.	A	36
	Hb level between 7–9 g/dL	A restrictive transfusion strategy should not be used in preterm infants or children with cyanotic heart disease, severe hypoxaemia, active blood loss, or haemodynamic instability.	B
Society of Thoracic Surgeons, Society of Cardiovascular Anesthesiologists (SCA), 2007; and 2011 Guidelines Update	Hb level <7 g/dL	Cardiac surgery	C, Class IIa	37,38
Italian Society of Transfusion Medicine and Imunohematology (SIMTI), 2011	Hb level <6 g/dL	Intra- or post-operative period	1C+	39,40
	Hb level between 6–10 g/dL	Presence of risk factors (i.e., CAD, heart failure, CVD) or symptoms indicative of hypoxia	1C+, 2C
European Society of Cardiology (ESC), 2011	Compromised haemodynamic status or Hb level <7 g/dL (Target Hb level of 9–10 g/dL) or haematocrit <25%	Anemic patients with ACS	B, Class I	41
American College of Gastroenterology (ACG), 2012	Hb level <7 g/dL	Patients with upper gastrointestinal bleeding. Blood transfusions should target Hb level ≥7 g/dL, with higher Hb targeted in patients with clinical evidence of intravascular volume depletion or comorbidities such as coronary artery disease.	Conditional recommendation, low-to-moderate-quality evidence	42
National Blood Authority. Patient blood management guidelines: Module 2 - Perioperative. Australia, 2012	Hb level <8 g/dL	In the absence of acute myocardial or cerebrovascular ischaemia, postoperative transfusion may be inappropriate for patients with a Hb level >8 g/dL.	NA	43
National Blood Authority. Patient blood management guidelines: Module 3 - Medical. Australia, 2012	Hb level <7 g/dL	Medical conditions	NA	43
	Hb level <8 g/dL	Patients with ACS	NA
National Blood Authority. Patient blood management guidelines: Module 4 - Critical Care. Australia, 2013	Hb level <7 g/dL	Critical care	NA	43
European Society of Anaesthesiology (ESA), 2017	Maintain Hb between 7–9 g/dL	Active bleeding	1C	44
	Maintain Hb between 7–9 g/dL	No active bleeding	1A
Seville Document, 2013 (six Spanish scientific societies)	Maintain Hb between 7–9 g/dL	Non bleeding critically ill patients, trauma and/or surgical patients, without cardiac and/or central nervous system dysfunction	1A	45
	Maintain Hb between 8–10 g/dL	Non bleeding critically ill patients, trauma and/or surgical patients, with cardiac and/or central nervous system dysfunction	1A
American College of Physicians, 2013	Hb level between 7–8 g/dL	Hospitalised patients with coronary heart disease	Weak recommendation; low-quality evidence	46
British Committee for Standards in Hematology (BCSH), 2013	Hb level ≤7 g/dL	Critically ill patients (target: Hb level 7–9 g/dL). Transfusion triggers should not exceed 9 g/dL in most critically ill patients (grade 1B).	1B	47
NCCN Guidelines Version 2.2014 Cancer- and Chemotherapy- Induced Anemia. NCCN Clinical Practice Guidelines in Oncology. Fort Washington, PA: National Comprehensive Cancer Network, 2013	Hb level between 7–9 g/dL	Haemodynamically stable chronic anaemia without ACS	2A	48
	Hb level between 8–10 g/dL	Symptomatic anaemia	2A
	Hb level between >10 g/dL	Anaemia with ACS or acute myocardial infarction	2A
The National Institute for Health and Care Excellence (NICE) Acute upper gastrointestinal bleeding, 2014	Hb level <7 g/dL	Patients with upper gastrointestinal bleeding. The strategy of providing blood transfusion when the patient’s haemoglobin drops to a lower threshold (7 g/dL) may be associated with lower mortality and fewer adverse events than transfusion at a higher threshold (9 g/dL)	Low	49
American Society of Anestesiologists, 2015	Hb level <6 g/dL	Perioperative blood management	NA	50
The National Institute for Health and Care Excellence (NICE) blood transfusion guideline NG24, 2015	Hb level ≤7 g/dL	Hb level ≤8 g/dL (target: Hb 8–10 g/dL after transfusion) for patients with ACS. Individual thresholds and Hb concentration targets for each patient who needs regular blood transfusions for chronic anaemia.	NA	51
UK National Clinical Guideline Centre (NCGC), 2015	Hb level <7 g/dL	Hb level >7 g/dL (target: Hb 7–9 g/dL)	NA	52
	Hb level <8 g/dL	ACS need regular blood transfusions for chronic anaemia (target: Hb 8–10 g/dL)	NA
Recommendations from the College of Intensive Care Medicine & the Australian and New Zealand Intensive Care Society on end-of-life care, invasive devices, anaemia, sedation & antibiotics, 2016	Hb level <7 g/dL	Transfuse red cells for anaemia only if the Hb level <7 g/dL or if the patient is haemodynamically unstable or has significant cardiovascular or respiratory comorbidity.	NA	53
AABB (formerly American Association of Blood Banks), 2016	Hb level <7 g/dL	Hospitalised adult patients who are haemodynamically stable, including critically ill patients	Strong recommendation, moderate quality evidence	54
	Hb level <8 g/dL	Patients undergoing orthopaedic surgery or cardiac surgery and patients with preexisting cardiovascular disease	Strong recommendation, moderate quality evidence

¹For the interpretation of the various grades of recommendations and levels of evidence, see material and methods of the related references.

Hb: haemoglobin; NA: not available; CAD: coronary artery disease; ACS: acute coronary syndrome; CVD: cardiovascular disease.