Table 2.
CPG characteristics and hemoglobin threshold recommendations
| Guideline | Organization | Year | Hemoglobin threshold recommendation | Country and language | Methods used to assess the quality and strength of the evidence |
|---|---|---|---|---|---|
| Blood transfusion and the anesthetists. Red cell transfusion22 | The Association of Anaesthetists of Great Britain and Ireland | 2008 | “The decision to transfuse should always be made on an individual patient basis. Patients should not normally be transfused if the hemoglobin concentration is >10 g/dL. A strong indication for transfusion is a hemoglobin concentration <7 g/dL″ (Perioperative patients) | UK/IR, English | Grading system not stated |
| Clinical practice guideline: red blood cell transfusion in adult trauma and critical care23 | The Eastern Association for Surgery of Trauma Practice Management Workgroup | 2009 | “The use of only Hb level as a ‘trigger’ for transfusion should be avoided. A ‘restrictive’ strategy of RBC transfusion (transfuse when Hb 7 g/dL) is as effective as a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in critically ill patients with hemodynamically stable anemia, except possibly in patients with acute myocardial ischemia” (Critically ill patients) | USA, English | Canadian and US Preventative Task Force grading system |
| Guidelines for red blood cell and plasma transfusion for adults and children. updated24 | Guidelines for Canadian Clinical Practice Guidelines. Expert Panel | 2009 | “Red blood cell transfusion should not be dictated by a single hemoglobin trigger but should be based on a complete evaluation of the patient including volume status, tissue perfusion and comorbid disease” (General medical patients) | Canada, English | Modified version of the Canadian Task Force on the Periodic Health Examination grading system |
| Clinical blood transfusion25 | Singapore Ministry of Health | 2011 | “When hemoglobin >10 g/dL, there is usually very little indication for red cell transfusion. When hemoglobin <7 g/dL, red cells transfusion may be beneficial particularly in symptomatic patients or ongoing blood loss is expected” (General medical patients) | Singapore, English | Own rating scheme used to assess the quality of the evidence |
| Blood transfusion guideline26 | Dutch Institute for Healthcare Improvement | 2011 | “The indication for administering erythrocytes is based on medical factors and is aimed at treating or preventing the symptoms of a lack of oxygen transport capacity by the blood. Consider a transfusion if the following occurs at a Hb < 4 mmol/L: acute blood loss in a healthy individual (ASA I) < 60 years, normovolemic, blood loss at 1 location” (General medical patients) | The Netherlands, English‐Dutch | Own rating scheme used to assess the quality of the evidence |
| Blood transfusion: indications, administration, and adverse reactions24 | Finnish Medical Society Duodecim | 2011 | “It is not possible to give single hemoglobin (Hb) value as a trigger for red cell transfusion since the requirement for a transfusion is based on anemia symptoms, the patient's age, and the underlying diseases (chronic or slowly developing anemia)” (General medical patients) | Finland, English | Rating scheme modified of GRADE 2011 by the EBM Guidelines Editorial Team |
| 2011 update to The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines28 | The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists | 2011 | “With hemoglobin levels below 6 g/dL, red blood cell transfusion is reasonable since this can be life‐saving. Transfusion is reasonable in most postoperative patients whose hemoglobin is less than 7 g/dL, but no high‐level evidence supports this recommendation” (Perioperative patients) | USA, English | The assessment was conducted according to the level of evidence recommended by the AHA/ACCF Task Force on Practice Guidelines |
| KDIGO Clinical Practice Guideline for anemia in chronic kidney disease29 | Kidney Disease: Improving Global Outcomes (KDIGO) | 2012 | “We suggest that the decision to transfuse a CKD patient with nonacute anemia should not be based on any arbitrary Hb threshold, but should be determined by the occurrence of symptoms caused by anemia” (Chronic kidney diseases patients) | USA, English | KDIGO grading system |
| The “Seville” document on consensus on the alternatives to allogenic blood transfusion30 | The Spanish Societies of Anesthesiology, Critical Care Medicine and Coronary Units, Hematology and Hemotherapy, Blood Transfusion and Thrombosis and Hemostasis | 2013 | “The majority of trauma, critical and surgical patients can tolerate hemoglobin levels of 70 g/L. However, if they present acute cardiological and/or central nervous system involvement, hemoglobin levels of at least 80 g/L may be required. In any case, the decision to transfuse should be individualized for each patient” (General medical patients) | Spain, Spanish | GRADE 2008 |
| Guidelines on the management of anemia and red cell transfusion in adult critically ill patients31 | British Committee for Standards in Haematology | 2013 | “A transfusion threshold of 70 g/L or below, with a target Hb range of 70–90 g/L, should be the default for all critically ill patients, unless specific comorbidities or acute illness‐related factors modify clinical decision‐making” (Critically ill patients) | UK, English | GRADE 2008 |
| Treatment of anemia in patients with heart disease: a clinical practice guideline from the American College of Physicians32 | American College of Physicians | 2013 | “ACP recommends using a restrictive red blood cell transfusion strategy (trigger hemoglobin threshold of 7 to 8 g/dL compared with higher hemoglobin levels) in hospitalized patients with coronary heart disease”(Patients with heart disease) | USA, English | ACP's clinical practice guidelines grading system |
| Practice guidelines for perioperative blood management—an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management33 | American Society of Anesthesiologists | 2014 | “A restrictive red blood cell transfusion strategy may be safely used to reduce transfusion administration” (Perioperative patients) | USA, English | ASA grading system |
| The National Blood Authority's Patient Blood Management Guideline: Module 2—Perioperative34 | National Blood Authority Australia | 2012 | “RBC transfusion should not be dictated by a hemoglobin ‘trigger’ alone but should be based on an assessment of the patient's clinical status” (Perioperative patients) | Australia, English | National Blood Authority scheme |
| The National Blood Authority's Patient Blood Management Guideline: Module 3—Medical35 | National Blood Authority Australia | 2012 | “RBC transfusion should not be dictated by a Hb concentration alone, but should also be based on an assessment of the patient's clinical status. Direct evidence is not available in general medical patients” (General medical patients) | Australia, English | National Blood Authority scheme |
| The National Blood Authority's Patient Blood Management Guideline: Module 4—Critical Care36 | National Blood Authority Australia | 2012 | “In critically ill patients, a restrictive transfusion strategy should be employed” (Critically ill patients) | Australia, English | National Blood Authority scheme |
| The National Blood Authority's Patient Blood Management Guideline: Module 5—Obstetrics and Maternity37 | National Blood Authority Australia | 2015 | “In maternity patients who are not actively bleeding, RBC transfusion should not be dictated by a Hb concentration alone, but should also be based on an assessment of the patient's clinical status (eg, the risk of further hemorrhage)” (Obstetric patients) | Australia, English | National Blood Authority scheme |
| Blood Transfusion NICE guideline38 | National Institute for Health and Care Excellence | 2015 | “Use restrictive red blood cell transfusion thresholds for patients who need red blood cell transfusions and who do not: have major hemorrhage, or have the acute coronary syndrome, or need regular blood transfusions for chronic anemia” (General medical patients) | UK, English | GRADE |
| Blood transfusion in obstetrics39 | Royal College of Obstetricians & Gynaecologists | 2015 | “There are no firm criteria for initiating red cell transfusion. The decision to provide blood transfusion should be made on clinical and hematological grounds” (Obstetric patients) | UK, English | Scheme using Royal College of Obstetricians and Gynaecologists for grading recommendations |
| Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage40 | American Association of Blood Banks | 2016 | “The AABB recommends a restrictive RBC transfusion threshold in which the transfusion is not indicated until the hemoglobin level is 7 g/dL for hospitalized adult patients who are hemodynamically stable, including critically ill patients, rather than a liberal threshold when the hemoglobin level is 10 g/dL” (General medical patients) | USA, English | GRADE |