Restrictive red blood cell transfusion: not just for the stable intensive care unit patient

Multiple studies report that patients receiving red blood cell (RBC) transfusion in the intensive care unit (ICU) are more likely to experience complications. Despite these findings, surgical patients are frequently transfused for operative procedures, trauma, and burns. We hypothesized that a RBC transfusion guideline would safely decrease our use of RBC transfusions in the ICU and lower the hematocrit at which our trauma and burn patients were transfused, both in the stable and symptomatic patient.

For each episode of RBC transfusion, the pretransfusion vital signs and reasons for transfusion were recorded prospectively from August 2003 through April 2004. Before institution of the transfusion guideline, which stressed withholding transfusion for hematocrit over 23 in asymptomatic patients, intensive education of all caregivers occurred. Data from all transfusions during 2005 were also reviewed for long-term compliance with the guideline.

Eighty-two of 316 ICU patients (26%) had 315 RBC transfusion events during the initial study period. Mean transfusion hematocrits decreased from 26.6 +/- 4.7 to 23.9 +/- 2.6 (P < .0003) for all patients. For the follow-up period in 2005, 94 of 523 patients (18%) were transfused in the ICU at a mean transfusion hematocrit of 24.1 for symptomatic (P < .0001) and 22.5 for asymptomatic patients (P < .0001). Low hematocrit was the most frequently cited reason for transfusion for all patients in the first part of the study, whereas hemodynamic instability (n = 91 events) and perioperative losses (n = 49 events) ranked highest for symptomatic patients.

A transfusion guideline accompanied by intensive education is effective in reducing RBC transfusions in a trauma-burn ICU. A lower hematocrit was well tolerated in both the symptomatic and asymptomatic groups of surgical patients. With education and follow-up, the changes in transfusion practices were durable and affected transfusion practices for both asymptomatic and symptomatic patients.