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Updated: May 4, 2026
A Precision Medicine Tool for Measurement and Monitoring of Hemoglobin S in Sickle Cell Disease Patients Receiving Transfusion Therapy
Assessment of hemoglobin threshold for packed RBC transfusion in a medical-surgical PICU
Stacey L Valentine1, Jenifer R Lightdale, Chau M Tran
11Critical Care Division, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA. 2Harvard Medical School, Boston, MA. 3Department of Pediatrics, Division of Pediatric Critical Care, University of Massachusetts Children's Medical Center, Worcester, MA. 4Department of Medicine, Boston Children's Hospital, Boston, MA. 5Clinical Research Center, Boston Children's Hospital, Boston, MA. 6Department of Laboratory and Transfusion Medicine, Boston Children's Hospital, Boston, MA. 7Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA.
Insights
Disseminating evidence on red blood cell (RBC) transfusion thresholds in pediatric intensive care units (PICUs) led to a significant decrease in hemoglobin thresholds. However, a majority of transfusions still occurred above the recommended 7 g/dL level.
Area of Science:
- Pediatric Critical Care Medicine
- Transfusion Medicine
- Evidence-Based Practice Implementation
Background:
- A 2007 clinical trial showed no benefit of liberal versus conservative red blood cell (RBC) transfusion thresholds in stable critically ill children.
- The conservative threshold reduced RBC transfusions without increasing adverse outcomes.
- The study aimed to assess the impact of this evidence on transfusion practices in a pediatric medical-surgical ICU.
Purpose of the Study:
- To determine if the dissemination of evidence regarding RBC transfusion thresholds altered clinical practice in a pediatric intensive care unit (PICU).
- To evaluate changes in hemoglobin thresholds for RBC transfusions in potentially stable critically ill children post-evidence dissemination.
Main Methods:
- A before-after retrospective cohort study design was employed.
- Data were collected from administrative databases and chart reviews within a pediatric medical-surgical ICU.
- Potentially stable children receiving RBC transfusions in 2006 (prepublication) and 2009-2010 (postpublication) were analyzed, excluding unstable patients.
Main Results:
- The median hemoglobin transfusion threshold significantly decreased from 8.0 g/dL in 2006 to 7.5 g/dL in 2009-2010 (p = 0.001).
- The percentage of transfusion days with a hemoglobin threshold >7 g/dL decreased from 81% in 2006 to 71% in 2009-2010.
- No significant differences were observed in patient demographics, diagnoses, illness severity, mortality, or length of stay between the two periods.
Conclusions:
- Dissemination of evidence on RBC transfusion thresholds led to a significant decrease in the hemoglobin threshold used in this PICU.
- Despite the decrease, a substantial proportion (71%) of transfusions in potentially stable critically ill children still occurred at hemoglobin levels above 7 g/dL.
- Further interventions may be needed to fully align clinical practice with evidence-based transfusion guidelines in pediatric critical care.
Objective:
Results of a large multicenter randomized clinical trial published in 2007 demonstrated no benefit in using a liberal versus conservative RBC transfusion threshold in stable critically ill children. Using the conservative threshold decreased the number of RBC transfusions without increasing adverse outcomes. We aimed to determine if wide dissemination of this evidence altered the hemoglobin threshold used for RBC transfusions in our pediatric medical-surgical ICU.
Design:
Before-after retrospective cohort study using multiple administrative databases and chart review.
Setting:
PICU serving medical and surgical patients.
Patients:
All potentially stable children receiving a RBC transfusion in the PICU in 2006 (prepublication) and in 2009-2010 (postpublication). Children were considered unstable and excluded if they were severely hypoxic, receiving renal replacement therapy, hemodynamically unstable, or bleeding.
Interventions:
Physician education on evidence supporting hemoglobin transfusion thresholds in teaching conferences, staff meetings, and via e-mail.
Measurements And Main Results:
In 2006, 14.6% of patients (n = 285/1,940) received a RBC transfusion. In 2009-2010, 12.1% of patients (n = 551/4,542) received a RBC transfusion. We evaluated patients transfused when they were potentially clinically stable, including 145 children in 2006 (191 transfusion days) and 266 children in 2009-2010 (369 transfusion days). We found no significant differences in age, sex, race, diagnoses, postoperative status, illness severity scores, mortality, or length of stay between these two groups. The median hemoglobin transfusion threshold decreased significantly from 8.0 g/dL (interquartile range 7.3, 8.6 g/dL) in 2006 to 7.5 g/dL (interquartile range 6.9, 8.1 g/dL) in 2009-2010 (p = 0.001). The percentage of transfusion days using a hemoglobin threshold more than 7 g/dL decreased from 81% (n = 154) in 2006 to 71% (n = 261) in 2009-2010.
Conclusion:
Although transfusion thresholds in potentially stable critically ill children in our PICU significantly decreased after dissemination of best available evidence, 71% of patients were transfused at a hemoglobin threshold more than 7 g/dL.
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