American Burn Association Clinical Practice Guideline on Blood Product Transfusion in Burn Care

This Clinical Practice Guideline addresses blood product transfusion among hospitalized acutely burned adults. The Investigator Panel, consisting of the authors of this paper, developed clinically relevant questions in PICO format (Population, Intervention, Comparator, Outcome). These questions informed a systematic literature search which returned 1947 titles, of which 10 articles met the criteria for inclusion and critical review. We strongly recommend the use of a restrictive red blood cell (RBC) transfusion threshold (hemoglobin level ≥ 7 g/dL), to reduce the number of blood transfusions administered to adults with burns ≥ 20% total burn surface area (TBSA). We also recommend a restrictive RBC transfusion threshold because the outcomes of infection, length of stay, and mortality are no worse than with liberal RBC transfusion thresholds (hemoglobin level ≥ 10 g/dL), while transfusing less blood. We make a weak recommendation to not use recombinant human erythropoietin to reduce the number of RBC transfusions. We make a weak conditional recommendation to consider the use of intraoperative intravenous tranexamic acid during major burn wound excision, to reduce the number of perioperative blood transfusions, preferably in conjunction with performing dynamic viscoelastic testing in this setting. We recommend that in the perioperative period during major burn debridement, thromboelastography and rotation thromboelastometry be used to guide blood product transfusion, to reduce the overall amount of blood product transfusion. No recommendation could be made on the use of a 1:1:1 RBC to fresh frozen plasma to platelet transfusion strategy to decrease the number of RBC transfusions or mortality in adult burn patients undergoing surgical burn wound excision.