Restrictive RBC transfusion in the ICU: Trends in clinical adherence

Introduction: The balance between the risks and benefits of red blood cell (RBC) transfusions in critically ill patients is of ongoing debate. Clinical guidelines suggest a restrictive transfusion strategy with a transfusion hemoglobin trigger of 7 g/dL for most critically ill patients. However, recent literature shows many RBC transfusions are given with a prior hemoglobin above 7 g/dL. We aimed to evaluate adherence to our own transfusion protocol and changes in transfusion policy over time for the entire Intensive Care Unit (ICU) and in subgroups. Methods: Retrospective observational cohort study of patients admitted between 2017 and 2024 to the ICU of Amsterdam UMC. Data was extracted from the electronic health record and the Dutch national quality registry (NICE). Subgroup analysis was done based on referring specialty. Results: In total 24 761 ICU stays were analyzed with 12 064 RBC transfusions in 3444 ICU stays. Median hemoglobin value before RBC transfusion decreased from 7.7 g/dL (1st–3rd quartile 7.1–8.4) in 2017 to 6.8 g/dL ((1st–3rd quartile 6.4–7.3) in 2024 (p < 0.001). This decrease was present in all subgroups. The percentage of RBC transfusions with a prior hemoglobin <7 g/dL increased from 18.8% to 64.8% (p < 0.001). Conclusion: We report the long term successful implementation of a comprehensive restrictive RBC transfusion protocol in a tertiary care ICU, independent of the patient's referring specialty. A median hemoglobin level of 6.8 g/dL before RBC transfusion was reached in 2024.