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Transfusion strategies in critical care

Key sources
The following summarized guidelines for the evaluation and management of transfusion strategies in critical care are prepared by our editorial team based on guidelines from the Pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma (ABC-T 2023), the American Association of Blood Banks (AABB 2023), the European Society of Intensive Care Medicine (ESICM 2021; 2020), the Eastern Association for the Surgery of Trauma (EAST 2020), and the British Society for Haematology (BSH 2018).
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Guidelines

1.Diagnostic investigations

Coagulation and viscoelastic testing: as per ABC-T 2023 guidelines, initiate monitoring and measures to support coagulation immediately upon hospital admission of patients with traumatic hemorrhage.
B
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2.Medical management

Tranexamic acid
As per ABC-T 2023 guidelines:
Administer tranexamic acid in patients with trauma with bleeding or at risk of significant bleeding as soon as possible, if feasible, en route to the hospital and within 3 hours after injury at a loading dose of 1 g infused over 10 minutes, followed by an IV infusion of 1 g over 8 hours.
A
Do not wait for results from a viscoelastic assessment to administer tranexamic acid.
D

3.Therapeutic procedures

Massive bleeding, transfusion strategies, ABC-T
Insufficient evidence to recommend in favor or against using pre-hospital blood products in patients with traumatic hemorrhage.
Target hemoglobin levels of 70-90 g/L if RBC transfusion is necessary in patients with major bleeding due to trauma.
B

More topics in this section

  • Massive bleeding (platelet transfusion)

  • Massive bleeding (plasma transfusion)

  • Massive bleeding (coagulation factor transfusion)

  • Non-massive bleeding (RBC transfusion)

  • Non-massive bleeding (platelet transfusion)

  • Non-massive bleeding (plasma and fibrinogen transfusion)

  • Non-bleeding (RBC transfusion thresholds)

  • Non-bleeding (RBC transfusion prevention)

  • Non-bleeding (platelet transfusion)

  • Non-bleeding (plasma transfusion)

4.Specific circumstances

Pediatric patients
Set a restrictive RBC transfusion threshold (< 7 g/dL) in critically ill pediatric patients and hemodynamically stable, hospitalized pediatric patients without a transfusion-dependent hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia but at risk of critical illness.
B
Consider setting a transfusion threshold in hemodynamically stable pediatric patients with congenital heart disease based on the cardiac abnormality and stage of surgical repair:
Situation
Guidance
Biventricular repair
7 g/dL
Single-ventricle palliation
9 g/dL
Uncorrected congenital heart disease
7-9 g/dL
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