IMPORTANCE: Red blood cell (RBC) transfusion is common among patients admitted to the intensive care unit (ICU). Despite multiple randomized clinical trials of hemoglobin (Hb) thresholds for transfusion, little is known about how these thresholds are incorporated into current practice. OBJECTIVE: To evaluate and describe ICU RBC transfusion practices worldwide. DESIGN, SETTING, AND PARTICIPANTS: International, prospective, cohort study that involved 3643 adult patients from 233 ICUs in 30 countries on 6 continents from March 2019 to October 2022 with data collection in prespecified weeks. EXPOSURE: ICU stay. MAIN OUTCOMES AND MEASURES: The primary outcome was the occurrence of RBC transfusion during ICU stay. Additional outcomes included the indication(s) for RBC transfusion (consisting of clinical reasons and physiological triggers), the stated Hb threshold and actual measured Hb values before and after an RBC transfusion, and the number of units transfused. RESULTS: Among 3908 potentially eligible patients, 3643 were included across 233 ICUs (median of 11 patients per ICU [IQR, 5-20]) in 30 countries on 6 continents. Among the participants, the mean (SD) age was 61 (16) years, 62% were male (2267/3643), and the median Sequential Organ Failure Assessment score was 3.2 (IQR, 1.5-6.0). A total of 894 patients (25%) received 1 or more RBC transfusions during their ICU stay, with a median total of 2 units per patient (IQR, 1-4). The proportion of patients who received a transfusion ranged from 0% to 100% across centers, from 0% to 80% across countries, and from 19% to 45% across continents. Among the patients who received a transfusion, a total of 1727 RBC transfusions were administered, wherein the most common clinical indications were low Hb value (n = 1412 [81.8%]; mean [SD] lowest Hb before transfusion, 7.4 [1.2] g/dL), active bleeding (n = 479; 27.7%), and hemodynamic instability (n = 406 [23.5%]). Among the events with a stated physiological trigger, the most frequently stated triggers were hypotension (n = 728 [42.2%]), tachycardia (n = 474 [27.4%]), and increased lactate levels (n = 308 [17.8%]). The median lowest Hb level on days with an RBC transfusion ranged from 5.2 g/dL to 13.1 g/dL across centers, from 5.3 g/dL to 9.1 g/dL across countries, and from 7.2 g/dL to 8.7 g/dL across continents. Approximately 84% of ICUs administered transfusions to patients at a median Hb level greater than 7 g/dL. CONCLUSIONS AND RELEVANCE: RBC transfusion was common in patients admitted to ICUs worldwide between 2019 and 2022, with high variability across centers in transfusion practices.

Department for Internal Intensive Care General Hospital Celje Medical Faculty University of Ljubljana Slovenia

Department of Anaesthesiology Intensive Care Medicine and Pain Therapy EvangKliniken Essen Mitte Huyssens Stiftung Knappschaft Essen Germany

Department of Anesthesia and Intensive Care Medicine Copenhagen University Hospital Gentofte Hellerup Denmark

Department of Anesthesia and Intensive Care Military Medical Academy Belgrade Belgrade Serbia

Department of Anesthesiology Aga Khan University Hospital Nairobi Kenya

Department of Anesthesiology and Intensive Care Institute of Medical Sciences University of Opole Opole Poland

Department of Anesthesiology and Intensive Care IRCCS Humanitas Research Hospital Milan Italy

Department of Anesthesiology and Intensive Care Kepler University Clinic Kepler University Linz Austria

Department of Anesthesiology and Intensive Care Medicine University Hospital and Faculty of Medicine in Plzen Charles University Plzen Czech Republic

Department of Anesthesiology and Intensive Care University Clinical Hospital Center Zagreb Croatia

Department of Anesthesiology and Post surgical Critical Care University Hospital Doctor Peset Valencia Spain

Department of Anesthesiology and Reanimation Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center University of Health Sciences Istanbul Turkey

Department of Anesthesiology Critical Care and Pain Tata Memorial Hospital Homi Bhabha National Institute Mumbai India

Department of Anesthesiology University Medical Center Groningen Groningen the Netherlands

Department of Cardiothoracic Surgery European Interbalkan Medical Center Thessaloniki Greece

Department of Child General and Specialistic Surgery University of Campania Luigi Vanvitelli Naples Italy

Department of Clinical Medicine University of Copenhagen Copenhagen Denmark

Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden

Department of Critical Care Asgar Ali Hospital Dhaka Bangladesh

Department of Critical Care Medicine Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow India

Department of Epidemiology and Data Science Amsterdam University Medical Centre Amsterdam Public Health University of Amsterdam Amsterdam the Netherlands

Department of Intensive Care Adults Erasmus MC University Medical Centers Rotterdam the Netherlands

Department of Intensive Care Amsterdam University Medical Centers Amsterdam the Netherlands

Department of Intensive Care Centro Hospitalar de Entro o Douro e Vouga Santa Maria da Feira Portugal

Department of Intensive Care CHU Charleroi Marie Curie Université Libre de Brussels Charleroi Belgium

Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Copenhagen Denmark

Department of Intensive Care Inselspital Bern University Hospital and University of Bern Bern Switzerland

Department of Intensive Care Pontificia Universidad Católica de Chile Santiago Chile

Department of Pulmonary and Critical Care New York University and Columbia University New York

Division of Pulmonary Critical Care and Sleep Medicine and Section of Transfusion Medicine and Therapeutic Pathology University of New Mexico School of Medicine Albuquerque

Faculty of Medicine University of Tripoli Tripoli Libya

Intensive Care Service Hospital Universitario La Paz Madrid Spain

Intensive Care Unit 1st Department of Respiratory Medicine National and Kapodistrian University of Athens Sotiria Chest Hospital Athens Greece

Médecine Intensive Réanimation CHU de Brest Université de Bretagne Occidentale Brest France

Nuffield Department of Clinical Neurosciences University of Oxford Oxford United Kingdom

School of Public Health and Preventive Medicine Monash University Melbourne Australia

The Australian and New Zealand Intensive Care Research Centre School of Public Health and Preventive Medicine Monash University Melbourne Australia

Unidad de Cuidados Intensivos Hospital Vicente Corral Moscoso Cuenca Ecuador

JAMA. 2024 Aug 6;332(5):428. doi: 10.1001/jama.2024.12247. PubMed

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Plasma transfusion in the intensive care unit