Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Use of blood products in the critically ill

Addison K May, MD
John P Reilly, MD, MSCE
Section Editors
Scott Manaker, MD, PhD
Arthur J Silvergleid, MD
Deputy Editor
Geraldine Finlay, MD


Transfusion of red blood cells or another blood product is common in the intensive care unit (ICU). It has been estimated that greater than 40 percent of patients receive one or more red blood cell transfusions while in the ICU, of which approximately 90 percent are provided in the context of stable anemia [1-4].

The appropriate use of blood products requires that the potential benefits and risks be carefully weighed for each patient. Indications and complications of blood product transfusion in the ICU are reviewed here, as well as the various types of blood products. Other issues related to transfusion of blood products are discussed separately. (See "Red blood cell transfusion in adults: Storage, specialized modifications, and infusion parameters" and "Clinical use of plasma components" and "Clinical use of Cryoprecipitate" and "Initial management of moderate to severe hemorrhage in the adult trauma patient" and "Clinical and laboratory aspects of platelet transfusion therapy".)


RBC indications — Indications for the transfusion of packed red blood cells (RBCs) in critically ill patients include the following [5,6]:

Acute hemorrhage with hemodynamic instability (ie, hemorrhagic shock).

Acute anemia with inadequate oxygen delivery (eg, cool vasoconstricted skin, obtundation or restlessness, oliguria or anuria, lactic acidosis, an oxygen extraction ratio of greater than 0.3, and/or an oxygen delivery of less than 10 to 12 mL/kg per minute). (See "Oxygen delivery and consumption".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Oct 2017. | This topic last updated: Sep 28, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Corwin HL, Gettinger A, Pearl RG, et al. The CRIT Study: Anemia and blood transfusion in the critically ill--current clinical practice in the United States. Crit Care Med 2004; 32:39.
  2. Raghavan M, Marik PE. Anemia, allogenic blood transfusion, and immunomodulation in the critically ill. Chest 2005; 127:295.
  3. Vincent JL, Baron JF, Reinhart K, et al. Anemia and blood transfusion in critically ill patients. JAMA 2002; 288:1499.
  4. Walsh TS, Garrioch M, Maciver C, et al. Red cell requirements for intensive care units adhering to evidence-based transfusion guidelines. Transfusion 2004; 44:1405.
  5. Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. Crit Care Med 2009; 37:3124.
  6. Retter A, Wyncoll D, Pearse R, et al. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Br J Haematol 2013; 160:445.
  7. Ding YY, Kader B, Christiansen CL, Berlowitz DR. Hemoglobin Level and Hospital Mortality Among ICU Patients With Cardiac Disease Who Received Transfusions. J Am Coll Cardiol 2015; 66:2510.
  8. Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999; 340:409.
  9. Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2012; :CD002042.
  10. Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med 2014; 127:124.
  11. Holst LB, Haase N, Wetterslev J, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 2014; 371:1381.
  12. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368:11.
  13. Hébert PC, Tinmouth A, Corwin HL. Controversies in RBC transfusion in the critically ill. Chest 2007; 131:1583.
  14. Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med 2008; 36:2667.
  15. Oliver E, Carrio ML, Rodríguez-Castro D, et al. Relationships among haemoglobin level, packed red cell transfusion and clinical outcomes in patients after cardiac surgery. Intensive Care Med 2009; 35:1548.
  16. Vamvakas EC, Blajchman MA. Transfusion-related immunomodulation (TRIM): an update. Blood Rev 2007; 21:327.
  17. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med 2012; 157:49.
  18. Hébert PC, Yetisir E, Martin C, et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med 2001; 29:227.
  19. Desmond M. Peroperative cell salvage. Transfus Clin Biol 2007; 14:530.
  20. The Watchtower Bible and Tract Society. Questions from readers. The Watchtower 1989; 110:30.
  21. Carless PA, Henry DA, Moxey AJ, et al. Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2006; :CD001888.
  22. Rogiers P, Zhang H, Leeman M, et al. Erythropoietin response is blunted in critically ill patients. Intensive Care Med 1997; 23:159.
  23. Corwin HL, Gettinger A, Rodriguez RM, et al. Efficacy of recombinant human erythropoietin in the critically ill patient: a randomized, double-blind, placebo-controlled trial. Crit Care Med 1999; 27:2346.
  24. Corwin HL, Gettinger A, Pearl RG, et al. Efficacy of recombinant human erythropoietin in critically ill patients: a randomized controlled trial. JAMA 2002; 288:2827.
  25. Corwin HL, Gettinger A, Fabian TC, et al. Efficacy and safety of epoetin alfa in critically ill patients. N Engl J Med 2007; 357:965.
  26. Napolitano LM, Fabian TC, Kelly KM, et al. Improved survival of critically ill trauma patients treated with recombinant human erythropoietin. J Trauma 2008; 65:285.
  27. Yang L, Stanworth S, Hopewell S, et al. Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized controlled trials. Transfusion 2012; 52:1673.
  28. Consensus conference. Fresh-frozen plasma. Indications and risks. JAMA 1985; 253:551.
  29. Practice parameter for the use of fresh-frozen plasma, cryoprecipitate, and platelets. Fresh-Frozen Plasma, Cryoprecipitate, and Platelets Administration Practice Guidelines Development Task Force of the College of American Pathologists. JAMA 1994; 271:777.
  30. Contreras M, Ala FA, Greaves M, et al. Guidelines for the use of fresh frozen plasma. British Committee for Standards in Haematology, Working Party of the Blood Transfusion Task Force. Transfus Med 1992; 2:57.
  31. Gajic O, Dzik WH, Toy P. Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: benefit or harm? Crit Care Med 2006; 34:S170.
  32. Stanworth SJ, Brunskill SJ, Hyde CJ, et al. Is fresh frozen plasma clinically effective? A systematic review of randomized controlled trials. Br J Haematol 2004; 126:139.
  33. Cotton BA, Gunter OL, Isbell J, et al. Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma 2008; 64:1177.
  34. Cotton BA, Au BK, Nunez TC, et al. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma 2009; 66:41.
  35. Gunter OL Jr, Au BK, Isbell JM, et al. Optimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival. J Trauma 2008; 65:527.
  36. Gordon JL, Fabian TC, Lee MD, Dugdale M. Anticoagulant and antiplatelet medications encountered in emergency surgery patients: a review of reversal strategies. J Trauma Acute Care Surg 2013; 75:475.
  37. Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e152S.
  38. Stanworth SJ, Hyde CJ, Murphy MF. Evidence for indications of fresh frozen plasma. Transfus Clin Biol 2007; 14:551.
  39. Abdel-Wahab OI, Healy B, Dzik WH. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Transfusion 2006; 46:1279.
  40. Consensus conference. Platelet transfusion therapy. JAMA 1987; 257:1777.
  41. British Committee for Standards in Haematology, Blood Transfusion Task Force. Guidelines for the use of platelet transfusions. Br J Haematol 2003; 122:10.
  42. Slichter SJ. Evidence-based platelet transfusion guidelines. Hematology Am Soc Hematol Educ Program 2007; :172.
  43. Klein HG. Pathogen inactivation technology: cleansing the blood supply. J Intern Med 2005; 257:224.
  44. Cohen MJ. Towards hemostatic resuscitation: the changing understanding of acute traumatic biology, massive bleeding, and damage-control resuscitation. Surg Clin North Am 2012; 92:877.
  45. Duchesne JC, McSwain NE Jr, Cotton BA, et al. Damage control resuscitation: the new face of damage control. J Trauma 2010; 69:976.
  46. Cotton BA, Reddy N, Hatch QM, et al. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg 2011; 254:598.
  47. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007; 63:805.
  48. Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 2008; 248:447.
  49. Shaz BH, Dente CJ, Nicholas J, et al. Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients. Transfusion 2010; 50:493.
  50. Inaba K, Lustenberger T, Rhee P, et al. The impact of platelet transfusion in massively transfused trauma patients. J Am Coll Surg 2010; 211:573.
  51. de Biasi AR, Stansbury LG, Dutton RP, et al. Blood product use in trauma resuscitation: plasma deficit versus plasma ratio as predictors of mortality in trauma (CME). Transfusion 2011; 51:1925.
  52. Perkins JG, Cap AP, Spinella PC, et al. An evaluation of the impact of apheresis platelets used in the setting of massively transfused trauma patients. J Trauma 2009; 66:S77.
  53. Johansson PI, Stensballe J, Rosenberg I, et al. Proactive administration of platelets and plasma for patients with a ruptured abdominal aortic aneurysm: evaluating a change in transfusion practice. Transfusion 2007; 47:593.