Transfusion — Products, Thresholds, TRALI & TACO

Also known as Blood transfusion · Packed red blood cells · Fresh frozen plasma · FFP · Cryoprecipitate · Restrictive transfusion · TRICC trial · TRISS trial · TRALI · TACO · Acute haemolytic transfusion reaction

The blood products (RBC, FFP, platelets, cryoprecipitate, PCC) and the restrictive transfusion strategy (RBC Hb under 70 for the most — the TRICC, TRISS trials; under 80 for the cardiovascular or the elderly; platelets under 10 prophylactic or under 50 bleeding; FFP if PT or APTT over 1.5 times; cryoprecipitate if fibrinogen under 1.5). The transfusion reactions: TRALI (the donor antibodies, the ARDS-like, the within 6 h, the NO overload — supportive), TACO (the circulatory overload, the pulmonary oedema — diuretics), the acute haemolytic (the ABO incompatibility — STOP immediately), the febrile non-haemolytic, the allergic (the mild to the anaphylaxis). The leukodepletion standard (reduces the febrile and the CMV). The male-donor plasma preferred (the TRALI prevention).

high47 referencesUpdated 26 July 202638 min readSource-verified · Sept 2026

Checked against its sources on 2 Sept 2026

Practise this topic

8 MCQs

Overview & definition

Blood transfusion in the ICU is three separate skills, not one. Know the products (RBC, FFP, platelets, cryo, PCC), know the restrictive thresholds (TRICC — Hb under 70), and recognise the reactions (TRALI, TACO, the acute haemolytic). Miss any one of the three and a patient dies on your shift.^[1]

Restrictive transfusion cuts harm without changing outcome. Six landmark RCTs — TRICC, TRISS, FOCUS, TITRe2, TRICS-3 and REALITY — plus Villanueva's GI-bleed trial converge on the same answer: transfuse less, and transfuse deliberately.^[1]^[8]

TRALI and TACO are the two pulmonary reactions, and the discriminator is volume. TRALI is capillary leak — ARDS-like, euvolaemic, supportive care, NO diuretics. TACO is circulatory overload — pulmonary oedema, raised JVP, furosemide.^[1]

References47Show

[1]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.PMID 9971864
[2]Holst LB, Haase N, Wetterslev J, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock N Engl J Med, 2014.PMID 25270275
[3]Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery N Engl J Med, 2011.PMID 22168590
[4]Murphy GJ, Pike K, Rogers CA, et al. Liberal or restrictive transfusion after cardiac surgery N Engl J Med, 2015.PMID 25760354
[5]Ducrocq G, Gonzalez-Juanatey JR, Puymirat E, et al. Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia: The REALITY Randomized Clinical Trial JAMA, 2021.PMID 33560322
[6]Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial JAMA, 2015.PMID 25647203
[7]Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery. N Engl J Med, 2017.PMID 29130845
[8]Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding N Engl J Med, 2013.PMID 23281973
[9]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
[10]Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial Lancet, 2016.PMID 27178479
[11]Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition Crit Care, 2023.PMID 36859355
[12]Santiago R, Slocum G, Riggi G Resuscitating massive transfusion knowledge: An update for the pharmacist Am J Health Syst Pharm, 2025.PMID 40580496
[13]Nunez TC, Voskresensky IV, Dossett LA, et al. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma, 2009.PMID 19204506
[14]Pollack CV Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for Dabigatran Reversal N Engl J Med, 2015.PMID 26095746
[15]Steiner T, Poli S, Griebe M, et al. Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists (INCH): a randomised trial Lancet Neurol, 2016.PMID 27302126
[16]Robinson D, McFadyen J, Merriman E, et al. Updated recommendations for warfarin reversal in the setting of four-factor prothrombin complex concentrate Med J Aust, 2025.PMID 39586827
[17]De Simone F, Nardelli P, Licheri M, et al. Less is more: We are administering too much protamine in cardiac surgery Ann Card Anaesth, 2021.PMID 33884973
[18]Robertson CS, Hannay HJ, Yamal JM, et al. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial JAMA, 2014.PMID 25058216
[19]Kaufman RM, Djulbegovic B, Gernsheimer T, et al. Platelet transfusion: a clinical practice guideline from the AABB Ann Intern Med, 2015.PMID 25383671
[20]Heddle NM, Cook RJ, Tinmouth A, et al. A randomized controlled trial comparing standard- and low-dose strategies for transfusion of platelets (SToP) to patients with thrombocytopenia Blood, 2009.PMID 19109560
[21]Slichter SJ, Davis K, Enright H, et al. Factors affecting posttransfusion platelet increments, platelet refractoriness, and platelet transfusion intervals in thrombocytopenic patients Blood, 2005.PMID 15692069
[22]Raturi M, Shastry S, Murugesan M, et al. Effect of plasma component transfusion on conventional coagulation screening tests Asian J Transfus Sci, 2018.PMID 29563677
[23]Holland LL, Brooks JP Toward rational fresh frozen plasma transfusion: The effect of plasma transfusion on coagulation test results Am J Clin Pathol, 2006.PMID 16753596
[24]Theodoulou A, Berryman J, Nathwani A, et al. Comparison of cryoprecipitate with fibrinogen concentrate for acquired hypofibrinogenaemia Transfus Apher Sci, 2012.PMID 22227402
[25]Callum J, Farkouh ME, Scales DC, et al. Effect of Fibrinogen Concentrate vs Cryoprecipitate on Blood Component Transfusion After Cardiac Surgery: The FIBRES Randomized Clinical Trial JAMA, 2019.PMID 31634905
[26]Davenport R, Curry N, Fox EE, et al. Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial JAMA, 2023.PMID 37824155
[27]Meizoso JP, Moore EE, Pieracci FM, et al. Role of Fibrinogen in Trauma-Induced Coagulopathy J Am Coll Surg, 2022.PMID 35290265
[28]Winearls J, Campbell D, Hurn C, et al. Fibrinogen Early In Severe Trauma studY (FEISTY): results from an Australian multicentre randomised controlled pilot trial Crit Care Resusc, 2021.PMID 38046391
[29]Baksaas-Aasen K, Gall LS, Stensballe J, et al. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial Intensive Care Med, 2021.PMID 33048195
[30]Takahashi K, Yamakawa K, Siletz AE, et al. Hyperfibrinolysis: a crucial phenotypic abnormality of posttraumatic fibrinolytic dysfunction Res Pract Thromb Haemost, 2024.PMID 39430866
[31]Lacroix J, Hébert PC, Fergusson DA, et al. Age of transfused blood in critically ill adults N Engl J Med, 2015.PMID 25853745
[32]Cooper DJ, McQuilten ZK, Nichol A, et al. Age of Red Cells for Transfusion and Outcomes in Critically Ill Adults N Engl J Med, 2017.PMID 28952891
[33]Raza S, Ali Baig M, Chang C, et al. A prospective study on red blood cell transfusion related hyperkalemia in critically ill patients J Clin Med Res, 2015.PMID 25883703
[34]Giancarelli A, Birrer KL, Alban RF, et al. Hypocalcemia in trauma patients receiving massive transfusion J Surg Res, 2016.PMID 27083965
[35]Tran A, Yates JM, Lau A, et al. Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trials J Trauma Acute Care Surg, 2018.PMID 29370058
[36]Vlaar AP, Juffermans NP Transfusion-related acute lung injury: a clinical review Lancet, 2013.PMID 23642914
[37]Vlaar APJ, Zwaginga JJ, Wiersum-Osselton JC How I diagnose and treat cardiorespiratory complications of transfusion Blood, 2025.PMID 39374519
[38]Semple JW, Rebetz J, Kapur R, et al. Transfusion-associated circulatory overload and transfusion-related acute lung injury Blood, 2019.PMID 30808638
[39]Delaney M, Wendel S, Bercovitz RS, et al. Transfusion reactions: prevention, diagnosis, and treatment Lancet, 2016.PMID 27083327
[40]Klanderman RB, Bosboom JJ, Migdady Y, et al. Transfusion-associated circulatory overload-a systematic review of diagnostic biomarkers Transfusion, 2019.PMID 30488959
[41]Tong N, Masel D, Nguyen PL, et al. The case for universal leukoreduction of blood transfusions Transfus Apher Sci, 2026.PMID 41435793
[42]Viele MK, Weiskopf RB What can we learn about the need for transfusion from patients who refuse blood? The experience with Jehovah's Witnesses Transfusion, 1994.PMID 8191563
[43]Lawson T, Ralph C Perioperative Jehovah's Witnesses: a review Br J Anaesth, 2015.PMID 26068896
[44]Kirpalani H, Whyte RK, Andersen C, et al. The Premature Infants in Need of Transfusion (PINT) study: a randomized, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants J Pediatr, 2006.PMID 16939737
[45]Agarkar R, Kesharwani R, Nagpal S, et al. Hemoglobin equilibration kinetics after single-unit red blood cell transfusion in stable hospitalized adults: A prospective cohort study Transfus Apher Sci, 2026.PMID 42048991
[46]Dodd A, Hughes A, Sargant N, et al. Evidence update for the treatment of anaphylaxis Resuscitation, 2021.PMID 33895231
[47]Carson JL, Stanworth SJ, Dennis JA, et al. Transfusion thresholds for guiding red blood cell transfusion Cochrane Database Syst Rev, 2021.PMID 34932836