ICU · Resuscitation

Blood transfusion in the ICU

Also known as Transfusion thresholds · Restrictive vs liberal transfusion · TRICC trial · TRISS trial · REALITY trial · Transfusion reactions · TRALI and TACO · Massive transfusion ratio 1:1:1 · PROPPR trial · Blood product administration · Transfusion-associated circulatory overload · Transfusion-related acute lung injury

The TRICC trial (1999) established that a RESTRICTIVE transfusion strategy (transfuse at Hb <70 g/L) is at least as effective as and possibly superior to a liberal strategy in most ICU patients, with the possible exception of acute MI and unstable angina. Restrictive strategies cut blood exposure and transfusion-hazard risk — TACO is the leading cause of transfusion-related death. Populations tested: acute MI (REALITY — restrictive trigger Hb ≤8 non-inferior for MACE), cardiac surgery (TRICS III — restrictive non-inferior), hip fracture surgery (FOCUS — liberal no better), septic shock (TRISS — restrictive non-inferior with median 1 vs 4 units), paediatric ICU (TRIPICU). Acute brain injury/TBI: debated, no trial-proven higher threshold. Single unit transfusion (one at a time, reassess, equilibration ~24 h) is standard. Transfusion reactions: TRALI (ARDS-type within hours, supportive care), TACO (volume overload, diuretic, leading cause of transfusion-related death), allergic, anaphylactic (anti-IgA), acute haemolytic (ABO mismatch), delayed haemolytic, febrile non-haemolytic, bacterial contamination (room-temperature platelets), transfusion-associated GVHD (irradiation prevents; leukoreduction does not). Blood products: PRBC, FFP, platelets, cryoprecipitate, PCC. Massive transfusion: balanced 1:1:1 ratios (PROPPR — more haemostasis, fewer exsanguination deaths), early TXA (CRASH-2), calcium for citrate hypocalcaemia.