Red Blood Cell Transfusion

RBC transfusion can increase oxygen delivery, expand blood

volume, alleviate symptoms of acute blood loss anemia, and relieve
cardiac ischemia (Table 18-1).10,11 A clear distinction needs to be made
between chronic anemia, which can be well tolerated by otherwise
healthy individuals, and acute hemorrhage, which represents loss
of red cell mass and intravascular volume. The initial Hgb and Hct
in acute blood loss do not reflect the actual extent of hemorrhage
since the recruitment of interstitial and intracellular fluid into the

intravascular space is not immediate. Unless crystalloid or colloid

is given to replace the volume lost, the Hgb and Hct levels will
underestimate the extent of the hemorrhage.7,12

Evidence of hemorrhagic shock

Acute blood loss of >20%–25% estimated blood volume

Symptomatic anemia in a euvolemic
patient

Hgb <7 g/dL in a critically ill

patient

Hgb <8 g/dL in a patient with an acute coronary syndrome

Hgb <9 g/dL preoperatively with expected blood loss of >500

mL
Hgb <10 g/dL in a possibly euvolemic patient with evidence of tissue
hypoxemia

Sickle cell acute chest syndrome if Hgb <10 g/dL or Hgb-SS

>30%

The degree of acute blood loss should be clinically evaluated

using vital signs and physical examination findings such as
tachycardia, orthostasis, decreased pulse pressure, pallor, cool
extremities, and delayed capillary refill. Frank arterial hypotension
is a late finding in acute blood loss.3 In hypovolemic shock, the
systolic pressure is decreased as a result of falling cardiac output
caused by lowered filling pressures, and the diastolic pressure
rises in response to increased systemic vascular resistance. This
compensatory effect is only temporary and goes away with frank
cardiovascular collapse.

The initial Hgb and Hct in acute blood loss do not reflect the
actual extent of hemorrhage since the recruitment of interstitial
and intracellular fluid into the intravascular space is not
immediate. Unless crystalloid or colloid is given to replace the
volume lost, the Hgb and Hct will underestimate the extent of
the hemorrhage.7,12

In a healthy person at rest, oxygen delivery is 4 times greater than

tissue utilization. Even with an isolated decrease in Hgb to 10 g/dL,
oxygen delivery will be twice that needed for resting consumption.13
Signs and symptoms of anemia are unlikely to be evident at Hgb
values above 7 or 8 g/dL in healthy patients. Even critically ill
 patients with chronic anemia can tolerate a Hgb of 7 g/dL, except
those with preexisting coronary, pulmonary, or cerebrovascular
disease.5,7,11 The anemic patient has a diminished arterial oxygen
content but is able to increase oxygen delivery by escalating cardiac
output and coronary blood flow through vasodilation.
Myocardial oxygen extraction increases from 25% at baseline; at
approximately 50%, the anaerobic threshold is reached and
myocardial lactate levels increase.7 Therefore, the current
recommendations for packed RBC transfusions are more liberal in
patients with coronary artery disease, particularly those with acute
myocardial ischemia.1,6,13,14 The likelihood of benefit from the
transfusion of packed RBCs to nonbleeding patients is summarized
in Table 18-2. Clinical judgment and data (such as lactate levels and
central venous oxygen saturation) should be used to individually
assess each case and weigh the benefits and risks of transfusion
against the dangers of ongoing anemia.1,12,14

Hgb Is transfusion beneficial?

>10 g/dL
Unlikely

7–10
g/dL
Potentially beneficial if other deficits in oxygen transport are present
<7 g/dL
Likely

In a healthy person at rest, oxygen delivery is 4 times greater

than tissue utilization. Even with an isolated decrease in Hgb to
10

g/dL, the oxygen delivered will still be twice that needed

for resting consumption.13

In a previously healthy patient with blood loss of less than 20% to

25% and no ongoing hemorrhage, only volume restoration with
crystalloid or colloid is needed.3,6 If the total blood volume loss
exceeds 20% to 25% (with a normal blood volume of 70 mL/kg),
regardless of the presenting blood indices, RBC transfusion may be
indicated. Transfusion can be indicated at lower percentages of
blood volume loss if there is a high risk of ongoing hemorrhage (eg,
patients with trauma, postpartum hemorrhage, or gastrointestinal
bleeding, particularly with concomitant cirrhosis). In such
situations, group O packed RBCs are given because this is the most
expedient blood product available. Type ABO-specific blood may
be given next if more is required, but eventually crossmatched
blood should be administered. Patients with sickle cell anemia
might require RBC transfusion upon arrival in the emergency
department. In those who are critically ill, particularly with acute
chest syndrome, a Hct of 30% and a Hgb-sickle of less than 30%
should be the goal.8
TBV estimation of actual body weight (mL/kg):
 For example, a 70-kg man would have a TBV of ~5 L (70 × 70
= 4,900), which is 10 units of whole blood.