Update of Red Blood Cell Transfusion Guidelines

Red blood cell transfusion is a key supportive therapy across critical care, surgical, and medical settings.However, excessive transfusion is associated with adverse outcomes and the inefficient use of limited blood resources.Traditionally, restrictive transfusion strategies have been shown to be as safe as liberal strategies in many populations, and this evidence has been incorporated into national and international guidelines and quality evaluations.However, recent data challenge the universal applicability of restrictive thresholds for acute myocardial infarction (AMI) and acute brain injury (ABI).Large, randomized trials such as the Myocardial Ischemia and Transfusion trial (MINT) and the REstrictive And LIberal Transfusion strategies in patients with AMI trial (REALITY), together with updated Association for the Advancement of Blood & Biotherapies (AABB) guidelines, now favor a liberal strategy around hemoglobin 10 g/dL in AMI.Similarly, a 2025 Cochrane review incorporating trials including the TRansfusion Requirements After Head Trauma trial (TRAHT), SubArachnoid Haemorrhage Red-cell transfusion And Outcome (SAHaRA), TRansfusion Strategies in Acute Brain INjured Patients (TRAIN), and HEMOglobin Transfusion Threshold in Traumatic brain Injury OptimizatioN (HEMOTION) suggests that restrictive thresholds may worsen neurologic outcomes in ABI.Overall, these evolving data highlight the need for a continuous reassessment of transfusion thresholds and careful, context-specific clinical application of guideline recommendations.(