The optimal threshold for initiating red blood cell transfusions in hospitalised patients and those undergoing surgery remains a topic of active debate. At Euroanaesthesia 2025, experts compared transfusion strategies and examined which patients stand to benefit from restrictive versus liberal approaches.
Ecaterina Scarlatescu, Assistant Professor of Anaesthesiology and Intensive Care Medicine at the University of Medicine and Pharmacy Carol Davila in Bucharest, Romania, highlighted that recent advancements in transfusion medicine have refined the understanding of when and how to administer red blood cell transfusions. Compared to more than 50 years ago, the pendulum has swung dramatically toward restrictive approaches, largely due to concerns about resource utilisation, transfusion-related complications, and emerging evidence supporting restriction in specific clinical settings.
Current international guidelines recommend a haemoglobin threshold of <7 g/dL for transfusion in haemodynamically stable hospitalised adults. Yet clinical judgment remains central to the decision-making process. For instance, a threshold of 7.5 g/dL is often applied in cardiac surgery, and 8 g/dL may be more appropriate for patients undergoing orthopaedic surgery or those with pre-existing cardiovascular disease.
While haemoglobin levels are the cornerstone of most institutional transfusion protocols, Dr Scarlatescu cautioned against interpreting them in isolation. Anaemia reflects reduced red blood cell mass, but direct measurement is impractical in clinical settings. Instead, clinicians rely on haemoglobin and haematocrit, both of which can be affected by plasma volume shifts and methodological variability. These values should be interpreted within the broader clinical picture. Using haemoglobin levels alone to guide transfusions is problematic, regardless of whether a restrictive or liberal approach is used.
Though restrictive strategies are often considered safer and more resource-conscious, liberal transfusion thresholds (typically 9 to 10 g/dL) may offer greater benefit in certain clinical contexts. For example, a recent multicentre randomised trial found that patients with anaemia and acute brain injury who received transfusions at 9 g/dL experienced better neurological outcomes at 180 days compared with those in the 7 g/dL group. Other studies suggest liberal transfusion thresholds may also benefit older surgical patients and those with myocardial infarction and anaemia.
Although advances in screening have reduced the risk of transfusion-transmitted infections, non-infectious complications continue to influence transfusion decisions. According to Dr Scarlatescu, the key lies in tailoring strategies to the individual. Clinicians should move towards a patient-centred precision transfusion medicine model that accounts for physiology, comorbidities, and context rather than rely on rigid thresholds. While restrictive strategies support resource conservation at the population level, clinical necessity should always come first. Transfusions should be reserved for those who truly need them.
Source: Euroanaesthesia 2025
Image Credit: iStock
