Review Article| Volume 39, ISSUE 2, P287-298, April 2023

Transfusion Strategies in the 21st Century

A Case-Based Narrative Report
Published:November 02, 2022DOI:


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribers receive full online access to your subscription and archive of back issues up to and including 2002.

      Content published before 2002 is available via pay-per-view purchase only.


      Subscribe to Critical Care Clinics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Napolitano L.M.
        • Kurek S.
        • Luchette F.A.
        • et al.
        Clinical practice guideline: red blood cell transfusion in adult trauma and critical care.
        Crit Care Med. 2009; 37: 3124-3157
        • van Bommel J.
        • de Korte D.
        • Lind A.
        • et al.
        The effect of the transfusion of stored RBCs on intestinal microvascular oxygenation in the rat.
        Transfusion. 2001; 41: 1515-1523
        • Raat N.J.
        • Verhoeven A.J.
        • Mik E.G.
        • et al.
        The effect of storage time of human red cells on intestinal microcirculatory oxygenation in a rat isovolemic exchange model.
        Crit Care Med. 2005; 33 ([discussion: 238-239]): 39-45
        • Karam O.
        • Demaret P.
        • Shefler A.
        • et al.
        Indications and Effects of plasma transfusions in critically ill children.
        Am J Respir Crit Care Med. 2015; 191: 1395-1402
        • Abdel-Wahab O.I.
        • Healy B.
        • Dzik W.H.
        Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities.
        Transfusion. 2006; 46: 1279-1285
        • Holland L.L.
        • Brooks J.P.
        Toward rational fresh frozen plasma transfusion: the effect of plasma transfusion on coagulation test results.
        Am J Clin Pathol. 2006; 126: 133-139
        • Haywood-Watson R.J.
        • Holcomb J.B.
        • Gonzalez E.A.
        • et al.
        Modulation of syndecan-1 shedding after hemorrhagic shock and resuscitation.
        PLoS One. 2011; 6: e23530
        • Kozar R.A.
        • Peng Z.
        • Zhang R.
        • et al.
        Plasma restoration of endothelial glycocalyx in a rodent model of hemorrhagic shock.
        Anesth Analg. 2011; 112: 1289-1295
        • Curley A.
        • Stanworth S.J.
        • Willoughby K.
        • et al.
        Randomized trial of platelet-transfusion thresholds in neonates.
        N Engl J Med. 2019; 380: 242-251
        • Cashen K.
        • Dalton H.
        • Reeder R.W.
        • et al.
        Platelet transfusion practice and related outcomes in pediatric extracorporeal membrane oxygenation.
        Pediatr Crit Care Med. 2020; 21: 178-185
        • Cognasse F.
        • Garraud O.
        Cytokines and related molecules, and adverse reactions related to platelet concentrate transfusions.
        Transfus Clin Biol. 2019; 26: 144-146
        • Zhao J.
        • Sun Z.
        • You G.
        • et al.
        Transfusion of cryopreserved platelets exacerbates inflammatory liver and lung injury in a mice model of hemorrhage.
        J Trauma Acute Care Surg. 2018; 85: 327-333
        • Politis C.
        • Wiersum-Osselton J.
        • Richardson C.
        • et al.
        Adverse reactions following transfusion of blood components, with a focus on some rare reactions: reports to the International Haemovigilance Network Database (ISTARE) in 2012-2016.
        Transfus Clin Biol. 2022; 29: 243-249
        • Tung J.P.
        • Chiaretti S.
        • Dean M.M.
        • et al.
        Transfusion-related acute lung injury (TRALI): potential pathways of development, strategies for prevention and treatment, and future research directions.
        Blood Rev. 2022; 53: 100926
        • Bulle E.B.
        • Klanderman R.B.
        • Pendergrast J.
        • et al.
        The recipe for TACO: a narrative review on the pathophysiology and potential mitigation strategies of transfusion-associated circulatory overload.
        Blood Rev. 2022; 52: 100891
        • Muszynski J.A.
        • Spinella P.C.
        • Cholette J.M.
        • et al.
        Transfusion-related immunomodulation: review of the literature and implications for pediatric critical illness.
        Transfusion. 2017; 57: 195-206
        • Remy K.E.
        • Hall M.W.
        • Cholette J.
        • et al.
        Mechanisms of red blood cell transfusion-related immunomodulation.
        Transfusion. 2018; 58: 804-815
        • Goel R.
        • Nellis M.E.
        • Karam O.
        • et al.
        Transfusion practices for pediatric oncology and hematopoietic stem cell transplantation patients: data from the National heart lung and blood Institute Recipient epidemiology and Donor evaluation study-III (REDS-III).
        Transfusion. 2021; 61: 2589-2600
        • Lacroix J.
        • Hébert P.C.
        • Hutchison J.S.
        • et al.
        Transfusion strategies for patients in pediatric intensive care units.
        N Engl J Med. 2007; 356: 1609-1619
        • Bateman S.T.
        • Lacroix J.
        • Boven K.
        • et al.
        Anemia, blood loss, and blood transfusions in North American children in the intensive care unit.
        Am J Respir Crit Care Med. 2008; 178: 26-33
        • Steiner M.E.
        • Zantek N.D.
        • Stanworth S.J.
        • et al.
        Recommendations on RBC transfusion support in children with Hematologic and oncologic diagnoses from the pediatric critical care transfusion and anemia Expertise initiative.
        Pediatr Crit Care Med. 2018; 19: S149-S156
        • Lieberman L.
        • Liu Y.
        • Barty R.
        • et al.
        Platelet transfusion practice and platelet refractoriness for a cohort of pediatric oncology patients: a single-center study.
        Pediatr Blood Cancer. 2020; 67: e28734
        • Rebulla P.
        • Finazzi G.
        • Marangoni F.
        • et al.
        The threshold for prophylactic platelet transfusions in adults with acute myeloid leukemia. Gruppo Italiano Malattie Ematologiche Maligne dell'Adulto.
        N Engl J Med. 1997; 337: 1870-1875
        • Heckman K.D.
        • Weiner G.J.
        • Davis C.S.
        • et al.
        Randomized study of prophylactic platelet transfusion threshold during induction therapy for adult acute leukemia: 10,000/microL versus 20,000/microL.
        J Clin Oncol. 1997; 15: 1143-1149
        • Zumberg M.S.
        • del Rosario M.L.
        • Nejame C.F.
        • et al.
        A prospective randomized trial of prophylactic platelet transfusion and bleeding incidence in hematopoietic stem cell transplant recipients: 10,000/L versus 20,000/microL trigger.
        Biol Blood Marrow Transpl. 2002; 8: 569-576
        • Lieberman L.
        • Karam O.
        • Stanworth S.J.
        • et al.
        Plasma and platelet transfusion strategies in critically ill children with Malignancy, acute liver failure and/or liver transplantation, or sepsis: from the transfusion and anemia EXpertise Initiative-Control/Avoidance of bleeding.
        Pediatr Crit Care Med. 2022; 23: e37-e49
        • Chung H.H.
        • Morjaria S.
        • Frame J.
        • et al.
        Rethinking the need for a platelet transfusion threshold of 50 × 10(9)/L for lumbar puncture in cancer patients.
        Transfusion. 2020; 60: 2243-2249
        • Karam O.
        • Lacroix J.
        • Robitaille N.
        • et al.
        Association between plasma transfusions and clinical outcome in critically ill children: a prospective observational study.
        Vox Sang. 2013; 104: 342-349
        • Bercovitz R.S.
        • Shewmake A.C.
        • Newman D.K.
        • et al.
        Validation of a definition of excessive postoperative bleeding in infants undergoing cardiac surgery with cardiopulmonary bypass.
        J Thorac Cardiovasc Surg. 2018; 155 (e2112): 2112-2124
        • Wolf M.J.
        • Maher K.O.
        • Kanter K.R.
        • et al.
        Early postoperative bleeding is independently associated with increased surgical mortality in infants after cardiopulmonary bypass.
        J Thorac Cardiovasc Surg. 2014; 148 (e631): 631-636
        • Savan V.
        • Willems A.
        • Faraoni D.
        • et al.
        Multivariate model for predicting postoperative blood loss in children undergoing cardiac surgery: a preliminary study.
        Br J Anaesth. 2014; 112: 708-714
        • Faraoni D.
        • Willems A.
        • Savan V.
        • et al.
        Plasma fibrinogen concentration is correlated with postoperative blood loss in children undergoing cardiac surgery. A retrospective review.
        Eur J Anaesthesiol. 2014; 31: 317-326
        • Henriksson P.
        • Värendh G.
        • Lundström N.R.
        Haemostatic defects in cyanotic congenital heart disease.
        Br Heart J. 1979; 41: 23-27
        • Bønding Andreasen J.
        • Hvas A.M.
        • Ravn H.B.
        Marked changes in platelet count and function following pediatric congenital heart surgery.
        Paediatr Anaesth. 2014; 24: 386-392
        • Epstein D.
        • Vishnepolsky A.
        • Bolotin G.
        • et al.
        Effect of Prolonged Hypothermic cardiopulmonary bypass, heparin, and protamine on platelet: a small-group study.
        Thorac Cardiovasc Surg. 2021; 69: 719-722
        • Hanson S.J.
        • Karam O.
        • Birch R.
        • et al.
        Transfusion practices in pediatric cardiac surgery requiring cardiopulmonary bypass: a secondary analysis of a clinical database.
        Pediatr Crit Care Med. 2021; 22: 978-987
        • Cholette J.M.
        • Muszynski J.A.
        • Ibla J.C.
        • et al.
        Plasma and platelet transfusions strategies in neonates and children undergoing cardiac surgery with cardiopulmonary bypass or neonates and children supported by extracorporeal membrane oxygenation: from the transfusion and anemia EXpertise Initiative-Control/Avoidance of bleeding.
        Pediatr Crit Care Med. 2022; 23: e25-e36
        • Chan A.K.
        • Leaker M.
        • Burrows F.A.
        • et al.
        Coagulation and fibrinolytic profile of paediatric patients undergoing cardiopulmonary bypass.
        Thromb Haemost. 1997; 77: 270-277
        • Willems A.
        • Patte P.
        • De Groote F.
        • et al.
        Cyanotic heart disease is an independent predicting factor for fresh frozen plasma and platelet transfusion after cardiac surgery.
        Transfus Apher Sci. 2019; 58: 304-309
        • Nellis M.E.
        • Karam O.
        • Valentine S.L.
        • et al.
        Executive summary of recommendations and expert consensus for plasma and platelet transfusion practice in critically ill children: from the transfusion and anemia EXpertise Initiative-Control/Avoidance of bleeding (TAXI-CAB).
        Pediatr Crit Care Med. 2022; 23: 34-51
        • Miller B.E.
        • Mochizuki T.
        • Levy J.H.
        • et al.
        Predicting and treating coagulopathies after cardiopulmonary bypass in children.
        Anesth Analg. 1997; 85: 1196-1202
        • Tirotta C.F.
        • Lagueruela R.G.
        • Gupta A.
        • et al.
        A randomized Pilot trial assessing the role of human fibrinogen concentrate in decreasing cryoprecipitate Use and blood loss in infants undergoing cardiopulmonary bypass.
        Pediatr Cardiol. 2022; 43: 1444-1454
        • Velik-Salchner C.
        • Tauber H.
        • Rastner V.
        • et al.
        Administration of fibrinogen concentrate combined with prothrombin complex maintains hemostasis in children undergoing congenital heart repair (a long-term propensity score-matched study).
        Acta Anaesthesiol Scand. 2021; 65: 1178-1186
        • Harris A.D.
        • Hubbard R.M.
        • Sam R.M.
        • et al.
        A retrospective analysis of the Use of 3-factor prothrombin complex concentrates for Refractory bleeding after cardiopulmonary bypass in children undergoing heart surgery: a matched Case-Control study.
        Semin Cardiothorac Vasc Anesth. 2020; 24: 227-231
        • Bulut Y.
        • Sapru A.
        • Roach G.D.
        Hemostatic balance in pediatric acute liver failure: epidemiology of bleeding and thrombosis, Physiology, and current strategies.
        Front Pediatr. 2020; 8: 618119
        • Lisman T.
        • Stravitz R.T.
        Rebalanced hemostasis in patients with acute liver failure.
        Semin Thromb Hemost. 2015; 41: 468-473
        • Lisman T.
        • Porte R.J.
        Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases.
        Res Pract Thromb Haemost. 2017; 1: 150-161
        • Hugenholtz G.C.
        • Adelmeijer J.
        • Meijers J.C.
        • et al.
        An unbalance between von Willebrand factor and ADAMTS13 in acute liver failure: implications for hemostasis and clinical outcome.
        Hepatology. 2013; 58: 752-761
        • Agarwal B.
        • Wright G.
        • Gatt A.
        • et al.
        Evaluation of coagulation abnormalities in acute liver failure.
        J Hepatol. 2012; 57: 780-786
        • Munoz S.J.
        • Stravitz R.T.
        • Gabriel D.A.
        Coagulopathy of acute liver failure.
        Clin Liver Dis. 2009; 13: 95-107
        • Sindram D.
        • Porte R.J.
        • Hoffman M.R.
        • et al.
        Platelets induce sinusoidal endothelial cell apoptosis upon reperfusion of the cold ischemic rat liver.
        Gastroenterology. 2000; 118: 183-191
        • de Boer M.T.
        • Christensen M.C.
        • Asmussen M.
        • et al.
        The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation.
        Anesth Analg. 2008; 106 (table of contents): 32-44
        • Karam O.
        • Russell R.T.
        • Stricker P.
        • et al.
        Recommendations on RBC transfusion in critically ill children with Nonlife-threatening bleeding or hemorrhagic shock from the pediatric critical care transfusion and anemia Expertise initiative.
        Pediatr Crit Care Med. 2018; 19: S127-S132
        • Russell R.
        • Bauer D.F.
        • Goobie S.M.
        • et al.
        Plasma and platelet transfusion strategies in critically ill children following severe trauma, traumatic Brain injury, and/or Intracranial hemorrhage: from the transfusion and anemia EXpertise Initiative-Control/Avoidance of bleeding.
        Pediatr Crit Care Med. 2022; 23: e14-e24
        • Holcomb J.B.
        • Tilley B.C.
        • 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; 313: 471-482
        • Lee J.S.
        • Khan A.D.
        • Wright F.L.
        • et al.
        Whole blood versus Conventional blood component massive transfusion Protocol therapy in Civilian trauma patients.
        Am Surg. 2022; 88: 880-886
        • Leeper C.M.
        • Yazer M.H.
        • Morgan K.M.
        • et al.
        Adverse events after low titer group O whole blood versus component product transfusion in pediatric trauma patients: a propensity-matched cohort study.
        Transfusion. 2021; 61: 2621-2628
        • Duchesne J.
        • Smith A.
        • Lawicki S.
        • et al.
        Single Institution trial comparing whole blood vs balanced component therapy: 50 Years Later.
        J Am Coll Surg. 2021; 232: 433-442
        • Leonard J.C.
        • Josephson C.D.
        • Luther J.F.
        • et al.
        Life-threatening bleeding in children: a prospective observational study.
        Crit Care Med. 2021; 49: 1943-1954
        • Spinella P.C.
        • Leonard J.C.
        • Marshall C.
        • et al.
        Transfusion ratios and deficits in injured children with life-threatening bleeding.
        Pediatr Crit Care Med. 2022; 23: 235-244
        • Spinella P.C.
        • Leonard J.C.
        • Gaines B.A.
        • et al.
        Use of antifibrinolytics in pediatric life-threatening hemorrhage: a prospective observational multicenter study.
        Crit Care Med. 2022; 50: e382-e392
        • Oren H.
        • Cingöz I.
        • Duman M.
        • et al.
        Disseminated intravascular coagulation in pediatric patients: clinical and laboratory features and prognostic factors influencing the survival.
        Pediatr Hematol Oncol. 2005; 22: 679-688
        • Fourrier F.
        • Lestavel P.
        • Chopin C.
        • et al.
        Meningococcemia and purpura fulminans in adults: acute deficiencies of proteins C and S and early treatment with antithrombin III concentrates.
        Intensive Care Med. 1990; 16: 121-124
        • Toh C.H.
        • Hoots W.K.
        The scoring system of the Scientific and Standardisation Committee on disseminated intravascular coagulation of the international Society on thrombosis and Haemostasis: a 5-year overview.
        J Thromb Haemost. 2007; 5: 604-606
        • Gando S.
        The utility of a diagnostic scoring system for disseminated intravascular coagulation.
        Crit Care Clin. 2012; 28 (vi): 373-388
        • Soundar E.P.
        • Jariwala P.
        • Nguyen T.C.
        • et al.
        Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients.
        Am J Clin Pathol. 2013; 139: 812-816
        • Weiss S.L.
        • Peters M.J.
        • Alhazzani W.
        • et al.
        Surviving sepsis Campaign international guidelines for the management of septic shock and sepsis-associated Organ dysfunction in children.
        Pediatr Crit Care Med. 2020; 21: e52-e106
        • Müller M.C.A.
        • Meijers J.C.
        • van Meenen D.M.
        • et al.
        Thromboelastometry in critically ill patients with disseminated intravascular coagulation.
        Blood Coagul Fibrinolysis. 2019; 30: 181-187