RBC Transfusion Practices in Critically Ill Patients With Sepsis

Objective: – To assess real-world RBC transfusion practices during early resuscitation in sepsis and evaluate their association with 60-day mortality. Design: – Secondary analysis of a prospective, multicenter observational cohort (the Korean Sepsis Alliance cohort) from September 2019 to December 2022. Setting: – Thirteen ICUs across South Korea. Patients: – Adults (19 yr old or older) admitted to the ICU with sepsis were categorized into transfused and non-transfused groups based on whether they received RBC transfusions during ICU days 1–3. Interventions: – None. Measurements and Main Results: – Among 2613 patients (mean age 71.9 ± 13.3 yr old), 45.3% received RBC transfusions during the early resuscitation phase. The mean lowest hemoglobin level on the day of transfusion was 8.8 ± 1.7 g/dL. RBC transfusion was associated with clinical factors beyond hemoglobin levels, including higher Simplified Acute Physiology Score 3 and Sepsis-Induced Coagulopathy scores, septic shock, surgical source control, elevated lactate and bilirubin levels, low platelet counts, the use of two or more vasopressors, and continuous renal replacement therapy. In the propensity score-matched cohort, there was no overall difference in 60-day mortality between groups. However, a significant qualitative interaction was observed when stratifying by an ICU day 1 hemoglobin threshold of 10 g/dL (p for interaction = 0.0124). RBC transfusion was linked to higher mortality at hemoglobin greater than or equal to 10 g/dL, but showed a trend toward decreased mortality below this threshold. Conclusions: – RBC transfusions are common in critically ill patients with sepsis, highlighting a gap between clinical practice and guideline recommendations. Although not associated with overall mortality, a qualitative interaction was observed at a hemoglobin threshold of 10 g/dL. Transfusion decisions may be guided by physiologic markers up to 9–10 g/dL, but should be avoided when hemoglobin levels exceed 10 g/dL due to the potential for harm.