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Clinical Review

Managing anaemia in critically ill adults

BMJ 2010; 341 doi: (Published 03 September 2010) Cite this as: BMJ 2010;341:c4408
  1. Timothy S Walsh, professor of critical care1,
  2. Duncan LA Wyncoll, consultant in critical care2,
  3. Simon J Stanworth, consultant haematologist3
  1. 1Royal Infirmary of Edinburgh, Edinburgh EH16 2SA
  2. 2Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH
  3. 3NHS Blood and Transplant, Oxford Radcliffe Hospitals Trust, Oxford OX3 9BQ
  1. Correspondence to: T S Walsh twalsh{at}

    Summary points

    • Acute anaemia is common in critically ill patients

    • Several factors, including blood sampling and reduced red cell production associated with systemic inflammation, can contribute to anaemia

    • The risk-benefit profile for red cell transfusions to treat anaemia in non-bleeding critically ill adults is uncertain, but they may contribute to adverse patient outcomes in some situations

    • Best evidence suggests that using single unit red cell transfusions when haemoglobin is close to 70 g/l and aiming for a haemoglobin of 70-90 g/l is not harmful in most patients

    • Aiming for a haemoglobin nearer to 90-100 g/l might be better for patients with acute cardiac disease and the early stages of severe sepsis

    Anaemia (haemoglobin <120 g/l for women, and <130 g/l for men) is common in acutely unwell patients. Maintaining sufficient oxygen transport to the tissues is fundamental to survival and recovery from acute illness, and in the United Kingdom 8-10% of the blood supply is used to treat patients in intensive care.1 Red blood cells transport more than 97% of the oxygen content of blood—about 200 ml/l—and anaemia greatly reduces oxygen delivery, especially if patients also have cardiovascular and respiratory compromise.2

    Transfusion of donor (allogeneic) red blood cells is the standard method for rapidly correcting anaemia in acutely unwell patients, but the risk-benefit balance of this intervention is a subject of continuing debate, controversy, and concern.3 We highlight uncertainties in the management of anaemia in critically ill patients, especially in relation to the use of red cells, and summarise current evidence from observational studies and randomised trials. We focus on the management of anaemia in critically ill patients without active bleeding, such as those who are in adult medical and surgical intensive care units, high dependency units, and other acute units. We do not discuss the management of patients …

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