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Special Communication
March 12, 2019

Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference

Author Affiliations
  • 1German Red Cross Blood Transfusion Service and Goethe University Clinics, Frankfurt/Main, Germany
  • 2Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen, Belgium
  • 3Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany
  • 4European Blood Alliance (EBA), Amsterdam, the Netherlands
  • 5Departments of Intensive Care and of Anesthesia, University Hospital of Brest, Brest, France
  • 6Robert-Koch-Institut (RKI), Berlin, Germany
  • 7Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
  • 8Paul-Ehrlich-Institut (PEI), Langen, Germany
  • 9Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
  • 10Canadian Blood Services, Ottawa, Ontario, Canada
  • 11Departments of Medicine, Surgery, Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
  • 12Société Française de Transfusion Sanguine (SFTS), Paris, France
  • 13Intensive Care, Western Health, Melbourne, Australia
  • 14Fairview Health Services, Minneapolis, Minnesota
  • 15OneBlood, Orlando, Florida
  • 16Department of Cardiothoracic Intensive Care Medicine, Duke University Medical Centre, Durham, North Carolina
  • 17National Health Service Blood and Transplant and University of Oxford, Oxford, United Kingdom
  • 18St. Michael’s Hospital and University of Toronto, Toronto, Canada
  • 19Sanquin Blood Bank, Leiden and Department of Haematology, Groene Hart Hospital, Gouda, the Netherlands
  • 20International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
  • 21Etablissement Français du Sang (EFS), Saint-Denis, France
  • 22Department of Clinical Epidemiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
  • 23Departments of Anesthesiology and Bioengineering, University of Pittsburgh Medical Centre, Pittsburgh, Pennsylvania
  • 24Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
JAMA. 2019;321(10):983-997. doi:10.1001/jama.2019.0554
Key Points

Questions  What is the current evidence base for patient blood management (PBM) in adults, and what international clinical recommendations can be derived for preoperative anemia, red blood cell transfusion thresholds, and PBM implementation strategies?

Findings  Diagnosis and management of preoperative anemia is crucial, and iron-deficient anemia should be treated with iron supplementation. Red blood cell transfusion thresholds for critically ill, clinically stable patients (hemoglobin concentration <7 g/dL), patients undergoing cardiac surgery (hemoglobin concentration <7.5 g/dL), patients with hip fractures and cardiovascular disease or risk factors (hemoglobin concentration <8 g/dL), and hemodynamically stable patients with acute gastrointestinal bleeding (hemoglobin concentration 7-8 g/dL) are relatively well defined, although the quality of evidence is moderate to low.

Meaning  Further high-quality research to support PBM is required for a range of clinical scenarios and implementation of PBM programs.


Importance  Blood transfusion is one of the most frequently used therapies worldwide and is associated with benefits, risks, and costs.

Objective  To develop a set of evidence-based recommendations for patient blood management (PBM) and for research.

Evidence Review  The scientific committee developed 17 Population/Intervention/Comparison/Outcome (PICO) questions for red blood cell (RBC) transfusion in adult patients in 3 areas: preoperative anemia (3 questions), RBC transfusion thresholds (11 questions), and implementation of PBM programs (3 questions). These questions guided the literature search in 4 biomedical databases (MEDLINE, EMBASE, Cochrane Library, Transfusion Evidence Library), searched from inception to January 2018. Meta-analyses were conducted with the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework by 3 panels including clinical and scientific experts, nurses, patient representatives, and methodologists, to develop clinical recommendations during a consensus conference in Frankfurt/Main, Germany, in April 2018.

Findings  From 17 607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23 143 patients and 82 observational studies with more than 4 million patients, were analyzed. For preoperative anemia, 4 clinical and 3 research recommendations were developed, including the strong recommendation to detect and manage anemia sufficiently early before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations were developed, including 2 strong clinical recommendations for critically ill but clinically stable intensive care patients with or without septic shock (recommended threshold for RBC transfusion, hemoglobin concentration <7 g/dL) as well as for patients undergoing cardiac surgery (recommended threshold for RBC transfusion, hemoglobin concentration <7.5 g/dL). For implementation of PBM programs, 2 clinical and 3 research recommendations were developed, including recommendations to implement comprehensive PBM programs and to use electronic decision support systems (both conditional recommendations) to improve appropriate RBC utilization.

Conclusions and Relevance  The 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.