Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 152 No. 2122 (2022)

Dissemination of patient blood management practices in Swiss intensive care units: a cross-sectional survey

  • Marco Previsdomini
  • Jacopo Colombo
  • Bernard Cerutti
  • Bernhard Gerber
  • Axel Hofmann
  • Alessandro F Chiesa
  • Andrea Saporito
  • Davide La Regina
  • Stefano Cafarotti
  • Miriam Patella
  • Andreas Perren
Cite this as:
Swiss Med Wkly. 2022;152:w30184


BACKGROUND: Patient blood management (PBM) promotes the routine detection and treatment of anaemia before surgery, optimising the management of bleeding disorders, thus minimising iatrogenic blood loss and pre-empting allogeneic blood utilisation. PBM programmes have expanded from the elective surgical setting to nonsurgical patients, including those in intensive care units (ICUs), but their dissemination in a whole country is unknown.

METHODS: We performed a cross-sectional, anonymous survey (10 October 2018 to 13 March 2019) of all ordinary medical members of the Swiss Society of Intensive Care Medicine and the registered ICU nurses from the 77 certified adult Swiss ICUs. We analysed PBM-related interventions adopted in Swiss ICUs and related them to the spread of PBM in Swiss hospitals. We explored blood test ordering policies, blood-sparing strategies and red blood cell-related transfusion practices in ICUs.

RESULTS: A total of 115 medical doctors and 624 nurses (response rates 27% and 30%, respectively) completed the surveys. Hospitals had implemented a PBM programme according to 42% of physicians, more commonly in Switzerland’s German-speaking regions (Odds Ratio [OR] 3.39, 95% confidence interval [CI] 1.23–9.35; p = 0.018) and in hospitals with more than 500 beds (OR 3.91, 95% CI 1.48–10.4; p = 0.006). The PBM programmes targeted the detection and correction of anaemia before surgery (79%), minimising perioperative blood loss (94%) and optimising anaemia tolerance (98%). Laboratory tests were ordered in 70.4% by the intensivist during morning rounds; the nurses performed arterial blood gas analyses autonomously in 48.4%. Blood-sparing techniques were used by only 42.1% of nurses (263 of 624, missing: 6) and 47.0% of physicians (54 of 115). Approximately 60% of respondents used an ICU-specific transfusion guideline. The reported haemoglobin threshold for the nonbleeding ICU population was 70 g/l and, therefore, was at the lower limit of current guidelines.

CONCLUSIONS: Based on this survey, the estimated proportion of the intensivists working in hospitals with a PBM initiative is 42%, with significant variability between regions and hospitals of various sizes. The risk of iatrogenic anaemia is relevant due to liberal blood sample collection practices and the underuse of blood-sparing techniques. The reported transfusion threshold suggests excellent adherence to current international ICU-specific transfusion guidelines.


  1. Koch CG, Li L, Sun Z, Hixson ED, Tang A, Phillips SC, et al. Hospital-acquired anemia: prevalence, outcomes, and healthcare implications. J Hosp Med. 2013 Sep;8(9):506–12.
  2. Corwin HL, Gettinger A, Pearl RG, Fink MP, Levy MM, Abraham E, et al. The CRIT Study: anemia and blood transfusion in the critically ill—current clinical practice in the United States. Crit Care Med. 2004 Jan;32(1):39–52.
  3. van Straten AH, Bekker MW, Soliman Hamad MA, van Zundert AA, Martens EJ, Schönberger JP, et al. Transfusion of red blood cells: the impact on short-term and long-term survival after coronary artery bypass grafting, a ten-year follow-up. Interact Cardiovasc Thorac Surg. 2010 Jan;10(1):37–42.
  4. Gulack BC, Kirkwood KA, Shi W, Smith PK, Alexander JH, Burks SG, et al.; Cardiothoracic Surgical Trials Network (CTSN). Secondary surgical-site infection after coronary artery bypass grafting: A multi-institutional prospective cohort study. J Thorac Cardiovasc Surg. 2018 Apr;155(4):1555–1562.e1.
  5. Vossoughi S, Gorlin J, Kessler DA, Hillyer CD, Van Buren NL, Jimenez A, et al. Ten years of TRALI mitigation: measuring our progress. Transfusion. 2019 Aug;59(8):2567–74.
  6. Koch CG, Li L, Duncan AI, Mihaljevic T, Cosgrove DM, Loop FD, et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med. 2006 Jun;34(6):1608–16.
  7. Menis M, Anderson SA, Forshee RA, McKean S, Johnson C, Holness L, et al. Transfusion-associated circulatory overload (TACO) and potential risk factors among the inpatient US elderly as recorded in Medicare administrative databases during 2011. Vox Sang. 2014 Feb;106(2):144–52.
  8. Goel R, Patel EU, Cushing MM, Frank SM, Ness PM, Takemoto CM, et al. Association of Perioperative Red Blood Cell Transfusions With Venous Thromboembolism in a North American Registry. JAMA Surg. 2018 Sep;153(9):826–33.
  9. Shorr AF, Jackson WL, Kelly KM, Fu M, Kollef MH. Transfusion practice and blood stream infections in critically ill patients. Chest. 2005 May;127(5):1722–8.
  10. Gong MN, Thompson BT, Williams P, Pothier L, Boyce PD, Christiani DC. Clinical predictors of and mortality in acute respiratory distress syndrome: potential role of red cell transfusion. Crit Care Med. 2005 Jun;33(6):1191–8.
  11. Kneyber MC, Hersi MI, Twisk JW, Markhorst DG, Plötz FB. Red blood cell transfusion in critically ill children is independently associated with increased mortality. Intensive Care Med. 2007 Aug;33(8):1414–22.
  12. Hébert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999 Feb;340(6):409–17.
  13. Trentino KM, Farmer SL, Leahy MF, Sanfilippo FM, Isbister JP, Mayberry R, et al. Systematic reviews and meta-analyses comparing mortality in restrictive and liberal haemoglobin thresholds for red cell transfusion: an overview of systematic reviews. BMC Med. 2020 Jun;18(1):154.
  14. Leahy MF, Hofmann A, Towler S, Trentino KM, Burrows SA, Swain SG, et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion. 2017 Jun;57(6):1347–58.
  15. Althoff FC, Neb H, Herrmann E, Trentino KM, Vernich L, Füllenbach C, et al. Multimodal Patient Blood Management Program Based on a Three-pillar Strategy: A Systematic Review and Meta-analysis. Ann Surg. 2019 May;269(5):794–804.
  16. Shander A, Javidroozi M, Lobel G. Patient Blood Management in the Intensive Care Unit. Transfus Med Rev. 2017 Oct;31(4):264–71.
  17. Shander A, Bracey AW Jr, Goodnough LT, Gross I, Hassan NE, Ozawa S, et al. Patient Blood Management as Standard of Care. Anesth Analg. 2016 Oct;123(4):1051–3.
  18. Shander A, Van Aken H, Colomina MJ, Gombotz H, Hofmann A, Krauspe R, et al. Patient blood management in Europe. Br J Anaesth. 2012 Jul;109(1):55–68.
  19. Bruun MT, Pendry K, Georgsen J, Manzini P, Lorenzi M, Wikman A, et al. Patient Blood Management in Europe: surveys on top indications for red blood cell use and Patient Blood Management organization and activities in seven European university hospitals. Vox Sang. 2016 Nov;111(4):391–8.
  20. Meybohm P, Richards T, Isbister J, Hofmann A, Shander A, Goodnough LT, et al. Patient Blood Management Bundles to Facilitate Implementation. Transfus Med Rev. 2017 Jan;31(1):62–71.
  21. Burns KEA, Burns KEA, Duffett M, Duffett M, Kho ME, Kho ME, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne. 2008 Jul 29;179(3):245–52.
  22. Kelley K, Clark B, Brown V, Sitzia J. Good practice in the conduct and reporting of survey research. Int J Qual Health Care. 2003 Jun;15(3):261–6.
  23. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP ; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med. 2007 Oct;4(10):e296.
  24. World Health Assembly Resolution WHA. 63.12. Availability, safety and quality of blood products [Internet]. Geneva: World Health Organization; 2010 May p. 1–4. Available from:
  25. Vaglio S, Gentili S, Marano G, Pupella S, Rafanelli D, Biancofiore G, et al. The Italian Regulatory Guidelines for the implementation of Patient Blood Management. Blood Transfus. 2017 Jul;15(4):325–8.
  26. Van der Linden P, Hardy JF. Implementation of patient blood management remains extremely variable in Europe and Canada: the NATA benchmark project: An observational study. Eur J Anaesthesiol. 2016 Dec;33(12):913–21.
  27. WHO. Anaemia [Internet]. 2008 [cited 2022 Jan 31]. Available from:
  28. WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity [Internet]. 2011 [cited 2022 Jan 31]. Available from:
  29. Vincent JL, Jaschinski U, Wittebole X, Lefrant JY, Jakob SM, Almekhlafi GA, et al.; ICON Investigators. Worldwide audit of blood transfusion practice in critically ill patients. Crit Care. 2018 Apr;22(1):102.
  30. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, et al.; ABC (Anemia and Blood Transfusion in Critical Care) Investigators. Anemia and blood transfusion in critically ill patients. JAMA. 2002 Sep;288(12):1499–507.
  31. Warner MA, Kor DJ, Frank RD, Dinglas VD, Mendez-Tellez P, Himmelfarb CR, et al. Anemia in Critically Ill Patients With Acute Respiratory Distress Syndrome and Posthospitalization Physical Outcomes. J Intensive Care Med. 2021 May;36(5):557–65.
  32. Thomas J, Jensen L, Nahirniak S, Gibney RT. Anemia and blood transfusion practices in the critically ill: a prospective cohort review. Heart Lung. 2010 May-Jun;39(3):217–25.
  33. Vincent JL, Sakr Y, Sprung C, Harboe S, Damas P, Investigators SO. in AIP (SOAP). Are Blood Transfusions Associated with Greater Mortality Rates? Anesthesiology. 2008;108(1):31–9.
  34. Palmieri TL, Caruso DM, Foster KN, Cairns BA, Peck MD, Gamelli RL, et al.; American Burn Association Burn Multicenter Trials Group. Effect of blood transfusion on outcome after major burn injury: a multicenter study. Crit Care Med. 2006 Jun;34(6):1602–7.
  35. Isbister JP, Shander A, Spahn DR, Erhard J, Farmer SL, Hofmann A. Adverse blood transfusion outcomes: establishing causation. Transfus Med Rev. 2011 Apr;25(2):89–101.
  36. Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med. 2008 Sep;36(9):2667–74.
  37. Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion. 2010 Apr;50(4):753–65.
  38. Shander A, Javidroozi M, Ozawa S, Hare GM. What is really dangerous: anaemia or transfusion? Br J Anaesth. 2011 Dec;107 Suppl 1:i41–59.
  39. Gross I, Seifert B, Hofmann A, Spahn DR. Patient blood management in cardiac surgery results in fewer transfusions and better outcome. Transfusion. 2015 May;55(5):1075–81.
  40. Smoller BR, Kruskall MS. Phlebotomy for diagnostic laboratory tests in adults. Pattern of use and effect on transfusion requirements. N Engl J Med. 1986 May;314(19):1233–5.
  41. Raad S, Elliott R, Dickerson E, Khan B, Diab K. Reduction of Laboratory Utilization in the Intensive Care Unit. J Intensive Care Med. 2017 Sep;32(8):500–7.
  42. Blum FE, Lund ET, Hall HA, Tachauer AD, Chedrawy EG, Zilberstein J. Reevaluation of the utilization of arterial blood gas analysis in the Intensive Care Unit: effects on patient safety and patient outcome. J Crit Care. 2015 Apr;30(2):438.e1–5.
  43. Sanchez-Giron F, Alvarez-Mora F. Reduction of blood loss from laboratory testing in hospitalized adult patients using small-volume (pediatric) tubes. Arch Pathol Lab Med. 2008 Dec;132(12):1916–9.
  44. Mukhopadhyay A, Yip HS, Prabhuswamy D, Chan YH, Phua J, Lim TK, et al. The use of a blood conservation device to reduce red blood cell transfusion requirements: a before and after study. Crit Care. 2010;14(1):R7.
  45. Henry ML, Garner WL, Fabri PJ. Iatrogenic anemia. Am J Surg. 1986 Mar;151(3):362–3.
  46. Vlaar AP, Juffermans NP. Transfusion-related acute lung injury: a clinical review. Lancet. 2013 Sep;382(9896):984–94.
  47. Vlaar AP, Oczkowski S, de Bruin S, Wijnberge M, Antonelli M, Aubron C, et al. Transfusion strategies in non-bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2020 Apr;46(4):673–96.
  48. Schweiz BS. Stabile Blutversorgung, Blutstammzellspende im Wachstum [Internet]. 2020 [cited 2020 Oct 13]. Available from:
  49. Berger MD, Gerber B, Arn K, Senn O, Schanz U, Stussi G. Significant reduction of red blood cell transfusion requirements by changing from a double-unit to a single-unit transfusion policy in patients receiving intensive chemotherapy or stem cell transplantation. Haematologica. 2012 Jan;97(1):116–22.
  50. Warner MA, Schaefer KK, Madde N, Burt JM, Higgins AA, Kor DJ. Improvements in red blood cell transfusion utilization following implementation of a single-unit default for electronic ordering. Transfusion. 2019 Jul;59(7):2218–22.
  51. Yang WW, Thakkar RN, Gehrie EA, Chen W, Frank SM. Single-unit transfusions and hemoglobin trigger: relative impact on red cell utilization. Transfusion. 2017 May;57(5):1163–70.
  52. Shih AW, Liu A, Elsharawi R, Crowther MA, Cook RJ, Heddle NM. Systematic reviews of guidelines and studies for single versus multiple unit transfusion strategies. Transfusion. 2018 Dec;58(12):2841–60.
  53. Lasocki S, Pène F, Ait-Oufella H, Aubron C, Ausset S, Buffet P, et al. Management and prevention of anemia (acute bleeding excluded) in adult critical care patients. Ann Intensive Care. 2020 Jul;10(1):97.
  54. Zha N, Alabousi M, Katz DS, Su J, Patlas M. Factors Affecting Response Rates in Medical Imaging Survey Studies. Acad Radiol. 2020 Mar;27(3):421–7.
  55. Fontela PC Jr, Forgiarini LA Jr, Friedman G. Clinical attitudes and perceived barriers to early mobilization of critically ill patients in adult intensive care units. Rev Bras Ter Intensiva. 2018 Apr-Jun;30(2):187–94.
  56. Eastwood GM, Peck L, Bellomo R, Baldwin I, Reade MC. A questionnaire survey of critical care nurses’ attitudes to delirium assessment before and after introduction of the CAM-ICU. Aust Crit Care. 2012 Aug;25(3):162–9.
  57. LeBlanc JM, Kane-Gill SL, Pohlman AS, Herr DL. Multiprofessional survey of protocol use in the intensive care unit. J Crit Care. 2012 Dec;27(6):738.e9–17.
  58. Zhou JJ, Patel SJ, Jia H, Weisenberg SA, Furuya EY, Kubin CJ, et al. Clinicians’ knowledge, attitudes, and practices regarding infections with multidrug-resistant gram-negative bacilli in intensive care units. Infect Control Hosp Epidemiol. 2013 Mar;34(3):274–83.
  59. de Bruin S, Scheeren TW, Bakker J, van Bruggen R, Vlaar AP, Antonelli M, et al.; Cardiovascular Dynamics Section and Transfusion Guideline Task Force of the ESICM. Transfusion practice in the non-bleeding critically ill: an international online survey-the TRACE survey. Crit Care. 2019 Sep;23(1):309.

Most read articles by the same author(s)

1 2 > >>