Best practices for iatrogenic anaemia prevention in the intensive care unit: Blood‐sparing techniques

EVIDENCE-BASED REVIEW Best practices for iatrogenic anaemia prevention in the intensive care unit: Blood-sparing techniques Marta Raurell-Torredà PhD, MSN 1 | Rafael-Jesús Fernández-Castillo PhD, MSN, CCRN 2,3 | María-Esther Rodríguez-Delgado MSc, RN 4 | Susana Arias-Rivera PhDc, MSN, RN 5 | Luis Basco-Prado PhD, MSN 1 1 Departament d'Infermeria Fonamental i Clínica, Universitat de Barcelona, Barcelona, Spain 2 Department of Nursing, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Seville, Spain 3 Intensive Care Clinical Unit, University Hospital Virgen Macarena, Seville, Spain 4 Unidad de Cuidados Intensivos, Hospital Universitario Clínico San Cecilio, Granada, Spain 5 Research Department, Hospital Universitario de Getafe, Madrid, Spain Correspondence Rafael-Jesús Fernández-Castillo, Department of Nursing, Faculty of Nursing, Physiotherapy and Podiatry, C/ Avenzoar, 6, 4th floor, office 4, Seville, Spain. Email: [email protected] Abstract Anaemia is a common issue in patients who are admitted to intensive care units and worsens their condition throughout the stay due to the extraction of blood for diagnostic purposes. It is also well-known that an important amount of the carbon dioxide produced by health services is likely attributable to blood donation, testing and manufacture, storage or distribution of blood components. This must be taken into account to perform nursing interventions consistent with the idea of sustainable health care. In this regard, within patient blood management bundles, with the objective of minimizing the use of blood products, it is recommended to use blood-sparing techniques: small volume tubes (SVT) or closed-blood sampling devices (CBSD). Published studies before 2014 (excepting two more recent ones) have shown that by themselves, both techniques reduce drawn volume but do not decrease haemoglobin reduction and/or need of transfusion. Given the lack of cost-effectiveness studies, it may be easier to implement the use of CBSD as it does not require prior consensus on the discard volume or adaptations in the processing of laboratory tests, as is the case with SVT. KEYWORDS anaemia prevention, blood-sparing techniques, closed blood sampling devices, intensive care nursing, small volume tubes 1|BACKGROUND AND CLINICAL QUESTION According to the British National Health Service Blood and Transplant services, around 15 000 tonnes of carbon dioxide were produced in 2019, most of which can be attributed to blood donation, testing and manufacture, storage and distribution of blood components. This does not include emissions from laboratory testing in hospitals and the transfusion process itself, or the full effect of clinical waste disposal. 1 McAlister et al. 2 calculated estimated CO 2 e emissions associated with five pathology tests frequently ordered for routine monitoring of hospital patients: full blood examination; coagulation profile (activated partial thromboplastin time [aPTT] and international normalized ratio of prothrombin time [INR]); urea and electrolyte levels (U&E); C-reactive protein concentration (CRP); and arterial blood gas testing (ABG). CO 2 e values for four of the five tests Received: 17 July 2023 Revised: 30 October 2023 Accepted: 15 April 2024 DOI: 10.1111/nicc.13084 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2024 The Authors. Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses. Nurs Crit Care. 2024;1–6. wileyonlinelibrary.com/journal/nicc 1 ranged between 49 g/test (95% CI, 45–53 g/test) for ABG and 116 g/test (95% CI, 101–135 g/test) for full blood examination. The main sources of CO 2 e emissions were sample collection consumables (swabs, gloves, vacutainer holders and collection tubes, specimen bags). The estimated CO 2 e emissions for each test were equivalent to those of driving a standard Australian car between 3 m (CRP) and 770 m (full blood examination). Anaemia is a common condition in patients who are admitted to intensive care units (ICU). According to an international study, 26% of the 9553 included patients had <9 g/dL haemoglobin (Hb) on the day of admission to the ICU and 44.1% throughout their stay in the ward. 3 The cause of anaemia in critically ill patients is multifactorial and worsens due to repeated blood samples taken with diagnostic purposes. 4 Patient blood management (PBM) is defined as strategies aimed at minimizing the use of blood products, improving the health outcomes of patients. These are based on three pillars: improving the clinical management of anaemia, minimizing iatrogenic blood loss and optimizing the physiological tolerance of patients to anaemia. 5,6 Therefore, it is recommended to implement measures to avoid iatrogenic blood loss, known as blood-sparing techniques: use of small volume tubes (SVT) or closed-blood sampling devices (CBSD). 3 Our question is: which is more effective to prevent iatrogenic anaemia in the critically ill patient, the use of SVT or CBSD? 2|SEARCH STRATEGY Prior to completing literature searches, important outcomes were considered to determine how the success or failure of each blood-sparing technique (BST) could be measured. These were based around blood sampling volumes in millilitres (mL), haemoglobin change (g/dL), packed red blood cell transfusion (number/proportion of patients and/or frequency), adverse events (infection or colonization of catheter, catheter obstruction, changes in arterial pressure measurements) and economic costs. This enabled a search strategy to be formulated that included key search terms for the measurable outcomes as well as the population and intervention. PubMed, Embase, CINAHL, CENTRAL and JBI EBP databases were searched with the keywords: ‘closed blood sampling system’,‘small volume tubes’,‘blood management protection’,‘phlebotomy’,‘blood discard’,‘iatrogenic blood loss’,‘blood hemoglobin level’,‘intensive care unit’and ‘critical illness’, with searches not limited to years and language. Our search identified 14 original papers which evaluated different outcomes in ICU patients using CBSD and nine papers using SVT, all of them being included in the presented systematic reviews, excepting the two more recent ones, analysed in Table 1. One systematic review was excluded because it did not add new studies compared with the others. 7 We analysed the described outcomes for each original article, and we excluded four papers which were included into the reviews that did no't use commercially available CBSD. We also excluded one manuscript that did not include ICU patients but conventional hospitalized patients. 3|REVIEW OF EVIDENCE All of the reviewed original papers were published more than 5 years ago, excepting Wu et al. 8 and Briggs et al. 9 Only one paper from 2022, whose main objective was to assess a CBSD clinical trial's feasibility was found, which shows significant reduction in daily blood sample losses [open system 32.7 (SD 1.58) mL vs. closed system 15.5 (SD 5.79) mL, t=8.454, df =78, p< .001]. However, there was no significant difference in haematocrit levels. Daily packed red blood cell use was less in the closed system group (5%) versus 11% in the open system group, though it was not significantly different. 10 There is consensus in the different reviews that both SVT and CBSD reduce blood loss but fail to stabilize the decrease in Hb or the need for transfusion. 11–14 In this sense, it seems to be necessary to combine different multidisciplinary blood saving strategies considered in the PBM programmes 5,6 : the use of point-of-care analysers, rational use of analysis and restrictive transfusion practices. Briggs et al. evaluated this combination of strategies through a pre-post study and showed significant reduction of the decrease in Hb levels in patients with hospital stays <7 days. 9 It must be taken into account that most of the experimental studies that evaluated CBSD effectiveness in anaemia prevention and/or transfusion needs had as an exclusion criterion the patients with active bleeding, these patients being the ones who could precisely get more benefit with blood saving strategies like CBSD, according to Page et al. 15 All the studies have been carried out in adult ICU patients, except of Tang et al., which assessed only the risk of infection with CBSD in What is known about the topic •Anaemia worsens the health outcomes of intensive care patients due to diagnostic practices, despite existing some care bundles to prevent this situation. •However, the scientific literature is not conclusive about which is the best nursing intervention to decrease its effects. •Furthermore, the most effective interventions which have been studied so far must be optimized regarding health care sustainability. What this paper adds •There is a clear lack of cost-effectiveness studies in regard to blood-sparing techniques in the intensive care patient. •The evidence suggests the use of closed-blood sampling systems as opposed to small volume tubes for laboratory diagnosis in order to prevent hospital acquired anaemia in the ICU. •Paying attention to the most sustainable interventions is mandatory to create an environmental-friendly space in the ICU. 2RAURELL-TORREDÀ ET AL. 14785153, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nicc.13084 by Universidad De Sevilla, Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TABLE 1 Papers' data extraction. Study Aim and method Key results Strengths Limitations Whitehead et al., 2019, USA Systematic review and meta-analysis Three papers included for SVT and eight papers for CBSD Aim to assess capacity of SVT or CBSD to reduce the volume of drawn blood, the decline in haemoglobin levels during admission or the need for transfusion SVT reduced blood loss by 0.7 (95% CI 0.6, 0.8) to 9.2 (95% CI 5.1, 13.3) mL/day/ patient. Hb concentrations decreased 1.6 g/L less and the mean units of PRBC transfused per patient decreased 27%, 1.6 units (95% CI 0.0, 3.2) on patients with Hb < 7.0 g/dL CBSD conserved blood by 24.7 mL/patient/ day (95% CI 12.1,37.1), but no differences on reduction in Hb decrease (RR 0.48 95% CI 0.7, 1.6) or need for transfusion (RR 0.9 95% CI 0.6–1.4) Extensive search strategy and analysis Independent analysis and review process by multiple researchers Only two papers were less than 10 years old One SVT and three CBSD studies were graded as fair quality François et al., 2022, Canada Scoping review Seven papers included for SVT and nine papers for CBSD Aim to assess capacity of SVT or CBSD to reduce the volume of drawn blood, the decrease in haemoglobin levels during admission or the need for transfusion Five studies with SVT reported a significant reduction of 40–47% in blood loss and one of 74%. Four studies with CBSD reported a statistically significant blood loss. One study with SVT and two with CBSD observed a significant decrease in transfusion number Extensive search strategy and analysis Independent analysis and review process by multiple researchers Five papers were less than 10 years old All the included studies had a high risk of bias Keogh et al., 2023, Australia Systematic review and meta-analysis Eight studies with CBSD Aim to assess capacity of CBSD to reduce the volume of drawn blood, the decline in haemoglobin levels during admission, the need for transfusion and colonization of arterial catheter tip and/or intraluminal fluid Two studies included in meta-analysis showed a reduction of need for transfusion (RR 0.65 95% CI 0.46, 0.92) Two studies included in meta-analysis showed a significant reduction of intraluminal fluid colonization (RR 0.2 95% CI 0.07, 0.58) Extensive search strategy and analysis Independent analysis and review process by multiple researchers Only RCT and clustered randomized trials were included Only one paper <10 years old All the included studies had a high risk of bias Unable to combine results from the papers for blood loss and Hb changes due to clinical heterogeneity and differences in measurable outcomes Raurell-Torredà et al., 2023, Spain Scoping review Guideline, 1 systematic reviews, 2 scoping review, 1 papers that analysed CBSD (2) related the volume of blood drawn, six decline in haemoglobin levels during admission and/or the need for transfusion, four infection or colonization, one catheter related adverse events, two change in arterial pressure monitorization RCT conclude that CBSD reduces the volume of drawn blood, as it is supported by reviews and clinical guidelines. Two papers associate CBSD use by itself or combined with a restrictive transfusion protocol with high Hb stability during ICU admission. Three studies report infection reduction. The use of CBSD is not related to adverse events with arterial catheters, such as thrombosis, catheter obstruction, pseudoaneurism development in radial artery or aerial embolism when it is used for glycemia control. There were no alterations in mean arterial pressure measurements, but it was reported systolic arterial pressure overestimation risk. Extensive search strategy and analysis Independent analysis and review process by multiple researchers It included adverse events relaetd to CBSD use in arterial catheters Only systematic reviews or scoping reviews were recent in time. Only one paper was less than 10 years old. It does not asses the risk of bias of not included papers in systematic reviews. (Continues) RAURELL-TORREDÀ ET AL.3 14785153, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nicc.13084 by Universidad De Sevilla, Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License patients under 12 years of age. 16 All the studies compared SVT versus conventional volume tubes or CBSD versus open systems, except Mahdy et al. who compared both strategies together (intervention group: CBSD with blood extraction using SVT vs. control group: open system and conventional volume tubes). 17 Mahdy et al. conclude the same as the other studies: a significant decrease in the volume of blood drawn for the intervention group, but without changes in the drop in Hb or the need for transfusion. 17 Within our review, an important fact is provided that can be taken into account: the difference in blood saving is primarily related to discarded volume. In the studies analysing CBSD, it is zero, since it is returned entirely to the venous or arterial circuit. However, in the studies with SVT it is variable, since the extraction is performed with an open system, except for Briggs et al. who performs it with CBSD. 9 Only two studies agreed on the discard volume: Smoller et al. 18 and Dolman et al., 19 being between 1 and 2 mL. The rest of the papers did not control it and even so, obtaining a decrease in blood loss. Another fact to take into account in studies with SVT is the need to repeat the extraction of samples, due to technical problems in the laboratory as the volume of blood to be analysed is smaller, issues that do not happen with CBSDs, because they use conventional volume tubes. The studies by Wu et al., 8 Smoller et al. 18 and Myles et al. 20 did not find a significant increase in redrawn with the implementation of SVT. Regarding CBSD it is important to pay attention to the possibility of adverse events related to the catheter: infection, obstruction and arterial pressure measurements changes in general. According to the most recent review, 14 which contemplated Hb decrease, need of transfusion and adverse catheter related events with the use of CBSD, its use shows less appearance of infection. 16,21–23 The studies do not report complications related to the catheter but, on the other hand, risk of systolic arterial pressure overestimation occurs, being all the papers from 2014 or earlier in time. 24 Finally, no studies have been located that analyse the cost-effec- tiveness of both interventions, neither for SVT nor for CBSD. Wu et al., 8 Briggs et al. 9 and Barreda et al. 25 recognize that the automation of the analyses, the lack of reserve blood volume capacity for future testing and the higher cost associated with the use of SVT due to having to prepare the laboratory for its use in adults are barriers to its implementation in clinical practice. In fact, one recent clinical practice guideline on transfusion strategies in non-bleeding critically ill adults from the European Society of Intensive Care 26 recommends both techniques as conditional with very low certainty for SVT and low certainty for CBSD. The authors believe that CBSDs can be cost-effec- tive, in the absence of studies, in patients with a long stay in the ICU who are exposed to multiple blood draws because they can reduce transfusion requirements. 4|IMPLEMENTATION INTO PRACTICE Although blood-sparing techniques have not shown iatrogenic anaemia prevention by themselves, they should be implemented in clinical practice as an important nursing intervention to reduce drawn blood TABLE 1 (Continued) Study Aim and method Key results Strengths Limitations Briggs et al., 2019, Australia Controlled before-and-after study of CVT versus SVT Aim to assess capacity of SVT to reduce the volume of blood drawn, the decline in Hb levels during admission and the need for transfusion Sample: 169 adult ICU patients Volumes of daily blood samples and total blood samples were reduced for short (2– 7 days) and long (>7 days) admission, p< .001. A significant reduction of fall in Hb level only in short admission (6.7 95% CI 2.8, 10.6) Not significant reduction in PRBC (OR 0.45 95% CI 0.21,1.01 for short and OR 2.49 95% CI 0.81, 7.69 for long admission) Clear aims and objectives Included medical and surgical patients except cardiac surgery, neurosurgery or major trauma Single centre study Sample size calculation not presented Wu et al., 2021, USA Three-phase prospective observational study preintervention (12 ICU patients), during implementation of SVT (28 ICU patients) and postintervention (20 ICU patients). Aim to assess capacity of SVT to reduce the volume of blood drawn and the decline in Hb levels, the need for transfusion and percent redraws The mean mL of blood drawn decrease 22.9% Multivariate regression models reported no significant differences between the phases when comparing mean Hb level. The IRR for transfusion was reduced between phases. No significant change in percent redraws with implementation of SVT Clear aims and objectives Single centre study Sample size calculation not presented Abbreviations: CBSD, cloosed blood sampling device; CVT, conventional volume tubes; Hb, haemoglobin; ICU, intensive care unit; IRR, incidence risk ratio; LOS, length of stay; OR, odds ratio; PRBC, packed red blood cells; RCT, randomized controlled clinical trials; RR, risk ratio; SVT, small volume tubes. 4RAURELL-TORREDÀ ET AL. 14785153, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nicc.13084 by Universidad De Sevilla, Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License volume related to diagnostic tests together with the protocolization of bundles recommended in PBM programmes. It is also important to get awareness about unnecessary testing repercussions for both patients (blood loss) and the environment (carbon footprint). In the absence of cost-effectiveness studies of both techniques, it may be easier to implement the use of CBSD, because it does not require prior consensus on the discard volume (since it is returned in full to the venous or arterial circuit), nor does it require adaptations in the processing of the laboratory diagnostic tests, as it happens with the SVT. ACKNOWLEDGEMENTS We would like to thank all the authors who did the previous research which enriched and made possible the development of this evidencebased review. CONFLICT OF INTEREST STATEMENT No conflict of interest has been declared by the authors. DATA AVAILABILITY STATEMENT The data that support the findings of this study are available on request from the corresponding author, Rafael-Jesús Fernández- Castillo. ETHICS STATEMENT This study followed in full accordance the ethics principles of the Declaration of Helsinki. Nonetheless, it has not been approved and independently reviewed by an ethical board due to the characteristics of the manuscript. ORCID Rafael-Jesús Fernández-Castillo https://orcid.org/0000-0002-6846- 0375 REFERENCES 1. Hibbs SP, Thomas S, Murphy MF. Convergence of zero carbon healthcare with patient blood management. BMJ. 2021;n3112. doi: 10.1136/bmj.n3112 2. McAlister S, Barratt AL, Bell KJ, McGain F. The carbon footprint of pathology testing. Med J Aus. 2020;212(8):377-382. doi:10.5694/ mja2.50583 3. on behalf of the ICON InvestigatorsVincent JL, Jaschinski U, et al. Worldwide audit of blood transfusion practice in critically ill patients. Crit Care. 2018;22(1):102. doi:10.1186/s13054-018-2018-9 4. Lasocki S, Pène F, Ait-Oufella H, et al. Management and prevention of anemia (acute bleeding excluded) in adult critical care patients. Ann Intensive Care. 2020;10(1):97. doi:10.1186/s13613-020-00711-6 5. Helmer P, Hottenrott S, Steinisch A, et al. Avoidable blood loss in critical care and patient blood management: scoping review of diagnostic blood loss. J Clin Med. 2022;11(2):320. doi:10.3390/jcm11020320 6. Franchini M, Marano G, Veropalumbo E, et al. Patient blood management: a revolutionary approach to transfusion medicine. Blood Transfus Trasfus Sangue. 2019;17(3):191-195. doi:10.2450/2019.0109-19 7. Siegal DM, Manning N, Jackson Chornenki NL, Hillis CM, Heddle NM. Devices to reduce the volume of blood taken for laboratory testing in ICU patients: a systematic review. J Intensive Care Med. 2020;35(10): 1074-1079. doi:10.1177/0885066618810374 8. Wu Y, Spaulding AC, Borkar S, et al. Reducing blood loss by changing to small volume tubes for laboratory testing. Mayo Clin Proc Innov Qual Outcomes. 2021;5(1):72-83. doi:10.1016/j.mayocpiqo.2020. 08.007 9. Briggs EN, Hawkins DJ, Hodges AM, Monk AM. Small volume vacuum phlebotomy tubes: a controlled before-and-after study of a patient blood management initiative in an Australian adult intensive care unit. Crit Care Resusc J Australas Acad Crit Care Med. 2019;21(4):251-257. doi:10.1016/S1441-2772(23)00550-1 10. Keogh S, Dhanani J, Levido A, et al. Evaluation of a closed loop-blood sampling system in intensive care: a pilot randomised controlled trial. The ENCLOSE trial. Intensive Crit Care Nurs. 2023;75:103364. doi:10. 1016/j.iccn.2022.103364 11. Whitehead NS, Williams LO, Meleth S, et al. Interventions to prevent iatrogenic anemia: a laboratory medicine best practices systematic review. Crit Care Lond Engl. 2019;23(1):278. doi:10.1186/s13054- 019-2511-9 12. François T, Charlier J, Balandier S, et al. Strategies to reduce diagnostic blood loss and anemia in hospitalized patients: a scoping review. Pediatr Crit Care Med. 2023;24(1):e44-e53. doi:10.1097/PCC. 0000000000003094 13. Keogh S, Mathew S, Ullman AJ, Rickard CM, Coyer F. What blood conservation practices are effective at reducing blood sampling volumes and other clinical sequelae in intensive care? A systematic review. Aust Crit Care. 2023;36(6):1129-1137. doi:10.1016/j.aucc. 2022.12.002 14. Raurell-Torredà M, Arias-Rivera S, Rodríguez-Delgado ME, Campos- Asensio C, Fernández-Castillo RJ. Effectiveness of closed blood sampling systems in intensive care patients: a scoping review. Enferm Intensiva Engl. 2023;S2529984023000265. doi:10.1016/j.enfie.2023. 05.001 15. Page C, Retter A, Wyncoll D. Blood conservation devices in critical care: a narrative review. Ann Intensive Care. 2013;3(1):14. doi:10. 1186/2110-5820-3-14 16. Tang M, Feng M, Chen L, Zhang J, Ji P, Luo S. Closed blood conservation device for reducing catheter-related infections in children after cardiac surgery. Crit Care Nurse. 2014;34(5):53-60. doi:10.4037/ ccn2014416 17. Mahdy S, Khan EI, Attia M, O'Brien B, Seigne P. Evaluation of a blood conservation strategy in the intensive care unit: a prospective, randomised study. 2009. 18. Smoller BR, Kruskall MS, Horowitz GL. Reducing adult phlebotomy blood loss with the use of pediatric-sized blood collection tubes. Am J Clin Pathol. 1989;91(6):701-703. doi:10.1093/ajcp/91.6.701 19. Dolman HS, Evans K, Zimmerman LH, et al. Impact of minimizing diagnostic blood loss in the critically ill. Surgery. 2015;158(4):1083- 1088. doi:10.1016/j.surg.2015.05.018 20. Myles N, von Wielligh J, Kyriacou M, Ventrice T, To B. A cohort study assessing the impact of small volume blood tubes on diagnostic test quality and iatrogenic blood loss in a cohort of adult haematology patients: small volume blood tubes. Intern Med J. 2018;48(7):817- 821. doi:10.1111/imj.13743 21. Peruzzi WT, Noskin GA, Moen SG, Yungbluth M, Lichtenthal P, Shapiro BA. Microbial contamination of blood conservation devices during routine use in the critical care setting: results of a prospective, randomized trial. Crit Care Med. 1996;24(7):1157-1162. doi:10.1097/ 00003246-199607000-00015 22. Raurell-Torredà M, Del Llano-Serrano C, Almirall-Solsona D, Nicolás- Arfelis JM. Arterial catheter setup for glucose control in critically ill patients: a randomized controlled trial. Am J Crit Care. 2014;23(2): 150-159. doi:10.4037/ajcc2014536 23. Oto J, Nakataki E, Hata M, et al. Comparison of bacterial contamination of blood conservation system and stopcock system arterial sampling lines used in critically ill patients. Am J Infect Control. 2012;40 (6):530-534. doi:10.1016/j.ajic.2011.08.006 RAURELL-TORREDÀ ET AL.5 14785153, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nicc.13084 by Universidad De Sevilla, Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 24. Woda RP, Dzwonczyk R, Buyama C, Bernacki BL, Kelly WB. On the dynamic performance of the abbott safeset2 blood-conserving arterial line system. 25. Barreda Garcia J, Xian JZ, Pedroza C, et al. Pediatric size phlebotomy tubes and transfusions in adult critically ill patients: a pilot randomized controlled trial. Pilot Feasibility Stud. 2020;6(1):112. doi:10.1186/ s40814-020-00657-3 26. Vlaar AP, Oczkowski S, de Bruin S, 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;46(4):673-696. doi:10.1007/s00134-019-05884-8 How to cite this article: Raurell-Torredà M, Fernández-Castillo R-J, Rodríguez-Delgado M-E, Arias-Rivera S, Basco-Prado L. Best practices for iatrogenic anaemia prevention in the intensive care unit: Blood-sparing techniques. Nurs Crit Care. 2024;1‐6. doi:10.1111/nicc.13084 6RAURELL-TORREDÀ ET AL. 14785153, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nicc.13084 by Universidad De Sevilla, Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License