Transfusion Practices in Intensive Care Units: a Hungarian Nationwide Survey
Conditions: Central Venous Oxygen Saturation, Anaemia, Lactate, Transfusion, Questionnaire and Survey
Sponsor: Pest County Flór Ferenc Hospital

 
 
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E-mail: flor@florhosp.hu
Fax: 06-28-507-648
 
DEPT. OF ANESTHESIOLOGY AND INTENSIVE THERAPY 
Head of Department: Zoltán Ruszkai, MD, PhD 
Tel: 00-36-28-507 600/228 
Fax: 00-36-28-507-611 
E-mail: ito@florhosp.hu 
 
 
Transfusion Practices in Intensive Care Units: 
a Hungarian Nationwide Survey 
 
STUDY PROTOCOL WITH SAP 
 
 
Approval Number: BM/8863-3/2025 
 
Last updated on June 4, 2025 
 
 
 
 
 
 
 
 
 

 
 
Telefon: 06-28-507-600, 06-28-507-700
E-mail: flor@florhosp.hu
Fax: 06-28-507-648
Introduction 
Blood transfusion, as a life-saving therapeutic intervention, is an essential part of patient care. 
However, like any therapeutic procedure, transfusion carries potential risks and 
complications; therefore, its indication must always be carefully considered. The decreasing 
number of blood donors and inadequate blood utilization represent an increasing global 
problem by limiting access to blood products, while the costs of producing and storing blood 
products place a significant burden on healthcare budgets. 
According to data from the Hungarian Central Statistical Office, in 2022 a total of 541,402 units 
of blood products were used in Hungary for patient care and transfusion purposes. 
In a recently published international prospective cohort study involving 223 intensive care 
units, transfusion rates were found to be high among critically ill patients during the study 
period (2019–2022). Twenty-five percent of patients received at least one unit of red blood 
cell transfusion (median: 2 units/patient) during their ICU stay. 
This is not surprising, as beyond bleeding complications and overt or occult hemorrhage, 
critically ill patients have numerous additional risk factors for anemia. The most common 
include myelosuppression associated with critical illness, chronic iron deficiency, renal failure, 
and iatrogenic blood loss related to invasive diagnostic and therapeutic procedures as well as 
laboratory testing. 
Based on results from previous randomized controlled trials, current recommendations and 
guidelines favor a restrictive transfusion strategy (indicated below hemoglobin levels of 7–8 
g/dL) over a liberal approach (9 g/dL) in critically ill patients. 
It is important to emphasize that the goal of red blood cell transfusion is not solely to 
normalize hemoglobin levels, but to ensure adequate tissue oxygenation by optimizing oxygen 
transport capacity. Given the significant heterogeneity of ICU patient populations, individual 
assessment is essential in all cases. Therefore, a single laboratory parameter—hemoglobin 
concentration—is insufficient to determine transfusion indication and required dose. In other 
words, not only the degree of anemia but its consequences determine the need for 
transfusion. 
Assessment should include clinical signs (e.g., general weakness, dizziness, tachycardia, 
circulatory failure, dyspnea, failed weaning, etc.) and physiological parameters reflecting 
impaired tissue oxygenation and oxygen deficit/debt (e.g., serum lactate, central venous 
oxygen saturation, arterio-venous carbon dioxide difference, arterio-venous oxygen content 
difference). 
Patient Blood Management (PBM) focuses on the triad of anemia, blood loss, and transfusion, 
emphasizing opportunities to modify these factors. Implementation of PBM programs and 
dedicated outpatient clinics has improved patient safety and reduced blood utilization in many 
countries. Although Hungary has introduced a National Blood Donation and Blood Saving 
Program and professional guidelines for managing life-threatening perioperative bleeding, 
these mainly focus on high-volume bleeding and hemostasis correction. PBM, however, 
extends beyond this and is also highly relevant in ICU care, even in non-bleeding patients. 

 
 
Telefon: 06-28-507-600, 06-28-507-700
E-mail: flor@florhosp.hu
Fax: 06-28-507-648
The aim of the present questionnaire-based survey is to assess daily transfusion practices in 
Hungarian ICUs. To our knowledge, no similar survey has previously been conducted in 
Hungary. 
 
Study Location 
Flór Ferenc Hospital, Kistarcsa 
Department of Anesthesiology and Intensive Care 
2143 Kistarcsa Semmelweis tér 1. 
 
Investigators 
Dr. Zoltán Ruszkai, PhD – Head of Department, Study Director 
Dr. Csanád Geréd – Senior Physician, Investigator 
Dr. Angéla Mikó – Senior Physician, Transfusion Responsible, Investigator 
Dr. Dorottya Csillag – Resident, Co-investigator 
 
Aim of the Study 
The aim is to assess transfusion practices in the management of anemic critically ill patients in 
Hungarian ICUs using an online questionnaire consisting of 15 mandatory and 1 optional 
question. The study evaluates the use and frequency of physiological transfusion triggers (e.g., 
serum lactate, ScvO₂, CO₂ gap, oxygen content difference) and the implementation of PBM 
programs. 
The results may contribute to improving transfusion practices, enhancing patient safety, 
improving outcomes, and promoting rational blood use. 
 
Study Type 
Non-interventional, cross-sectional observational survey study. 
 

 
 
Telefon: 06-28-507-600, 06-28-507-700
E-mail: flor@florhosp.hu
Fax: 06-28-507-648
Participants 
Physicians working in Hungarian ICUs 
Planned number: minimum 100 respondents 
Participation is voluntary and anonymous. 
 
Inclusion Criteria 
Registered anesthesiology and intensive care residents, trainees, and specialists working in 
Hungary. 
Exclusion Criteria 
Anesthesiologists and intensive care practitioners working in non-Hungarian intensive care 
units. 
 
Funding 
No special equipment or financial resources required. 
 
Methods 
A descriptive online questionnaire (Google Forms) in Hungarian. No personal or sensitive data 
are collected. Institutional names are recorded only for geographical analysis. Data collection 
period: July 1 – September 30, 2025. 
 
Information for Respondents 
Dear Colleague, 
Transfusion is essential but carries risks. Current evidence supports restrictive strategies. 
However, Hungarian data on ICU transfusion practices are limited, which is why this survey is 
conducted. 
The questionnaire takes approximately 10–15 minutes. Participation is voluntary and 
anonymous. 

 
 
Telefon: 06-28-507-600, 06-28-507-700
E-mail: flor@florhosp.hu
Fax: 06-28-507-648
Contact: ruszkai.zoltan@florhosp.hu 
 
Questionnaire Structure (Summary) 
• 
Type of institution 
• 
Institution and department name 
• 
Years of professional experience 
• 
ICU profile 
• 
Number of ICU beds 
• 
Annual patient volume 
• 
Use of PBM protocol 
• 
Presence of PBM clinic 
• 
Local transfusion protocol 
• 
Transfusion practices (1 vs 2 units) 
• 
Clinical indications 
• 
Hemoglobin thresholds 
• 
Physiological triggers (e.g., lactate, ScvO₂, CO₂ gap) 
• 
Target hemoglobin and physiological values 
 
Endpoints 
Primary endpoint: 
Use of physiological parameters in transfusion decision-making. 
Secondary endpoints: 
• 
Restrictive vs liberal transfusion strategy 
• 
PBM implementation 
• 
Relationship between PBM and transfusion triggers 
• 
Presence of local protocols 
 
Statistical Analysis Plan 
Data analyzed using MedCalc software. Results expressed as percentages with 95% confidence 
intervals. Normality tested with Kolmogorov–Smirnov test. Group comparisons via chi-square 
test, correlations via Pearson method, and PBM effects via two-way RM ANOVA. Significance: 
p < 0.05. 
 

 
 
Telefon: 06-28-507-600, 06-28-507-700
E-mail: flor@florhosp.hu
Fax: 06-28-507-648
Publication Policy 
Results will be published in Q1/Q2 journals and presented at conferences. Data will be handled 
confidentially in compliance with Hungarian data protection laws. No personally identifiable 
data will be disclosed. 
 
Kistarcsa, June 4, 2025 
 
Zoltán Ruszkai, MD, PhD 
Study Director