The ICUs and institutions that participated in the study are a representative cross-section of ICUs in the United States, including large and small hospitals and teaching and nonteaching hospitals. Therefore, the results of the study likely reflect general transfusion practice patterns in ICUs in the United States today. A minority of ICUs (<20%) participating in the current study had an institutional or ICU transfusion protocol in place at the time of the study; however, the existence of such a protocol did not seem to affect transfusion-related practices. Although transfusion practice was reasonably consistent across institutions and ICUs, surgical patients tended to receive transfusions more frequently. This observation is consistent with the study by Groeger et al. (8), which reported that as many as 25% of patients in surgical ICUs receive transfusions on any given day, as compared with 14% in the overall population.
The magnitude of RBC transfusion in the critically ill today is surprising, given the scrutiny to which transfusion practice has been subjected during the last decade. In a prospective randomized study of critically ill patients, Hebert et al. (10) demonstrated that maintaining hemoglobin levels in the 7–9 g/dL range is at least equivalent, and in some patients (APACHE II of ≤20 or age of <55 yrs) superior, to maintaining hemoglobin levels of >10 g/dL with RBC transfusion. This finding also seemed to apply to patients with underlying cardiac disease, although other data suggest that patients with active ischemic cardiac disease may require a higher hemoglobin level (11). The studies by Hebert et al. (10, 11) and Dietrich et al. (12) have raised questions regarding the validity of the historic assumption that RBC transfusion is beneficial for all critically ill patients with anemia. Recent recommendations have advocated that empirical automatic transfusion thresholds be abandoned in favor of a practice of RBC transfusion only for defined physiologic need (2, 3). However, the suggestion for a more conservative approach to RBC transfusion does not as yet seem to have resulted in any major alteration in practice patterns.
Decisions about transfusing RBCs are often made without a complete understanding of the risks and benefits of transfusion (13). Although a much clearer understanding of the risks of RBC transfusion has developed since the 1980s, the risks of anemia and the benefit of RBC transfusion are much less well characterized. For more than five decades, a hemoglobin level of 10 g/dL and a hematocrit of 30% were generally accepted minimum levels, particularly in the surgical setting. First proposed in 1942 (14), the “10/30” rule has become more a matter of faith than data. Although it is clear that transfusions at hemoglobin levels in the 10 g/dL range are much less common today, we observed that only about 25% of RBC transfusions occur in a range consistent with the findings reported by Hebert et al (10).
This transfusion behavior is consistent with previous studies, which noted that transfusion decisions tend to be driven by individual transfusion triggers rather than specific physiologic indications (6). In these studies, pretransfusion hematocrit was the same, regardless of transfusion indication. In the present study, there was little evidence that either age or co-morbidities significantly influenced transfusion practice. On the other hand, a low baseline hemoglobin level was associated with more RBC transfusions. The time to first transfusion was significantly longer in those patients who presented with a high baseline hemoglobin level (1.8 ± 1.7 days with baseline hemoglobin of ≤8 g/dL vs. 6.3 ± 6.2 days with baseline hemoglobin of >12 g/dL, p < .05). These results support the hypothesis that RBC transfusion in many critically ill patients is driven by arbitrary transfusion triggers rather than physiologic findings (6). The fact that a low hemoglobin level was noted as one of the transfusion indications in 90% of transfusions is consistent with this hypothesis. The similarity between the apparent transfusion thresholds in the ICU and after ICU discharge also supports the view that hemoglobin level rather than clinical or physiologic factors drives transfusion decisions.
In general, more severely ill patients, as measured by either APACHE II or SOFA score, had a low baseline hemoglobin level and received more RBC transfusions. However, after correcting for baseline hemoglobin level and severity of illness, more RBC transfusions were independently associated with worse clinical outcomes. This is similar to the finding by Vincent et al (9). On the other hand, although both studies found that baseline hemoglobin level was not associated with mortality, we did find that a nadir hemoglobin level of <9 g/dL was associated with a higher mortality. Given the observational design of these studies, these findings should be interpreted with caution. However, the transfusion results are consistent with recent data suggesting that a liberal RBC transfusion policy may be deleterious for some critically ill patients (10, 15).
Why RBC transfusions are associated with worse clinical outcomes is unclear. A substantial amount of literature has developed since the early 1980s suggesting that exposure to allogeneic leukocytes in transfusions may trigger an immune system response in the recipient leading to increased risk of infection, earlier recurrence of malignancy, and increased likelihood of mortality (16). A significant association between the number of RBC transfusions and risk of subsequent infection has been reported in patients after trauma, burns, and a variety of surgical procedures, both elective and emergency (17–19). In the critically ill, Taylor et al. (20) demonstrated an association between RBC transfusion and nosocomial infection and mortality in the critically ill. These data have in turn led to the hypothesis that giving patients transfusions with leuko-reduced blood should result in reduced morbidity and mortality compared with patients receiving transfusions with non–leuko-reduced blood. However, most of the studies bearing on these questions have been flawed by retrospective design and inadequate consideration of the effects of co-morbidities, whereas the few prospective studies in specific patient populations have reached contradictory conclusions. Meta-analyses of this substantial literature have failed to identify a statistically significant effect of leuko-reduction (16, 21, 22). A recent study evaluating clinical outcomes after the institution of a universal leuko-reduction program in Canada noted a reduction in hospital mortality after introduction of this program (23). On the other hand, a randomized prospective study comparing outcomes in patients receiving either leuko-reduced or non–leuko-reduced RBCs failed to demonstrate any beneficial effect of leuko-reduction on clinical outcome (24). The question therefore still remains as to whether there are in fact clinical benefits associated with leuko-reduction of transfused RBCs (25). We do not have data from the current study that would allow us to answer this question.
Recent data have also raised the issue that transfusion of “old” blood may be associated with worse outcomes (26, 27). The current study provides robust data regarding the age of RBCs critically ill patients receive. The mean age of RBCs transfused was 3 wks, and >25% of transfused RBCs were >1 month old. This is somewhat older than the mean 16 ± 6.7 days for RBCs transfused in Western Europe (9). There were no differences in the age of RBCs transfused across institutions or ICUs. Although there was a trend toward worse clinical outcome among patients receiving transfusions with relatively old blood, this relationship was weak and did not achieve statistical significance. The clinical significance of the age of blood remains controversial and will require further study.
Why critically ill patients are anemic is multifactorial. Phlebotomy and blood loss undoubtedly play a role (6, 9). Nevertheless, a number of studies suggest that an underproduction of erythrocytes similar to that observed in chronic inflammatory diseases significantly contributes to the anemia in critical illness (28). More than 90% of ICU patients have low serum iron, total iron binding capacity, and iron–total iron binding capacity ratio (5, 29). In addition, these patients typically have an elevated serum ferritin level (5, 19). At a time when the iron studies are abnormal, serum erythropoietin levels are only mildly elevated, with little evidence of a reticulocyte response to endogenous erythropoietin (5). Therefore, the anemia of critical illness is a distinct clinical entity characterized by a blunted erythropoietin production and abnormalities in iron metabolism. This is reflected in the fall in hemoglobin level observed during the course of a patient’s critical illness.
The data from this study should be interpreted recognizing that this is an observational study. Although the analysis attempted to control for confounding factors, it was limited to only the factors recorded. Given the complexity of critical illness, all of the factors influencing outcome may not have been included. For example, although there are considerable baseline clinical data available, fewer data are available regarding a patient’s clinical status at the time of a RBC transfusion. The inferences drawn between variables can only indicate association not causation.
*See also p. 290.
Definitions of Terms
Acute Respiratory Distress Syndrome.
Acute respiratory distress syndrome manifested by acute onset, Pao2/Fio2 of ≤200 torr, bilateral infiltrates on frontal chest radiograph, pulmonary artery occlusion pressure of ≤18 mm Hg when measured, or no clinical evidence of left atrial hypertension.
Deep Vein Thrombosis.
Clinical suspicion of deep vein thrombosis confirmed by either duplex ultrasonography or venography.
Clinical suspicion of pulmonary embolism confirmed by either ventilation/perfusion scan or pulmonary angiogram, particularly in the presence of deep vein thrombosis.
Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention; Sequential Organ Failure Assessment scoring was used in this study to track organ failure/dysfunction.
Microbial phenomenon characterized by an inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by those organisms.
- Bacteremia: positive blood cultures for bacteria.
- Wound infection: presence of signs and symptoms consistent with a wound infection (erythema, edema, tenderness, and pus) along with positive wound cultures.
- Catheter infection: confirmed using semiquantitative cultures of the catheter portion residing in the intracutaneous area with ≥15 colony-forming units present.
- Pneumonia: presence of fever, leukocytosis, purulent secretions, new or progressive chest radiograph infiltrates, or pathologic bacteria in tracheobronchial secretions.
- Urinary tract infection: presence of signs/symptoms consistent with a urinary tract infection (e.g., pyuria, dysuria, frequency, urgency, flank pain) along with positive urine cultures (from a good-quality specimen) containing >100,000 colony-forming units, >5 white blood cells per high-power field.
- Fungal infection: presence of fungi as determined by culture from any sterile site (e.g., blood, cerebrospinal fluid, urine, sputum).
Intubation occurring after extubation by a healthcare professional.
Failed Weaning Attempt.
Failed definitive attempt to remove patient from ventilatory support.
Presence of one or more of the following: 1) respiratory rate of ≤5 breaths/min or ≥49 breaths/min, 2) Paco2 of ≥50 torr (≥6.7 kPa), 3) alveolar-arterial oxygen tension difference (P[a-a]o2) of ≥350 torr (P[a-a]o2 = 713 Fio2 − Paco2 − Pao2), or 4) dependent on ventilator on day 4 of organ system failure (e.g., not necessarily applicable for the initial 72 hrs of organ system failure).
Acute Lung Injury.
Acute onset, Pao2/Fio2 of ≤300 torr, bilateral infiltrates on frontal chest radiograph, pulmonary artery occlusion pressure of ≤18 mm Hg, or no clinical evidence of left atrial hypertension (not as serious as acute respiratory distress syndrome).
Edema in the lung tissues, best evidenced by chest radiograph.
Known or suspected infection. The systemic response to infection, manifested by two or more of the following conditions as a result of infection: 1) temperature of >38°C (100.4°F) or <36°C (96.8°F); 2) heart rate of >90 beats/min; 3) respiratory rate of >20 breaths/min or Paco2 of <32 torr; and 4) white blood cell count of >12,000/mm3, <4,000/mm3, or >10% immature (band) forms.
Sepsis-induced hypotension or the requirement for vasopressors/inotropes to maintain blood pressure despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or acute alteration in mental status.
Systemic Inflammatory Response Syndrome.
The systemic inflammatory response to a variety of severe clinical insults. The response is manifested by two or more of the following conditions: 1) temperature of >38°C (100.4°F) or <36°C (96.8°F); 2) heart rate of >90 beats/min; 3) respiratory rate of >20 breaths/min or Paco2 of <32 torr (<4.3 kPa); or 4) white blood cell count of >12,000 cells/mm3, <4000 cells/mm3, or >10% immature (bands) cells.
Arrest of cardiac function, even if patient is successfully resuscitated.
Electrocardiographic and laboratory (creatine kinase, isoenzyme of creatine kinase with muscle and brain subunits, troponin) abnormalities suggestive of myocardial infarction.
Diagnosis confirmed by computed tomographic scan.
Disseminated Intravascular Coagulopathy.
Clinical suspicion of disseminated intravascular coagulopathy confirmed with the following laboratory tests: prolonged prothrombin time, activated partial thromboplastin time, and thrombin time; decreased fibrinogen and platelets; positive fibrin degradation products, d-dimer; and decreased factors V, VIII, and II (late).
Major Bleed on Study.
Significant bleeding (>1 unit of blood) from a single source, typically resulting in a decrease in hemoglobin/hematocrit and the need for transfusion.
List of Investigators.
- Gaeton D. Lorino, MD: Providence Hospital, surgical intensive care unit (SICU) and medical intensive care unit (MICU), Mobile
- Richard W. Carlson, MD, PhD: Maricopa Medical Center, MICU, SICU, Phoenix
- Philip J. Fracica, MD: St. Joseph’s Hospital and Medical Center, MICU, SICU, Phoenix
- Robert Kearl, MD: St. Luke’s Medical Center, combined, Phoenix
- Mohamed Y. A. Rady, MD, PhD: Mayo Clinic Hospital, Combined, Phoenix
- Jeffrey G. Ronn, MD: Walter O. Boswell Memorial Hospital, MICU, SICU, Sun City
- Ronald J. Servi, DO: Good Samaritan Regional Medical Center, MICU, SICU, and Thunderbird Samaritan Medical Center, MICU, SICU, Phoenix
- Neal Beaton, MD: Baptist Medical Center, MICU, SICU, Little Rock
- Robert V. Sanders III, MD: St. Edward Mercy Medical Center, combined, Ft. Smith
- Elizabeth Beale, MD: County-USC Medical Center, SICU, Los Angeles
- Christopher R. Brown, MD: California Pacific Medical Center, combined, San Francisco
- Lawrence A. Cone, MD, DSc: Eisenhower Medical Center, MICU, Rancho Mirage
- Bertrand DeSilva, MD: Western Medical Center/Santa Ana, combined, Santa Ana
- Peter F. Fedullo, MD: UCSD Medical Center, combined, San Diego
- Gregory L. Hirsch, MD: Palomar Medical Center, combined, Escondido
- Allen L. Hoffman, MD, FACS: St. Vincent Medical Center, combined, Los Angeles
- Kenneth G. Kalassian, MD: White Memorial Medical Center, combined, Los Angeles
- Krista L. Kaups, MD, FACS: University Medical Center, SICU, Fresno
- James J. Krueger, MD: Long Beach Memorial Hospital, combined, Long Beach
- Louis McNabb, MD: St. Jude Medical Center, combined, Anaheim
- James N. Nishio, MD: Sutter General Hospital, combined, Sacramento
- Ashok Raheja, MD: St. Francis Medical Center, combined, Lynwood
- Adarsh Sharma, MD: Hoag Memorial Hospital, combined, Newport Beach
- John P. Sherck, MD: Santa Clara Valley Medical Center, SICU, MICU, San Jose
- Susan Sprau, MD: St. John’s Health Center, combined, Santa Monica
- Jack O. Stewart, MD: St. Joseph Hospital, combined, Orange
- “Raj” E. V. Sunderrajan, MD, FCCP: Fountain Valley Regional Hospital, combined, Fountain Valley
- Robert S. Wright, MD, FACP: Santa Barbara Cottage Hospital, combined, Santa Barbara
- Steven M. Weiss, MD: Presbyterian/Saint Lukes Denver Hospital, Denver
- Carlos Barba, MD, FRCS (C), FACS: St. Francis Hospital and Medical Center, SICU, Hartford
- John Bonadies, MD: Hospital of St. Raphaels, SICU, MICU, New Haven
- Kevin Keating, MD: Hartford Hospital, SICU, MICU, Hartford
- Constantine Manthous, MD: Bridgeport Hospital, MICU, Bridgeport
- Mark Siegel, MD: Yale New Haven Hospital, SICU, MICU, New Haven
- District of Columbia
- Charles A. Read Jr, MD: Georgetown University Medical Center, combined, Washington
- Michael Seneff, MD: George Washington University Hospital, combined, Washington
- Sigfredo Aldarondo, MD: Florida Hospital, SICU, Orlando
- Theodore R. Amgott, MD: Holmes Regional Medical Center, MICU, Melbourne
- Keane L. Arney, MD, FCCP: Sacred Heart Hospital, MICU, SICU, Pensacola
- Francis J. Averill, MD, FCCP: Largo Medical Center, combined, Largo
- Stephen M. Cohn, MD, FACS: Jackson Memorial Hospital, SICU, Miami
- Francisco Calimano, MD: Florida Hospital Altamonte, combined, Orlando
- Daniel Haim, MD: Florida Hospital, MICU, Orlando
- Eloise M. Harman, MD: Shands Hospital, MICU, Gainesville
- Emran R. Imami, MD, FACS: Holmes Regional Medical Center, SICU, Melbourne
- Daniel Kett, MD: Jackson Memorial Hospital, MICU, Miami
- Martin A. Kubiet, MD: Orlando Regional Medical Center, MICU, Orlando
- Lawrence Lottenberg, MD, FACS: Memorial Regional Hospital, SICU, Hollywood
- Mario J. Mangas, MD: Kendall Regional Medical Center, combined, Miami
- Ressa M. McDonald, MD: Morton Plant Hospital, combined, Clearwater
- Timothy G. Moriarty, MD: Bay Medical Center, SICU, MICU, Panama City
- Carlos Sklaver, MD: Cedars Medical Center, combined, Miami Beach
- Bahman Venus, MD: Memorial Hospital of Jacksonville, combined, Jacksonville
- Michael L. Hawkins, MD: Medical College of Georgia Research Institute, Augusta
- I. Marc Moss, MD: Grady Memorial Hospital, MICU, and Crawford Long Hospital, MICU, Atlanta
- Larry J. Kaufman, MD: St. Francis Medical Center/University of Hawaii, Honolulu
- Janice E. Manjuck, MD: Queens Medical Center, MICU, Honolulu
- Thomas O. Kraner, MD: St. Aphonsus Regional Medical Center, combined, Boise
- Thomas Corbridge, MD, FCCP: Northwestern Memorial Hospital, MICU, Chicago
- Kimberly A. Davis, MD: Loyola University Medical Center, SICU, Maywood
- Elamin M. Elamin, MD: Memorial Hospital, combined, Springfield
- Andrew Fischer, MD: Lutheran General, MICU, SICU, Park Ridge
- Don R. Fishman, MD: Christ Hospital and Medical Center, SICU, Oak Lawn
- Nathan Lidsky, MD: Northwest Community Hospital, combined, Arlington Heights
- Jacob Samuel, DO: Cook County Hospital, MICU, Chicago
- Philip H. Sheridan Jr, MD: St. Francis Hospital/Evanston, combined, Melrose Park
- William P. Tillis, MD: St. Francis Medical Center, MICU, SICU, and Methodist Medical Center of Illinois, MICU, Peoria
- James Unti, MD: St. Joseph Hospital, MICU, Chicago
- John M. Walsh, MD: Provena St. Joseph Medical Center, MICU, SICU, Joliet
- H. Scott Bjerke, MD, FACS: Methodist Hospital, MICU, Indianapolis
- Robert S. Joseph, MD: Community Hospital East, combined, Indianapolis
- Karen M. Wolf, MD: Wishard Memorial Hospital, MICU, SICU, Indianapolis
- Gregory A. Hicklin, MD: Methodist Hospital-Iowa Lung Center, combined, Des Moines
- Akshay Mahadevia, MD: Genesis Medical Center, MICU, Davenport
- Gregory E. Peterson, DO: Mercy Medical Center, MICU, SICU, Des Moines
- Rolando Berger, MD: University of Kentucky Medical Center, MICU, Lexington
- Antara Mallampalli, MD: University of Louisville, MICU, Louisville
- Betty Tsuei, MD: University of Kentucky Medical Center, SICU, Lexington
- Yuri Villaran, MD: Central Baptist Hospital, combined, MICU, Lexington
- Richard Casey, MD: North Oaks Rehabilitation Center, combined, and St. Tammany Parish Hospital, Covington
- Steven A. Conrad, MD: Louisiana State University Health Sciences, MICU, SICU, Shreveport
- Richard W. Kearley, MD: Our Lady of the Lake Medical Center, combined, Baton Rouge
- Kevin Kovitz, MD: Medical Center of Louisiana–Tulane University, New Orleans
- Kenneth B. Smith, MD: East Jefferson General Hospital, combined, Metarie
- George Bedon, MD: Greater Baltimore Medical Center, MICU, Baltimore
- Wilhemina M. Cruz, MD: Doctors Community Hospital, combined, Clinton
- Steven R. Gambert, MD: Sinai Hospital, MICU, Baltimore
- Lena Napolitano, MD, FACS: R. W. Cowley Shock Trauma, Trauma, Baltimore VA Medical Center, MICU, and University of Maryland Medical Center, SICU, Baltimore
- Carl B. Shanholtz, MD: University of Maryland Medical Center, MICU, Baltimore
- Thomas Higgins, MD: Baystate Medical Center, combined, Springfield
- David A. Kaufman, MD, FRCP: Saint Vincent Hospital at Worcester Medical Center, Worcester
- Howard Kesselman, MD: Massachusetts General Hospital, MICU, Boston
- Andrew Villanueva, MD: Lahey Clinic Medical Center, MICU, SICU, Burlington
- Lisa L. Allenspach, MD: Henry Ford Hospital, MICU, Detroit
- Adeeb Atassi, MD: Oakwood Hospital and Medical Center, combined, Dearborn
- Michael DeJong, MD: St. Mary’s Hospital, combined, Grand Rapids
- Angela DeSantis, MD: Oakwood Hospital and Medical Center, combined, Dearborn
- Scott Dulchavsky, MD: Detroit Receiving Hospital and University, SICU, Detroit
- Jorge A. Guzman, MD: Detroit Receiving Hospital and University, Detroit
- Michael Harrison, MD: Spectrum Health/Downtown Campus, MICU, SICU, Grand Rapids
- Greg R. Neagos, MD: St. Joseph Mercy Hospital, MICU, Ann Arbor
- Charles J. Shanley, MD: St. Joseph Mercy Hospital, SICU, Ann Arbor
- Jeffrey Wilt, MD: Spectrum Health East Campus, MICU, SICU, Grand Rapids
- Timothy Aksamit, MD: Mayo Clinic, MICU, Rochester
- David Ingbar, MD: University of Minnesota Pulmonary, MICU, SICU, Minneapolis
- Avi Nahum, MD, PhD: Regions Hospital, MICU, St. Paul
- Corydon W. Siffring, MD: Duluth Clinic, MICU, SICU, Duluth
- Michael West, MD: Hennepin County Medical Center, SICU, Minneapolis
- James Rish, MD: North Mississippi Medical Center, MICU, SICU, Tupelo
- Diana S. Dark, MD: St. Luke’s Hospital Medical Education, MICU, SICU, Kansas City
- Robert V. Griesbaum, MD: St. Anthony’s Medical Center, MICU, SICU, St. Louis
- Garth F. Harrison, MD: Research Medical Center, combined, Kansas City
- Marin Kollef, MD: Washington University School of Medicine, St. Louis
- Isabelle Kopec, MD: DePaul Health Center, combined, Bridgeton
- Joan Shaffer, MD: St. John’s Mercy Medical Center, combined, St. Louis
- William C. Brandes, MD: Sunrise Hospital and Medical Center, MICU, SICU, Las Vegas
- New Jersey
- Hormoz Ashtyani, MD: Hackensack University Medical Center, MICU, SICU, Hackensack
- James Brody, MD: Jersey Shore Medical Center, MICU, SICU, Neptune
- Aloysius Cuyjet, MD: University of Medical/Dentistry of New Jersey, MICU, Newark
- Dennis Filippone, MD: St. Barnabas Medical Center, combined, Livingston
- Anne Mosenthal, MD: University of Medicine/Dentistry of New Jersey, SICU, Newark
- New York
- Michael J. Apostolakos, MD: University of Rochester/Strong Memorial, Rochester
- Ernest Benjamin, MD: Mt. Sinai Medical Center, SICU, New York
- Mary C. Birmingham, PharmD: Millard Fillmore Gates Hospital, SICU, Buffalo
- Collin Brathwaite, MD: SUNY Stony Brook Hospital, SICU, Stony Brook
- Charles M. Carpati, MD: St. Vincents Hospital and Medical Center, SICU, New York
- C. Gene Cayten, MD: Our Lady of Mercy Medical Center, SICU, Bronx
- Robert Cherry: Lincoln Hospital, SICU, Bronx
- Ali El-Solh, MD: Erie County Medical Center, MICU, Buffalo
- Liziamma George, MD: Nassau County Medical Center, MICU, East Meadow
- David C. Kaufman, MD: University of Rochester/Strong Memorial, Rochester
- Hassan Khouli, MD: Roosevelt Hospital, combined, and St. Luke’s Hospital, combined, New York
- Linda Kirschenbaum, DO: St. Vincents Hospital and Medical Center, MICU, New York
- James Lampasso, MD: Millard Fillmore Gates Hospital, MICU, Buffalo
- Stuart G. Lehrman, MD: Westchester County Medical Center, MICU, Valhalla
- William Marino: Our Lady of Mercy Medical Center, MICU, Bronx
- Jeffrey Marsh, MD: Wilson Memorial Hospital, combined, Johnson City
- Marvin A. McMillen, MD: Montefiore Medical Center, SICU, Bronx
- David Nierman, MD: Mt. Sinai Medical Center, MICU, NY
- Patricia O’Neill, MD: Kings County Hospital, combined, Brooklyn
- Cuthbert O. Simpkins, MD: Nassau County Medical Center, SICU, East Meadow
- Edward D. Sivak, MD: SUNY Upstate Medical Center, MICU, Syracuse
- Thomas C. Smith, MD: Albany Medical College, MICU, Albany
- Sophia Socaris, MD: Albany Medical Center, SICU, Albany
- Mohammad Zaman, MD: Brookdale Medical Center, MICU, Brooklyn
- North Carolina
- Webster Carlyle Bazemore Jr: Mission–St. Joseph’s Hospital, combined, Asheville
- Shannon S. Carson, MD: University of North Carolina Hospitals, MICU, Chapel Hill
- R. Duncan Hite, MD: Wake Forest Baptist Medical Center, MICU, Winston-Salem
- Milton L. McPherson Jr, MD: Northeast Medical Center, combined, Concord
- David B. Simonds, MD: Moses Cone Hospital, combined, Greensboro
- North Dakota
- Mark Tieszen, MD: MeritCare Medical Group, combined, Fargo
- James N. Allen, MD: Ohio State University Medical Center, MICU, Columbus
- Robert Barker, MD: Kettering Medical Center, SICU, Dayton
- Charles Cook, MD: Ohio State University Medical Center, SICU, Columbus
- Kenneth Davis Jr, MD, FACS: University of Cincinnati Medical Center, SICU, Cincinnati
- David K. Epperson, MD: Toledo Hospital, SICU, Toledo
- Shahpour Esfandiari, MD: Cleveland Clinic Foundation, MICU, SICU, Cleveland
- William F. Fallon Jr, MD: MetroHealth Medical Center, SICU, Cleveland
- Darell E. Heiselman, DO, FAC: Akron General Medical Center, MICU, Akron
- Bradley R. Martin, MD: Akron City Hospital, combined, Akron
- Hugo D. Montenegro, MD: University Hospitals of Cleveland, MICU, SICU, Cleveland
- Farid F. Muakkassa, MD: Akron General Medical Center, SICU, Akron
- Lisa A. Patterson, MD: Miami Valley Hospital, combined, Dayton
- Douglas B. Paul, DO: Good Samaritan Hospital/Dayton, combined, Dayton
- John Porter, MD: St. Elizabeth’s Health Center, SICU, Youngstown
- Joseph Sopko, MD: St. Vincent Charity Hospital, MICU, SICU, Cleveland
- Kwang Suh, MD: Grant Medical Center, SICU, Columbus
- Sheldon M. Traeger, MD: Akron City Hospital, combined, Akron
- Ronald Wainz, MD: Toledo Hospital, MICU, Toledo
- Steven Katsis, MD: St. Francis Medical Center, combined, Tulsa
- Michael Lewis, MD: Legacy Emanuel Hospital, combined, and Good Samaritan Hospital, MICU, Portland
- Sandralee A. Blosser, MD: Hershey Medical Center/Penn State College, SICU, Hershey
- Murray Cohen, MD: Thomas Jefferson University Hospital, SICU, Philadelphia
- Richard A. Damian, MD: Robert Packer Hospital–Guthrie Clinic, combined, Sayre
- Barry Fuchs, MD: Hospital of the University of Pennsylvania, MICU, Philadelphia
- Susan A Gregory, MD: Pennsylvania Hospital, combined, Philadelphia
- John W. Hoyt, MD: St. Francis Medical Center, combined, Pittsburgh
- Joan L. Huffman, MD: Crozer-Chester Medical Center, combined, Upland
- Michael S. Sherman, MD: MCP/Hahnemann University, MICU, Philadelphia
- Margaret Wojnar, MD: Hershey Medical Center/Penn State College, MICU, Hershey
- Rhode Island
- Vera A. De Palo, MD: Memorial Hospital of Rhode Island, combined, Pawtucket
- South Carolina
- Lloyd E. Hayes Sr, MD: Greenville Memorial Medical Center, combined, Greenville
- Harold G. Morse, MD, FACP: Anderson Area Medical Center, combined, Anderson
- Wilson P. Smith Jr, MD: Spartanburg Regional Medical Center, combined, Spartanburg
- Suresh Enjeti, MD: Erlanger Health Systems, MICU, Chattanooga
- Amado X. Freire, MD: The Regional Medical Center, MICU, Memphis
- Emmel B. Golden Jr, MD: Baptist Memorial Hospital East, MICU, SICU, combined, and Baptist Memorial Restorative Care, combined, Memphis
- Bruce S. Grover, MD: Wellmont Holston Valley Hospital, combined, Kingsport
- Richard W. Light, MD: St. Thomas Hospital, combined, Nashville
- Charles M. Richart, MD: Erlanger Health Systems, SICU, Chattanooga
- Elise Schriver, MD: University of Tennessee Medical Center, MICU, SICU, Knoxville
- D. Matthew Sellers, MD: Fort Sanders Regional Medical Center, combined, MICU, Knoxville
- Victor Cardenas, MD: University of Texas Medical Branch at Galveston, MICU, Galveston
- Christine S. Cocanour, MD: University of Texas–Houston Medical Center, Houston
- Peter Fornos, MD: Baptist Medical Center, MICU, San Antonio
- Joyce T. Hohn, MD: Methodist Medical Center, combined, and Charlton Methodist Hospital, combined, Dallas
- David I. Jones, MD: East Texas Medical Center, combined, Tyler
- William W. Lunn, MD: East Texas Medical Center, combined, Tyler
- John G. Myers, MD: University Health System (UTHSCSA), SICU, San Antonio
- Prakash Palimar, MD: McAllen Medical Center, combined, McAllen
- Craig Rhyne, MD: Covenant Medical Center, MICU, SICU, Lubbock
- Jesus Sahad, MD: Baptist St. Anthony’s Health System, MICU, SICU, Amarillo
- Louis Sloan: Baylor University Medical Center, combined, Dallas
- Lisa Weavind, MD: Anderson, MICU, Houston
- Jordan S. Weingarten, MD: Brackenridge Hospital, combined, and Seton Medical Center, combined, Austin
- Michael W. Wooley, MD: Southwest Texas Methodist Hospital, MICU, SICU, San Antonio
- Daniel W. Ziegler, MD: John Peter Smith Hospital, combined, Ft. Worth
- Edward J. Kimball, MD: University of Utah Medical Center, SICU, Salt Lake City
- John Michael, MD: University of Utah Medical Center, MICU, Salt Lake City
- Katherine Habeeb, MD: Fletcher Allen Health Care, MICU, Colchester
- Mark A. Healey, MD: Fletcher Allen Health Care, SICU, Burlington
- Alfred Randolph Garnett, MD: Sentara Norfolk General Hospital, combined, Norfolk
- Rao Ivatury, MD: Medical College of Virginia, SICU, Richmond
- William Lee, MD: Rockingham Memorial Hospital, combined, Harrisonburg
- Mary Therese O’Donnell, MD: Inova Fairfax Hospital, combined, Falls Church
- Daniel R. Coulston, MD: Deaconess Medical Center, combined, Spokane
- Rolf H. O. Holle, MD: Providence Everett Medical Center, combined, Seattle
- Samuel G. Joseph, DO: Sacred Heart Medical Center, combined, Spokane
- Edward LeDoux, MD: Tacoma General, combined, Tacoma
- Phillip I. Menashe, MD, FCCP: Providence Yakima Medical Center, combined, Yakima
- Curtis Veal Jr, MD: Swedish Medical Center, MICU, Seattle
- West Virginia
- Harakh V. Dedhia, MD: West Virginia University Hospital, SICU, MICU, Morgantown
- Nicholas Omdahl, MD: St. Mary’s Medical Center, combined, Racine
- Mark D. Plumb, MD: West Allis Memorial Hospital, combined, West Allis
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