The optimal threshold for PRBC transfusion remains a clinically relevant question in contemporary pediatric critical care. Very few studies have investigated the optimal transfusion thresholds in patients with sepsis, and even fewer in patients with septic shock. Current recommendations by the Surviving Sepsis Campaign, published in 2020, recommend against transfusing hemodynamically stabilized children with septic shock with a hemoglobin of more than  equal to 7 g/dL; however, specific recommendations for unstable septic shock patients remain limited due to a lack of evidence.⁶  The Pediatric Critical Care Transfusion and Anemia Expertise Initiative TAXI has provided nuanced recommendations for hemodynamically unstable and stable children. For hemodynamically stable children, they recommend against transfusing at a hemoglobin of more than 7 g/dl, while acknowledging that for unstable children, a higher hemoglobin may be beneficial, and that a lack of evidence precludes them from recommending thresholds in such children.

There is thus a pressing need for further studies that help determine optimal transfusion thresholds in critically ill children with septic shock and hemodynamic instability, preventing undue exposure to blood products and infections while also optimising oxygen delivery in a background of compromised perfusion. We, thus plan to conduct this study to determine whether a restrictive or a liberal transfusion threshold is optimal for transfusion in patients with septic shock.