In comparison with a liberal transfusion strategy (high haemoglobin threshold), a restrictive transfusion strategy leads to around 50% decrease in the total number of transfused red blood cells (RBC) units and 30% to 40% fewer transfused patients, without any difference in mortality. However, the optimal transfusion strategy where RBC benefits outweigh the risk of both anaemia and RBC transfusion), that depends on patients comorbidities and conditions, is likely to change over the stay in intensive care. Ventilator liberation is one of those clinical states with an increase in oxygen consumption. Low haemoglobin at the time of extubation has been identified to be associated with an increased risk of reintubation. The rate of reintubation has decreased over the last decades thanks to the development of post extubation strategies; however, reintubation remains a dreaded event associated with an increased morbidity and mortality.

The hypothesis is that a single unit of RBC transfused at the time of extubation would increase the success of extubation defined by survival without reintubation at day 7.

Inclusion Criteria:

• Age ≥ 18 years
• Duration of invasive mechanical ventilation prior to extubation ≥ 24h
• Planned extubation after weaning trial success
• Patients at high risk of reintubation having at least one of the following criteria: older than 65 years, underlying chronic cardiac disease (including: left ventricular ejection fraction ≤ 45%, documented ischemic cardiopathy, chronic supraventricular arrhythmia, history of cardiogenic pulmonary edema) or lung disease (including documented or suspected: chronic obstructive pulmonary disease, obesity-hypoventilation syndrome, or restrictive pulmonary disease)
• Haemoglobin level between 7.5 and 9.5 g/dl in the previous 48 hours (with no active bleeding and no transfusion in the interval)
• Express informed consent (oral) from the relatives or the patient himself, or emergency inclusion procedure in case of inability of patient or proxy relatives to give consent
• Affiliated to social security

Exclusion Criteria:

• Acute coronary syndrome with ST elevation in the previous 4 weeks
• Peripheral neuromuscular disease as reason for intubation (underlying myopathy or myasthenia gravis)
• Known objection to the administration of human blood products
• Active bleeding
• Inclusion in another trial investigating RBC transfusion and/or erythropoietin/ and/or post extubation strategies
• Do-not-reintubate order at time of extubation
• Vulnerable persons, under the protection of justice
• Persons deprived of their liberty by judicial or administrative decision
• Persons under legal protection (guardianship, curatorship)
• Pregnant or breast-feeding woman