Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion

Discipline of Clinical Pharmacology, Faculty of Health, University of Newcastle, Level 5, Clinical Sciences Building, Newcastle Mater Hospital, Edith Street, Waratah, Newcastle, New South Wales, Australia, 2298.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 10/2010; 10(10):CD002042. DOI: 10.1002/14651858.CD002042.pub2
Source: PubMed


Many people are given a transfusion of blood from an unrelated donor as part of their medical treatment. There are, however, risks involved. In particular, infections (including HIV and certain types of hepatitis) may be passed on to the person receiving the blood. This risk is small in high income countries but much larger in poor countries which lack good facilities to test the blood for infections. Because of the risks, doctors try to avoid giving blood unless it is really necessary. One approach is to give the transfusion only if the amount of haemoglobin in the patient's blood has dropped below a certain 'threshold' level. The authors looked for controlled studies evaluating the effectiveness of this approach. They found 17, with a total of 3746 patients. The authors say that more research is needed and that, until more is known, patients who have a serious heart problem should not be treated in this way. The authors conclude that, for most patients, blood transfusion is probably not essential until haemoglobin levels drop below 7.0 grammes per decilitre.

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Article: Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion

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    • "In 1999, the Transfusion Requirements in Critical Care (TRICC) trial demonstrated that a restrictive transfusion policy significantly decreased mortality during hospitalization in patients less acutely ill without active coronary ischemia [6]. Since the publication of that trial, Carless et al. confirmed that restricting transfusions does not increase the rates of cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism , and mortality [7]. An additional study by Herbert et al. showed lower rates of worsening organ dysfunction when transfusions were restricted [8]. "
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    ABSTRACT: Blood products are scarce but essential medical resources. Initially transfusions showed increased perioperative complications, prolonged hospitalizations, and higher mortality. Recently developed restrictive transfusion policies have not shown those adverse affects in critically ill patients. Hospitals adopted these policies to guide blood product administration. The objective of this study is to determine compliance with a restrictive transfusion policy in gynecologic oncology patients. A retrospective chart review of gynecologic oncology patients undergoing transfusion with packed red blood cells (pRBCs) from 12/2008-9/2011 was performed. Cancer type and stage, surgical procedure, hemoglobin values, pRBC transfusions, intraoperative blood loss, and postoperative complications were collected. Each transfusion was classified as compliant or noncompliant. 582 patients requiring 2,276 blood transfusions were identified. The mean age was 55.9years. Ovarian and endometrial cancers were the most common malignancies. Gynecologic oncologists were 81.1% compliant with the restrictive transfusion policy; 59.0% of transfusions were secondary to exceptions. Noncompliant transfusions were commonly given on the day of surgery when intraoperative blood loss was<1500cc and for asymptomatic anemia. Only 64.7% of the transfusions were ordered in single unit increments. There was no significant difference in postoperative infections, thrombotic events, and mortality between compliant and noncompliant transfusions. The majority of gynecologic oncology patients receive transfusions compliant with the restrictive transfusion policy. Morbidity and mortality are not increased with a restrictive transfusion policy. Efforts to improve compliance should focus on limiting transfusions when the hemoglobin is≥7g/dL and transfusing in single pRBCs unit increments.
    Gynecologic Oncology 10/2013; 132(1). DOI:10.1016/j.ygyno.2013.10.019 · 3.77 Impact Factor
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    • "If normovolemia cannot be maintained, the patient is critically ill or the patient has other co-morbidities (e.g. cardiovascular and chronic pulmonary disease, receiving chemotherapy etc.) a blood transfusion has to be considered earlier and despite higher hemoglobin levels [5-7]. "
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    ABSTRACT: To analyze the characteristics of patients who needed a blood transfusion due to epistaxis-caused anemia and to define potential risk factors. Retrospective cohort study. A total cohort of 591 epistaxis patients, prospectively included between March 2007 and April 2008 at the ENT department of the University Hospital of Zurich, was evaluated concerning the need for blood transfusions. The clinical charts and medical histories of these patients were evaluated. Common parameters that increase the risk for severe anemia due to epistaxis. Twenty-two patients required blood transfusions due to their medical condition. 22.7% suffered from traumatic nosebleeds. Another 27.3% had a known medical condition with an increased bleeding tendency. These proportions were significantly higher than in the group of patients without need of blood transfusion. The odds ratio for receiving a blood transfusion was 14.0 in patients with hematologic disorders, 4.3 in traumatic epistaxis and 7.7 in posterior bleeders. The transfusion-dependent epistaxis patients suffered significantly more often from severe posterior nosebleeds with the need for a surgical therapeutic approach. Patients with severe nosebleeds either from the posterior part of the nose or with known hematologic disorders or traumatic epistaxis should be closely monitored by blood parameter analyses to evaluate the indication for hemotransfusion. The acronym THREAT (Trauma, Hematologic disorder, and REAr origin of bleeding → Transfusion) helps to remember and identify the factors associated with an increased risk of receiving blood transfusion.
    Journal of otolaryngology - head & neck surgery = Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale 01/2013; 42(1):4. DOI:10.1186/1916-0216-42-4 · 0.89 Impact Factor
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    • "However, allogenic RBC transfusions carry risks that may adversely affect clinical outcomes [3,4]. Evidence suggests that it is safe to adopt a lower transfusion threshold for the general medical/surgical ICU population [1,4-8]. This has led to a paradigm shift concerning RBC transfusions in the ICU, with most guidelines now recommending hemoglobin levels around 7 g/dl for transfusion in patients without significant comorbidities to minimize exposure to allogenic blood [9-11]. "
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    ABSTRACT: Introduction Accumulating evidence suggests that, in critically ill patients, a lower hemoglobin transfusion threshold is safe. However, the optimal hemoglobin level and associated transfusion threshold remain unknown in neurocritically ill patients. Methods We conducted a systematic review of comparative studies (randomized and nonrandomized) to evaluate the effect of hemoglobin levels on mortality, neurologic function, intensive care unit (ICU) and hospital length of stay, duration of mechanical ventilation, and multiple organ failure in adult and pediatric neurocritically ill patients. We searched MEDLINE, The Cochrane Central Register of Controlled Trials, Embase, Web of Knowledge, and Google Scholar. Studies focusing on any neurocritical care conditions were included. Data are presented by using odds ratios for dichotomous outcomes and mean differences for continuous outcomes. Results Among 4,310 retrieved records, six studies met inclusion criteria (n = 537). Four studies were conducted in traumatic brain injury (TBI), one in subarachnoid hemorrhage (SAH), and one in a mixed population of neurocritically ill patients. The minimal hemoglobin levels or transfusion thresholds ranged from 7 to 10 g/dl in the lower-Hb groups and from 9.3 to 11.5 g/dl in the higher-Hb groups. Three studies had a low risk of bias, and three had a high risk of bias. No effect was observed on mortality, duration of mechanical ventilation, or multiple organ failure. In studies reporting on length of stay (n = 4), one reported a significant shorter ICU stay (mean, -11.4 days (95% confidence interval, -16.1 to -6.7)), and one, a shorter hospital stay (mean, -5.7 days (-10.3 to -1.1)) in the lower-Hb groups, whereas the other two found no significant association. Conclusions We found insufficient evidence to confirm or refute a difference in effect between lower- and higher-Hb groups in neurocritically ill patients. Considering the lack of evidence regarding long-term neurologic functional outcomes and the high risk of bias of half the studies, no recommendation can be made regarding which hemoglobin level to target and which associated transfusion strategy (restrictive or liberal) to favor in neurocritically ill patients.
    Critical care (London, England) 04/2012; 16(2):R54. DOI:10.1186/cc11293 · 4.48 Impact Factor
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