Fresh Guidelines Issued for Red Blood Cell Transfusion

Wide variability in the use of transfusions in the United States indicates that in many settings patients are receiving unnecessary transfusions.

Evidence shows no difference in mortality, ability to walk independently, or length of hospital stay between patients on a liberal transfusion strategy or a restrictive strategy of red blood cell transfusions.

The AABB (formerly known as the American Association of Blood Banks; Bethesda, MD, USA), has recently updated its guidelines for a red blood cell transfusion strategy for stable adults and children. A 20-member panel of experts based their assessment on a systematic review of research published from 1950 to 2011 to determine optimal use of red blood cells to maximize clinical outcomes and avoid the harms and costs of unnecessary transfusions.

The panel examined the proportion of patients who received any red cell transfusion and the number of red cell units transfused to describe the impact of restrictive transfusion strategies on red blood cell usage. To determine the clinical consequences of a restrictive strategy, the scientists examined overall mortality, nonfatal myocardial infarction, cardiac events, pulmonary edema, stroke, thromboembolism, renal failure, infection, hemorrhage, mental confusion, functional recovery, and length of hospital stay.

They recommended that physicians should consider transfusing at a hemoglobin threshold of 7 to 8 g/dL. Physicians should also consider transfusion for patients with symptoms of anemia or a hemoglobin of less than or equal to 8 g/dL. However, the researchers caution that there was some uncertainty about risk for perioperative myocardial infarction associated with this approach. The panel found insufficient evidence to recommend a liberal or restrictive transfusion strategy for patients with acute coronary syndrome. While physicians most commonly use hemoglobin concentration to decide when to transfuse, the panel suggests that physicians also consider symptoms of anemia in their decision-making.

Jeffrey L. Carson, MD, from the Robert Wood Johnson Medical School, (New Brunswick, NJ, USA), and lead author of the guidelines, said, "Our recommendation is based on the evidence that restrictive transfusion is safe and associated with less blood use. Of course, clinical judgment is critical.

Physicians may choose to transfuse above or below the specified hemoglobin threshold based on individual patient characteristics.” Darrell J. Triulzi, MD, the president of AABB, added, "AABB believes that hospitals and clinicians can reduce the number of unnecessary transfusions. Implementing evidence-based transfusion is perhaps the most important step hospitals can take to achieve this goal." The guidelines were published in the March 26, 2012, online edition of the Annals of Internal Medicine.

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