Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care*

Abstract

Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.

Indications for red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis

“…Such uncertainty with respect to an expensive pharmacological intervention would be unthinkable. The results of RCTs in non-cardiac surgery patients may not be transferrable to a population with symptomatic cardiac disease and it is of concern that these, as well as the results of observational studies, which we have concluded are unable to guide transfusion practice, form the basis of national and international blood conservation guidelines 4,5,84 . Such guidelines urge clinicians to adopt restrictive transfusion practices due to the adverse outcomes demonstrated in these studies 4,5 .…”

“…The results of RCTs in non-cardiac surgery patients may not be transferrable to a population with symptomatic cardiac disease and it is of concern that these, as well as the results of observational studies, which we have concluded are unable to guide transfusion practice, form the basis of national and international blood conservation guidelines 4,5,84 . Such guidelines urge clinicians to adopt restrictive transfusion practices due to the adverse outcomes demonstrated in these studies 4,5 . Reduction of this uncertainty requires adequately powered and well conducted RCTs that anticipate the limitations that we have described: they should include patients at high-risk of transfusion (for example by using validated transfusion risk scores), and document measures taken to ensure that other aspects of care are the same across intervention groups, for example by blinding surgeons and anaesthetists to treatment allocation and allowing other staff to make transfusion decisions according to the study protocol.…”

“…Importantly, no RCT has shown that transfusion in these patients should be withheld until haemoglobin thresholds of 6-7g/dL (except in patients with evidence of critical end-organ ischemia), as per current guidelines 4,5 .…”

“…A protocol was developed (eAppendix pg 21) that was restricted to RCTs and observational studies of transfusion in cardiac surgery, but because current transfusion guidelines 4,5 are also based on RCTs in non-cardiac surgical patients, we subsequently decided to include these in this systematic review. Despite the limitations of comparing different study designs, we chose to compare RCTs and observational studies as these are the evidence base for current guidelines.…”

“…The decision to transfuse is complicated by several factors; severe anaemia and excessive blood loss are common in this setting 1,2 , and patients with cardiovascular disease have different transfusion requirements to other patient groups 3 . Transfusion decisions in cardiac surgery are most commonly based on the severity of perioperative anaemia: guidelines currently recommend (Grade C recommendation) highly restrictive transfusion thresholds with Haemoglobin (Hb) concentrations of 6-7g/dL 4,5 . These are based largely on the results of RCTs in non-cardiac surgery patients that indicate equivalence for restrictive transfusion thresholds [6][7][8] .…”