Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB*

Abstract

These guidelines are based on a systematic review of randomized clinical trials evaluating transfusion thresholds. We performed a literature search from 1950 to February 2011 with no language restrictions. We examined the proportion of patients who received any RBC transfusion and the number of RBC units transfused to describe the effect of restrictive transfusion strategies on RBC use. To determine the clinical consequences of restrictive transfusion strategies, we 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. RECOMMENDATION 1: The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence). RECOMMENDATION 2: The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence). RECOMMENDATION 3: The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence). RECOMMENDATION 4: The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence).

2015 Japanese Society for Dialysis Therapy: Guidelines for Renal Anemia in Chronic Kidney Disease

“…RBC transfusion is a palliative therapeutic modality, and not a definitive treatment. Careful prior evaluation to determine the possible improvement in clinical symptoms by transfusion should be carried out before RBC transfusion [207]. RBC transfusion should be performed only when the advantages are considered to exceed the disadvantages, and the blood volume for transfusion should be as low as possible [32].…”

“…Therefore, the timing of the treatment of anemia by RBC transfusion should be determined considering the target Hb level. The condition of each patient should be carefully observed, and the blood volume for transfusion should be as low as possible [21,[207][208][209][210]. Before RBC transfusion, written informed consent should be obtained by practitioners after explaining the necessity and risks of RBC transfusion to the patient in an easy-tounderstand manner.…”

A multicentre randomised controlled trial of Transfusion Indication Threshold Reduction on transfusion rates, morbidity and health-care resource use following cardiac surgery (TITRe2)

“…2,10,11 In contrast, randomised controlled trials (RCTs) comparing a restrictive red blood cell transfusion threshold (allowing a participant's haemoglobin level to drop to a lower level before transfusing) with a more liberal strategy (transfusing a participant at a higher haemoglobin level) have not demonstrated adverse effects directly attributable to transfusion in patients undergoing major surgery or in the critically ill. [12][13][14] The absence of harm from restrictive practice in RCTs combined with the evidence from observational studies has been interpreted as being supportive of restrictive transfusion practice. 15 Alongside the well-documented risks of more liberal transfusion (including haemolytic and non-haemolytic transfusion reactions and transfusion-associated lung injury, 16 increasing demands on blood services 17 as well as additional and important cost implications associated with the storage, handling and administration of red blood cell units 18 ), this evidence has led to an emphasis on restrictive transfusion in contemporary blood management guidelines [19][20][21] and increasingly in health policy. 22,23 The Transfusion Indication Threshold Reduction (TITRe2) trial was designed in 2006 and was prompted by the widely varying transfusion thresholds that were being applied at the time and by a detailed observational analysis of data from the hospital in which the triallists worked.…”

A clinical audit of the utilisation of red cell products in elective total hip replacement surgery

“…The findings of this audit have led to the conclusion and recommendation that all centres should have a policy for blood management that should include the following: • A guideline 'trigger' Hb value of 8.0 g/dL is recommended because studies have shown that a restrictive transfusion policy is safe in otherwise stable isovolaemic patients, and guidelines [14,15] have endorsed this.This is a guideline, however, and must be used together with clinical evaluation.…”