Restrictive and liberal red cell transfusion strategies in adult patients: reconciling clinical data with best practice

Abstract

Red blood cell (RBC) transfusion guidelines correctly promote a general restrictive transfusion approach for anemic hospitalized patients. Such recommendations have been derived from evaluation of specific patient populations, and it is important to recognize that engaging a strict guideline approach has the potential to incur harm if the clinician fails to provide a comprehensive review of the patient’s physiological status in determining the benefit and risks of transfusion. We reviewed the data in support of a restrictive or a more liberal RBC transfusion practice, and examined the quality of the datasets and manner of their interpretation to provide better context by which a physician can make a sound decision regarding RBC transfusion therapy. Reviewed studies included PubMed-cited (1974 to 2013) prospective randomized clinical trials, prospective subset analyses of randomized studies, nonrandomized controlled trials, observational case series, consecutive and nonconsecutive case series, and review articles. Prospective randomized clinical trials were acknowledged and emphasized as the best-quality evidence. The results of the analysis support that restrictive RBC transfusion practices appear safe in the hospitalized populations studied, although patients with acute coronary syndromes, traumatic brain injury and patients at risk for brain or spinal cord ischemia were not well represented in the reviewed studies. The lack of quality data regarding the purported adverse effects of RBC transfusion at best suggests that restrictive strategies are no worse than liberal strategies under the studied protocol conditions, and RBC transfusion therapy in the majority of instances represents a marker for greater severity of illness. The conclusion is that in the majority of clinical settings a restrictive RBC transfusion strategy is cost-effective, reduces the risk of adverse events specific to transfusion, and introduces no harm. In anemic patients with ongoing hemorrhage, with risk of significant bleeding, or with concurrent ischemic brain, spinal cord, or myocardium, the optimal hemoglobin transfusion trigger remains unknown. Broad-based adherence to guideline approaches of therapy must respect the individual patient condition as interpreted by comprehensive clinical review.

Comparison of liberal and restrictive blood transfusion: current insights into clinical outcomes

“…Simply by equalizing the patient number in this category, death and transfusion policy were no longer related. 40 The ongoing bleeding may have contributed to the increased mortality. Jairath et al 41 examined RBC transfusion strategies in 936 patients in the TRIGGER study.…”

Evidence-based practice for red blood cell transfusions

“…[25][26][27] The following questions can provide guidance when caring for a patient with a low Hb value (<10 g/dL): 25 • Is the patient actively bleeding (Hb drop greater than 2 g in 24 hours)? Use clinical assessment findings and other objective data rather than Hb values in isolation and collaborate with the HCP to determine the most effective treatment plan for the patient.…”

“…27 If vital signs are stable (no hypotension, tachycardia, or hypoxemia), urine output is adequate, and the patient is participating in activities, a transfusion may not be needed. If the answer to either of the first two questions is yes, a RBC transfusion is appropriate.…”

“…[25][26][27][28] Assess patients for changes in cardiopulmonary status, including a sudden decrease in SpO 2 , dyspnea, shortness of breath, tachypnea, changes in breath or heart sounds, or tachycardia that occur during or within 6 hours after the transfusion is completed. Changes in the patient's clinical status during the transfusion should be compared to baseline assessment data.…”

Iatrogenic hemodilution: a possible cause for avoidable blood transfusions?

“…Others suggest that in some patients a more liberal transfusion strategy may be beneficial [3]. However, the extensive discussions regarding the appropriate transfusion threshold have not adequately addressed the potential impact of iatrogenic hemodilution on the hemoglobin (Hb) level during dynamic clinical conditions that necessitate fluid administration [4, 5].…”