Should blood transfusion be individualised? We are not sure

Docherty, Annemarie B; Walsh, Timothy

doi:10.1007/s00134-015-4034-4

Cited by 5 publications

(3 citation statements)

References 14 publications

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“…There is ongoing discussion about the appropriateness and feasibility of individualized RBC transfusion thresholds and triggers . Although a wide range of markers and methods have been studied, inconclusive results for their use limit the development of an optimal personalized approach.…”

Section: Discussionmentioning

confidence: 99%

Red Blood Cell Transfusion in the Intensive Care Unit

Raasveld,

de Bruin,

Reuland

et al. 2023

JAMA

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ImportanceRed blood cell (RBC) transfusion is common among patients admitted to the intensive care unit (ICU). Despite multiple randomized clinical trials of hemoglobin (Hb) thresholds for transfusion, little is known about how these thresholds are incorporated into current practice.ObjectiveTo evaluate and describe ICU RBC transfusion practices worldwide.Design, Setting, and ParticipantsInternational, prospective, cohort study that involved 3643 adult patients from 233 ICUs in 30 countries on 6 continents from March 2019 to October 2022 with data collection in prespecified weeks.ExposureICU stay.Main Outcomes and MeasuresThe primary outcome was the occurrence of RBC transfusion during ICU stay. Additional outcomes included the indication(s) for RBC transfusion (consisting of clinical reasons and physiological triggers), the stated Hb threshold and actual measured Hb values before and after an RBC transfusion, and the number of units transfused.ResultsAmong 3908 potentially eligible patients, 3643 were included across 233 ICUs (median of 11 patients per ICU [IQR, 5-20]) in 30 countries on 6 continents. Among the participants, the mean (SD) age was 61 (16) years, 62% were male (2267/3643), and the median Sequential Organ Failure Assessment score was 3.2 (IQR, 1.5-6.0). A total of 894 patients (25%) received 1 or more RBC transfusions during their ICU stay, with a median total of 2 units per patient (IQR, 1-4). The proportion of patients who received a transfusion ranged from 0% to 100% across centers, from 0% to 80% across countries, and from 19% to 45% across continents. Among the patients who received a transfusion, a total of 1727 RBC transfusions were administered, wherein the most common clinical indications were low Hb value (n = 1412 [81.8%]; mean [SD] lowest Hb before transfusion, 7.4 [1.2] g/dL), active bleeding (n = 479; 27.7%), and hemodynamic instability (n = 406 [23.5%]). Among the events with a stated physiological trigger, the most frequently stated triggers were hypotension (n = 728 [42.2%]), tachycardia (n = 474 [27.4%]), and increased lactate levels (n = 308 [17.8%]). The median lowest Hb level on days with an RBC transfusion ranged from 5.2 g/dL to 13.1 g/dL across centers, from 5.3 g/dL to 9.1 g/dL across countries, and from 7.2 g/dL to 8.7 g/dL across continents. Approximately 84% of ICUs administered transfusions to patients at a median Hb level greater than 7 g/dL.Conclusions and RelevanceRBC transfusion was common in patients admitted to ICUs worldwide between 2019 and 2022, with high variability across centers in transfusion practices.

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Section: Discussionmentioning

confidence: 99%

Red Blood Cell Transfusion in the Intensive Care Unit

Raasveld,

de Bruin,

Reuland

et al. 2023

JAMA

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“…Trials exploring the optimum transfusion trigger in the critically‐ill clearly indicate that a ‘default’ trigger of 70 g L −1 is associated with similar, and possibly better, outcomes than more liberal triggers (Holst et al, ). However, uncertainty remains for specific subgroups, such as patients with acute and chronic CVD, in whom opposite effects may exist (Docherty & Walsh, ).…”

Section: Evidence‐based Transfusion Practicementioning

confidence: 99%

Advances in transfusion medicine RCPath, November 2016

Withanawasam

Wright

2017

Transfusion Medicine

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“…Docherty et al . distinguished two different settings: (1) in young and non‐severe patients, without coexisting substantial comorbidities, it is safe to restrict the decision to transfuse to the Hb level; (2) in other clinical situations, Hb is the primary determinant for RBC transfusion, but all the above parameters must be integrated to individualise the transfusion decision‐making process . It has also been suggested that additional biological parameters may be useful in this setting to better guide clinicians in their decision making .…”

Section: Is Haemoglobin the Only Transfusion Trigger To Consider?mentioning

confidence: 99%

Making transfusion decisions in critical care

Aubron

2017

ISBT Science Series

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Transfusion triggers and parameters to consider in the decision to transfuse depend on the setting. In cases of massive bleeding, transfusion decision is made on haemodynamic parameters, vital signs and when possible on bleeding volume estimation. In anaemic haemodynamically stable patients, haemoglobin remains the primary trigger for transfusion. In the less severe or in the youngest critically ill patients, transfusion for a haemoglobin threshold of 7 g/dl has been shown to be associated with higher survival in comparison with a haemoglobin threshold of 10 g/dl. This lower threshold of 7 g/dl appears to be also safe in patients with upper gastrointestinal bleeding. In patients with acute ischaemic heart disease, where anaemia may worsen myocardial ischaemia, pathophysiology and findings from large observational studies support the benefit of a higher haemoglobin threshold (between 9 and 10 g/dl). Elderly and cardiovascular patients should be monitored for cardiac tolerance of anaemia and transfused accordingly. In haematology–oncology patients and in neuro critically ill patients, the optimal strategy for red blood cell (RBC) transfusion remains unknown. Transfusion practices have shifted from liberal towards restrictive strategy, making the monitoring of anaemia tolerance an important element in the decision to transfuse. Substantial comorbidities and conditions that influence anaemia tolerance should be integrated into clinicians’ transfusion decision‐making process. Research evaluating the benefit to consider additional triggers in the decision to transfuse RBC in critically ill patients is warranted.

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Should blood transfusion be individualised? We are not sure

Cited by 5 publications

References 14 publications

Red Blood Cell Transfusion in the Intensive Care Unit

Red Blood Cell Transfusion in the Intensive Care Unit

Advances in transfusion medicine RCPath, November 2016

Making transfusion decisions in critical care

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