Should red cell transfusion be individualized? Yes

Sakr, Yasser; Vincent, Jean‐Louis

doi:10.1007/s00134-015-3950-7

Cited by 20 publications

(11 citation statements)

References 20 publications

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“…The guidelines are based on results from several randomized clinical studies that showed that liberal transfusion strategies (keeping Hb > 9-10 g/dL) provided no clinical benefit in different populations when compared to a restrictive strategy [11][12][13][14]. However, the decision to transfuse should not be based only on Hb concentration [15,16], because the optimal DO 2 can differ from one patient to another [17] and over time in any one patient. These elements have resulted in considerable variability in worldwide transfusion practice, with the average Hb concentrations used to initiate transfusions higher than those recommended [7].…”

Section: Introductionmentioning

confidence: 99%

Using arterial-venous oxygen difference to guide red blood cell transfusion strategy

et al. 2020

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Background: Guidelines recommend a restrictive red blood cell transfusion strategy based on hemoglobin (Hb) concentrations in critically ill patients. We hypothesized that the arterial-venous oxygen difference (A-V O 2diff), a surrogate for the oxygen delivery to consumption ratio, could provide a more personalized approach to identify patients who may benefit from transfusion. Methods: A prospective observational study including 177 non-bleeding adult patients with a Hb concentration of 7.0-10.0 g/dL within 72 h after ICU admission. The A-V O 2diff , central venous oxygen saturation (ScvO 2), and oxygen extraction ratio (O 2 ER) were noted when a patient's Hb was first within this range. Transfusion decisions were made by the treating physician according to institutional policy. We used the median A-V O 2diff value in the study cohort (3.7 mL) to classify the transfusion strategy in each patient as "appropriate" (patient transfused when the A-V O 2diff > 3.7 mL or not transfused when the A-V O 2diff ≤ 3.7 mL) or "inappropriate" (patient transfused when the A-V O 2diff ≤ 3.7 mL or not transfused when the A-V O 2diff > 3.7 mL). The primary outcome was 90-day mortality. Results: Patients managed with an "appropriate" strategy had lower mortality rates (23/96 [24%] vs. 36/81 [44%]; p = 0.004), and an "appropriate" strategy was independently associated with reduced mortality (hazard ratio [HR] 0.51 [95% CI 0.30-0.89], p = 0.01). There was a trend to less acute kidney injury with the "appropriate" than with the "inappropriate" strategy (13% vs. 26%, p = 0.06), and the Sequential Organ Failure Assessment (SOFA) score decreased more rapidly (p = 0.01). The A-V O 2diff , but not the ScvO 2 , predicted 90-day mortality in transfused (AUROC = 0.656) and non-transfused (AUROC = 0.630) patients with moderate accuracy. Using the ROC curve analysis, the best A-V O 2diff cutoffs for predicting mortality were 3.6 mL in transfused and 3.5 mL in non-transfused patients. Conclusions: In anemic, non-bleeding critically ill patients, transfusion may be associated with lower 90-day mortality and morbidity in patients with higher A-V O 2diff. Trial registration: ClinicalTrials.gov, NCT03767127. Retrospectively registered on 6 December 2018.

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Section: Introductionmentioning

confidence: 99%

Using arterial-venous oxygen difference to guide red blood cell transfusion strategy

et al. 2020

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“…Our sensitivity analyses further indicate such variations have substantial impact on cost‐effectiveness, highlighting the need to reinforce implementation of protocols that outweigh benefits against cost and risk. Third, we are also informed that good clinical judgements may also contribute to personalized transfusion , as reflected by the result that patients not transfused were generally at very low risk of adverse outcomes, even at Hb <8 g/dl. This renders routine practice, though with fewer RBCs transfused, related to better patient outcomes when restrictive protocol was even slightly violated.…”

Section: Discussionmentioning

confidence: 99%

“…Tailored treatment and lack of standards are the double edges of routine transfusion. Towards an era of precise patient blood management , an iterative circle of ‘summarize experience ‐ validate protocol ‐ refine practice’ needs to be established.…”

Section: Discussionmentioning

confidence: 99%

Cost‐effectiveness comparison of routine transfusion with restrictive and liberal transfusion strategies for surgical patients in China

Wang

et al. 2019

Vox Sanguinis

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Background and Objectives A health industry standard recommending restrictive transfusion is to be in effect in China in April 2019. We aim to explore its potential economic and clinical impacts among surgical patients. Materials and Methods A decision tree model was applied to compare cost‐effectiveness of current routine transfusion in China, a restrictive (transfusion at Hb < 8 g/dl or ischaemic symptoms) and a liberal (transfusion at Hb < 10 g/dl) strategy. Parameters were estimated from empirical data of 25 227 surgical inpatients aged ≥30 years in a multicenter study and supplemented by meta‐analysis when necessary. Results are shown for cardio‐cerebral‐vascular (CCV) surgery and non‐CCV (orthopaedics, general, thoracic) surgery separately. Results Per 10 000 patients in routine, restrictive, liberal transfusion scenarios, total spending (transfusion and length of stay related) was 7·67, 7·58 and 9·39 million CNY (1 CNY × 0.157 = 1 US dollar) for CCV surgery and 6·35, 6·70 and 8·09 million CNY for non‐CCV surgery; infectious and severe complications numbered 354, 290, and 290 (CCV) and 315, 286, and 330 (non‐CCV), respectively. Acceptability curves showed high probabilities for restrictive strategy to be cost‐effective across a wide range of willingness‐to‐pay values. Such findings were mostly consistent in sensitivity and subgroup analyses except for patients with cardiac problems. Conclusion We showed strong rationale, succeeding previous findings only in cardiac or joint procedures, to comply with the new standard as restrictive transfusion has high potential to save blood, secure safety, and is cost‐effective for a wide spectrum of surgical patients. Experiences should be further summarized to pave the way towards individualized transfusion.

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“…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 . Physiologic transfusion triggers may include indices of tissue perfusion, central oxygen venous saturation or jugular oxygen venous saturation in neuro critically ill patients .…”

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

confidence: 99%

“…It has also been suggested that additional biological parameters may be useful in this setting to better guide clinicians in their decision making . Physiologic transfusion triggers may include indices of tissue perfusion, central oxygen venous saturation or jugular oxygen venous saturation in neuro critically ill patients . Further research is warranted to define the benefit of the use of additional transfusion triggers.…”

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 red cell transfusion be individualized? Yes

Cited by 20 publications

References 20 publications

Using arterial-venous oxygen difference to guide red blood cell transfusion strategy

Using arterial-venous oxygen difference to guide red blood cell transfusion strategy

Cost‐effectiveness comparison of routine transfusion with restrictive and liberal transfusion strategies for surgical patients in China

Making transfusion decisions in critical care

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