Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion

Abstract

Background Most clinical practice guidelines recommend restrictive red cell transfusion practices, with the goal of minimising exposure to allogeneic blood. The purpose of this review is to compare clinical outcomes in patients randomised to restrictive versus liberal transfusion thresholds (triggers). Objectives To examine the evidence for the effect of transfusion thresholds on the use of allogeneic and/or autologous red cell transfusion, and the evidence for any effect on clinical outcomes. Search methods We identified trials by searching: the Cochrane Injuries Group Specialised Register (searched 1 February 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), MEDLINE (Ovid) 1948 to January Week 3 2011, EMBASE (Ovid) 1980 to 2011 (Week 04), ISI Web of Science: Science Citation Index Expanded (1970 to February 2011) and ISI Web of Science: Conference Proceedings Citation Index - Science (1990 to February 2011). We checked reference lists of other published reviews and relevant papers to identify any additional trials. Selection criteria Controlled trials in which patients were randomised to an intervention group or to a control group. We included trials where intervention groups were assigned on the basis of a clear transfusion ‘trigger’, described as a haemoglobin (Hb) or haematocrit (Hct) level below which a red blood cell (RBC) transfusion was to be administered. Data collection and analysis We pooled risk ratios of requiring allogeneic blood transfusion, transfused blood volumes and other clinical outcomes across trials using a random-effects model. Two people performed data extraction and assessment of the risk of bias. Main results We included 19 trials involving a total of 6264 patients and they were similar enough that results could be combined. Restrictive transfusion strategies reduced the risk of receiving a RBC transfusion by 39% (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.52 to 0.72). This equates to an average absolute risk reduction (ARR) of 34% (95% CI 24% to 45%). The volume of RBCs transfused was reduced on average by 1.19 units (95% CI 0.53 to 1.85 units). However, heterogeneity between trials was statistically significant (P < 0.00001; I2 ≥ 93%) for these outcomes. Restrictive transfusion strategies did not appear to impact the rate of adverse events compared to liberal transfusion strategies (i.e. mortality, cardiac events, myocardial infarction, stroke, pneumonia and thromboembolism). Restrictive transfusion strategies were associated with a statistically significant reduction in hospital mortality (RR 0.77, 95% CI 0.62 to 0.95) but not 30-day mortality (RR 0.85, 95% CI 0.70 to 1.03). The use of restrictive transfusion strategies did not reduce functional recovery, hospital or intensive care length of stay. The majority of patients randomised were included in good-quality trials, but some items of methodological quality were unclear. There are no trials in patients with acute coronary syndrome. Authors’ conclusions...

Lower versus higher hemoglobin threshold for transfusion in ARDS patients with and without ECMO

“…In accordance with the results of previous RCTs on transfusion thresholds in various patient populations, the data of this study demonstrate that a lower (restrictive) transfusion threshold compared to a higher (liberal) transfusion threshold was not associated with an increase in 28-day mortality in ICU-patients with ARDS who received a blood transfusion [4,22,24,26,30]. In addition, applying a higher transfusion threshold was not associated with an increase in the chances for a successful weaning from ECMO within 28 days after onset of ARDS.…”

Lower versus higher hemoglobin threshold for transfusion in ARDS patients with and without ECMO

“…In accordance with the results of previous RCTs on transfusion thresholds in various patient populations, the data of this study demonstrate that a lower (restrictive) transfusion threshold compared to a higher (liberal) transfusion threshold was not associated with an increase in 28-day mortality in ICU-patients with ARDS who received a blood transfusion [4,22,24,26,30]. In addition, applying a higher transfusion threshold was not associated with an increase in the chances for a successful weaning from ECMO within 28 days after onset of ARDS.…”

Red blood cell concentrate transfusion strategies utilised at a tertiary-level paediatric intensive care unit: A descriptive study on impact and cost

“…ARTICLE strategy (with haemoglobin levels at ≤7 g/dL) does not adversely affect clinical outcome. [16] Similar to the findings of our study, the TRIPICU study -the only robust trial in children -has not shown any differences in mortality or multiple organ dysfunction syndromes between patients for whom a restrictive strategy was adopted and haemodynamically stable patients when a more liberal strategy was used. [17] The TRIPICU study further recommends a restrictive transfusion strategy for stable PICU patients, but not for premature infants, older children, patients with coronary artery disease, or children with severe hypoxaemia, haemodynamic instability, active blood loss or cyanotic heart disease.…”

Daily Lowest Hemoglobin and Risk of Organ Dysfunctions in Critically Ill Patients

“…There was no evidence that lower hemoglobin levels were associated with risk of developing delirium, renal dysfunction, or ICU-mortality. These data suggest that anemia does not consistently increase the risk for end organ dysfunction or mortality, and corroborates a growing body of literature (11) (17). …”

Lower versus higher hemoglobin threshold for transfusion in ARDS patients with and without ECMO

“…In accordance with the results of previous RCTs on transfusion thresholds in various patient populations, the data of this study demonstrate that a lower (restrictive) transfusion threshold compared to a higher (liberal) transfusion threshold was not associated with an increase in 28-day mortality in ICU-patients with ARDS who received a blood transfusion [4,22,24,26,30]. In addition, applying a higher transfusion threshold was not associated with an increase in the chances for a successful weaning from ECMO within 28 days after onset of ARDS.…”

Red blood cell concentrate transfusion strategies utilised at a tertiary-level paediatric intensive care unit: A descriptive study on impact and cost

“…ARTICLE strategy (with haemoglobin levels at ≤7 g/dL) does not adversely affect clinical outcome. [16] Similar to the findings of our study, the TRIPICU study -the only robust trial in children -has not shown any differences in mortality or multiple organ dysfunction syndromes between patients for whom a restrictive strategy was adopted and haemodynamically stable patients when a more liberal strategy was used. [17] The TRIPICU study further recommends a restrictive transfusion strategy for stable PICU patients, but not for premature infants, older children, patients with coronary artery disease, or children with severe hypoxaemia, haemodynamic instability, active blood loss or cyanotic heart disease.…”

Daily Lowest Hemoglobin and Risk of Organ Dysfunctions in Critically Ill Patients

“…There was no evidence that lower hemoglobin levels were associated with risk of developing delirium, renal dysfunction, or ICU-mortality. These data suggest that anemia does not consistently increase the risk for end organ dysfunction or mortality, and corroborates a growing body of literature (11) (17). …”

Lower versus higher hemoglobin threshold for transfusion in ARDS patients with and without ECMO

“…In accordance with the results of previous RCTs on transfusion thresholds in various patient populations, the data of this study demonstrate that a lower (restrictive) transfusion threshold compared to a higher (liberal) transfusion threshold was not associated with an increase in 28-day mortality in ICU-patients with ARDS who received a blood transfusion [4,22,24,26,30]. In addition, applying a higher transfusion threshold was not associated with an increase in the chances for a successful weaning from ECMO within 28 days after onset of ARDS.…”

Red blood cell concentrate transfusion strategies utilised at a tertiary-level paediatric intensive care unit: A descriptive study on impact and cost

“…ARTICLE strategy (with haemoglobin levels at ≤7 g/dL) does not adversely affect clinical outcome. [16] Similar to the findings of our study, the TRIPICU study -the only robust trial in children -has not shown any differences in mortality or multiple organ dysfunction syndromes between patients for whom a restrictive strategy was adopted and haemodynamically stable patients when a more liberal strategy was used. [17] The TRIPICU study further recommends a restrictive transfusion strategy for stable PICU patients, but not for premature infants, older children, patients with coronary artery disease, or children with severe hypoxaemia, haemodynamic instability, active blood loss or cyanotic heart disease.…”

Daily Lowest Hemoglobin and Risk of Organ Dysfunctions in Critically Ill Patients

“…There was no evidence that lower hemoglobin levels were associated with risk of developing delirium, renal dysfunction, or ICU-mortality. These data suggest that anemia does not consistently increase the risk for end organ dysfunction or mortality, and corroborates a growing body of literature (11) (17). …”