New Red Blood Cell Transfusion Guidelines Recommend an Individualized Approach

For most patients requiring red blood cell transfusions, a restrictive transfusion strategy is often optimal, according to new guidelines developed by an international panel of experts and published today in JAMA. However, the panel urged that an overall clinical context, “including signs, symptoms, co-morbidities conditions, and patient values and preferences that will differ between patients” should be taken into account on a case-by-case basis to ensure each patient receives optimal treatment.

The panel of experts, led by a working group initiated by AABB, used a systemic review and a meta-analysis from Cochrane to determine optimal transfusion strategies. For adult populations, the experts reviewed 45 randomized clinical trials representing a total of 20,599 patients; for pediatric populations, they reviewed seven randomized clinical trials representing 2,730 patients. The panel compared patient outcomes with restrictive hemoglobin-based transfusion thresholds – defined as 7 to 8 g/dL – with more liberal transfusion thresholds – defined as 9 to 10 g/dL.

Based on their analysis, the experts developed four key recommendations:

• For most hospitalized adult patients who are hemodynamically stable, a restrictive transfusion strategy is recommended. Transfusion should be considered when hemoglobin concentration is less than 7 g/dL. Alternatively, based on the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for patients undergoing orthopedic surgery or those with pre-existing cardiovascular disease.
• For hospitalized adult patients with hematologic and oncologic disorders, a restrictive transfusion strategy is recommended. For this group, the experts also recommend transfusion when hemoglobin concentration is less than 7 g/dL.
• For critically ill children and those at risk of critical illness who are hemodynamically stable – and do not present with symptoms of hemoglobinopathy, cyanotic cardiac condition or severe hypoxemia – a restrictive transfusion strategy is also recommended. Transfusion should be considered when hemoglobin concentration is less than 7 g/dL.
• For hemodynamically stable children with congenital heart disease, a transfusion threshold based on the cardiac abnormality and stage of surgical repair is recommended. A threshold of 7 g/dL is recommended for patients undergoing biventricular repair. A threshold of 9 g/dL is recommended for patients with single-ventricle 1 palliation. A threshold of 7-9 g/dL is recommended for patients with uncorrected congenital heart disease.

The experts noted that although these guidelines will serve to provide transfusion recommendations for many patients, some knowledge gaps remain. They said that additional research is needed to better determine optimal transfusion thresholds for patients with acute myocardial infarction, vascular disease, and neurological disorders, among other health conditions.

“We know clinicians commonly use only hemoglobin thresholds to decide when to transfuse. Alternatively, we urge clinicians to incorporate into the decision to transfuse an assessment of each patient’s co-morbidity, symptoms and signs in addition to hemoglobin concentration,” said Jeffrey Carson, MD, lead author of the new guidelines and distinguished professor of medicine and Richard C. Reynolds, M.D. chair in general internal medicine at Rutgers Robert Wood Johnson Medical School.

Claudia Cohn, MD, PhD, AABB’s chief medical officer and a member of the panel that developed the recommendations, said the new guidelines represented important new strategies to determine optimal treatment for patients requiring transfusion. “These recommendations, based on a thorough analysis of currently available scientific literature, represent an important approach to determine treatment based on each patients’ individual health factors,” she said.

Other members of the panel agreed that the recommendations filled a need for the field. “Representatives from the International Society of Blood Transfusion [ISBT] were pleased to collaborate with AABB and the other organizations to develop these important guidelines. The recommendations will help clinicians in their decision-making, and also highlight evidence gaps for future research,” said Prof. Erica Wood, member of the expert panel and immediate past president of ISBT.