In the current issue of JAMA, published October 12, Carson et el have updated red blood cell (RBC) transfusion guidelines by AABB (American Association of Blood Banks). Based on review of 31 randomized clinical trials (RCTs) performed in a variety of different clinical settings involving more than 12 587 patients.
Main recommendations
- Transfusion not indicated until the hemoglobin level is 7g/dL for hospitalized adult patients who are hemodynamically stable, including critically ill patients
- For patients undergoing orthopedic surgery or cardiac surgery and with preexisting cardiovascular disease, transfusion threshold is Hb of 8gm/dl(You may be wondering why 8 ? The RCTs involving these patients used 8 as their level for some reason!)
- No need to limiting patients (including neonates) to transfusion of only fresh RBCs (storage length: <10 days)
NO recommendations
- No recommendation for or against a liberal or restrictive transfusion threshold in patients with acute coronary syndrome.
- No recommendation for a transfusion threshold in patients treated for hematological or oncological disorders and for those with severe thrombocytopenia who are at risk of bleeding or for those with chronic transfusion–dependent anemia.
Why important
RBC transfusion is associated with significant adverse effects
| Adverse Event | Approximate Risk Per-Unit
Transfusion of RBCs |
| Febrile reaction | 1:60 |
| Transfusion-associated circulatory overload | 1:100 |
| Allergic reaction | 1:250 |
| Transfusion-related acute lung injury | 1:12 000 |
| Hepatitis C virus infection | 1:1 149 000 |
| Hepatitis B virus infection | 1:1 208 000 to 1:843 000 |
| Human immunodeficiency virus infection | 1:1 467 000 |
| Fatal hemolysis | 1:1 972 000 |
CAVEAT
Current RCTs on which these guidelines are based did not show increased transfusion related adverse events in liberal strategy group as seen in other observational studies.
References
- Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA. doi:10.1001/jama.2016.9185
- Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion. Ann Intern Med. 2012;157(1):49-58.
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