Guias De Transfusion

Clinical Guidelines

Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB

Jeffrey L. Carson, MD; Brenda J. Grossman, MD, MPH; Steven Kleinman, MD; Alan T. Tinmouth, MD; Marisa B. Marques, MD; Mark K. Fung, MD, PhD; John B. Holcomb, MD; Orieji Illoh, MD; Lewis J. Kaplan, MD; Louis M. Katz, MD; Sunil V. Rao, MD; John D. Roback, MD, PhD; Aryeh Shander, MD; AaronA.R. Tobian, MD, PhD; Robert Weinstein, MD; Lisa Grace Swinton McLaughlin, MD; and Benjamin Djulbegovic, MD, PhD, for the Clinical Transfusion Medicine Committee of the AABB*

Next Section
Abstract

Description: Although approximately 85 million units of red blood cells (RBCs) are transfused annually worldwide, transfusion practices vary widely. The AABB (formerly, the American Association ofBlood Banks) developed this guideline to provide clinical recommendations about hemoglobin concentration thresholds and other clinical variables that trigger RBC transfusions in hemodynamically stable adults and children.

Methods: These guidelines are based on a systematic review of the literature on randomized clinical trials evaluating transfusion thresholds. We performed a literature searchfrom 1950 to February 2011 with no language restrictions. We examined the proportion of patients who received any RBC transfusion and the number of RBC units transfused to describe the effect of restrictive transfusion strategies on RBC use. To determine the clinical consequences of restrictive transfusion strategies, we examined overall mortality, nonfatal myocardial infarction, cardiac events,pulmonary edema, stroke, thromboembolism, renal failure, infection, hemorrhage, mental confusion, functional recovery, and length of hospital stay.

Recommendation 1: The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence).

Recommendation 2: The AABB suggests adhering to arestrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence).

Recommendation 3: The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with theacute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence).

Recommendation 4: The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence).

Approximately 15 million red blood cell (RBC) units are transfused annually in the United States (1); about 85 million are transfusedannually worldwide (2). Although there are many potential reasons for the different RBC transfusion practices that exist throughout the world, one reason may be the limited high-quality evidence of the benefits and harms of RBC transfusions.

Physicians most commonly use hemoglobin concentration to decide when to transfuse (3). However, most guidelines (4, 5) emphasize that transfusion should begiven for symptoms of anemia and should not be based on hemoglobin concentration alone.

Previous guidelines have identified patients with coronary artery disease as an important subgroup that may need to be treated differently. Oxygen delivery from RBCs to the heart is critical and may be reduced by obstructed coronary arteries or anemia. Animal (6–8) and human studies (9) indicate higher riskfor death and complications associated with anemia in the presence of coronary artery disease. Hence, there is concern about withholding RBC transfusion in patients with ischemic cardiovascular disease.

Optimal use should involve administering enough RBCs to maximize clinical outcomes while avoiding unnecessary transfusions that increase costs and expose patients to potential infectious or...