Journal Article: Blood Transfusions in Anemic Patients

In Brookdale ED, the criteria to transfuse blood is when a patient’s Hgb is ~7 with a significant drop from their baseline.  During my rotation there was a patient who was actively bleeding, with a Hgb of 7.2 requiring a blood transfusion while in the ED and was being admitted for symptomatic anemia.  The article in question discusses transfusion thresholds and strategies that help guide red blood cell transfusions.

According to UptoDate, ‘optimal transfusion practice should provide enough RBCs to maximize clinical outcomes while avoiding unnecessary transfusions.’  Decisions to transfuse should include clinical status, co-morbidity and wishes of the patient.  What the article and UptoDate recognizes is that Hgb can guide a practitioner but clinical judgment is required. UptoDate also recognizes a threshold hemoglobin of 7 or 8 g/dL for patients based on systematic reviews and meta-analyses.  It is important to note that threshold also changes based on whether or not the patient is symptomatic or not.

The article highlights the varying uncertainty regarding optimal Hgb threshold for using RBC in anemic patients and notes that in some countries blood is a sacred treatment and not available for all patients.  Additionally in these countries, adequate testing may not be done on the RBC prior to transfusions leading to pathogens and more harm for the patient being transfused — in these instances the lower the patients receiving the transfusions the better.

This Cochrane Systematic Review included articles and trials from reputable databases and worked to compare 30-day mortality as well as other clinical outcomes with varying RBC transfusion thresholds.  The article divided the thresholds into two categories: restrictive (at 7 or 8g/dL) or liberal (at 9 or 10g/dL) and compared outcomes on the ‘basis of a clear transfusion trigger.’  Given the side effects of transfusion, understanding an appropriate threshold allows us as practitioners to be make better clinical decisions for the patients.

This article reviewed 31 trials and evaluated results from 12,587 patients with a number of different problems and clinical issues.  Ultimately, transfusing RBCs at a Hgb level between 7 and 8 g/dL decreased the proportion of participants exposed to transfusion but there was ‘no evidence that a restrictive transfusion strategy impacts 30-day mortality or morbidity’ in comparison with the more liberal approach.  Most importantly – the article notes ‘the findings provide good evidence that transfusions with allogeneic RBCs can be avoided in patients with Hgb thresholds above 7-8 g/dL.

Interestingly, this article is a continuation and updated from its initial publication to include more data and information.  Given the large sample size and the enormous pool of people included in this study, the results allow us to apply the findings to clinical practice and feel comfortable transfusing with the lower Hgb value.

https://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-red-blood-cell-transfusion-in-the-adult

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