Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB*FREE
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Abstract
Description:
Methods:
Recommendation 1:
Recommendation 2:
Recommendation 3:
Recommendation 4:
Guideline Focus
Target Population
Guideline Development Process
Panel Composition
Evidence Review and Grading
Systematic Review
Grading of Evidence
Comments and Modification
Clinical Recommendations
Question 1
Recommendations
Evidence Summary
Rationale for Recommendations
Question 2
Recommendations
Evidence Summary
Rationale for Recommendations
Question 3
Recommendations
Evidence Summary
Rationale for Recommendations
Question 4
Recommendations
Evidence Summary
Rationale for Recommendations
Discussion
Comparison With Other Guidelines
Research Recommendations
Appendix 1: Members of the AABB Guideline Group
Appendix 2: GRADE Methodology
References
Information & Authors
Information
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History
Keywords
- Biochemistry
- Blood cells
- Cardiology and cardiovascular diseases
- Cardiovascular diseases
- Cell biology
- Cells
- Clinical trials
- Cognitive psychology
- Coronary heart disease
- Drug research and development
- Heart diseases
- Hemoglobin
- Hospital medicine
- Mortality
- Myocardial infarction
- Pharmacology
- Population statistics
- Prevention, policy, and public health
- Proteins
- Psychiatry and mental health
- Psychology
- Red blood cells
- Research and reporting methods
- Research assessment
- Vascular diseases
- Vascular medicine
- Vital statistics
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Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB*. Ann Intern Med.2012;157:49-58. [Epub 3 July 2012]. doi:10.7326/0003-4819-157-1-201206190-00429
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Author's Response
We appreciate the opportunity to reiterate that our guidelines state that transfusion be CONSIDERED in specific patient subgroups when the nadir hemoglobin reaches 7-8 g/dL.(1) In addition, the decision to transfuse should be influenced by signs and symptoms. We based our recommendations on the best available evidence: 19 randomized clinical trials in 6,264 patients. However, clinical trials provide an average effect in the population studied. Thus, it is likely that some patients need more or less blood to improve outcomes. The “conundrum” is what clinical factors should influence the “routine titrated” transfusion decision. The largest trial evaluating transfusion thresholds used pre-specified symptoms (e.g., chest pain, orthostatic hypotension or tachycardia unresponsive to fluid resuscitation),(2) which we included in our guidelines. While this approach is based on a randomized trial, these symptoms will not be applicable to all clinical settings. We agree with the editorial accompanying the guidelines that other parameters such as fatigue, dyspnea, mechanical ventilation, or the use of low SvO2 (venous oxygen saturation) are unproven.(3)Unfortunately, there is no evidence to support other “important individual patient laboratory and physiological variables” as the basis for transfusion decisions. Drs. Klein and Natanson suggest that clinical trials evaluating transfusion thresholds should include an arm where patients are managed using the standard of care, which, in their opinion, is individually titrated transfusions. While it is true that this approach is often recommended, the evidence strongly suggests that clinicians do not follow this recommendation and have not adopted this approach as standard of care. For example, a recent study in orthopedic surgery documents that transfusion decisions were mostly based on hemoglobin levels.(4) Similarly, a study conducted in patients undergoing percutaneous coronary intervention showed that most transfusions were given when the hemoglobin dropped to a certain threshold, rather than for individual clinical circumstances. (5) This is also consistent with our anecdotal observations at our own hospitals. Given that most clinicians do not individually titrate transfusions, the proposed design would be very difficult to implement and would not reflect “real-world” practice. A more clinically applicable trial design incorporates pre-specified symptoms for transfusion along with hemoglobin thresholds. We stand by our recommendations: in pre-specified groups of patients, randomized clinical trials have demonstrated that restrictive transfusion using 7-8 g/dL threshold reduces blood use without harm. When this hemoglobin level is reached, we recommend considering transfusion, but only after evaluating the patient’s clinical status. Jeffrey L Carson, MDSunil V Rao, MDLouis M Katz, MD
References
1. Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, et al. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB*. Annals of internal medicine. 2012;157(1):49-58.
2. Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. The New England journal of medicine. 2011;365(26):2453-62.
3. Vincent JL. Indications for blood transfusions: too complex to base on a single number? Annals of internal medicine. 2012;157(1):71-2.
4. Vuille-Lessard E, Boudreault D, Girard F, Ruel M, Chagnon M, Hardy JF. Red blood cell transfusion practice in elective orthopedic surgery: a multicenter cohort study. Transfusion. 2010;50(10):2117-24.
5. Moscucci M, Ricciardi M, Eagle KA, Kline E, Bates ER, Werns SW, et al. Frequency, predictors, and appropriateness of blood transfusion after percutaneous coronary interventions. The American journal of cardiology. 1998;81(6):702-7.
A Conundrum
The AABB’s recommendation, adhering to a “restrictive” transfusion threshold that relies on a hemoglobin determination of 7-8 gm/dL or less for hemodynamically stable patients, is well-intentioned, but problematic.(1) We are not surprised that the editorial accompanying this proposed new guideline arrives at a different conclusion.(2) We concur. We too believe that transfusion thresholds should be titrated based on many important individual patient laboratory and physiological variables. Why the disparity after considering the same decade of clinical experience and trial data? The weaknesses of the most influential trial are well described in the accompanying editorial. Since this and other trials upon which the AABB guideline committee based their recommendations never tested routine titrated care, the standard of care at the time, the trials could not determine whether either treatment – two arbitrarily selected hemoglobin determinations defined as “restrictive” or “liberal”- improved outcome or saved blood.(3) This trial design allows one to conclude only which of these two strategies should not be used. The less harmful treatment could still be worse than usual titrated care. The patients in this trial had a mortality risk of approximately 2/1000 or 0.2% per unit of transfused red blood cells, a death rate from transfusion some two orders of magnitude greater than that estimated at the time by the General Accounting Office for usual transfusion practice (0.001% or one death for every 10,000 units of transfused blood).(4) Differences in patient mix and follow-up seem unlikely to explain this enormous discrepancy. There is a real possibility that the new AABB guidelines have come to the wrong conclusion. We recognize that Carson et al. have softened their recommendations by acknowledging that “clinical judgment is critical in the decision to transfuse … transfusing RBCs above or below the specified hemoglobin threshold may be dictated by the clinical context.” We hope that this sentence will not be overlooked by those who seek a simple protocol-driven care approach. We do not believe that their systematic review provides sufficient direct evidence to change the previous recommendations by AABB and others regarding titrated transfusion practice. We concur with the authors’ observation that “clinical trials are needed in other patient populations.” However randomized, controlled trials with the addition of a titrated care arm in each of the conditions they describe are neither practical nor affordable. Since expert clinicians now appear to recognize more than one “standard of care” for red cell transfusion, the time is ripe to undertake comparative effectiveness trials using real world data and large populations to help resolve this conundrum. (5)
References
(1) Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, Rao SV, Roback JD, Shander A, Tobian AA, Weinstein R, Swinton McLaughlin LG, Djulbegovic B; for the Clinical Transfusion Medicine Committee of the AABB. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB Ann Intern Med. 2012;157(1):49-58
(2) Vincent JL. Indications for blood transfusions: too complex to base on a single number? Ann Intern Med. 2012;157(1):71-2
(3) Deans KJ, Minneci PC, Suffredini AF, Danner RL, Hoffman WD, Ciu X, Klein HG, Schechter AN, Banks SM, Eichacker PQ, Natanson C. Randomization in clinical trials of titrated therapies: unintended consequences of using fixed treatment protocols. Crit Care Med. 2007;35(6):1509-16
(4) United States General Accounting Office. Blood Supply: Transfusion- Associated Risks. 1997, Washington DC, GAO/PEMD-97-2
(5) Klein HG. Comparative effectiveness research: welcome to the real world. Transfusion. 2012; 52(6):1162-4
TRANSFUSION TRIGGERS point is how much effective?
Thanks to all authors and AARB for such a beautiful updated recommendation. Since beginning of my hospitalist carrier, every time I have been thinking are we over utilizing our resources regarding blood transfusion. From observation I have seen physician transfusing blood at number he/or she does not feel comfortable. Well known terms as "transfusion triggers differed among physician". I have been encouraging my resident group that don't learn what your attending wants, try to look for evidence behind it. I guess this new update will be great resource for me to teach my resident group. Again I would love to see more study regarding cost-effectiveness too. Since we are in the era of going through medical reforming, cost cutting, preventing readmission to save money. Can we save really reasonable amount of money avoiding aggressive blood transfusion. Now a days lot of talk going on regarding , cardiovascular disease, MI, CHF, infection (pneumonia), readmission, cutting payment by insurance providers. Surprisingly all these medical conditions was evaluated in different Blood transfusion study, such as FOCUS trial, TRICC study. Wondering, are we contributing or provocation some way by doing blood transfusion in this group of pt , when they come to hospital with borderline hb of 7-8, and receive blood transfusion along with Rx for admitted condition (PNA/MI/CHF etc). Hope to see in near future readmission group of pt with blood transfusion association from any trials for further evidence that will help to make clear decision. Not sure current recommendation with "TRANSFUSION TRIGGERS" point is how much effective. Rewarding Physician/hospital for less blood transfusion by insurance provider also might be very encouraging.
Conflict of Interest:None declared