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Restrictive transfusion strategy is best for hospitalized patients

Clinical Question:
What is the optimal transfusion strategy for hospitalized patients?

Bottom Line:
Citing evidence from an updated systematic review, the American Association of Blood Banks recommends implementing a restrictive transfusion strategy with a transfusion threshold hemoglobin of 7 g/dL to 8 g/dL for stable hospitalized patients. A restrictive strategy should also be used for those with preexisting cardiovascular disease, with consideration of transfusion for symptomatic patients and those with a hemoglobin of 8 g/dL or below. Overall, the decision to transfuse should be influenced not only by the hemoglobin concentration but also by the presence of symptoms. Finally, more data are needed to guide transfusions for patients with acute coronary syndrome. (LOE = 1a)

Reference:
Carson JL, Grossman BJ, Kleinman S, et al, for the Clinical Transfusion Medicine Committee of the AABB. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med 2012 Mar 26 [Epub ahead of print].  [PMID:22454395]

Study Design:
Practice guideline

Funding:
Foundation

Allocation:
Uncertain

Setting:
Various (meta-analysis)

Synopsis:
The American Association of Blood Banks developed these guidelines based on an updated systematic review of the literature (Cochrane Database Syst Rev 2012:CD002042) that evaluated the risks and benefits of restrictive and liberal red blood cell (RBC) transfusion strategies. The authors searched multiple databases including the Cochrane Register and MEDLINE, as well as reference lists from relevant studies to identify randomized controlled trials that compared the use of restrictive strategies for RBC transfusion with more liberal strategies in both surgical and medical patients. Two authors independently selected studies and extracted data while one assessed each study for quality using the Cochrane Collaboration methods. The primary outcome was the number of patients who received transfusions; the secondary outcomes included mortality, length of stay, and morbidities such as acute cardiovascular events and infection. Data addressing patients with preexisting cardiovascular disease were sparse and there were no trials that examined transfusion thresholds in patients with acute coronary syndrome. Only one trial evaluated the benefit of transfusing symptomatic patients (Carter et al; Daily POEM 2/17/12). The implementation of restrictive strategies reduced the risk of receiving an RBC transfusion (relative risk = 0.61; 95% CI, 0.52-0.72) without significantly affecting mortality or morbidity. Based on the results reported in the systematic review, this committee recommends the following: (1) a restrictive strategy, using a transfusion threshold of 7 g/dL to 8 g/dL, should be implemented in hospitalized, stable patients; (2) a restrictive strategy should also be used for patients with existing cardiovascular disease; and (3) both hemoglobin thresholds and symptoms should influence the decision to transfuse. Finally, there is not enough data to make recommendations for transfusion in patients with acute coronary syndrome.

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