What’s New in the Patient Safety World
November 2016
AABB Updates Transfusion Guidelines Again
We’ve done numerous columns over the years about the increasing evidence that more restrictive criteria for transfusions do not lead to worse outcomes for many or even most patient conditions and that transfusions may be associated with a variety of potential adverse effects. The AABB (American Association of Blood Banks) updated its guidelines on transfusion in 2012 (see our April 2012 What's New in the Patient Safety World column “New Transfusion Guidelines from the AABB”) to reflect the trending literature. Now the AABB has once again updated its transfusion guidelines after reviewing the updated literature for randomized controlled trials (RCT’s) dealing with transfusion criteria (Carson 2016).
The updated AABB
guideline recommends two tiers of hemoglobin level transfusion triggers:
- 7 g/dL for hemodynamically stable adults,
even those in critical care
- 8 g/dL for patients with preexisting
cardiovascular disease or those undergoing cardiac or orthopedic surgery
The guidelines do
not include any recommendations regarding patients with acute coronary
syndromes, severe thrombocytopenia, or chronic transfusion–dependent anemia.
Interestingly, one
point brought out in the discussion is that "standard practice should be
to initiate a transfusion with 1 unit of blood rather than 2 units. This would
have potentially important implications for the use of blood transfusions and minimize
the risks of infectious and noninfectious complications”. That is of interest because one of the
triggers historically used by transfusion committees to review cases for
appropriateness was the use of a single unit of packed RBC’s rather than at
least two units.
The other new
recommendation has to do with the freshness of the RBC’s. It states that
patients, including neonates, should receive RBC units selected at any point
within their licensed dating period rather than limiting patients to
transfusion of only fresh (storage length: <10 days) RBC units.
The Carson article
also includes the evidence summary and has a nice table summarizing the odds of
the various adverse effects of RBC transfusions.
In an accompanying
editorial (Yazer 2016)
Yazer and Triulzi remind us
that good clinical practice dictates
that the decision to transfuse should not be solely based on the hemoglobin
level. They suggest that future studies look at inclusion of some sort of
measure of tissue oxygenation to aid in the clinical decision about
transfusion.
The Carson article
includes the following Good Clinical Practice Statement: “When deciding to
transfuse an individual patient, it is good practice to consider not only the
hemoglobin level, but the overall clinical context and alternative therapies to
transfusion. Variables to take into consideration include the rate of decline
in hemoglobin level, intravascular volume status, shortness of breath, exercise
tolerance, lightheadedness, chest pain thought to be cardiac in origin,
hypotension or tachycardia unresponsive to fluid challenge, and patient
preferences. This practice guideline is not intended as an absolute standard
and will not apply to all individual transfusion decisions.”
Prior columns on potential detrimental effects related to red blood cell transfusions:
- March 2011 “Downside of Transfusions in Surgery”
- February 2012 “More
Bad News on Transfusions”
- January 2012 “Need
for New Transfusion Criteria?”
- April 2012 “New
Transfusion Guidelines from the AABB”
- February 2013 “More
Evidence Favoring Restriction of Transfusions”
- June 2013 “Hopkins
Blood Ordering Initiative”
- May 2014 “Blood
Transfusion and Infection Risk”
- June 2015 “Economics
and Blood Transfusion”
References:
Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines from the AABB. Red Blood Cell Transfusion Thresholds and Storage. JAMA 2016; Published online October 12, 2016
http://jamanetwork.com/journals/jama/article-abstract/2569055
Yazer MH, Triulzi DJ. AABB Red Blood Cell Transfusion Guidelines. Something for Almost Everyone. JAMA 2016; Published online October 12, 2016
http://jamanetwork.com/journals/jama/fullarticle/2569053
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