The Generalist: Blood Transfusions—Thresholds and Complications
Jake Anderson, DO, and Heidi James, MD
Jake Anderson joins Heidi to talk about the ins and outs of blood transfusions. They review transfusion thresholds for various groups of patients and discuss significant complications.
Transfusion thresholds
- Decisions to transfuse red blood cells (RBC) should be based on clinical status:
- Hemodynamic stability
- Presence and severity of ongoing blood loss
- Patient’s symptoms
- Hemoglobin level
- Liberal transfusion thresholds
- Transfusion for hemoglobin <10 g/dL
- No longer indicated for most
- Restrictive transfusion thresholds
- Transfusion for hemoglobin of <7 to 8 g/dL
- Appropriate for the majority of patients
- Studies have shown similar or better outcomes, including in
- Critically ill patients
- Those with upper gastrointestinal bleeds
- Transfusion for specific populations:
- Cardiovascular disease
- The American Association of Blood Banks (AABB) recommends using a threshold hemoglobin level of 8 g/dL in hemodynamically stable cardiac disease.
- Orthopedic or cardiac surgery patients
- The AABB recommends transfusion for a hemoglobin of 8 g/dL or less.
- Patients with chronic anemia
- Use a lower threshold.
- This is especially true anemia of chronic disease due to kidney disease.
- Consider reserving transfusion for a hemoglobin <6 g/dL.
Transfusion reactions
- Many of these reactions can be avoided by thorough typing and matching.
- Immediate (acute) reactions:
- Occur within 24 hours of the transfusion
- Suspect if
- Fever
- Pain at the infusion site
- Constellation of dyspnea, flank pain, and hypotension, hemoglobinuria
- Disseminated intravascular coagulation
- Investigate for hemolysis and incompatibility
- Treatment
- Focus on maintaining urinary output with fluids and IV diuretics
- Analgesia
- Correcting hypotension if needed
- Administering plasma and other blood products if needed
- TRALI (transfusion-related acute lung injury)
- Suspect in someone who develops pulmonary edema and hypoxemia
- Treatment is supportive until recovery
- May require respiratory support
- TACO (transfusion-associated circulatory overload)
- More common in elderly and those with impaired fluid balance like heart failure
- Presentation and investigations
- Dyspnea and cough due to pulmonary edema
- ST segment changes on ECG
- Chest X-ray may show cardiac enlargement
- Troponin may suggest cardiac strain
- Treatment
- Diuresis
- Respiratory support
- Delayed reactions
- Occur >24 hours after transfusion
- Include
- Delayed hemolytic reaction
- Alloimmunization
- Graft versus host disease
PEARL: Restrictive transfusion thresholds, transfusing at <8 g/dL, are appropriate for most patients.
REFERENCES:
Clinical Practice Guidelines from the AABB: Red blood cell transfusion thresholds and storage
Carson JL, Guyatt G, Heddle NM, et al. JAMA. 2016;316(19):2025-2035. doi: 10.1001/jama.2016.9185.
Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion
Carson JL, Stanworth SJ, Roubinian N, et al. Cochrane Database Syst Rev. 2016;10(10):CD002042. doi: 10.1002/14651858.CD002042.
Effect of restrictive versus liberal transfusion strategies on outcomes in patients with cardiovascular disease in a non-cardiac surgery setting: systematic review and meta-analysis
Docherty AB, O’Donnell R, Brunskill S, et al. BMJ. 2016;352:i1351. doi: 10.1136/bmj.i1351.
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