Restrictive transfusion strategy of red cell concentrate often optimal for most patients, asserts AABB Guideline

In their guideline published in the Journal of the American Medical Association (JAMA), the panel recommend that a restrictive transfusion strategy is often optimal for most patients requiring RBC transfusions. However, the panel urged that an overall clinical context, including symptoms, signs, patient values and preferences, and co-morbidities conditions, that will differ between patients should be taken into account on a case-by-case basis to ensure each patient receives optimal treatment.

"It is good practice to consider the overall clinical context and alternative therapies for transfusion when making transfusion decisions about an individual patient," the guideline stated.

The panel of experts used a meta-analysis and systematic review from Cochrane to determine optimal transfusion strategies. For adult populations, Jeffrey L. Carson, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, and the team reviewed seven randomized clinical trials comprising 2,730 patients. The panel compared patient outcomes with restrictive hemoglobin-based transfusion thresholds – defined as 7 to 8 g/dL – with more liberal transfusion thresholds – defined as 9 to 10 g/dL.

Based on their analysis, the team developed four key recommendations:

• For most hospitalized adult patients who are hemodynamically stable, a restrictive transfusion strategy is recommended. Transfusion should be considered when the haemoglobin concentration is less than 7 g/dL. Alternatively, based on the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for patients undergoing orthopaedic surgery or those with pre-existing cardiovascular disease.
• For critically ill children and those at risk of critical illness who are hemodynamically stable – and do not present with symptoms of hemoglobinopathy, cyanotic cardiac condition or severe hypoxemia – a restrictive transfusion strategy is also recommended. Transfusion should be considered when the haemoglobin concentration is less than 7 g/dL.
• For hospitalized adult patients with hematologic and oncologic disorders, a restrictive transfusion strategy is recommended. For this group, the experts also recommend transfusion when the haemoglobin concentration is less than 7 g/dL.
• For hemodynamically stable children with congenital heart disease, a transfusion threshold based on the cardiac abnormality and stage of surgical repair is recommended. A threshold of 7 g/dL is recommended for patients undergoing biventricular repair. A threshold of 9 g/dL is recommended for patients with single-ventricle 1 palliation. A threshold of 7-9 g/dL is recommended for patients with uncorrected congenital heart disease.

According to the experts, "these guidelines will serve to provide transfusion recommendations for many patients, but some knowledge gaps remain."

They add that, "there is a need for additional research to better determine optimal transfusion thresholds for patients with vascular disease, acute myocardial infarction, and neurological disorders, among other health conditions."

Reference:

Carson JL, Stanworth SJ, Guyatt G, et al. Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA. Published online October 12, 2023. doi:10.1001/jama.2023.12914