Transfusion medicine

New consensus on red cell use

A rigorous international consensus process on red cell transfusion in adults has supported the use of a restrictive transfusion haemoglobin threshold of 7-8 g/dL (70-80g/L) for most hospitalised patients.

Patient Blood Management Recommendations From the 2018 Frankfurt Consensus Conference, published in JAMA, also included two strong recommendations for specific patient groups – a threshold of < 7g/dL (<70g/L) for critically ill but stable ICU patients and <7.5g/dL (<75g/L) for patients undergoing cardiac surgery.

Other conditional recommendations were a threshold of <8g/dL (<80g/L) for patients with hip fracture and cardiovascular disease or other risk factors and 7-8 g/dL(70-80g/L) for haemodynamically stable patients with acute gastrointestinal bleeding.

No specific recommendations were made for other patient groups under consideration including those with septic shock, haematological or solid cancers, or acute CNS injuries.

A co-author on the JAMA paper Professor Erica Wood told the limbic Australia already had a lot of ‘runs on the board’ in patient blood management (PBM) but opportunity to contribute more through high quality research.

“I think there are still some patient groups where we have relatively little solid evidence – patients in haematology and oncology who receive a lot of red cells for bone marrow failure and other conditions, but also elderly patients. We need to know more about the impact of anaemia and transfusion on older people who are of course receiving a lot of transfusions.”

“For example, just in our group we are doing some studies looking at red cell transfusion in people with myelodysplasia, many of whom are older. We need to know more about this. It is possible that a restrictive approach is not necessarily one size fits all.”

Professor Wood, head of the Transfusion Research Unit at Monash University and president-elect of the International Society of Blood Transfusion, said one of the strengths of the conference was the diversity of input.

“It was very important that this was not a group of transfusionists talking to themselves but a broad approach across the clinical spectrum and people had really different things to bring to the table.”

Recommendations regarding clinical management of pre-operative anaemia included the use of iron supplementation but not routine use of erythropoiesis-stimulating agents to reduce transfusion rates in patients undergoing elective surgery.

However it found some evidence for adding short-acting erythropoietins to iron supplementation in patients with preoperative haemoglobin levels <13 g/dL (>130g/L) and scheduled for major orthopaedic surgery.

“I think the messages around identification and management of anaemia in the pre-op setting are important for us. We still have patients going for surgery who are anaemic in Australian hospitals,” Professor Wood said.

She said further PBM research had to include patient outcomes not just measures of red cells transfused.

“It’s easy to count the number of red cells out the door, and red cell use has been falling in developed countries over recent years partly related to PBM programs, but we need both research and in our clinical practice to understand the impact on patient functional outcomes as well as quality of life.”

“Consensus gives us additional information which will inform updates of our national guidelines but also help direct research – where we have evidence gaps and where we should be focusing our attention.”

An editorial in JAMA said the guidelines should be widely embraced.

“Some of the transfusion recommendations may seem peculiarly specific (ie, use a haemoglobin level <7.0 g/dL (<70g/L) for patients in intensive care but <7.5 g/dL (<75g/L) for patients undergoing cardiac surgery). The panel, appropriately, recommended the exact transfusion thresholds that had been tested in large RCTs.”

“Hospitals may choose to adopt simpler restrictive thresholds when developing local transfusion guidelines.”

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