Survival in Individuals with Profound Anemia Treated without the Use of Blood Transfusions.

Abstract

Although there is an emerging trend to reduce blood transfusions, there is still very little randomized data outside of the critical care setting that identifies the risks and benefits of transfusion support. Many clinicians base the decision to transfuse primarily on the hemoglobin (Hb) level independent of symptoms. Little is known about the clinical consequences of profound anemia although there is concern that withholding transfusion support will result in adverse outcomes in those with advanced age or underlying cardiovascular conditions. Prior studies have reported a significant mortality rate with Hb levels under 5 g/dL. This in part has led to the use of extreme measures such as hyperbaric chambers, ventilation or paralysis for profound anemia and the establishment of specialized Centers for Bloodless Medicine and Surgery to care for individuals refusing blood products. A retrospective chart review of 128 patients declining blood transfusions with Hb values under 7 g/dL from January 2002 until August 2005 was performed. This population included a broad range of medical, surgical and obstetrical cases with a mean age, Hb and length of stay of 52 years, 5.4 g/dL and 11 days respectively. Table 1 summarizes the survival rates based on the severity of anemia. Our nonblood approach included simultaneous interventions to stimulate erythropoiesis, control bleeding, enhance hemostasis, minimize iatrogenic blood loss and maintain hemodynamic stability. All patients received erythropoietin and iron with antifibrinolytic agents added for any active bleeding. To keep laboratory sampling at a minimum, physicians were required to rely on their basic clinical assessment skills to manage patients. The need for critical care monitoring, volume resuscitation and oxygen support was determined based on changes in blood pressure, heart rate, urine output, and cognitive function. Patients experienced slower recovery times with more frequent cardiac monitoring and increased length of hospital stays. This series demonstrates that the majority of individuals can survive with Hb levels as low as 2.5 g/dL utilizing simple nonblood strategies. The low mortality rate supports the elimination of any predetermined transfusion trigger. Survival Rates in Patients with Profound AnemiaTable 1Survival Rates in Patients with Profound AnemiaHb Level (g/dL)Proportion Who Survived2.5–3.06/7 (85.7%)3.1–4.09/11 (81.8%)4.1–5.029/32 (90.6%)5.1–6.030/30 (100%)6.1–7.048/48 (100%)Overall122/128 (95.3%)