Red Blood Cell Transfusion Strategy Research Articles

PERIOPERATIVE PATIENT BLOOD MANAGEMENT

Anemia and its treatment using red blood cell (RBC) transfusions are known to be the risk factors for posto­perative morbidity and mortality. These disadvantages led to the need for an approach that supports the proper and timely evaluation and management of anemia as well as a rational utilization of blood products. In recent de­cades, the World Health Organization (WHO) advoca­ted Patient Blood Management (PBM), which focuses on the patient’s own blood as a resource that should be conserved and managed appropriately, and the avoidance of irrational use of blood transfusions. The implemen­tation of PBM in the perioperative period is based on 3 pillars: 1. the optimization of the erythrocyte volume, through early detection of anemia before surgery, its pro­per management, and evaluation of applied treatment; 2. minimization of blood loss, by limiting blood drawn for blood testing, adhering to adequate anesthetic principles to maintain hemodynamics, using blood-sparing surgical techniques, implementing viscoelastic methods for the evaluation of blood, and prescribing antifibrinolytics; 3. optimization of the patient’s physiological tolerance toward anemia and rational usage of blood transfusion, which can be achieved by ensuring optimized cardiac output, minimized oxygen consumption, and maximi­zed oxygen delivery to tissues as well as following a restrictive RBC transfusion strategy.

Impact of restrictive red blood cell transfusion strategy on thrombosis-related events: A meta-analysis and systematic review.

There is an ongoing controversy regarding the risks of restrictive and liberal red blood cell (RBC) transfusion strategies. This meta-analysis assessed whether transfusion at a lower threshold was superior to transfusion at a higher threshold, with regard to thrombosis-related events, that is, whether these outcomes can benefit from a restrictive transfusion strategy is debated. We searched PubMed, Cochrane Central Register of Controlled Trials and Scopus from inception up to 31 July 2021. We included randomized controlled trials (RCTs) in any clinical setting that evaluated the effects of restrictive versus liberal RBC transfusion in adults. We used random-effects models to calculate the risk ratios (RRs) and 95% confidence intervals (CIs) based on pooled data. Thirty RCTs involving 17,334 participants were included. The pooled RR for thromboembolic events was 0.65 (95% CI 0.44-0.94; p= 0.020; I2 = 0.0%, very low-quality evidence), favouring the restrictive strategy. There were no significant differences in cerebrovascular accidents (RR=0.83; 95% CI 0.64-1.09; p= 0.180; I2 = 0.0%, very low-quality evidence) or myocardial infarction (RR=1.05; 95% CI 0.87-1.26; p= 0.620; I2 = 0.0%, low-quality evidence). Subgroup analyses showed that a restrictive (relative to liberal) strategy reduced (1) thromboembolic events in RCTs conducted in North America and (2) myocardial infarctions in the subgroup of RCTs where the restrictive transfusion threshold was 7g/dl but not in the 8g/dl subgroup (with a liberal transfusion threshold of 10g/dl in both subgroups). A restrictive (relative to liberal) transfusion strategy may be effective in reducing venous thrombosis but not arterial thrombosis.

Clinical practice for outpatients that are chronically red cell dependent: A survey in the Netherlands.

Background and ObjectivesLimited data are available to guide physicians on how to determine the red blood cell (RBC) transfusion regimen in chronically transfusion‐dependent patients. The lack of clarity on thresholds and targets to be used for transfusion could easily result in either under or over transfusion in these patients. The aim of our survey is to investigate (1) transfusion thresholds; (2) number of RBC units given per transfusion episode; (3) interval between transfusions and (4) patient factors, like decreased cardiac function modulating the former.Materials and MethodsWe sent a web‐based 44‐question survey to members of the Dutch Haematology Association.ResultsFifty physicians responded between June and October 2020 (response rate 30%), well‐distributed between community and academic hospitals. A wide variation in transfusion strategies was reported: Most patients have transfused 1–2 RBC units (range: 0–3 units) every 2–4 weeks (range: 1–12 weeks) with a median threshold of 8.0 g/dl ranging from 6.4 to 9.6 g/dl. Patient‐specific clinical factors that are most frequently reported to influence the transfusion strategy are angina pectoris, cardiac failure and dyspnoea, softer parameters that are of influence are the quality of life and self‐sustainability.ConclusionThe results of this survey indicate a broad variation in RBC transfusion strategies in Dutch patients with chronic transfusion dependency. While the current variation in transfusion strategies may be unavoidable in an individualized approach, randomized trials and better defined usable parameters to evaluate the effect of transfusion strategies are required to reach a consensus on how to determine the transfusion strategy.

Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial

BackgroundCurrent practice guidelines for red blood cell (RBC) transfusion in ICUs are based on haemoglobin threshold, without consideration of oxygen delivery or consumption. We aimed to evaluate an individual physiological threshold-guided by central venous oxygen saturation ScvO2. MethodsIn a randomised study in two French academic hospitals, 164 patients who were admitted to ICU after cardiac surgery with postoperative haemoglobin <9 g dl−1 were randomised to receive a transfusion with one unit of RBCs (haemoglobin group) or transfusion only if the ScvO2 was <70% (individualised group). The primary outcome was the number of subjects receiving at least one unit of RBCs. The secondary composite outcome was acute kidney injury, stroke, myocardial infarction, acute heart failure, mesenteric ischaemia, or in-hospital mortality. One- and 6-month mortality were evaluated during follow-up. ResultsThe primary outcome was observed for 80 of 80 subjects (100%) in the haemoglobin group and in 61 of 77 patients (79%) in the individualised group (absolute risk –21% [–32.0; –14.0]; P<0.001). There was no significant difference in the secondary outcome between the two groups. Follow-up showed a non-significant difference in mortality at 1 and 6 months. ConclusionsAn individualised strategy based on an central venous oxygen saturation threshold of 70% allows for a more restrictive red blood cell transfusion strategy with no incidence on postoperative morbidity or 6-month mortality. Clinical trial registrationNCT02963883.

Restrictive vs. Liberal Red Blood Cell Transfusion Strategy in Patients With Acute Myocardial Infarction and Anemia: A Systematic Review and Meta-Analysis

Objective: Anemia is frequent in patients with acute myocardial infarction (AMI), and the optimal red blood cell transfusion strategy for AMI patients with anemia is still controversial. We aimed to compare the efficacy of restrictive and liberal red cell transfusion strategies in AMI patients with anemia.Methods: We systematically searched PubMed, EMBASE, Web of Science, Cochrane Library, and Clinicaltrials.gov, from their inception until March 2021. Studies designed to compare the efficacy between restrictive and liberal red blood cell transfusion strategies in patients with AMI were included. The primary outcome was all-cause mortality, including overall mortality, in-hospital or follow-up mortality. Risk ratios (RR) with 95% confidence intervals (CI) were presented and pooled by random-effects models.Results: The search yielded a total of 6,630 participants in six studies. A total of 2,008 patients received restrictive red blood cell transfusion while 4,622 patients were given liberal red blood cell transfusion. No difference was found in overall mortality and follow-up mortality between restrictive and liberal transfusion groups (RR = 1.07, 95% CI = 0.82–1.40, P = 0.62; RR = 0.89, 95% CI = 0.56–1.42, P = 0.62). However, restrictive transfusion tended to have a higher risk of in-hospital mortality compared with liberal transfusion (RR = 1.22, 95% CI = 1.00–1.50, P = 0.05). No secondary outcomes, including follow-up reinfarction, stroke, and acute heart failure, differed significantly between the two groups. In addition, subgroup analysis showed no differences in overall mortality between the two groups based on sample size and design.Conclusion: Restrictive and liberal red blood cell transfusion have a similar effect on overall mortality and follow-up mortality in AMI patients with anemia. However, restrictive transfusion tended to have a higher risk of in-hospital mortality compared with liberal transfusion. The findings suggest that transfusion strategy should be further evaluated in future studies.

Red blood cell transfusion in animal models of acute brain injuries: a systematic review protocol

BackgroundAnemia is common in neurocritically ill patients. Considering the limited clinical evidence in this population, preclinical data may provide some understanding of the potential impact of anemia and of red blood cell transfusion in these patients. We aim to estimate the association between different transfusion strategies and neurobehavioral outcome in animal models.MethodsWe will conduct a systematic review of comparative studies of red blood cell transfusion strategies using animal models of traumatic brain injury, ischemic stroke or cerebral hemorrhage. We will search MEDLINE, EMBASE, and Web of Science databases for eligible studies from inception onwards. Two independent reviewers will perform study selection and data extraction. We will report our results in a descriptive synthesis focusing on characteristics of included studies, reported outcomes, risk of bias, and construct validity. Our primary outcome is the neurological function (neurobehavioral performance) and our secondary outcomes include mortality, infarct size, intracranial pressure, cerebral perfusion pressure, cerebral blood flow, and brain tissue oxygen tension. If appropriate, we will also perform a quantitative synthesis and pool results using random-effect models. Heterogeneity will be expressed with I2 statistics. Subgroup analyses are planned according to animal model characteristics, co-interventions, and risks of bias.DiscussionOur study is aligned with the efforts to better understand the level of evidence on the impact of red blood cell transfusion strategies from preclinical studies in animal models of acute brain injury and the potential translation of information from the preclinical to the clinical research field.Systematic review registrationPROSPERO CRD42018086662.

Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

1: ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 : ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable.Strong recommendation, low quality evidence. 4 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 : ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 : ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 : ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9: ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10: ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.

Transfusion Strategies for Pediatric Cardiac Surgery: A Meta-Analysis and Trial Sequential Analysis.

This study aimed to compare the effects of restrictive and liberal red blood cell (RBC) transfusion strategies on pediatric patients undergoing cardiac surgery, including cyanotic and non-cyanotic children. A literature search of the MEDLINE, EMBASE, PubMed, and the Cochrane Library database was conducted. Meta-analyses were carried out comparing restrictive and liberal transfusion strategies. Subgroup analyses were performed based on the basis of cyanotic status. Five randomized controlled trials with a total of 497 children were included. There was no significant difference in the risk of in-hospital mortality between the two transfusion strategies (risk ratio 1.21; 95% confidence interval 0.49 to 2.99; P = 0.68). The trial sequential analysis suggested that the current meta-analysis had an absence of evidence for in-hospital mortality, and the data were insufficient. Moreover, no significant differences existed between groups in terms of risk of infection, blood loss, duration of mechanical ventilation, pediatric intensive care unit (PICU) stay duration, or hospital stay duration. Cyanotic children treated with a liberal transfusion strategy had a shorter ventilator duration, but the transfusion strategy did not affect in-hospital mortality, infection, hospital stay, or PICU stay duration. On the basis of the available data, our analysis indicates that a liberal transfusion strategy did not lead to a better outcomes, but the data are extremely sparse, which highlights the need for clearer transfusion guidelines specific to this specific population.Trial registration number CRD42018102283.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00246-021-02644-8.

Liberal blood transfusion strategies and associated infection in orthopedic patients: A meta-analysis.

Objective:It remains unclear whether transfusion strategies during orthopedic surgery and infection are related. The purpose of this study is to evaluate whether liberal blood transfusion strategies contribute to infection risk in orthopedic patients by analyzing randomized controlled trials (RCTs).Methods:RCTs with liberal versus restrictive red blood cell (RBC) transfusion strategies were identified by searching PubMed, Embase, the Cochrane Central Register of Controlled Trials from their inception to July 2019. Ten studies with infections as outcomes were included in the final analysis. According to the Jadad scale, all studies were considered to be of high quality.Results:Ten trials involving 3938 participants were included in this study. The pooled risk ratio (RR) for the association between liberal transfusion strategy and infection was 1.34 (95% confidence intervals [CI], 0.94–1.90; P = .106). The sensitivity analysis indicated unstable results, and no significant publication bias was observed.Conclusion:This pooled analysis of RCTs demonstrates that liberal transfusion strategies in orthopedic patients result in a nonsignificant increase in infections compared with more restrictive strategies. The conclusions are mainly based on retrospective studies and should not be considered as recommendation before they are supported by larger scale and well-designed RCTs.

Restrictive vs liberal red blood cell transfusion strategies in patients with acute myocardial infarction and anemia: Rationale and design of the REALITY trial.

BackgroundAnemia is common in patients with acute myocardial infarction (AMI), and is an independent predictor of mortality. The optimal transfusion strategy in these patients is unclear.HypothesisWe hypothesized that a “restrictive” transfusion strategy (triggered by hemoglobin ≤8 g/dL) is clinically noninferior to a “liberal” transfusion strategy (triggered by hemoglobin ≤10 g/dL), but is less costly.MethodsREALITY is an international, randomized, multicenter, open‐label trial comparing a restrictive vs a liberal transfusion strategy in patients with AMI and anemia. The primary outcome is the incremental cost‐effectiveness ratio (ICER) at 30 days, using the primary composite clinical outcome of major adverse cardiovascular events (MACE; comprising all‐cause death, nonfatal stroke, nonfatal recurrent myocardial infarction, or emergency revascularization prompted by ischemia) as the effectiveness criterion. Secondary outcomes include the ICER at 1 year, and MACE (and its components) at 30 days and at 1 year.ResultsThe trial aimed to enroll 630 patients. Based on estimated event rates of 11% in the restrictive group and 15% in the liberal group, this number will provide 80% power to demonstrate clinical noninferiority of the restrictive group, with a noninferiority margin corresponding to a relative risk equal to 1.25. The sample size will also provide 80% power to show the cost‐effectiveness of the restrictive strategy at a threshold of €50 000 per quality‐adjusted life year.ConclusionsREALITY will provide important guidance on the management of patients with AMI and anemia.

Restrictive transfusion strategy for critically injured patients (RESTRIC) trial: a study protocol for a cluster-randomised, crossover non-inferiority trial

IntroductionResuscitation using blood products is critical during the acute postinjury period. However, the optimal target haemoglobin (Hb) levels have not been adequately investigated. With the restrictive transfusion strategy for critically...

Effects of Liberal vs Restrictive Transfusion Thresholds on Survival and Neurocognitive Outcomes in Extremely Low-Birth-Weight Infants

Red blood cell transfusions are commonly administered to infants weighing less than 1000 g at birth. Evidence-based transfusion thresholds have not been established. Previous studies have suggested higher rates of cognitive impairment with restrictive transfusion thresholds. To compare the effect of liberal vs restrictive red blood cell transfusion strategies on death or disability. Randomized clinical trial conducted in 36 level III/IV neonatal intensive care units in Europe among 1013 infants with birth weights of 400 g to 999 g at less than 72 hours after birth; enrollment took place between July 14, 2011, and November 14, 2014, and follow-up was completed by January 15, 2018. Infants were randomly assigned to liberal (n = 492) or restrictive (n = 521) red blood cell transfusion thresholds based on infants' postnatal age and current health state. The primary outcome, measured at 24 months of corrected age, was death or disability, defined as any of cognitive deficit, cerebral palsy, or severe visual or hearing impairment. Secondary outcome measures included individual components of the primary outcome, complications of prematurity, and growth. Among 1013 patients randomized (median gestational age at birth, 26.3 [interquartile range {IQR}, 24.9-27.6] weeks; 509 [50.2%] females), 928 (91.6%) completed the trial. Among infants in the liberal vs restrictive transfusion thresholds groups, respectively, incidence of any transfusion was 400/492 (81.3%) vs 315/521 (60.5%); median volume transfused was 40 mL (IQR, 16-73 mL) vs 19 mL (IQR, 0-46 mL); and weekly mean hematocrit was 3 percentage points higher with liberal thresholds. Among infants in the liberal vs restrictive thresholds groups, the primary outcome occurred in 200/450 (44.4%) vs 205/478 (42.9%), respectively, for a difference of 1.6% (95% CI, -4.8% to 7.9%; P = .72). Death by 24 months occurred in 38/460 (8.3%) vs 44/491 (9.0%), for a difference of -0.7% (95% CI, -4.3% to 2.9%; P = .70), cognitive deficit was observed in 154/410 (37.6%) vs 148/430 (34.4%), for a difference of 3.2% (95% CI, -3.3% to 9.6%; P = .47), and cerebral palsy occurred in 18/419 (4.3%) vs 25/443 (5.6%), for a difference of -1.3% (95% CI, -4.2% to 1.5%; P = .37), in the liberal vs the restrictive thresholds groups, respectively. In the liberal vs restrictive thresholds groups, necrotizing enterocolitis requiring surgical intervention occurred in 20/492 (4.1%) vs 28/518 (5.4%); bronchopulmonary dysplasia occurred in 130/458 (28.4%) vs 126/485 (26.0%); and treatment for retinopathy of prematurity was required in 41/472 (8.7%) vs 38/492 (7.7%). Growth at follow-up was also not significantly different between groups. Among infants with birth weights of less than 1000 g, a strategy of liberal blood transfusions compared with restrictive transfusions did not reduce the likelihood of death or disability at 24 months of corrected age. ClinicalTrials.gov Identifier: NCT01393496.

Using arterial-venous oxygen difference to guide red blood cell transfusion strategy

BackgroundGuidelines recommend a restrictive red blood cell transfusion strategy based on hemoglobin (Hb) concentrations in critically ill patients. We hypothesized that the arterial-venous oxygen difference (A-V O2diff), a surrogate for the oxygen delivery to consumption ratio, could provide a more personalized approach to identify patients who may benefit from transfusion.MethodsA prospective observational study including 177 non-bleeding adult patients with a Hb concentration of 7.0–10.0 g/dL within 72 h after ICU admission. The A-V O2diff, central venous oxygen saturation (ScvO2), and oxygen extraction ratio (O2ER) were noted when a patient’s Hb was first within this range. Transfusion decisions were made by the treating physician according to institutional policy. We used the median A-V O2diff value in the study cohort (3.7 mL) to classify the transfusion strategy in each patient as “appropriate” (patient transfused when the A-V O2diff > 3.7 mL or not transfused when the A-V O2diff ≤ 3.7 mL) or “inappropriate” (patient transfused when the A-V O2diff ≤ 3.7 mL or not transfused when the A-V O2diff > 3.7 mL). The primary outcome was 90-day mortality.ResultsPatients managed with an “appropriate” strategy had lower mortality rates (23/96 [24%] vs. 36/81 [44%]; p = 0.004), and an “appropriate” strategy was independently associated with reduced mortality (hazard ratio [HR] 0.51 [95% CI 0.30–0.89], p = 0.01). There was a trend to less acute kidney injury with the “appropriate” than with the “inappropriate” strategy (13% vs. 26%, p = 0.06), and the Sequential Organ Failure Assessment (SOFA) score decreased more rapidly (p = 0.01). The A-V O2diff, but not the ScvO2, predicted 90-day mortality in transfused (AUROC = 0.656) and non-transfused (AUROC = 0.630) patients with moderate accuracy. Using the ROC curve analysis, the best A-V O2diff cutoffs for predicting mortality were 3.6 mL in transfused and 3.5 mL in non-transfused patients.ConclusionsIn anemic, non-bleeding critically ill patients, transfusion may be associated with lower 90-day mortality and morbidity in patients with higher A-V O2diff.Trial registrationClinicalTrials.gov, NCT03767127. Retrospectively registered on 6 December 2018.

BLOOD TRANSFUSION IN CARDIAC SURGERY- NEED TO FOLLOW BASICS!

More and more data is coming in recent times about hazards of blood transfusion. In a landmark TRICC1 trial Euvolemic patients in the intensive care unit (ICU) with Hb&lt;9 g/dl were randomized to a restrictive transfusion strategy for transfusion of PRBCs (transfused if Hb&lt;7 g/dl to maintain Hb between 7 and 9 g/dl) or a liberal strategy (transfused if Hb&lt;10 g/dl to maintain Hb 10-12 g/dl). Mortality was similar in both groups, indicating that liberal transfusions were not beneficial. An Updated Report by the American Society of AnaesthesiologistsTask Force on Perioperative Blood Management tells us restrictive red blood cell transfusion strategy may be safely used to reduce transfusion administration. It further states that The determination of whether hemoglobin concentrations between 6 and 10 g/dl justify or require red blood cell transfusion should be based on potential or actual on going bleeding (rate and magnitude), intravascular volume status, signs of organ ischemia, and adequacy of cardiopulmonary reserve. Should we extrapolate these guidelines in Cardiac surgery? TRACS2 trial concluded that among patients undergoing cardiac surgery, the use of a restrictive perioperative transfusion strategy compared with a more liberal strategy resulted in noninferior rates of the combined outcome of 30-day all-cause mortality and severe morbidity.They advocated use of restrictive strategy, but 5 years later, the authors 3concluded that A restrictive transfusion threshold after cardiac surgery was not superior to a liberal threshold with respect to morbidity or health care costs. With this conflicting evidence, by which way anaesthesiologist to go?

The Impact of Red Blood Cell Transfusion on Mortality and Treatment Efficacy in Patients Treated with Radiation: A Systematic Review of the Literature

Introduction: Oncology patients are generally transfused to maintain a hemoglobin (Hb) above 7 g/dL (Holst et. al. BMJ 2015). Some centers use higher Hb thresholds before radiation therapy (RT) because pre-clinical data suggest that oncology patients with low hemoglobin levels may respond sub-optimally to radiation therapy due to hypoxia-induced radio-resistance (Pitson et. al. Int J Radiat Oncol Biol Phys 2001; Tatum et. al. Int J Radiat Biol 2006). It is hypothesized that higher hemoglobin levels improve tissue oxygenation, which facilitates formation of reactive oxygen species that optimize cancer cell death. No standard red blood cell transfusion thresholds have been established using interventional study data for patients with malignancies treated with radiation. This systematic review aimed to investigate the role of red blood cell (RBC) transfusion in radiation oncology patients and whether maintaining a higher Hb leads to improved overall survival, efficacy of RT on disease control and transfusion-related morbidity. Methods: We performed a literature search of PubMed, EMBASE and the Cochrane Library for randomized controlled trials, cohort studies and large case series comparing RBC transfusion thresholds in radiation oncology patients. We hand-searched references of identified articles. Eligibility criteria were studies that assessed patients receiving any RT modality for malignancy of any diagnosis and stage. Exclusion criteria were studies that did not evaluate hemoglobin or transfusion as an intervention or outcome. The primary outcome was overall survival. Secondary outcomes included locoregional tumor control, number of transfusions and adverse events associated with either radiation or transfusion. Screening and data extraction were done in duplicate. A meta-analysis was planned with outcomes presented as odds ratios with 95% confidence intervals. Results: Our search yielded 6172 titles. After exclusions, 39 articles underwent full text review (Figure 1). Only one study met the pre-specified inclusion criteria; therefore, a meta-analysis was not performed. The identified study pooled results from two Danish randomized controlled trials (DAHANCA 5 and 7) that stratified patients with head and neck squamous cell carcinoma with low pre-radiation hemoglobin levels (females &lt;13 g/dL and males &lt;14.5 g/dL) to RBC transfusion (235 patients) versus no transfusion (230 patients) (Hoff et. al. Acta Oncol 2011). The study found no significant differences between groups in locoregional disease control or overall survival after five years of follow up, despite increased hemoglobin levels in the transfused group. Given the search results, we expanded the review to extract data from other relevant trials not meeting inclusion criteria to conduct a narrative review of the available literature. The extracted studies involved a variety of malignancies and were primarily single-center retrospective studies assessing outcomes of local transfusion policies. Some studies featured univariate and multivariate analyses, but had conflicting results on the effects of transfusion on disease control and mortality. A major criticism of these studies was the lack of comparison between different transfusion thresholds in anemic patients. Conclusions: This systematic review illustrates the lack of data on the effect of RBC transfusion strategies in oncology patients undergoing radiation. Well-designed prospective studies are urgently needed in this area due to variability in practice. Disclosures No relevant conflicts of interest to declare.

Red blood cell transfusion in surgery: an observational study of the trends in the USA from 2011 to 2016

Guidelines recommend restrictive red blood cell transfusion strategies. We conducted an observational study to examine whether the rate of peri-operative red blood cell transfusion in the USA had declined during the period from 01 January 2011 to 31 December 2016. We included 4,273,168 patients from all surgical subspecialties. We examined parallel trends in rates of the following: pre-operative transfusion; prevalence of bleeding disorders and coagulopathy; and minimally invasive procedures. To account for changes in population and procedure characteristics, we performed multivariable logistic regression to assess whether the risk of receiving a transfusion had declined over the study period. Clinical outcomes included peri-operative myocardial infarction, stroke and all-cause mortality at 30days. Peri-operative red blood cell transfusion rates declined from 37,040/441,255 (8.4%) in 2011 to 46,845/1,000,195 (4.6%) in 2016 (p<0.001) across all subspecialties. Compared with 2011, the corresponding adjusted OR (95%CI) for red blood cell transfusion decreased gradually from 0.88 (0.86-0.90) in 2012 to 0.51 (0.50-0.51) in 2016 (p<0.001). Pre-operative red blood cell transfusion rates and the prevalence of bleeding disorders decreased, whereas haematocrit levels and the proportion of minimally invasive procedures increased. Compared with 2011, the adjusted hazard ratios (95%CI) in 2012 and 2016 were 0.96 (0.90-1.02) and 1.05 (0.99-1.11) for myocardial infarction, 0.91 (0.83-0.99) and 0.99 (0.92-1.07) for stroke and 0.98 (0.94-1.02) and 0.99 (0.96-1.03) for all-cause mortality. Use of peri-operative red blood cell transfusion declined from 2011 to 2016. This was not associated with an increase in adverse clinical outcomes.

Transfusion in children with acute respiratory distress syndrome.

Transfusion is a frequent treatment in pediatric patients with acute respiratory distress syndrome (PARDS) although evidence to support transfusion decision-making is lacking. The purpose of this review is to review the current state of knowledge on the issue of transfusion in children with PARDS and to detail the possible beneficial effects and potential deleterious impacts of transfusion in this patient population. Based on the current literature and recent guidelines, a restrictive red blood cell (RBC) transfusion strategy (avoidance of transfusion when the haemoglobin level is above 7 g/dL) is indicated in stable patients without severe PARDS, as these were excluded from the large trials. In children with severe PARDS, further research is needed to determine if factors other than the haemoglobin level might guide RBC transfusion decision-making by better characterizing the presence of low oxygen delivery (DO2). Additionally, appropriate indications for prophylactic transfusion of hemostatic products (plasma or platelets) in children with PARDS are lacking.

Restrictive versus liberal strategy for red blood-cell transfusion in hip fracture patients: A systematic review and meta-analysis.

Background:Most clinical guidelines recommend a restrictive red-blood-cell (RBC) transfusion threshold. However, indications for transfusion in patients with a hip fracture have not been definitively evaluated or remain controversial. We compared the pros and cons of restrictive versus liberal transfusion strategies in patients undergoing hip fracture surgery.Methods:Electronic databases were searched to identify randomized controlled trials (RCTs) and retrospective cohort studies (RCSs) to investigate the effects of a restrictive strategy versus its liberal counterpart in patients undergoing hip fracture surgery. The main clinical outcomes included delirium, mortality, infections, cardiogenic complications, thromboembolic events, cerebrovascular accidents, and length of hospital stay. The meta-analysis program of the Cochrane Collaboration (RevMan version 5.3.0) was used for data analysis. Statistical heterogeneity was assessed by both Cochran chi-squared test (Q test) and I2 test. Both Begg and Egger tests were used to assess potential publication bias.Results:We identified 7 eligible RCTs and 2 eligible RCSs, involving 3,575 patients in total. In patients undergoing hip fracture surgery, we found no differences in frequency of delirium, mortality, the incidence rates of all infections, pneumonia, wound infection, all cardiovascular events, congestive heart failure, thromboembolic events or length of hospital stay between restrictive and liberal thresholds for RBC transfusion (P >.05). However, we found that the use of restrictive transfusion thresholds is associated with higher rates of acute coronary syndrome (P <.05) while liberal transfusion thresholds increase the risk of cerebrovascular accidents (P <.05).Conclusion:In patients undergoing hip fracture surgery, clinicians should evaluate the patient's condition in detail and adopt different transfusion strategies according to the patient's specific situation rather than merely using a certain transfusion strategy.

Liberal versus restrictive red blood cell transfusion strategy in sepsis or septic shock: a systematic review and meta-analysis of randomized trials

BackgroundWe assessed the effect of liberal versus restrictive red blood cell transfusion strategy on survival outcome in sepsis or septic shock by systematically reviewing the literature and synthesizing evidence from randomized controlled trials (RCTs).MethodsWe searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases. We included RCTs that compared mortality between a liberal transfusion strategy with a hemoglobin threshold of 9 or 10 g/dL and a restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL in adults with sepsis or septic shock. Two investigators independently screened citations and conducted data extraction. The primary outcome was 28- or 30-day mortality. Secondary outcomes were 60- and 90-day mortality, use of life support at 28 days of admission, and number of patients transfused during their intensive care unit stay. DerSimonian-Laird random-effects models were used to report pooled odds ratios (ORs).ResultsA total of 1516 patients from three RCTs were included; 749 were randomly assigned to the liberal transfusion group and 767 to the restrictive strategy group. Within 28–30 days, 273 patients (36.4%) died in the liberal transfusion group, while 278 (36.2%) died in the restrictive transfusion group (pooled OR, 0.99; 95% confidence interval [CI], 0.67–1.46). For the primary outcome, heterogeneity was observed among the studies (I2 = 61.0%, χ2 = 5.13, p = 0.08). For secondary outcomes, only two RCTs were included. There were no significant differences in secondary outcomes between the two groups.ConclusionsWe could not show any difference in 28- or 30-day mortality between the liberal and restrictive transfusion strategies in sepsis or septic shock patients by meta-analysis of RCTs. Our results should be interpreted with caution due to the existence of heterogeneity. As sepsis complicates a potentially wide range of underlying diseases, further trials in carefully selected populations are anticipated.Trial registrationThis present study was registered in the PROSPERO database (CRD42018108578).

Red blood cell transfusion in critically ill patients with traumatic brain injury: an international survey of physicians' attitudes.

Restrictive transfusion strategies have been advocated in critically ill patients. Nevertheless, considerable uncertainty exists regarding optimal transfusion thresholds in traumatic brain injury (TBI) patients because the injured brain is susceptible to hypoxemic damage. We aimed to identify the determinants of red blood cell (RBC) transfusion and the perceived optimal transfusion thresholds in adult patients with moderate-to-severe TBI. We conducted an electronic, self-administered survey targeting critical care specialists and neurosurgeons from Canada, Australia, and the United Kingdom caring for TBI patients. The questionnaire was initially developed by a panel of experts using a structured process (domains/items generation and reduction). The questionnaire was validated for clinical sensibility, reliability, and content. The response rate was 28.7% (218/760). When presented with the hypothetical scenario of a young adult TBI patient, a wide range of transfusion practices was observed, with 47 (95% confidence interval [CI], 41 to 54)% favouring RBC transfusion at a hemoglobin level of ≤ 70 g·L-1 in the acute phase of care, while 73 (95% CI, 67 to 79)% would use this trigger in the plateau phase of care. Multiple trauma, neuro-monitoring data, hemorrhagic shock, and planned surgery were the main factors that influenced the need for transfusion. The lack of clinical evidence and guidelines was responsible for uncertainty regarding RBC transfusion strategies in this patient population. In our survey about critically ill TBI patients, transfusion practice was found to be mainly influenced by the acuity of care, patient characteristics, and neuro-monitoring. Clinical equipoise regarding optimal transfusion strategy is believed to be mainly attributed to the lack of clear clinical evidence and guidelines. Appropriate randomized-controlled trials are required to determine the optimal transfusion strategies in TBI patients.