Restrictive Red Blood Cell Transfusion Strategy Research Articles

Red blood cell transfusion in neurocritical patients: a systematic review and meta-analysis

BackgroundAnemia can lead to secondary brain damage by reducing arterial oxygen content and brain oxygen supply. Patients with acute brain injury have impaired self-regulation. Brain hypoxia may also occur even in mild anemia. Red blood cell (RBC) transfusion is associated with increased postoperative complications, poor neurological recovery, and mortality in critically ill neurologic patients. Balancing the risks of anemia and red blood cell transfusion-associated adverse effects is challenging in neurocritical settings.MethodsWe searched the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE (PubMed) from inception to January 31, 2024. We included all randomized controlled trials (RCTs) assessing liberal versus restrictive RBC transfusion strategies in neurocritical patients. We included all relevant studies published in English. The primary outcome was mortality at intensive care unit (ICU), discharge, and six months.ResultsOf 5195 records retrieved, 84 full-text articles were reviewed, and five eligible studies were included. There was no significant difference between the restrictive and liberal transfusion groups in ICU mortality (RR: 2.53, 95% CI: 0.53 to 12.13), in-hospital mortality (RR: 2.34, 95% CI: 0.50 to 11.00), mortality at six months (RR: 1.42, 95% CI: 0.42 to 4.78) and long-term mortality (RR: 1.22, 95% CI: 0.64 to 2.33). The occurrence of neurological adverse events and most major non-neurological complications was similar in the two groups. The incidence of deep venous thrombosis was lower in the restrictive strategy group (RR: 0.41, 95% CI: 0.18 to 0.91).ConclusionsDue to the small sample size of current studies, the evidence is insufficiently robust to confirm definitive conclusions for neurocritical patients. Therefore, further investigation is encouraged to define appropriate RBC transfusion thresholds in the neurocritical setting.

Adherence to a restrictive red blood cell transfusion strategy in critically ill patients: An observational study.

Randomized controlled trials relatively consistently show that restrictive red blood cell (RBC) transfusion strategies are safe and associated with similar outcomes compared to liberal transfusion strategies in critically ill patients. Based on these data, the general threshold for RBC transfusion was changed to 70 g/L at a 9-bed tertiary level intensive care unit in September 2020. Implementation measures included lectures, webinars and feedback during clinical practice. The aim of this study was to investigate how implementation of a restrictive transfusion strategy influenced RBC usage, haemoglobin trigger levels and adherence to prescribed trigger levels. In this registry-based, observational study, critically ill adult patients without massive bleeding were included and divided into a pre-cohort, with admissions prior to the change of transfusion strategy, and a post-cohort, with admissions following the change of transfusion strategy. These cohorts were compared regarding key RBC transfusion-related variables. In total 5626 admissions were included in the analyses (pre-cohort n = 4373, post-cohort n = 1253). The median volume (interquartile range, IQR) of RBC transfusions per 100 admission days, in the pre-cohort was 6120 (4110-8110) mL versus 3010 (2890-4970) mL in the post-cohort (p < .001). This corresponds to an estimated median saving of 1128 € per 100 admission days after a restrictive RBC transfusion strategy was implemented. In total, 26% of the admissions in the pre-cohort and 19% in the post-cohort (p < .001) received RBC transfusion(s) during days 0-10. Both median (IQR) prescribed trigger levels (determined by intensivist) and actual haemoglobin trigger levels (i.e., levels prior to actual administration of transfusion) were higher in the pre- versus post-cohort (90 [80-100] vs. 80 [72-90] g/L, p < .001 and 89 [82-96] g/L vs. 83 [79-94], p < .001, respectively). Percentage of days without compliance with the prescribed transfusion trigger was higher in the pre-cohort than in the post-cohort (23% vs. 14%, p < .001). Sensitivity analyses, excluding patients with traumatic brain injury, ischemic heart disease and COVID-19 demonstrated similar results. Implementation of a restrictive transfusion trigger in a critical care setting resulted in lasting decreased RBC transfusion use and costs, decreased prescribed and actual haemoglobin trigger levels and improved adherence to prescribed haemoglobin trigger levels.

Restrictive Versus Liberal Red Blood Cell Transfusion Strategies for Patients with Hematologic Malignancies Receiving Intensive Chemotherapy

Background: It is estimated that one-quarter to one-half of people diagnosed with hematologic malignancies experience anemia and red blood cell (RBC) transfusion plays an essential supportive role in their management. There are different strategies for RBC transfusions to treat anemia. A restrictive transfusion strategy seeks to maintain a lower hemoglobin level (usually between 70 g/L to 90 g/L with a trigger for transfusion when the hemoglobin drops below 70 g/L), whereas a liberal transfusion strategy aims to maintain a higher hemoglobin (usually between 100 g/L to 120 g/L, with a threshold for transfusion when hemoglobin drops below 100 g/L). The most effective and safest strategy is unknown in people with hematological malignancies. Objectives: To determine the efficacy and safety of a restrictive versus liberal RBC transfusion strategies for people diagnosed with hematological malignancies treated with intensive chemotherapy, radiotherapy, or both, with or without a hematopoietic stem cell transplant (HSCT). Methods: Review was completed using Cochrane standard methodological procedures. We included randomized controlled trials RCTs and prospective non-randomized studies NRS that evaluated a liberal compared with a restrictive RBC transfusion strategy in children or adults with malignant hematological disorders receiving intensive chemotherapy/radiotherapy or undergoing HSCT. We searched for RCTs and NRS in MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and eight other databases and three trial registries to 21 March 2023. For dichotomous outcomes such as mortality, results were presented as a risk ratio (RR) with 95% confidence interval (CI) to compare restrictive versus liberal transfusion strategies. For continuous outcomes using the same scale, we assessed the mean difference (MD) with 95% CI. Where outcome measures were heterogenous, a narrative synthesis was used. Review Manager Web was used to meta-analyze the data. GRADE rating methodology was used for the overall certainty of evidence from included studies. Main Results: Nine studies were included: eight RCTs and one NRS. 644 participants were included in analyses from six completed RCTs (n=560) and one completed NRS (n=84). Two ongoing RCTs consisting of 294 participants (260 adult and 34 pediatric) are pending inclusion. One completed RCT included children receiving HSCT (n=6) and five RCTs only included adults (n=239 with acute leukemia receiving chemotherapy and n=315 with a hematological malignancy receiving HSCT). The restrictive strategies varied from 70 g/L to 80 g/L and liberal strategies from 80 g/L to 120 g/L. A restrictive strategy was found to result in a reduction in the number of RBC units per participant compared to a liberal strategy (Four studies; 457 participants; MD: -2.39, 95%CI -3.38 to -1.39, P = &amp;lt;0.00001). No difference was seen in bleeding between strategies although there was high concern for bias in included trials. Effects were reported in the summary of findings tables for RCTs (Table 1) which included results from adults only to reduce indirectness as a result of limited information from the single published pediatric RCT which was terminated early. Overall, a restrictive RBC transfusion strategy may result in little to no difference in the risk of death at 31 to 100 days compared to a liberal transfusion strategy (three studies; 382 participants; RR 0.74, 95% CI 0.13 to 4.09, P= 0.73; I 2=28%; low-certainty evidence). Two outcomes (mortality at 31 to 100 days and clinically significant bleeding) were reported from the one NRS (Table 2). The evidence is very uncertain whether there is a difference in mortality and clinically significant bleeding between the transfusion strategies based on the very low-certainty evidence. Conclusions: A restrictive transfusion strategy demonstrated a reduction in RBC usage, while there may be no impact on mortality. Definite conclusions are challenging given the relatively few studies with low numbers of included participants, concern for bias, heterogeneity of intervention and outcome reporting and overall certainty of evidence. There is a need for larger and methodologically better designed and executed studies. There is insufficient evidence to answer this review's primary outcome. Further RCTs are required overall, particularly trials inclusive of pediatric participants.

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.

Outcomes following restrictive or liberal red blood cell transfusion in patients with lower gastrointestinal bleeding.

Restrictive red blood cell (RBC) transfusion reduces mortality and rebleeding after upper gastrointestinal bleeding (UGIB). However, there is no evidence to guide transfusion strategies in lower gastrointestinal bleeding (LGIB). To assess the association between RBC transfusion strategies and outcomes in patients with LGIB METHODS: This was a post hoc analysis of the UK National Comparative Audit of LGIB and the Use of Blood. The relationships between liberal RBC transfusion and clinical outcomes of rebleeding, mortality and a composite outcome for safe discharge were examined. Transfusion strategy was dichotomised and defined as "liberal" when transfusion was administered for haemoglobin (Hb) ≥80g/L (or ≥90g/L in patients with acute coronary syndrome) or major haemorrhage, and "restrictive" otherwise. Multivariable logistic regression models were used to assess the independent association between liberal RBC transfusion and outcomes. Of 2528 consecutive patients enrolled from 143 hospitals in the original study, 666 (26.3%) received RBC transfusion (mean age 73.3±16years, 49% female, initial mean haemoglobin 90±24g/L, 2.3% had haemodynamic instability). The rebleeding rate in transfused patients was 42.3%. After adjusting for potential confounders, there was no difference between liberal and restrictive RBC transfusion strategies for the odds of rebleeding (OR 0.89, 95% CI 0.6-1.22), in-hospital mortality (OR 0.54, 95% CI 0.3-1.1) or of achieving the composite outcome (OR 0.72, 95% CI 0.5-1.1). Although these results could be due to residual confounding, they provide an important foundation for the design of randomised trials to evaluate transfusion strategies for LGIB.

Restrictive versus liberal red blood cell transfusion for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials.

Patients undergoing cardiac surgery are among the most common recipients of allogeneic red blood cell (RBC) transfusions. However, whether restrictive RBC transfusion strategies for cardiac surgery achieve a similar clinical outcome in comparison with liberal strategies remains unclear. We searched electronic databases from inception to December 2017 for randomized controlled trials (RCTs). We calculated the risk ratios (RRs) and weighted-mean difference (MD) using a random-effects model. We included 9 RCTs with a total of 9005 patients. There was no significant difference in mortality between groups [RR 1.03; 95% confidence interval (CI) 0.74-1.45; P = 0.86]. In addition, there were no significant differences between groups in the clinical outcomes of infections (RR 1.09; 95% CI 0.94-1.26; P = 0.26), stroke (RR 0.98; 95% CI 0.72-1.35; P = 0.91), respiratory morbidity (RR 1.05; 95% CI 0.89-1.24; P = 0.58), renal morbidity (RR 1.02; 95% CI 0.94-1.09; P = 0.68), myocardial infarction (RR 1.00; 95% CI 0.80-1.24; P = 0.99), cardiac arrhythmia (RR 1.05; 95% CI 0.88-1.26; P = 0.56), gastrointestinal morbidity (RR 1.93; 95% CI 0.81-4.63; P = 0.14), or reoperation (RR 0.90; 95% CI 0.67-1.20; P = 0.46). There was a significant difference in the intensive care unit length of stay (h) (MD 4.29; 95% CI 2.19-6.39, P < 0.01) favoring the liberal group. However, there was no significant difference in the hospital length of stay (days) (MD 0.15; 95% CI - 0.18 to 0.48; P = 0.38). In conclusion, this meta-analysis showed that restrictive strategies for RBC transfusion are as safe as liberal strategies in patients undergoing cardiac surgery with regards to short-term clinical outcomes.

Restrictive Versus Liberal Red Blood Cell Transfusion for Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Introduction:Patients undergoing cardiac surgery are among the most common recipients of allogenic red blood cell (RBC) transfusions. However, whether restrictive RBC transfusion strategies for cardiac surgery achieve a similar clinical outcome in comparison with liberal strategies remains unclear.Methods:We searched PubMed, Embase, the Cochrane Collaboration Central Register of Controlled Trials, and conference proceedings from inception to December 2017 for all randomized trials (RCTs). The primary outcome was mortality. Secondary outcomes were stroke, respiratory morbidity, renal morbidity, infections, myocardial infarction (MI), cardiac arrhythmia, gut morbidity, reoperation, intensive care unit (ICU) length of stay (hours), and hospital length of stay (days). We calculated the risk ratios (RR) and weighted mean difference (MD) for the clinical outcomes using a random-effects model.Results:We included 9 RCTs with a total of 9,005 patients. There was no significant difference in mortality between groups (RR 1.03; 95% CI 0.74-1.45; P=0.86). In addition, there were no significant differences between groups in the clinical outcomes of infections (RR 1.09; 95% CI 0.94-1.26; P=0.26), stroke (RR 0.98; 95% CI 0.72-1.35; P=0.91), respiratory morbidity (RR 1.05; 95% CI 0.89-1.24; P=0.58), renal morbidity (RR 1.02; 95% CI 0.94-1.09; P=0.68), myocardial infarction (RR 1.00; 95% CI 0.80-1.24; P=0.99), cardiac arrhythmia (RR 1.05; 95% CI 0.88-1.26; P=0.56), gastrointestinal morbidity (RR 1.93; 95% CI 0.81-4.63; P=0.14), or reoperation (RR 0.90; 95% CI 0.67-1.20; P=0.46). There was a significant difference in the intensive care unit length of stay (hours) (MD 4.29; 95% CI: 2.19-6.39, P<0.01) favoring the liberal group. However, there was no significant difference in the hospital length of stay (days) (MD 0.15; 95% CI -0.18-0.48; P=0.38).Conclusion:This meta-analysis showed that restrictive strategies for RBC transfusion are as safe as liberal strategies in patients undergoing cardiac surgery.Key points:•Restrictive strategies for red blood cell transfusion are as safe as liberal approaches in patients undergoing cardiac surgery.•Longer duration of stay in the intensive care unit is more common in patients managed with a restrictive transfusion approach. However, the overall hospital length of stay appeared to be similar between both groups.•Further studies are needed to ascertain threshold triggers for RBC transfusion. [Display omitted] DisclosuresHassan:abott: Other: grant. Bhatt:American Heart Association Quality Oversight Committee: Other: chair; Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSof: Membership on an entity's Board of Directors or advisory committees; Medscape Cardiology: Consultancy; Regado Biosciences: Consultancy; Elsevier Practice Update Cardiology: Consultancy, trustee; cardax: Consultancy; Abbott, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Idorsia, Ironwood, Ischemix, Lilly, Medtronic, PhaseBio, Pfizer, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines: Research Funding; Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic, Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, Population: Other: Data monitoring committee; American College of Cardiology; Unfunded Research: FlowCo, Merck, PLx Pharma, Takeda.: Other: trustee; ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim), Belvoir Publications (Editor in Chief, Harvard Heart Letter),: Other: board member; American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org: Honoraria.

Restrictive versus liberal red blood cell transfusion strategies for people with haematological malignancies treated with intensive chemotherapy or radiotherapy, or both, with or without haematopoietic stem cell support.

Restrictive versus liberal red blood cell transfusion strategies for people with haematological malignancies treated with intensive chemotherapy or radiotherapy, or both, with or without haematopoietic stem cell support.

Restrictive and liberal red cell transfusion strategies in adult patients: reconciling clinical data with best practice.

Red blood cell (RBC) transfusion guidelines correctly promote a general restrictive transfusion approach for anemic hospitalized patients. Such recommendations have been derived from evaluation of specific patient populations, and it is important to recognize that engaging a strict guideline approach has the potential to incur harm if the clinician fails to provide a comprehensive review of the patient’s physiological status in determining the benefit and risks of transfusion. We reviewed the data in support of a restrictive or a more liberal RBC transfusion practice, and examined the quality of the datasets and manner of their interpretation to provide better context by which a physician can make a sound decision regarding RBC transfusion therapy. Reviewed studies included PubMed-cited (1974 to 2013) prospective randomized clinical trials, prospective subset analyses of randomized studies, nonrandomized controlled trials, observational case series, consecutive and nonconsecutive case series, and review articles. Prospective randomized clinical trials were acknowledged and emphasized as the best-quality evidence. The results of the analysis support that restrictive RBC transfusion practices appear safe in the hospitalized populations studied, although patients with acute coronary syndromes, traumatic brain injury and patients at risk for brain or spinal cord ischemia were not well represented in the reviewed studies. The lack of quality data regarding the purported adverse effects of RBC transfusion at best suggests that restrictive strategies are no worse than liberal strategies under the studied protocol conditions, and RBC transfusion therapy in the majority of instances represents a marker for greater severity of illness. The conclusion is that in the majority of clinical settings a restrictive RBC transfusion strategy is cost-effective, reduces the risk of adverse events specific to transfusion, and introduces no harm. In anemic patients with ongoing hemorrhage, with risk of significant bleeding, or with concurrent ischemic brain, spinal cord, or myocardium, the optimal hemoglobin transfusion trigger remains unknown. Broad-based adherence to guideline approaches of therapy must respect the individual patient condition as interpreted by comprehensive clinical review.

Blood Transfusion and Overall Quality of Life After Hip Fracture in Frail Elderly Patients—The Transfusion Requirements in Frail Elderly Randomized Controlled Trial

BackgroundWe examined possible associations between different red blood cell (RBC) transfusion strategies, overall quality of life (OQoL), and recovery of activities of daily living (ADL) in operated frail elderly hip fracture patients, and the possibility that OQoL was related to ADL recovery. MethodsA prospective, assessor-blinded, randomized controlled trial was carried out among 157 elderly residents (≥65 years) from nursing homes and sheltered housing facilities with Mini-Mental State Examination scores ≥5 points. Patients were assigned to either a restrictive RBC transfusion strategy [hemoglobin (Hb) < 9.7 g/dL, 6 mmol/L] or a liberal strategy (Hb < 11.3 g/dL, 7 mmol/L) during the first 30 days after surgery. An interview-based questionnaire, the depression list (DL) assessing OQoL, and the modified Barthel Index (MBI) assessing ADL performance, were conducted on day 30 and 1 year after hip fracture surgery. Sum-scores of DL, MBI, and their changes from day 30 until 1 year (expressing recovery) were compared between RBC transfusion groups. Possible associations between changes of DL and MBI sum-scores were tested for across total patient population. ResultsThere was no association between OQoL and RBC transfusion strategies on day 30 or at 1 year. The DL sum-score changes were similar for both groups, (ie, 1.06 points) [95% confidence interval (CI) −0.62, 2.76)] P = .21. The MBI sum-scores increased at 1 year following the liberal transfusion strategy (ie, by 6.86 points) (95% CI 0.41, 13.3) P = .03. Recoveries of OQoL and ADL were associated: β = −0.06 (95% CI −0.11, −0.01) P = .02. ConclusionsAccording to our Hb threshold criteria, OQoL and RBC transfusion strategies for frail elderly hip fracture patients are not associated. However, for survivors with less severe dementia, ADL recovery after 1 year is greater following a liberal transfusion strategy than a restrictive strategy. OQoL progress and ADL recovery were associated.

Blood transfusion and risk of infection in frail elderly after hip fracture surgery: the TRIFE randomized controlled trial.

It is still under debate that red blood cell (RBC) transfusions might increase the risk of healthcare-associated infections after hip fracture surgery. Previously, we found that a liberal RBC transfusion strategy improved survival in nursing home residents. Our aim, therefore, was to investigate whether a more liberal RBC transfusion strategy was associated with a higher infection risk in frail elderly hip fracture patients. Prospective, assessor-blinded, randomized and controlled trial. Orthopedic ward, Geriatric ward, and Hospital-at-home. 284 consecutively hospital-admitted elderly with hip fracture from nursing homes or sheltered housing facilities were included. A restrictive RBC transfusion strategy (hemoglobin <9.7g/dL; 6mmol/L) compared with a liberal strategy (hemoglobin <11.3g/dL; 7mmol/L) administered within 30days after surgery. Leukocytes and C-reactive protein (CRP) in repeated blood samples within 30days, and number of all infections (pneumonia, urinary tract infection, and other infections) within 10days. 88% of the patients received a RBC transfusion. A median of 1 RBC unit (interquartile range (IQR): 1-2) was transfused for the restrictive strategy group versus 3 RBC units (IQR: 2-5) for the liberal group. Leukocytes and CRP measurements were similar for both groups. Rates of infection were 72% for the restrictive group compared to 66% for the liberal group (risk ratio 1.08; 95% confidence interval 0.93-1.27, p value 0.29). A more liberal RBC transfusion strategy was not associated with higher risk of infection among residents from nursing homes or sheltered housing undergoing hip fracture surgery.

Postoperative blood transfusion strategy in frail, anemic elderly patients with hip fracture

Background and purpose — Hip fracture (HF) in frail elderly patients is associated with poor physical recovery and death. There is often postoperative blood loss and the hemoglobin (Hb) threshold for red blood cell (RBC) transfusions in these patients is unknown. We investigated whether RBC transfusion strategies were associated with the degree of physical recovery or with reduced mortality after HF surgery.Patients and methods — We enrolled 284 consecutive post-surgical HF patients (aged ≥ 65 years) with Hb levels < 11.3 g/dL (7 mmol/L) who had been admitted from nursing homes or sheltered housing. Allocation was stratified by residence. The patients were randomly assigned to either restrictive (Hb < 9.7 g/dL; < 6 mmol/L) or liberal (Hb < 11.3 g/dL; < 7 mmol/L) RBC transfusions given within the first 30 days postoperatively. Follow-up was at 90 days.Results — No statistically significant differences were found in repeated measures of daily living activities or in 90-day mortality rate between the restrictive group (where 27% died) and the liberal group (where 21% died). Per-protocol 30-day mortality was higher with the restrictive strategy (hazard ratio (HR) = 2.4, 95% CI: 1.1–5.2; p = 0.03). The 90-day mortality rate was higher for nursing home residents in the restrictive transfusion group (36%) than for those in the liberal group (20%) (HR = 2.0, 95% CI: 1.1–3.6; p = 0.01).Interpretation — According to our Hb thresholds, recovery from physical disabilities in frail elderly hip fracture patients was similar after a restrictive RBC transfusion strategy and after a liberal strategy. Implementation of a liberal RBC transfusion strategy in nursing home residents has the potential to increase survival.

Health Care–Associated Infection After Red Blood Cell Transfusion

The association between red blood cell (RBC) transfusion strategies and health care-associated infection is not fully understood. To evaluate whether RBC transfusion thresholds are associated with the risk of infection and whether risk is independent of leukocyte reduction. MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Cochrane Database of Sytematic Reviews, ClinicalTrials.gov, International Clinical Trials Registry, and the International Standard Randomized Controlled Trial Number register were searched through January 22, 2014. Randomized clinical trials with restrictive vs liberal RBC transfusion strategies. Twenty-one randomized trials with 8735 patients met eligibility criteria, of which 18 trials (n = 7593 patients) contained sufficient information for meta-analyses. DerSimonian and Laird random-effects models were used to report pooled risk ratios. Absolute risks of infection were calculated using the profile likelihood random-effects method. Incidence of health care-associated infection such as pneumonia, mediastinitis, wound infection, and sepsis. The pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity (I2 = 0%; τ2 <.0001). The number needed to treat (NNT) with restrictive strategies to prevent serious infection was 38 (95% CI, 24-122). The risk of infection remained reduced with a restrictive strategy, even with leukocyte reduction (RR, 0.80 [95% CI, 0.67-0.95]). For trials with a restrictive hemoglobin threshold of <7.0 g/dL, the RR was 0.82 (95% CI, 0.70-0.97) with NNT of 20 (95% CI, 12-133). With stratification by patient type, the RR was 0.70 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery and 0.51 (95% CI, 0.28-0.95) in patients presenting with sepsis. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight. Among hospitalized patients, a restrictive RBC transfusion strategy was associated with a reduced risk of health care-associated infection compared with a liberal transfusion strategy. Implementing restrictive strategies may have the potential to lower the incidence of health care-associated infection.

Safety and effects of two red blood cell transfusion strategies in pediatric cardiac surgery patients: a randomized controlled trial

To investigate the safety and effects of a restrictive red blood cell (RBC) transfusion strategy in pediatric cardiac surgery patients. Randomized controlled trial. Pediatric ICU in an academic tertiary care center, Leiden University Medical Center, Leiden, The Netherlands. One hundred seven patients with non-cyanotic congenital heart defects between 6 weeks and 6 years of age. One hundred three patients underwent corrective surgery on cardiopulmonary bypass. Prior to surgery patients were randomly assigned to one of two groups with specific RBC transfusion thresholds: Hb 10.8 g/dl (6.8 mmol/l) and Hb 8.0 g/dl (5.0 mmol/l). Length of stay in hospital (primary outcome), length of stay in PICU, duration of ventilation (secondary outcome), incidence of adverse events and complications related to randomization (intention to treat analysis). In the restrictive transfusion group, mean volume of transfused RBC was 186 (±70) ml per patient and in the liberal transfusion group 258 (±87) ml per patient, (95% CI 40.6-104.6), p < 0.001. Length of hospital stay was shorter in patients with a restrictive RBC transfusion strategy: median 8 (IQR 7-11) vs. 9 (IQR 7-14) days, p = 0.047. All other outcome measures and incidence of adverse effects were equal in both RBC transfusion groups. Cost of blood products for the liberal transfusion group was 438.35 (±203.39) vs. 316.27 (±189.96) euros (95% CI 46.61-197.51) per patient in the restrictive transfusion group, p = 0.002. For patients with a non-cyanotic congenital heart defect undergoing elective cardiac surgery, a restrictive RBC transfusion policy (threshold of Hb 8.0 g/dl) during the entire perioperative period is safe, leads to a shorter hospital stay and is less expensive.

Haemoglobin management in acute brain injury

Anaemia is common among patients in the neurocritical care unit (NCCU) and is thought to exacerbate brain injury. However, the optimal haemoglobin (Hgb) level still remains to be elucidated for traumatic brain injury (TBI), subarachnoid haemorrhage (SAH) and acute ischaemic stroke (AIS). This review outlines recent studies about anaemia and the effects of red blood cell transfusion (RBCT) on outcome in TBI, SAH and AIS patients admitted to the NCCU. Patients with severe SAH, AIS and TBI often develop anaemia and require RBCT. In general critical care, a restrictive RBCT strategy (Hgb ~7 g/dl) is preferable in patients without serious cardiac disease. In severe TBI, AIS and SAH, both anaemia and RBCT may negatively influence clinical outcome. However, the appropriate RBCT trigger remains unclear and there is great variance in how these patients are transfused. There is evidence from PET and microdialysis studies in humans that RBCT can favourably influence brain metabolism and oxygenation. This correction of hypoxia or altered metabolism rather than anaemia may be of greater importance. Results from general critical care should not be extrapolated to all patients with acute brain injury. Transfusion is not risk free, but RBCT use needs to be considered also in terms of potential benefit.

Red Blood Cell Transfusion Practices

Background and Objectives. High-intensity ICU staffing model is associated with quality and outcome improvements. Restrictive red blood cell (RBC) transfusion strategies have been shown to have equivalent mortality to a more liberal strategy in the ICU. We examined the effect of high-intensity staffing on pretransfusion hemoglobin levels, RBC transfusion rates and length of ICU stay. Materials and Methods. The study was a retrospective chart review (n = 196) of all patients admitted to the adult medical/surgical ICU for more than 24 hours one year prior to and after institution of the high-intensity staffing model. Results. Matched for demographics and diagnosis, RBC transfusion rates pre- versus postinstitution of the high-intensity staffing model was 42% versus 27%, respectively, and pretransfusion hemoglobin levels were lower (8.94 to 7.39 g/dL). Length of stay was 4.1 days pre–high-intensity staffing and 4.0 days post–high-intensity staffing. Conclusions. High-intensity ICU staffing resulted in fewer RBC transfusions and lower transfusion thresholds. This restrictive RBC transfusion strategy had no adverse effects on patient ICU length of stay.

Red blood cell transfusion in critically ill children: A narrative review*

To review the pathophysiology of anemia, as well as transfusion-related complications and indications for red blood cell (RBC) transfusion, in critically ill children. Although allogeneic blood has become increasingly safer from infectious agents, mounting evidence indicates that RBC transfusions are associated with complications and unfavorable outcomes. As a result, there has been growing interest and efforts to limit RBC transfusion, and indications are being revisited and revamped. Although a so-called restrictive RBC transfusion strategy has been shown to improve morbidity and mortality in critically ill adults, there have been relatively few studies on RBC transfusion performed in critically ill children. Published literature on transfusion medicine and outcomes of RBC transfusion. STUDY SELECTION, DATA EXTRACTION, AND SYNTHESIS: After a brief overview of physiology of oxygen transportation, anemia compensation, and current transfusion guidelines based on available literature, risks and outcomes of transfusion in general and in critically ill children are summarized in conjunction with studies investigating the safety of restrictive transfusion strategies in this patient population. The available evidence does not support the extensive use of RBC transfusions in general or critically ill patients. Transfusions are still associated with risks, and although their benefits are established in limited situations, the associated negative outcomes in many more patients must be closely addressed. Given the frequency of anemia and its proven negative outcomes, transfusion decisions in the critically ill children should be based on individual patient's characteristics rather than generalized triggers, with consideration of potential risks and benefits, and available blood conservation strategies that can reduce transfusion needs.