You have admitted a 54 year old female with shortness of breath, abdominal pain, and a hgb of 7.5. She is hemodynamically stable and her oxygen saturations are 90%. Based on the information available, should this patient be transfused? Give supporting data/information for your answer.
According to NEJM Resident 360 Transfusion information, the 1999 TRICC trial found no difference in mortality or severity of organ dysfunction between a restrictive (hemoglobin <7 g/dL) and liberal (hemoglobin <9 g/dL) transfusion threshold in a general ICU patient population.The 2014 follow-up TRISS trial compared the same restrictive or liberal transfusion thresholds as the 1999 TRICC trial but in patients with septic shock. This trial also found no difference in mortality and ischemic events between the two transfusion thresholds.Note: Patients with acute coronary syndrome were excluded from the TRISS trial, and evidence is lacking for this patient population and other populations, including patients with hematologic disorders, cancer, thrombocytopenia, or acute neurologic disorders.The AABB (formerly the American Association of Blood Banks) recommends a restrictive hemoglobin threshold <7 g/dL for adults who are hemodynamically stable, including critically ill patients, and a threshold of <8 g/dL for those with underlying cardiovascular disease. The Society of Critical Care Medicine recommends a similar threshold of <7 g/dL for general critically ill patients and those with stable cardiac disease who are hemodynamically stable, and to reserve the <8 g/dL threshold for patients with acute coronary syndrome.Ultimately, the hemoglobin threshold should not be the only trigger for transfusion. Blood transfusion is preferred for resuscitation of patients with hemorrhagic shock and indicated for anyone with hemodynamic instability or inadequate oxygen delivery.
ReplyDeleteGood work citing two of the landmark articles
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ReplyDeletePlease read the TRICC and TRISS trials. I tried to post a link above but it would not take you to the article.
ReplyDeleteA Cochrane review updated in 2016 supports this data. After review of 31 trials, the authors found no difference from restricted and liberal transfusion criteria regarding 30 day morbidity or mortality. It did remark on the reduction of exposure to allogenic blood that would result from adopting a more liberal criteria( 8-9g/dl) at no expense to patient safety or outcomes .
ReplyDeleteGood point about risk of blood transfusion
DeleteUptoDate mentions exactly what Dr. Marcoe explains above. It’s important to also know that these two trials were performed on critically ill ICU patients.
ReplyDeleteThe American association of blood bank guidelines:
Restrictive threshold if 7 to 8g hgb per deciliter. 8 is the threshold in patients with preexisting cardiovascular disease and those undergoing cardiac or orthopedic surgery. 7g is the threshold in most patients including CCU patients
It’s also important to know that the delivery of oxygen is dependent on cardiac output and arterial oxygen content. If someone is hypoxic it could be due to anemia and a blood transfusion may be necessary.
Per up to date here are some thresholds:
Symptomatic anemia (MI) : 10
Preexisting cad or non cardiac surgery :8
ACS 8-10
Cardiac surgery 7.5
ICU and hemodynamically stable 7
GI bleed and hemodynamically stable 7
Oncology patient in treatment 7-8
I would not transfuse a hemodynamically stable patient with I presume a GI bleed with abdominal pain. SOB could be a symtoms if anemia burnher O2 is at 90%. I would monitor her H&H I would get a type and screen and tranfuse per guidelines- if you hold blood and you need to tranfuse you can always do that quickly 😉
According to up to date, any patient with symptomatic anemia -weakness, fatigue, dizziness, lightheadedness etc should be transfused even if their hemoglobin is 8, because there is no threshold for symptomatic anemia. The main focus for an asymptotic anemia is to look for a cause of the anemia, whether it’s iron deficiency, hypothyroidism etc. This patient is asymptomatic at this time and transfusion would not be warranted, however a type and screen should be obtained.
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