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.

A Conceptual Framework for Evaluating Patients Who May Need Red Cell Transfusion

Blood transfusion is an extremely common procedure that may be associated with significant risks, and orders for transfusion are common targets for "Choosing Wisely" Campaigns. Evaluating a patient for the need for red blood cells (RBCs) transfusion is not always a simple process. Although several guidelines are published to aid in determining which patients need a transfusion of RBCs, the decision can be complicated and must be individualized. Guidelines are frequently updated based on current published literature, but several elements must always be considered during patient evaluation for the possible need for RBC transfusion. We suggest using the acronym HOPES 2 C as a reminder of these elements (Hemoglobin level, Onset of anemia, Patient view, Extremes of age, Symptoms, Cause of anemia, and Co-morbidities). Hemoglobin level must always be taken into account when evaluating a patient for the need for RBC transfusion. Many randomized clinical trials (RCTs) have shown that following a restrictive transfusion strategy (avoiding transfusion until Hb reaches 7 or 8 g/dL) is either equal or superior when compared with a liberal transfusion strategy (transfusion for Hb of 9-10 g/dL). The lower the hemoglobin, the more likely the patient will require a transfusion. Onset of anemia: Patients with chronic anemia rarely require rapid transfusion, allowing time for investigation and provision of other effective treatments, such as iron or B12. These patients are also at increased risk of transfusion-associated circulatory overload. On the other hand, most patients with acute blood loss will require transfusion as part of resuscitation efforts. Patient view: Patient caremust be guided by the individual patient's values and preferences. Extremes of age: Patients at extremes of age (newborns and geriatric patients) may require different transfusion thresholds. This point needs further evaluation through RCTs. Symptoms: The presence of hypotension, tachycardia, and end-organ dysfunction secondary to anemia indicate the need for transfusion. Cause: Patients with anemia must not be transfused without an attempt to understand the cause of anemia. History, physical examination, and laboratory tests must be reviewed to evaluate for cause of anemia that may be correctable through effective alternatives to transfusions, such as iron or B12. Co-morbidities: Patients with acute coronary syndrome or other diseases affecting oxygen delivery may need special consideration at the time of assessment. RCTs were published about a number of these settings, such as acute coronary syndrome, but further evidence is awaited for others. It must be emphasized that this conceptual framework does not apply to patients with thalassemia and hemoglobinopathies, as care of these patients must follow disease-specific guidelines. We hope that this conceptual framework helps physicians capture all assessment elements of a patient who may need a blood transfusion. We expect that this will reduce unnecessary transfusions while maintaining patient safety and quality of care. Disclosures No relevant conflicts of interest to declare.

Transfusion Strategy in Crimean-congo Hemorrhagic Fever Treatment

The article's abstract is not available.

An Individualized Red Blood Cell Transfusion Strategy Using Pediatric Perioperative-Transfusion-Trigger Score Reduced Perioperative Blood Exposure for Children: A Randomized Controlled Clinical Trial

Background The optimal red blood cell transfusion strategy in children remains unclear. We developed an individualized pediatric red blood cell transfusion strategy, and postulated that red blood cell transfusion guided by this strategy in children would reduce blood exposure without compromising patients’ safety. Methods In this randomized controlled clinical trial, 99 children undergoing non-cardiac surgeries who had blood loss of more than 20% total blood volume were randomly assigned to an individualized-strategy group using Pediatric Perioperative-Transfusion-Trigger Score, or a control group. The amount of transfused red blood cells was counted, and patients were followed up for postoperative complications by day-30. This trial was registered at the Chinese Clinical Trial Registry (Registration number: ChiCTR-IRP-16007909, Date:07/02/2016). Results 26 children (53.1%) in individualized-strategy group received transfusion perioperatively, as compared with 37 children (74%) in the control group (p<0.05). During surgery, children in individualized-strategy group were exposed to fewer transfusions than in the control group (0.87±1.03 vs. 1.33±1.20 red-blood-cell units per patient, p<0.05). The incidence of severe complications in individualized-strategy group had the lower trend compare to the control group (8.2% vs. 18%, p=0.160). No significant differences were found in the other outcomes. Conclusion This study proved that transfusion guided by the individualized strategy reduced perioperative blood exposure in children, without increasing the incidence of severe complications. This conclusion needs to be further confirmed by implementing multicenter, large-sample clinical trials. Trial registration The study was registered at http://www.chictr.org.cn/showprojen.aspx?proj=13361 (Registration number: ChiCTR-IRP-16007909, Date:07/02/2016).

Using blood wisely in oncology patients: An institutional analysis of the Choosing Wisely Canada restrictive transfusion strategy guidelines.

10 Background: Numerous studies support the safety of single-unit red red blood cell (RBC) transfusions and restrictive pre-transfusion hemoglobin (Hg) thresholds (≤ 70-80 g/L) among diverse populations of hospitalized patients, including those with malignancies on myelosuppressive systemic therapy. Using Blood Wisely is a national Choosing Wisely Canada (CWC) initiative that challenges hospitals to benchmark themselves on evidence-informed restrictive transfusion strategies, with the aim to decrease inappropriate RBC transfusions in Canada. We assessed transfusion practices among oncology inpatients at BC Cancer Vancouver Centre as part of this initiative and performed an exploratory analysis among outpatients. Methods: BC Cancer Vancouver RBC transfusion records were obtained for the period of October 2019-September 2020. The percentage of single-unit transfusions and transfusions for Hg ≤ 80 g/L were measured, to assess adherence to CWC targets of ≥ 65% and ≥ 80%, respectively, for these metrics. Univariate analyses were used to compare treatment variables and transfusion outcomes. Results: During the 1-year audit period, 120 inpatient and 586 outpatient RBC transfusions occurred. For inpatient transfusions, 40.8% (n = 49) were single-unit and 79.2% (n = 95) were for Hg ≤ 80 g/L. For outpatient transfusions, 11.8% (n = 69) were single-unit and 65.7% (n = 304) were for Hg ≤ 80 g/L. Outpatients and patients with solid malignancies were more likely to receive multiple-unit transfusions, compared to inpatients (p < 0.001) and patients with hematological malignancies (p < 0.001), respectively. Patients with solid malignancies and those on active treatment were more likely to be transfused when Hg was > 80 g/L, compared to patients with hematological malignancies (p = 0.004) and those off treatment (p = 0.003), respectively. Multiple RBC units were more likely to transfused when the interval from pre-transfusion bloodwork to receipt of transfusion was > 3 days (p = 0.029). Conclusions: A high rate of inappropriate RBC transfusions are being ordered for oncology patients at our institution, in discordance with CWC restrictive transfusion strategy guidelines. Quality improvement interventions are planned to adopt best practices in transfusion medicine in this high-use population.[Table: see text]