Pablo M. Bedano M.D. Community Regional Cancer Care

 Treatment of symptomatic anemia  Prophylaxis of life threatening anemia  Restoration of oxygen-carrying capacity in the case of hemorrhage

 Oxygen delivery (DO2)= cardiac output x arterial O2 content  At rest in healthy adults delivery exceeds consumption x4  Delivery can be raised by increasing cardiac output  Ill adults with other medical comorbidities may have impaired compensatory mechanisms

 31 healthy adults had aliquots of blood ( ml) removed to achieve Hgb 5 g/dL  Isovolemia was maintained  Statistically significant increases in heart rate and stroke volume (increased cardiac output)  Cognitive function impaired at Hgb 5-6  No increase in plasma lactate concentration  2 individuals developed reversible EKG changes consistent with ischemia Weiskopff et al JAMA Jan 21;279(3):

 A retrospective cohort study of 1958 patients who declined transfusion for religious reasons showed 30 day mortality 1.3% Hgb >12 g/dL, 33% if Hb <6, greater odds of death if underlying CV disease  A subset analysis of 300 post-operative patients postoperative risk of death increased progressively when Hb < 7 g/dL  Retrospective review of 310,311 patients undergoing non-cardiac surgery revealed 10% increase cardiac events Hct , 52% Hct Carson et al Lancet 1996; 348:1055 Carson et al Transfusion 2002; 42:812 Wu et al JAMA 2007; 297:2481

 Infection  Allergic reactions  Volume overload  Iron overload  Cost

 Hgb < 6 g/dL – Transfusion recommended except in rare circumstances  Hgb 6 to 7 g/dL – Transfusion likely to be recommended  Hgb 7-8 g/dL – Consider transfusion in postoperative surgical patients  Hgb 8-10 g/dL – Transfusion generally not indicated, consider in special situations (symptomatic anemia, ongoing bleeding, acute coronary syndrome with ischemia  Hgb > 10 g/dL – Transfusion generally not indicated

 19 randomized clinical trials identified including 6264 patients  All trials included used a transfusion threshold  Most trials used thresholds between 7-10  39% decrease in probability of receiving transfusion  Fewer units (1.19) transfused per patient  Trend towards lower 30 day mortality  Trend toward lower infection rate, no difference seen with pneumonia  No difference in functional recovery or length of stay Carson et al JAMA 2013; 309:83

 No increased risk of MI found on meta-analysis  TRICC 838 ICU patients with Hgb 10) vs. restrictive (hgb>7). Lower overall mortality in restrictive group, lower risk of MI (0.7 vs 2.9%)  FOCUS 2016 patients >50 with history or risk factors for CAD and Hgb 10) or restrictive (Hgb>8) transfusion threshold. No- statistically significant increase of MI (3.8 vs 2.3). No difference in survival Hebert et al NEJM 1999; 340: Carson et al NEJM 2011; 365(26):

 Most guidelines recommend transfusion when Hgb between 8-10 g/dL in the setting of active ischemia  Pilot trial 110 patients with ACS undergoing cardiac cath. with Hgb 10) vs restrictive (>8). Endpoint death, MI or revascularization <30 days. Trend to better outcome in liberal group (10.9% vs 25.5% P=0.54) Carson et al Am Heart J 2013; 165:964

 AABB guidelines recommend transfusion threshold of 8 g/dL in asymptomatic patient and 7-10 g/dL in symptomatic patient  Fluid overload is a concern

 In case of massive bleeding transfusion should be guided by rate of bleeding and not Hgb  Hemodynamically stable patients restrictive strategy may be safe  Single center trial randomized 921 patients with acute upper GI bleed to restrictive (Hgb>7) vs liberal (Hgb >9) strategy, excluding massive bleeding, ACS or CVD. All patients underwent endoscopic treatment within 6 hs  Lower rate of transfusion (49 vs 89 percent)  Fewer deaths from bleeding (0.7 vs 3.1 percent) and from any cause (5 vs 9 percent)

 Based on FOCUS trial a transfusion threshold of Hgb 8 g/dL seems to be safe  Hgb threshold of 8 g/dL seems safe in patients undergoing cardiac surgery with cardiopulmonary bypass  428 patients randomized to threshold 8 vs 9, no differences in outcome  TRACS 502 patients undergoing cardiac surgery with CP bypass, no differences in outcome. Independent of transfusion strategy, overall mortality correlated with number of transfusions Bracey et al Transfusion 1999;39:1070 Hajjar et al JAMA 2010; 304:1559

 In patients undergoing active treatment maintain Hgb > 7-8 g/dL  No randomize studies to guide palliative benefit of blood transfusions in terminal patients

 Multiple clinical trials validate a restrictive transfusion strategy for most adults, with threshold Hgb 7-8 g/dL  In medically stable ICU patients Hgb threshold of 7 g/dL safe based on TRICC trial  Symptomatic patients with Hgb <10 g/dL should be transfused as clinically indicated  In patients with acute coronary syndrome, Hgb should be kept > 8 g/dL and > 10 g/dL in ongoing ischemia  Patients with massive bleeding cannot be managed based on Hgb thresholds  Transfusion on 1 unit of blood at a time is reasonable in the hemodynamically stable patient