A large variation in transfusion policy between countries and even between hospitals within a country can still be seen as common practice:
- In the first Austrian benchmark study, Gombotz and colleagues found a transfusion rate varying from 16 to 85% for patients undergoing primary total hip replacement (THR) and a 12-87% transfusion rate for patients undergoing primary total knee replacement (TKR) surgery (Gombotz et al. Transfusion 2007).
- In the second benchmark study, which was published recently, transfusion rates have decreased in THR (from 41 to 30%) and TKR (41 to 25%) however with still substantial inter-centre variability (Gombotz et al. Transfusion 2014) These studies show, that the implementation of guidelines in daily practice is often difficult. This is not only relevant for implementing transfusion thresholds, but also for the number of transfusions at each event to reach a particular target Haemoglobin (Hb) level.
Barr and co-workers investigated red blood cell transfusion practice in Northern Ireland in 2005 and still found a two-unit instead of single-unit transfusion practice in medical and surgery patients (n=1474) (Barr et al. Vox Sang 2010).
In 1988 the NIH published consensus guidelines for red blood cell transfusions. Since then, several guidelines have been published, recommending that a range of Hb levels between 6 and 10 g/dL can be used, depending on the presence of serious co-morbidity:
- Consensus statement on red cell transfusion
- Blood component therapy
- Perioperative blood transfusion and adjuvant therapies
- Consensus conference. Perioperative red blood cell transfusion.JAMA 1988; 260: 2700-03.
- Consensus statement on red cell transfusion. Royal College of Physicians of Edinburgh.Transfus. Med. 1994; 4: 177-78.
- Practice Guidelines for blood component therapy: A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy.Anesthesiology 1996; 84: 732-47.
- Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies.Anesthesiology 2006; 105: 198-208.
- Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusionCarson JL, Stanworth SJ, Roubinian N, et alCochrane Database Syst Rev 2016; 10:CD002042).
- Clinical trials evaluating red blood cel transfusion thresholds: An updated systematic review and with additional focus on patients with cardiovascular diseaseCarson JL, Stanworth SJ, Alexander JH, et alAmerican Heart Journal 2018; 200:96-101
- Transfusion strategies for acute upper gastrointestinal bleeding. Villanueva C et al.NEJM 2013; 368: 11-21.
Manish S. Patel, MD Associate Professor of Medicine
Jeffrey L. Carson, MD Distinguished Professor of Medicine
Provost, Rutgers Biomedical Health Sciences
Division of General Internal Medicine
Rutgers – Robert Wood Johnson Medical School
New Brunswick, New Jersey, USA