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The Value of a Restrictive Blood Transfusion Strategy for Hospitalized Patients

Posted Feb 04 2013 12:00am

In a previous note, I quoted a NYT article stating that the Cleveland Clinic was purposefully reducing blood transfusion as a quality initiative, although there are certainly cost-saving implications involved (see: Avoiding Blood Transfusion as a Hospital Quality and Cost-Savings Measure ). Here's a quote from that note:

The statement [from the article] ...that patients who "received blood transfusions during surgery had higher complication rates afterward and a lower long-term survival rate" is quite dramatic and could probably be challenged. However, the fact that it even appeared in an article about the Cleveland Clinic's quality/cost containment initiatives, in my mind, is highly significant.

In reaction to that note, Dr. Claire Friedman submitted the following comment:

At [ The Hospital of the University of Pennsylvania ], the [Medical Intensive Care Unit] (MICU) has adopted aggressive transfusion guidelines to prevent unnecessary transfusions; we now only transfuse for a hemoglobin less than 7.

According to her, the key journal article underlying this decision is the following:  A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care . Here is an excerpt from its results and conclusions section:

RESULTS: Overall, 30-day mortality was similar in the two [test] groups....However, the rates were significantly lower with the restrictive transfusion strategy among patients who were less acutely ill ...and among patients who were less than 55 years of age ... but not among patients with clinically significant cardiac disease....The mortality rate during hospitalization was significantly lower in the restrictive-strategy group ....

CONCLUSIONS: A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction and unstable angina.

I draw two major conclusions from this article regarding blood transfusion to hospitalized patients. The first point relates to the transfusion trigger, the factor or constellation of factors that precipitate a decision to transfuse blood. I and co-authors coined this phrase in an article published in 1980 (see: An Analysis of Blood Transfusion of Surgical Patients by Sex: A Quest for the Transfusion Trigger ). The hemoglobin level has always been used by clinicians as one of the most important factors in assessing the need for blood transfusion. The hemoglobin level used in this regard seems to have trended downward by two or more grams during the last three decades. The second point in the article is that a "restrictive blood transfusion strategy" now seems to be gaining favor. I interpret this to mean that physicians prefer not to transfuse blood at all unless they are pushed to do so. Possible exceptions to this rule are patients with acute myocardial infarctions and unstable angina for whom oxygen delivery to damaged heart muscle takes precedence.

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