Clinical Practice Guidelines From the AABB Red Blood Cell Transfusion Thresholds and Storage

被引:783
作者
Carson, Jeffrey L. [1 ]
Guyatt, Gordon [2 ,3 ]
Heddle, Nancy M. [3 ]
Grossman, Brenda J. [4 ]
Cohn, Claudia S. [5 ]
Fung, Mark K. [6 ]
Gernsheimer, Terry [7 ]
Holcomb, John B. [8 ]
Kaplan, Lewis J. [9 ]
Katz, Louis M. [10 ,11 ]
Peterson, Nikki
Ramsey, Glenn [12 ]
Rao, Sunil V. [13 ]
Roback, John D. [14 ]
Shander, Aryeh [15 ,16 ,17 ,18 ]
Tobian, Aaron A. R. [19 ]
机构
[1] Rutgers State Univ, Rutgers RobertWood Johnson Med Sch, Div Gen Internal Med, New Brunswick, NJ USA
[2] McMaster Univ, Dept Clin Epidemiol & Biostat, Hamilton, ON, Canada
[3] McMaster Univ, Dept Med, Hamilton, ON, Canada
[4] Washington Univ, Sch Med, Dept Pathol & Immunol, St Louis, MO USA
[5] Univ Minnesota, Sch Med, Dept Lab Med & Pathol, Minneapolis, MN 55455 USA
[6] Univ Vermont, Med Ctr, Dept Pathol & Lab Med, Burlington, VT USA
[7] Univ Washington, Div Hematol, Seattle, WA 98195 USA
[8] Univ Texas Med Sch, Dept Surg, Galveston, TX USA
[9] Univ Penn, Dept Surg, Perelman Sch Med, Philadelphia, PA 19104 USA
[10] Amer Blood Ctr, Washington, DC USA
[11] Univ Iowa, Dept Med, Div Infect Dis, Carver Coll Med, Iowa City, IA 52242 USA
[12] Northwestern Univ, Dept Pathol, Feinberg Sch Med, Evanston, IL USA
[13] Duke Univ, Med Ctr, Div Cardiol, Durham, NC 27710 USA
[14] Emory Univ, Sch Med, Dept Pathol & Lab Med, Atlanta, GA 30322 USA
[15] Englewood Hosp & Med Ctr, Dept Anesthesiol, Englewood, NJ USA
[16] Englewood Hosp & Med Ctr, Dept Crit Care Med, Englewood, NJ USA
[17] Englewood Hosp & Med Ctr, Dept Pain Management, Englewood, NJ USA
[18] Englewood Hosp & Med Ctr, Dept Hyperbar Med, Englewood, NJ USA
[19] Johns Hopkins Univ, Sch Med, Dept Pathol, Baltimore, MD 21205 USA
来源
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION | 2016年 / 316卷 / 19期
关键词
RANDOMIZED CONTROLLED-TRIAL; ELECTIVE ORTHOPEDIC-SURGERY; RESTRICTIVE TRANSFUSION; HIP FRACTURE; HEMOGLOBIN THRESHOLD; FEASIBILITY TRIAL; ELDERLY-PATIENTS; CARDIAC-SURGERY; ACUTE-LEUKEMIA; PILOT;
D O I
10.1001/jama.2016.9185
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
IMPORTANCE More than 100 million units of blood are collected worldwide each year, yet the indication for red blood cell (RBC) transfusion and the optimal length of RBC storage prior to transfusion are uncertain. OBJECTIVE To provide recommendations for the target hemoglobin level for RBC transfusion among hospitalized adult patients who are hemodynamically stable and the length of time RBCs should be stored prior to transfusion. EVIDENCE REVIEW Reference librarians conducted a literature search for randomized clinical trials (RCTs) evaluating hemoglobin thresholds for RBC transfusion (1950-May 2016) and RBC storage duration (1948-May 2016) without language restrictions. The results were summarized using the Grading of Recommendations Assessment, Development and Evaluation method. For RBC transfusion thresholds, 31 RCTs included 12 587 participants and compared restrictive thresholds (transfusion not indicated until the hemoglobin level is 7-8 g/dL) with liberal thresholds (transfusion not indicated until the hemoglobin level is 9-10 g/dL). The summary estimates across trials demonstrated that restrictive RBC transfusion thresholds were not associated with higher rates of adverse clinical outcomes, including 30-day mortality, myocardial infarction, cerebrovascular accident, rebleeding, pneumonia, or thromboembolism. For RBC storage duration, 13 RCTs included 5515 participants randomly allocated to receive fresher blood or standard-issue blood. These RCTs demonstrated that fresher blood did not improve clinical outcomes. FINDINGS It is good practice to consider the hemoglobin level, the overall clinical context, patient preferences, and alternative therapies when making transfusion decisions regarding an individual patient. Recommendation 1: a restrictive RBC transfusion threshold in which the transfusion is not indicated until the hemoglobin level is 7 g/dL is recommended for hospitalized adult patients who are hemodynamically stable, including critically ill patients, rather than when the hemoglobin level is 10 g/dL (strong recommendation, moderate quality evidence). A restrictive RBC transfusion threshold of 8 g/dL is recommended for patients undergoing orthopedic surgery, cardiac surgery, and those with preexisting cardiovascular disease (strong recommendation, moderate quality evidence). The restrictive transfusion threshold of 7 g/dL is likely comparable with 8 g/dL, but RCT evidence is not available for all patient categories. These recommendations do not apply to patients with acute coronary syndrome, severe thrombocytopenia (patients treated for hematological or oncological reasons who are at risk of bleeding), and chronic transfusion-dependent anemia (not recommended due to insufficient evidence). Recommendation 2: patients, including neonates, should receive RBC units selected at any point within their licensed dating period (standard issue) rather than limiting patients to transfusion of only fresh (storage length: <10 days) RBC units (strong recommendation, moderate quality evidence). CONCLUSIONS AND RELEVANCE Research in RBC transfusion medicine has significantly advanced the science in recent years and provides high-quality evidence to inform guidelines. A restrictive transfusion threshold is safe in most clinical settings and the current blood banking practices of using standard-issue blood should be continued.
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收藏
页码:2025 / 2035
页数:11
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