Review Article
Red Cell Transfusion “Trigger” : A Review
Abstract
Despite the publication of several consensus guidelines that set forth recommendations for the transfusion of red cells, actual clinical practice continues to vary widely. Animal data and studies in human volunteers and patients support a red cell transfusion threshold of 7 to 8 g/dl in most patients. However, conflicting data, particularly in cardiac patients and in the elderly, suggest that it may be impossible to define a single red cell “trigger” for all patients. A well-designed, randomized, controlled trial is still needed to establish a safe threshold for red cell transfusion in adults with coronary artery disease.This content is limited to qualifying members.
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References
1. Welch HG, Meehan KR, Goodnough LT. Prudent strategies for elective red blood cell transfusion. Ann Intern Med 1992; 116: 393–402.
2. Audet AM, Goodnough LT. Practice strategies for elective red blood cell transfusion. Ann Intern Med 1992; 116: 404–406.
3. Stehling L, Luban NL, Anderson KC, Sayers MH, Long A, Attar S, et al. Guidelines for blood utilization review. Transfusion 1994; 34: 438–448.
4. Becker J, Evans C; American Association of Blood Banks. Guidelines for Blood Utilization Review. Bethesda, MD, American Association of Blood Banks Press, 2001, pp 13–14.
5. American Society of Anesthesiologists Task Force on Blood Component Therapy. Practice guidelines for blood component therapy: A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology 1996; 84: 732–747.
6. Simon TL, Alverson DC, AuBuchon J, Cooper ES, DeChristopher PJ, Glenn GC, et al. Practice parameter for the use of red blood cell transfusions: Developed by the Red Blood Cell Administration Practice Guideline Development Task Force of the College of American Pathologists. Arch Pathol Lab Med 1998; 122: 130–138.
7. Halsey PB, Lave JR, Kapoor WN. The necessary and unnecessary transfusion: A critical review or reported appropriateness rates and criteria for red cell transfusions. Transfusion 1994; 34: 110–115.
8. Chiavetta JA, Herst R, Freedman J, Axcell TJ, Wall AJ, van Rooy SC. A survey of red cell use in 45 hospitals in central Ontario, Canada. Transfusion 1996; 36: 699–706.
9. Hebert PC, Wells G, Martin C, Tweeddale M, Marshall J, Blajchman M, et al. A Canadian survey of transfusion practices in critically ill patients: Transfusion Requirements in Critical Care Investigators and the Canadian Critical Care Trials Group. Crit Care Med 1998; 26: 482–487.
10. Blajchman MA. Immunomodulatory effects of allogeneic blood transfusions: Clinical manifestations and mechanisms. Vox Sang 1998; 74( Suppl 2): 315–319.
11. Kao KJ. Mechanisms and new approaches for the allogeneic blood-transfusion induced immunomodulatory effects. Transfus Med Rev 2000; 14: 12–22.
12. Langenfield JE, Livingston DH, Machiedo GW. Red cell deformability is an early indicator of infection. Surgery 1991; 110: 398–404.
13. Schumacker PT, Guth B, Suggett AJ, Wagner PD, West JB. Effects of transfusion-induced polycythemia on O2 transport during exercise in the dog. J Appl Physiol 1985; 58: 749–758.
14. Julien M, Hakim TS, Vahi R, Chang HK. Effect of hematocrit on vascular pressure profile in dog lungs. J Appl Physiol 1985; 58: 743–748.
15. Levine E, Rosen A, Sehgal L, Gould S, Sehgal H, Moss G. Physiologic effects of acute anemia: Implications for a reduced transfusion trigger. Transfusion 1990; 30: 11–14.
16. Wilkerson DK, Rosen AL, Sehgal LR, Gould SA, Sehgal HL, Moss GS. Limits of cardiac compensation in anemic baboons. Surgery 1988; 103: 665–670.
17. Geha AS. Coronary and cardiovascular dynamics and oxygen availability during acute normovolemic anemia. Surgery 1976; 80: 47–53.
18. Wright CJ. The effects of severe progressive hemodilution on regional blood flow and oxygen consumption. Surgery 1976; 79: 299–305.
19. Brazier J, Cooper N, Maloney JV Jr, Buckberg G. The adequacy of myocardial oxygen delivery in acute normovolemic anemia. Surgery 1974; 75: 508–516.
20. Geha AS, Baue AE. Graded coronary stenosis and coronary flow during acute normovolemic anemia. World J Surg 1978; 2: 645–652.
21. Anderson HT, Kessinger JM, McFarland WJ Jr, Laks H, Geha AS. The response of hypertrophied heart to acute anemia and coronary stenosis. Surgery 1978; 84: 8–15.
22. Spahn DR, Smith LR, Veronee CD, McRae RL, Hu WC, Menius AJ, et al. Acute isovolemic hemodilution and blood transfusion: Effects on regional function and metabolism in myocardium with compromised coronary blood flow. J Thorac Cardiovasc Surg 1993; 105: 694–704.
23. Weiskopf RB, Viele MK, Feiner J, Kelley S, Lieberman J, Noorani M, et al. Human cardiovascular and metabolic response to acute, severe isovolemic anemia. JAMA 1998; 279: 217–221.
24. Weiskopf RB, Kramer JH, Viele M, Neumann M, Feiner JR, Watson JJ, et al. Acute severe isovolemic anemia impairs cognitive function and memory in humans. Anesthesiology 2000; 92: 1646–1652.
25. Carson JL, Poses RM, Spence RK, Bonavita G. Severe anaemia and operative mortality and morbidity. Lancet 1988; 1: 727–729.
26. Carson JL, Duff A, Poses RM, Berlin JA, Spence RK, Trout R, et al. Effect of anaemia and cardiovascular disease on surgical morbidity and mortality. Lancet 1996; 348: 1055–1060.
27. Viele MK, Weiskopf RB. What can we learn about the need for transfusion from patients who refuse blood? The experience in Jehovah's Witnesses. Transfusion 1994; 34: 396–401.
28. Botero C, Smith CE, Morscher AH. Anemia and perioperative myocardial ischemia in a Jehovah's Witness patient. J Clin Anesth 1996; 8: 386–391.
29. Mathru M, Kleinman B, Blakeman B, Dries D, Zecca A, Rao T. Cardiovascular adjustments and gas exchange during extreme hemodilution in humans. Crit Care Med 1991; 19: 700–704.
30. Mathru M, Kleinman B, Blakeman B, Sullivan H, Kumar P, Dries DJ. Myocardial metabolism and adaptation during extreme hemodilution in humans after coronary revascularization. Crit Care Med 1992; 20: 1420–1425.
31. Lapin R. Major surgery in Jehovah's Witnesses. Contemp Orthop 1980; 2: 647–654.
32. Kitchens CS. Are transfusions overrated? Surgical outcome of Jehovah's Witnesses. Am J Med 1993; 94: 117–119.
33. Nelson CL, Bowen WS. Total hip arthroplasty in Jehovah's Witnesses without blood transfusion. J Bone Joint Surg Am 1986; 68; 350–353.
34. Carson JL, Duff A, Berlin JA, Lawrence VA, Poses RM, Huber EC, et al. Perioperative blood transfusion and postoperative mortality. JAMA 1998; 279: 199–205.
35. Spiess BD, Ley C, Body SC, Siegel LC, Stover EP, Maddi R, et al. Hematocrit value on intensive care unit entry influences the frequency of Q-wave myocardial infarction after coronary artery bypass grafting: The Institutions of the Multicenter Study of Perioperative Ischemia (McSPI) Research Group. J Thorac Cardiovasc Surg 1998; 116: 460–467.
36. DeFoe GR, Ross CS, Olmstead EM, Surgenor SD, Fillinger MP, Groom RC, et al. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting: Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg 2001; 71: 769–776.
37. Nelson AH, Fleisher LA, Rosenbaum SH. Relationship between postoperative anemia and cardiac morbidity in high risk vascular patients in the intensive care unit. Crit Care Med 1993; 21: 860–866.
38. Hebert PC, Wells G, Tweeddale M, Martin C, Marshall J, Pham B, et al. Does transfusion practice affect mortality in critically ill patients? Transfusion Requirements in Critical Care (TRICC) Investigators and the Canadian Critical Care Trials Group. Am J Respir Crit Care Med 1997; 155: 1618–1623.
39. Wu WC, Rathore SS, Wang Y, Radford MJ, Krumholz HM. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med 2001; 345: 1230–1236.
40. Hebert PC, Wells G, Marshall J, Martin C, Tweeddale M, Pagliarello G, et al. Transfusion requirements in critical care: A pilot study—Canadian Critical Care Trials Group. JAMA 1995; 273: 1439–1444.
41. Johnson RG, Thurer RL, Kruskall MS, Sirois C, Gervino EV, Critchlow J, et al. Comparison of two transfusion strategies after elective operations for myocardial revascularization. J Thorac Cardiovasc Surg 1992; 104: 307–314.
42. Weisel RD, Charlesworth DC, Mickleborough LL, Fremes SE, Ivanov J, Mickle DA, et al. Limitations of blood conservation. J Thorac Cardiovasc Surg 1984; 88: 26–38.
43. Fortune JB, Feustel PJ, Saifi J, Stratton HH, Newell JC, Shah DM. Influence of hematocrit on cardiopulmonary function after acute hemorrhage. J Trauma 1987; 27: 243–249.
44. Blair SD, Janvrin SB, McCollum CN, Greenhalgh RM. Effect of early blood transfusion on gastrointestinal haemorrhage. Br J Surg 1986; 73: 783–785.
45. Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care: Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999; 340: 409–417.
46. Hebert PC, Yetisir E, Martin C, Blajchman MA, Wells G, Marshall J, et al; Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care Trials Group. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med 2001; 29: 227–234.
