3.3 Effect of red blood cell transfusion on outcomes

3.3.2 Effect of liberal versus restrictive red blood cell transfusion protocols

Five randomised controlled trials (RCTs) investigated the effect of a restrictive transfusion strategy (in which transfusion was not undertaken until the haemoglobin reached a defined threshold, unless symptoms of oxygen transport deficit were present) on patient outcomes in a perioperative population (one cardiac90 and four noncardiac91–94), as described below.

Cardiac

The one study in cardiac patients90 was of poor quality; thus, the effect of a restrictive transfusion strategy is unclear.

Noncardiac studies

The four studies in noncardiac patients91–94 were small, underpowered RCTs of fair to good quality; thus, the effect of a restrictive transfusion strategy on morbidity and mortality is unclear.

EVIDENCE STATEMENTS – red blood cell transfusion and restrictive transfusion strategy	Evidence	Consistency	Generalisability
In patients undergoing cardiac surgery, RBC transfusion is independently associated with increased morbidity. This relationship is dose dependent.
In patients undergoing cardiac surgery, RBC transfusion is independently associated with increased mortality. This relationship is dose dependent.
In patients undergoing cardiac surgery, RBC transfusion is independently associated with increased ICU and hospital length of stay.
In patients undergoing cardiac surgery, there is insufficient evidence to determine the effect of RBC transfusion on quality of life.	X	NA
In patients undergoing noncardiac surgery, RBC transfusion is independently associated with increased morbidity. This relationship is dose dependent.
In patients undergoing noncardiac surgery, RBC transfusion is independently associated with increased mortality. This relationship is dose dependent.
In patients undergoing noncardiac surgery, RBC transfusion is independently associated with increased ICU length of stay and hospital length of stay.
In patients undergoing cardiac surgery, use of a restrictive transfusion strategy is not associated with increased mortality, morbidity or hospital length of stay.		NA
In patients undergoing noncardiac surgery, the effect of a restrictive transfusion strategy on mortality and morbidity is uncertain.			X
In patients undergoing orthopaedic or vascular surgery, the use of a restrictive transfusion strategy is not associated with increased hospital length of stay.

ICU, intensive care unit; RBC, red blood cell

3 ticks = A; 2 ticks B; 1 tick = C; X = D; NA = not applicable (See Table 2.2)

RECOMMENDATIONS – red blood cell transfusion

R2 Grade C	In patients undergoing cardiac surgery, preoperative anaemia should be identified, evaluated and managed to minimise RBC transfusion, which may be associated with an increased risk of morbidity, mortality, ICU length of stay and hospital length of stay (Grade C).
R3 Grade C	In patients undergoing noncardiac surgery, preoperative anaemia should be identified, evaluated and managed to minimise RBC transfusion, which may be associated with an increased risk of morbidity, mortality, ICU length of stay and hospital length of stay (Grade C).

PRACTICE POINTS – red blood cell transfusion

PP1	To implement the above recommendations, a multimodal, multidisciplinary patient blood management program is required. All surgical patients should be evaluated as early as possible to coordinate scheduling of surgery with optimisation of the patient’s haemoglobin and iron stores.
PP2	RBC transfusion should not be dictated by a haemoglobin ‘trigger’ alone, but should be based on assessment of the patient’s clinical status. In the absence of acute myocardial or cerebrovascular ischaemia, postoperative transfusion may be inappropriate for patients with a haemoglobin level of >80 g/L.
PP3	Patients should not receive a transfusion when the haemoglobin level is ≥100 g/L. In postoperative patients with acute myocardial or cerebrovascular ischaemia and a haemoglobin level of 70–100 g/L, transfusion of a single unit of RBC, followed by reassessment of clinical efficacy, is appropriate.