Blood transfusion:
When to transfuse and risks involved
Yung Lyou | June 2014
Department of Internal Medicine
Case
A 67 y/o male w/ h/o CAD s/p CABG, CKD stage III, HTN, HLD, DM
is admitted for community acquired pneumonia. After 3x days of
inpatient treatment with IV antibiotics he is ready to be
discharged home with oral antibiotics.
His hemoglobin at admission was 8.2 and on admission his anemia
was found to be due to CKD. On the day of discharge he is able to
climb 2 flights of stairs without dyspnea or CP. On the day of
discharge his Hgb is 7.6. His vital signs are temp (36.5 C), HR is 70,
BP 120/80, RR 20, 95% on RA.
‹#›
Which of the following is the best approach in treating his
anemia?
A)
B)
C)
D)
‹#›
Transfuse 2 units PRBC
Transfuse to goal Hg >10
Recheck Hg/Hct
Discharge patent and have PCP follow-up CBC
Which of the following is the best approach in treating his
anemia?
A)
B)
C)
D)
Transfuse 2 units PRBC
Transfuse to goal Hg >10
Recheck Hg/Hct
Discharge patient and have PCP follow-up CBC
We will go over this question again at the end of this lecture.
‹#›
Objectives
• Know when pRBC blood transfusion is indicated
• Know when pRBC blood transfusion is not indicated
• Know some of the basic risks of blood transfusion
‹#›
Goals of blood transfusion
• Increase oxygen delivery to tissues
• Relieve symptomatic anemia
‹#›
Basics principles
• Decision should not be based on only hemoglobin value. Think
of the whole clinical picture
-Remember the patient is more than just a number
• 1 unit of pRBC will usually increase Hgb by 1
• American Association of Blood Banks (AABB) guidelines should
be used in guiding decision when to transfuse
‹#›
Current guidelines for when to transfuse blood(American
Association of Blood Banks, 2012)
‹#›
•
Hgb < 6 – Transfusion recommended
•
Hgb 6-7 – Transfusion likely recommended
•
Hgb 7-8 – Restrictive Transfusion Strategy for stable patients (Strong
recommendation).
 Consider transfusion only if post-operative or symptomatic (chest
pain, orthostatic hypotension or tachycardia unresponsive to fluid
resuscitation, or congestive heart failure).
When NOT to transfuse blood
•
Hgb 8 – 10 – TRANSFUSION GENERALLY NOT INDICATED
-Exceptions to consider transfusing
 ACS w/ active ischemia
 symptomatic anemia
 active bleeding
 critical ill septic shock with ScVO2<70 (although this is now considered
controversial)
•
‹#›
Hgb >10 – TRANSFUSION NOT INDICATED
Risks of Blood Transfusion
•
Transfusion-transmitted pathogens (HIV, HBV, HCV,
CMV, bacteria, parasites)
•
Allergic and Immunologic Reactions
•
Transfusion Associated Circulatory Overload (TACO)
•
Transfusion Related Acute Lung Injury (TRALI)
•
‹#›
Electrolyte abnormalities, hyperkalemia, citrate
toxicity (metabolic alkalosis or ionized hypocalcemia)
Risks of Blood Transfusion
‹#›
ref: Blood Transfusion - When to Transfuse and Risks involved. John Zhang. UCI Mini-Lectures2013
Case
A 67 y/o male w/ h/o CAD s/p CABG, CKD stage III, HTN, HLD, DM
is admitted for community acquired pneumonia. After 3x days of
inpatient treatment with IV antibiotics he is ready to be
discharged home with oral antibiotics.
His hemoglobin at admission was 8.2 and on admission his anemia
was found to be due to CKD. On the day of discharge he is able to
climb 2 flights of stairs without dyspnea or CP. On the day of
discharge his Hgb is 7.6. His vital signs are temp (36.5 C), HR is 70,
BP 120/80, RR 20, 95% on RA.
‹#›
Which of the following is the best approach in treating his
anemia?
A)
B)
C)
D)
‹#›
Transfuse 2 units PRBC
Transfuse to goal Hg >10
Recheck Hg/Hct
Discharge patent and have PCP follow-up CBC
Which of the following is the best approach in treating his
anemia?
A)
B)
C)
D)
‹#›
Transfuse 2 units PRBC
Transfuse to goal Hg >10
Recheck Hg/Hct
Discharge patient and have PCP follow-up CBC
Explanation
Answer: D - discharge patient and have PCP follow up
CBC
The patient currently has asymptomatic anemia with a
decrease in Hgb. This was most likely cause by repeat
blood draws during his hospitalization. He has CAD but
no chest pain or clinical signs of ACS.
Since he is asymptomatic with no chest pain, dyspnea on
exertion, or fatigue blood transfusion is not indicated in
this patient at this time according to current AABB.
‹#›
Summary

Evaluate patient’s complete clinical status before ordering
transfusion.

Generally avoid transfusion for Hgb above 7 in stable patients
without active cardiovascular disease or active bleeding.

Fever and TACO are the most common complications occurring
about 1 in 100 transfusions.
‹#›
References
• “RedBlood Cell Transfusion: A Clinical Practice Guideline from the AABB” Ann Intern Med.
2012;157:49-58
• Carson et al. “Mortality and morbidity in patients with very low postoperative Hb levels
who decline blood transfusion.” Transfusion 2002
• Blood Transfusion - When to Transfuse and Risks involved. John Zhang. UCI MiniLectures2013
• Wang JK, Klein HG. Red blood cell transfusion in the treatment and management of
anaemia: the search for the elusive transfusion trigger. Vox Sang. 2010 Jan;98(1):2-11.
• www.uptodate.com
‹#›