Sunday, April 13, 2014

Blood transfusion - the risk of infection - a game changer

Health Care–Associated Infection After Red Blood Cell TransfusionA Systematic Review and Meta-analysis

Confession: We used to insist on a 'good solid hemoglobin' before our patients were discharged because of fear of syncope and increased risk of infection and poor wound healing.

These authors challenged that practice by studying the association between red blood cell transfusion strategies and health care–associated infection.

They performed a meta-analysis of 21 randomized trials comparing restrictive vs liberal transfusion strategies (8735 patients). Most trials define a restrictive transfusion strategy as the administration of red blood cells once hemoglobin falls below either 7 or 8 g/dL, and most trials define a liberal strategy as transfusion once hemoglobin level falls below 10 g/dL.

They found that the pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity.

With stratification by patient type, the RR was 0.70 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight.

They concluded that among hospitalized patients, a restrictive transfusion strategy was associated with a reduced risk of health care–associated infection compared with a liberal transfusion strategy. 

Comment: This article has changed our practice to a restrictive transfusion strategy unless there are overriding reasons to be more liberal.

A very nice discussion of this paper can be found here. In this discussion the point is made that the ideal  threshold for transfusion has yet to be determined.

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