BLOOD TRANSFUSION:

WHEN TO TRANSFUSE AND

RISKS INVOLVED
UC Irvine Internal Medicine
Mini-Lecture

Johnathan Zhang June 2013

OBJECTIVES
Understand when blood transfusion is indicated
and not indicated.
Know the risks involved with blood transfusion.

CASE
A 67 y/o M w/ h/o CAD s/p CABG, CKD stage III, HTN,
HLD, DM is admitted for fever, cough, and SOB. He is
diagnosed with community acquired pneumonia.
Hemoglobin at admission is 8.2. There is no evidence of
active bleeding. At baseline the patient is able to climb 2
flights of stairs without SOB or CP. During
hospitalization, the patient received multiple blood
draws. After 4 days, Pts symptoms have improved. He is
AF, HR is 70, BP 120/80, RR 20, 95% on RA. You are
planning discharge today. Hemoglobin this morning is
7.3.
What is the best approach to managing this pts Anemia?

CASE
A)
B)
C)
D)

Transfuse 2 units PRBC

Transfuse to goal Hg >10
Recheck Hg/Hct
Discharge with outpatient follow-up

Blood transfusion is not indicated in this patient at

this time. His anemia is asymptomatic. He has a
h/o CAD but no e/o active ischemia. His Hg is likely
not lab error given that he has been in the hospital
for multiple days and has received numerous blood
draws likely leading to phlebotomy associated
anemia.

PURPOSE OF BLOOD TRANSFUSION

To increase oxygen delivery to tissues.
DO = cardiac output x arterial oxygen content
2

BACKGROUND

Carson et al. Mortality and morbidity in patients

with very low postoperative Hb levels who decline
blood transfusion. Transfusion 2002
Mortality

Hgb 7.1 to 8.0 (n = 99) zero percent

Hgb 5.1 to 7.0 (n = 110) 9 percent
Hgb 3.1 to 5.0 (n = 60) 30 percent
Hgb 3.0 (n = 31) 64 percent

Viele MK, Weiskopf RB. What can we learn about

the need for transfusion from patients who refuse
blood? The experience with Jehovah's Witnesses.
Transfusion 1994
Review

of 61 case reports w/ Hg <8 or Hct <24 in

critically ill or post-surgery. 25 survivors reported Hg <5.

BACKGROUND

Hbert PC 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. NEJM
1999
838

Critically ill, euvolemic patients w/ 2 study arms

Liberal Transfusion Goal Hg 10-12, Transfuse w/ Hg<10

Restrictive Transfusion Goal Hg 7-9, Transfuse w/ Hg<7.

No

difference 30 day mortality

In-hospital mortality lower for restrictive
transfusion (significant)

BACKGROUND

Carson et al. Liberal versus restrictive

transfusion thresholds for patients with
symptomatic coronary artery disease American
Heart Journal June 2013
Pilot

study 110 pts

Transfusion to Hg >10 for pts with ACS compared to
transfusion for Hg <8 or symptomatic.
liberal transfusion had trend toward greater 30 day
survival (not statistically significant).

BACKGROUND

Villanueva et al. Transfusion strategies for

acute upper gastrointestinal bleeding. NEJM
Jan 2013.
2

Arms. Patients w/o significant comorbid illnesses.

Restrictive transfusion strategy: Tx only for Hg<7

Liberal transfusion strategy: Tx when Hg <9.

Patients

receiving a restrictive transfusion

strategy had significantly less rebleeding and
adverse events.
Restrictive transfusion also w/ trend toward lower
mortality for Peptic ulcer bleeding (not significant)
and pts w/ Cirrhosis Child Pugh classes A and B
(significantly less).

WHEN TO PULL THE TRANSFUSION

TRIGGER?

Should not be based solely on hemoglobin

number.
Decision should consider clinical scenario,
patient characteristics, and symptoms.

WHEN TO PULL THE TRANSFUSION

TRIGGER?

American Association of Blood Banks Guidelines

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).
Hgb 8 10 TRANSFUSION GENERALLY NOT
INDICATED

Can consider Tx in special circumstances (ie ACS w/ active

ischemia, symptomatic anemia, active bleeding, critical ill septic
shock with ScVO2<70).

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)

Consider

giving Calcium prophylactically with

massive transfusion

ORDERING TRANSFUSION
Try to order 1 unit at a time.
Pre-medication w/ benadryl +/- acetaminophen
not supported by data.
Infusion rate: 1-2ml/min x15 min then as rapid
as needed.
No need to recheck Hg/Hct following transfusion
unless concerned for active bleeding or hemolysis.

CASE
74 y/o F w/ h/o peripheral vascular disease, aplastic
anemia and MDS presents with progressive SOB,
lightheadedness, and generalized weakness.
Hemoglobin is 5.1. There is no evidence of bleeding.
Patient is hemodynamically stable.
2U PRBC is ordered and begin running. After 1.5
U, the patient develops sudden shortness of breath
and agitation. Wheezing is heard in bilateral lung
fields. O2 sat is 80%. ABG shows pH 7.02, PCO2
70, PaO2 65 on 100% O2 non-rebreather. CXR as
follows

CXR EARLIER IN DAY

CXR W/ SUDDEN SOB.

WHAT IS THE MOST LIKELY

DIAGNOSIS
A)
B)
C)
D)
E)

Pulmonary Embolism
Transfusion Related Acute Lung Injury
Transfusion Associated Circulatory Overload
Anaphylaxis
Acute Respiratory Distress Syndrome

More common than TRALI (1 in 100 vs 1 in 10,000). This case

was confirmed to be TACO.
PE usually causes respiratory alkalosis with hypoxia on ABG.
Anaphylaxis should be considered but TACO is more likely in
this scenario.
ARDS is less likely given no evidence of infection or
inflammation prior to the sudden event.

SUMMARY
Blood transfusion is not benign and should be
ordered judiciously.
Most patients with chronic anemia can
compensate oxygen delivery by increasing cardiac
output.
Generally avoid transfusion for Hg>7 for most
stable patients without active cardiovascular
disease or active bleeding.
Fever and TACO are the most common
complications occurring about 1 in 100
transfusions.

REFERENCES
Carson JL et al. Red blood cell transfusion: a
clinical practice guideline from the AABB*. Ann
Intern Med. 2012 Jul 3;157(1):49-58
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.
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