Lancet 2013; 381: 184554 CONCEPTS OF BLOOD

TRANSFUSION IN ADULTS
Departments of Pathology
and Medicine, Stanford
University, Stanford, CA, USA
(Prof L T Goodnough MD);
Department of
Anesthesiology, Duke
University School of
Medicine, Durham, NC, USA
(Prof J H Levy MD); Rahmanizar
NHS Blood and Transplant, 1507101030050
Oxford University Hospitals
and University of Oxford,
Supervisor:
Oxford, UK
(Prof M F Murphy FRCP)
dr. Yusmalinda, Sp.An
Introduction

Every year, 24 3 million of

million of blood blood
components are components are
transfused in the transfused in the
USA UK
Blood transfusion = lifesaving
never been proven in a
prospective controlled trial
5-8% (2-3
Transfusion
million) of
happen in more
hospital
than 10% of all
discharges in the
hospital stays
USA, are
that include a
associated with
procedure
blood transfusion
 Introduction

The use of blood has been affected by:

risk In 2011, 69
fatalities among
cost transfusion
recipients were
inventory constraint reported in the USA
and 8 in the UK

Followed by
In view of the risks, the safest Beetween 2007 haemolytic
and 2011 in the transfusion
blood transfusion is the one USA, TRALI reaction (23%)
not given10-12 caused the attributable to
highest non-ABO blood
number of group (13%) or
fatalities (43%) ABO (10%)
incompabilities
Introduction

Awareness of the risk, cost, and effect on blood inventory has

increased focus on evidence-based transfusion practice and
minimisation of blood loss.

However, the decision to transfuse a patient is not always

straightforward. No well-defined criteria are available to show the
ideal moment to start transfusion treatment.
Red Blood Cell Transfusion

Historical practice: when the concentration of haemoglobin is less

than 810 g/dL, it is wise to give a blood transfusion before
operation.19

studies show that no clinically significant difference exists in

oxygen delivery between haemoglobin concentrations
ranging from 10060 g/L.18
Red Blood Cell Transfusion

Postoperative mortality is higher in patients

with cardiovascular disease. Therefore, the
transfusion trigger should be different.

A previously published guidelines concluded

that the presence of coronary artery
disease likely constitutes an
important factor in determining a
patients tolerance to low Hb25
Red Blood Cell Transfusion

Tables 1 show the largest and most influential level I studies of red blood cell.3336 Each
studied whether such patients can tolerate a restrictive transfusion strategy with the
threshold for red blood cell transfusion set at a haemoglobin concentration of 70 g/L or 80
g/L. These trials found clinical outcomes were similar to patients transfused to a
haemoglobin concentration of more than 90100 g/L.
Red Blood Cell Transfusion

Published guidelines generally agree

that transfusion is not beneficial
when the Hb concentration
>100 g/L, but might be
beneficial when the Hb
concentration is < 60-70 g/L

Some guidelines concluded that

Hb 70 g/L is appropriate for use as
a transfusion trigger in patients in
coronary care.
 Treatment with Platelets

The platelet count threshold for prophylactic transfusions in patients with haematological
cancers has been reduced from 2010/L to 1010/L on the basis of trials,37 which showed
little or no increased bleeding. In another trial, the dose of platelets had no effect on the
incidence of bleeding.38 The incidence of bleeding was lower in the prophylaxis group than in
the no-prophylaxis group (43% vs 50%).
Treatment with Platelets
Treatment with Plasma
Patient with trauma

Haemorrhage is responsible for almost 50% of deaths occurring within 24 h

of traumatic injury and for up to 80% of intraoperative trauma mortalities.

Observational studies of military and civilian trauma report the benefit of

transfusion of whole blood or whole blood equivalents in patients needing
massive transfusion.104,105 However, other studies have reported increased
morbidity such as multi organ system failure associated with transfusion of
plasma products106
 Conclusion

Blood transfusions carry risks, and are expensive, and blood supply is
scarce. Despite recent progress made on the basis of high-quality
clinical trials, many uncertainties remain in the identification and
implementation of best transfusion practices. Additional data are
needed to establish the optimum use of red cell, platelet, and plasma
transfusions in different clinical settingseg, trauma and cardiac
surgery.