Wednesday, January 2, 2013

Less is more - additional evidence against liberal blood transfusion (or in favor for parsimonious use of blood).

I went last year (yes, the year that just ended 2 days ago) to Mexico City to give a lecture at the International  Course of Internal Medicine sponsored by the Mexican College of Internal Medicine. My lecture was named "Blood is life: to transfuse or not" - and it was targeted toward presenting the evidence for parsimonious blood utilization. This invitation came as a result of my involvement with the preoperative anemia optimization program at the Cleveland Clinic.

At the Cleveland Clinic, a large effort was initiated about 6 years ago in order to decrease the number of transfusions, mainly red blood cells, and mostly in surgical patients. The efforts have yielded in an impressive decrease in blood utilization as well as in a more proactive behavior to optimize the patients' anemia before undergoing surgery. One of my main areas of interest is preoperative anemia optimization to minimize the risks of intra-operative or post-operative blood transfusion. We optimize the iron stores, or in special cases, use erithropoiesis stimulating agents (Jehovah's witnesses, hip and knee arthroplasties mainly).

The culture change has been slow but steady. Nowadays, nobody attempts to transfuse liberally in anybody with hemoglobin more than 7 g/dL; of course, each patients is evaluated individually and certainly you can transfuse at higher numbers in patients with other co-morbidities (for example, patients with severe chronic lung disease and active ischemic cardiomyopathy, or severe acute ischemic renal injury, etc.).

I have undergone a large review of literature which I presented in Mexico (the translated slide presentation can be seen here). The presentation raised controversy - some of my Mexican colleagues still transfuse based on "their experience" and not on the evidence; they are scared of using intravenous iron preparations; they still think an hemoglobin of 10 in a critically ill patient is an indication to transfuse. It was a big cultural shock to find out that it was in critical care patients where the evidence came from, supporting a parsimonious blood utilization. Some people advocate autologous blood donation (which we do not use here), as well as the use of perfluorocarbon blood substitutes (which as well we do not utilize here neither). A long road is to be traveled and a large educational effort is required to change long-standing practices; I was grateful by receiving the opportunity to help in the initiation of these efforts and will continue to share our experience and growing literature available.

In the past 2 weeks, two articles have come out to provide additional support to the parsimonious blood utilization - one published online in Archives of Internal Medicine which demonstrates and increased mortality in patients with acute myocardial infarction who were transfused - and the other published in tomorrow's NEJM - which fills out the missing part of the puzzle: whether pursuing a parsimonious blood utilization in active GI bleeding was a safe initiative.

The article in Archives, is a well designed metaanalysis which review 10 studies out of 729 finding interestingly a mortality risk ratio of 2.91 with a number needed to harm of 8 in patients hospitalized with myocardial infarction who were transfused. In addition, this risk was independent of the baseline hemoglobin level and to muddy the waters more, it was associated with increased risk of subsequent myocardial infarction. This is very interesting, as most guidelines recommend a higher threshold for transfusion (e.g 8 g/dL instead of 7 g/dL) in anemic patients with myocardial ischemia. I don't think clinicians should stop from transfusing patients that need blood; but I would advocate a more conservative approach looking into the causes of anemia - hematinic deficiencies (iron, vitamin B12, folate, etc.); bone marrow suppression or dysfunction; ongoing blood losses; etc. As the authors conclude a larger trial is needed and I concur; however, it is interesting to see the trend toward the worse outcomes, including reinfarction. 

The article in the NEJM, comes to provide very needed information in the actively bleeding population. We tend to transfuse as in an actively bleeding patient it is unclear whether the hemoglobin will stabilize or how low it can go. In my institution, we tend to monitor the hemoglobin every 4 to 6 hours in these patients - and hold for transfusion until the hemoglobin reaches 7 g/dL or less. This behavior is supported by this article, which certainly provides a sigh of relief to all who practice a parsimonious blood management. Of course, that in addition to this, clinicians should always optimize the hematinic deficiencies (iron stores, folate, vitamin B12, etc.), in order to maintain the substrate for an adequate hematopoietic response. I'm glad this article is out in print as certainly will provide a stronger support for all blood management programs, and minimize worse outcomes in our patients. 

Doctors and midlevel providers want the best for their patients. It is a matter of education and reaching a comfort level to pursue evidence based and common-sense based medicine. As always, we all strive for the best....primum non nocere.

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