Friday, February 24, 2017

Reinforcing a parsimonious approach toward blood transfusion

Blood transfusion as a treatment modality became a prominent resource throughout the last century. However, in the late 1980’s an analysis of the high volume of blood transfusions associated with its inherent cost and risks, raised concern and skepticism regarding the arbitrary hemoglobin and hematocrit cut-offs of “10/30” which were followed since the 1940 following the recommendations by Adams and Lundy. 1 The NIH consensus statement on blood transfusions published in 1988 brought into question the previous practice and propose more parsimonious thresholds of transfusion (Hb 7 g/dL).2

The evidence that supports the safety of parsimonious approach to blood utilization was built over the decades of 1990 and 2000 with very robust and compelling results. The hemodilution studies demonstrated that the human body could tolerate lower hemoglobin values, and subsequently, clinical comparison of restrictive versus liberal transfusional approaches demonstrated the safety of restrictive transfusional approach in different clinical scenarios such as critical care, high cardiovascular risk surgical patients, sepsis, etc. 3  

In this decade, the AABB has published 2 guidelines (2012 and 2016) which are robustly supported by evidence with recommendations for consideration (not an immediately actionable item) of blood transfusion when the hemoglobin reaches a value of less than 7 g/dL in non-cardiac patients, or 8 g/dL in cardiac patients.4 More importantly, the guideline also demystified a current practice that has increased the costs of blood management - which was avoiding the use of blood older than 14 days; the evidence that “old” blood is not associated with worse outcomes is extremely compelling. 4

The current practices of Medicine are substantially different from 10 years ago - at least from blood utilization - not only it is a lower transfusional threshold being utilized, but also there is a decrease in the number of units of blood transfused at a given time. In addition, the clinicians are increasingly mindful of addressing the primary etiology of anemia with focus on hematinic replacement. Also, the behavior has gradually shifted toward mitigating the risk of iatrogenic blood loss by means of decreasing the routine ancillary diagnostic blood tests, which may not necessarily change management.

There are multiple venues which have adopted the recommendations of parsimonious approach to blood utilization such as the ABIM Foundation Choosing Wisely. And it is highly likely that newer organizations aimed to pursue high value and low cost medical care, will adopt the recommendations of restrictive transfusional thresholds to mitigate excess blood use with its associated inherent risks. 

Less is more - the increased focus on enhancing patient outcomes and minimizing the risk associated with excessive diagnostic and therapeutic approaches, will yield in a safer, more effective and less costly practice of Medicine, pursuing the most elemental principle of medicine...primum non nocere.

References
1. Adams RC, Lundy JS. Anesthesia in cases of poor surgical risk: Some suggestions for decreasing the risk. Surg Gynecol Obstet.1942;74:1011-1119.
2. Consensus Conference. Perioperative red blood cell transfusion. JAMA, 1988; 260: 2700-2703.
3. Auron M, Duran-Castillo MY, Kumar A. Parsimonious blood utilization and transfusion triggers. Clev Clin J Med. 2017;84(1):43-51.
4. Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA. 2016;316:2025-35.

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