Jeffrey L. Carson, MD; Sunil V. Rao, MD; Louis M. Katz, MD
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-3065.
Carson JL, Rao SV, Katz LM. Red Blood Cell Transfusion. Ann Intern Med. 2012;157:754-755. doi: 10.7326/0003-4819-157-10-201211200-00020
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Published: Ann Intern Med. 2012;157(10):754-755.
We appreciate the opportunity to reiterate that our guideline states that transfusion should be considered in specific patient subgroups when the nadir hemoglobin reaches 7 to 8 g/dL. In addition, the decision to transfuse should be influenced by signs and symptoms. We based our recommendations on the best available evidence: 19 randomized clinical trials in 6264 patients. However, clinical trials provide an average effect in the population studied. Thus, it is likely that some patients need more or less blood to improve outcomes.
The “conundrum” is what clinical factors should influence the “routine titrated” transfusion decision. The largest trial evaluating transfusion thresholds used prespecified symptoms (such as chest pain, orthostatic hypotension, or tachycardia unresponsive to fluid resuscitation) (1), which we included in our guideline. Although this approach is based on a randomized trial, these symptoms will not apply to all clinical settings. We agree with the accompanying editorial (2) that other variables (such as fatigue, dyspnea, mechanical ventilation, or the use of low Svo2) are unproven. Unfortunately, there is no evidence to support other “important individual patient laboratory and physiologic variables” as the basis for transfusion decisions.
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