From the Guidelines
Blood transfusions are indicated when a patient's hemoglobin level falls below 7 g/dL in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, or acute hemorrhage. This recommendation is based on the strongest and most recent evidence from the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 1. The guidelines suggest that red blood cell transfusion should occur only when hemoglobin concentration decreases to < 7.0 g/dL in adults, with a strong recommendation and high quality of evidence.
Key Indications for Blood Transfusion
- Hemoglobin level below 7 g/dL in stable patients
- Myocardial ischemia
- Severe hypoxemia
- Acute hemorrhage
- Symptomatic anemia, such as fatigue, dyspnea, or tachycardia
- Ongoing bleeding with hemodynamic compromise
- Certain hemoglobinopathies, like sickle cell disease during crises
- Severe thrombocytopenia, with platelets <10,000/μL or <50,000/μL with active bleeding
The decision to transfuse should be based on an individual patient's intravascular volume status, evidence of shock, duration and extent of anemia, and cardiopulmonary physiologic parameters, rather than relying solely on hemoglobin level 1. Additionally, the AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients, with a strong recommendation and high-quality evidence 1.
Transfusion Thresholds
- Stable patients: 7 g/dL
- Patients with cardiovascular disease: 8 g/dL
- Patients with acute coronary syndrome: 8-10 g/dL
It is essential to consider the patient's symptoms and clinical context when making transfusion decisions, rather than relying solely on hemoglobin concentration 1. Blood transfusions provide immediate oxygen-carrying capacity through functional red blood cells, which is critical when a patient's own erythropoiesis cannot keep pace with blood loss or red cell destruction.
From the FDA Drug Label
1.1 Anemia Due to Chronic Kidney Disease Epogen is indicated for the treatment of anemia due to chronic kidney disease (CKD), including patients on dialysis and not on dialysis to decrease the need for red blood cell (RBC) transfusion.
- 2 Anemia Due to Zidovudine in Patients with HIV Infection Epogen is indicated for the treatment of anemia due to zidovudine administered at ≤ 4200 mg/week in patients with HIV infection with endogenous serum erythropoietin levels of ≤ 500 mUnits/mL.
- 3 Anemia Due to Chemotherapy in Patients with Cancer Epogen is indicated for the treatment of anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitant myelosuppressive chemotherapy, and upon initiation, there is a minimum of two additional months of planned chemotherapy.
- 4 Reduction of Allogeneic Red Blood Cell Transfusions in Patients Undergoing Elective, Noncardiac, Nonvascular Surgery Epogen is indicated to reduce the need for allogeneic RBC transfusions among patients with perioperative hemoglobin > 10 to ≤ 13 g/dL who are at high risk for perioperative blood loss from elective, noncardiac, nonvascular surgery.
The indications for blood transfusion are not directly stated in the provided drug labels, but the labels do mention situations where red blood cell (RBC) transfusions may be necessary or avoided:
- In patients with chronic kidney disease (CKD), RBC transfusions may be decreased with Epogen treatment.
- In patients with anemia due to zidovudine in HIV infection, RBC transfusions may be decreased with Epogen treatment.
- In patients with anemia due to chemotherapy in cancer, RBC transfusions may be decreased with Epogen treatment.
- In patients undergoing elective, noncardiac, nonvascular surgery, RBC transfusions may be reduced with Epogen treatment. However, the labels also state that Epogen is not indicated as a substitute for RBC transfusions in patients who require immediate correction of anemia 2 2.
Key points:
- Epogen decreases the need for RBC transfusions in certain conditions.
- Epogen is not a substitute for RBC transfusions in cases where immediate anemia correction is needed.
From the Research
Indications for Blood Transfusion
- Red blood cell transfusions are used to treat hemorrhage and to improve oxygen delivery to tissues 3
- Indications for transfusion include:
- Symptomatic anemia (causing shortness of breath, dizziness, congestive heart failure, and decreased exercise tolerance) 3
- Acute sickle cell crisis 3
- Acute blood loss of more than 30 percent of blood volume 3
- Severe anemia, with a restrictive transfusion strategy of 7 to 8 g/dL being as safe as a liberal transfusion strategy of 9 to 10 g/dL in many clinical settings 4
- Fresh frozen plasma infusion can be used for reversal of anticoagulant effects 3
- Platelet transfusion is indicated to prevent hemorrhage in patients with:
- Thrombocytopenia or platelet function defects 3
- Hypoproliferative thrombocytopenia in nonbleeding patients receiving chemotherapy or undergoing allogeneic stem cell transplant, when platelet count is less than 10 × 103/μL 5
- Consumptive thrombocytopenia in neonates without major bleeding, when platelet count is less than 25 × 103/μL 5
- Patients undergoing lumbar puncture, when platelet count is less than 20 × 103/μL 5
- Cryoprecipitate is used in cases of hypofibrinogenemia, which most often occurs in the setting of massive hemorrhage or consumptive coagulopathy 3
Considerations for Transfusion
- Transfusion practice should be guided by patient symptoms and preferences in conjunction with the patient's hemoglobin concentration 4
- Evaluation and management of the etiology of the anemia is essential 4
- Iron-restricted erythropoiesis is a common cause of anemia severe enough to be considered for red blood cell transfusion, but diagnosis and management of absolute iron deficiency anemia, the anemia of inflammation with functional iron deficiency, or their combination may be problematic 4
- Intravenous iron therapy is generally the treatment of choice for absolute iron deficiency in patients with complex medical disorders, with or without coexisting functional iron deficiency 4
Risks and Benefits of Transfusion
- Transfusion-related infections are less common than noninfectious complications 3
- All noninfectious complications of transfusion are classified as noninfectious serious hazards of transfusion 3
- Acute complications occur within minutes to 24 hours of the transfusion, whereas delayed complications may develop days, months, or even years later 3
- Restrictive transfusion strategies probably do not cause increases in mortality or bleeding relative to liberal strategies across predefined clinical populations 5
- Restrictive strategies reduce risk of adverse reactions, mitigate platelet shortages, and reduce costs 5