What is restrictive transfusion?

From the Guidelines

Restrictive transfusion is a blood management strategy that uses a hemoglobin threshold of 7-8 g/dL to guide red blood cell transfusions, and it is recommended for most hospitalized, stable patients, including those with preexisting cardiovascular disease, as it has been shown to be as safe as liberal transfusion while reducing transfusion-related complications 1.

Key Points

• Restrictive transfusion strategies aim to minimize unnecessary transfusions by using lower hemoglobin thresholds to guide when to administer red blood cell transfusions.
• The hemoglobin threshold for restrictive transfusion is typically 7-8 g/dL, compared to liberal strategies that use higher thresholds of 9-10 g/dL.
• This approach has been shown to be safe and effective in reducing transfusion-related complications, such as transfusion reactions, infections, volume overload, and immunomodulation, in most stable, non-bleeding adult patients, including those with cardiovascular disease 1.
• The physiological basis for this approach is that most patients can compensate for moderate anemia through increased cardiac output and enhanced oxygen extraction, making transfusion unnecessary until more severe anemia develops.

Clinical Application

• For most stable, non-bleeding adult patients, transfusion is typically initiated when hemoglobin falls below 7 g/dL, while patients with cardiovascular disease may have a slightly higher threshold of 8 g/dL.
• When transfusion is needed, it's generally administered as single units followed by reassessment rather than automatically giving multiple units.
• This restrictive approach helps conserve limited blood resources and reduces the risk of transfusion-related complications, making it a recommended strategy for most hospitalized, stable patients 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Definition of Restrictive Transfusion

• Restrictive transfusion refers to a strategy of transfusing red blood cells at a lower hemoglobin threshold, typically 7 to 8 g/dL, rather than at a higher threshold of 9 to 10 g/dL 2, 3, 4.
• This approach aims to minimize the use of blood transfusions and reduce the risks associated with transfusion, such as transfusion-related complications and immune system modulation 3, 4.

Clinical Applications of Restrictive Transfusion

• Restrictive transfusion strategies have been shown to be safe and effective in various clinical settings, including hospitalized adult patients who are hemodynamically stable, critically ill patients, and patients undergoing surgery 2, 3, 4.
• The use of restrictive transfusion thresholds has been recommended for patients with certain medical conditions, such as coronary artery disease, congestive heart failure, and myelodysplastic neoplasms, although the evidence is limited in these areas 5.
• Restrictive transfusion policies have also been found to be feasible and safe in patients treated with intensive chemotherapy for acute myeloid leukemia 6.

Benefits of Restrictive Transfusion

• Restrictive transfusion strategies can reduce the number of red blood cell transfusions and minimize the risks associated with transfusion 3, 4.
• The use of restrictive transfusion thresholds can also decrease the proportion of patients exposed to red blood cell transfusions by 43% across a broad range of clinical specialties 4.
• Additionally, restrictive transfusion policies may help to conserve blood resources and reduce healthcare costs 3, 4.

Considerations for Implementing Restrictive Transfusion

• The decision to implement a restrictive transfusion strategy should be based on individual patient needs and clinical context, taking into account factors such as symptoms, hemoglobin level, and underlying medical conditions 2, 3, 5.
• Clinicians should also consider alternative therapies, such as iron supplementation, and evaluate the etiology of anemia in patients who require transfusions 5.