Appropriateness of Allogeneic Red Blood Cell Transfusion: The International Consensus Conference on Transfusion Outcomes

https://doi.org/10.1016/j.tmrv.2011.02.001Get rights and content

An international multidisciplinary panel of 15 experts reviewed 494 published articles and used the RAND/UCLA Appropriateness Method to determine the appropriateness of allogeneic red blood cell (RBC) transfusion based on its expected impact on outcomes of stable nonbleeding patients in 450 typical inpatient medical, surgical, or trauma scenarios. Panelists rated allogeneic RBC transfusion as appropriate in 53 of the scenarios (11.8%), inappropriate in 267 (59.3%), and uncertain in 130 (28.9%). Red blood cell transfusion was most often rated appropriate (81%) in scenarios featuring patients with hemoglobin (Hb) level 7.9 g/dL or less, associated comorbidities, and age older than 65 years. Red blood cell transfusion was rated inappropriate in all scenarios featuring patients with Hb level 10 g/dL or more and in 71.3% of scenarios featuring patients with Hb level 8 to 9.9 g/dL. Conversely, no scenario with patient's Hb level of 8 g/dL or more was rated as appropriate. Nearly one third of all scenarios were rated uncertain, indicating the need for more research. The observation that allogeneic RBC transfusions were rated as either inappropriate or uncertain in most scenarios in this study supports a more judicious transfusion strategy. In addition, the large number of scenarios in which RBC transfusions were rated as uncertain can serve as a road map to identify areas in need of further investigation.

Section snippets

Methods

The authors used the RAND/UCLA Appropriateness Method (RUAM), a structured process for integrating evidence from the scientific literature with experts' clinical judgment to produce explicit criteria for determining the appropriateness of specific procedures when high-quality and definitive evidence (usually from large randomized controlled trials) are missing.20, 21, 22, 23 The RUAM is an important clinical tool that has been used worldwide for more than 2 decades to identify criteria for the

Results

In the first round of panel ratings, there was disagreement on the appropriateness rating of 63 (14%) of 450 scenarios. Clinical setting, age, and comorbidities were not significantly associated with disagreement, but most scenarios with disagreement (68.3%) had Hb level 7.9 g/L or less, and there was no scenario with disagreement with Hb level 10 g/L or more (P < .001 compared with scenarios without disagreement). The median of the ratings in scenarios with disagreement was significantly

Discussion

The panel rated allogeneic RBC transfusion as inappropriate and unlikely to improve patient outcomes in most of the scenarios discussed in this study, which were based on hypothetical not actively bleeding average (not extreme) patients with stable vital signs. These included all scenarios in which patients had an Hb level 10 g/dL or more as well as more than 70% of scenarios featuring patients with an Hb level 8 to 9.9 g/dL and 6.7% of scenarios with an Hb level 7.9 g/dL or less. In scenarios

Conclusions

The findings of the ICCTO panel suggest that clinical situations in which allogeneic RBC transfusion has demonstrated unequivocal benefit based on available data are uncommon. In the most rated scenarios, RBC transfusions are not deemed likely to improve outcomes and, in fact, may lead to harm. In a substantial number of cases, the impact of RBC transfusion on outcomes still remains uncertain and in need of further investigation. These observations, in combination with data indicating that RBC

Acknowledgments

The authors are grateful to Alan Tinmouth, MD (Ottawa Hospital, General Campus Clinical Epidemiology Research Unit, Ottawa, ON), for the review of the manuscript. We are thankful to Harriet Gammon, RN (Joint Commission, Villa Park, IL), Hans Gombotz, MD, PhD (Chair, General Hospital, Department of Anesthesiology and Intensive Care, Linz, Austria), Peter Page, MD (American Red Cross, West Hollywood, CA), Toby Silverman, MD (Chief, Clinical Review Branch, Division of Hematology, US Food and Drug

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