Hgb < 7–8 g/dL—red blood cell transfusion is indicated
Hgb 8–10 g/dL—optimal transfusion threshold is unclear
Hgb > 10 g/dL—red blood cell transfusion is usually not necessary
Effect of Red Blood Cell Transfusion
One unit of packed red blood cells (~300 mL) is expected to increase the hemoglobin by 1 g/dL or the hematocrit by ~3 % in an average 70 kg adult patient, if there is no active bleeding.
A posttransfusion hemoglobin or hematocrit can be sent as soon as 15 min following transfusion to assess for response.
Risks of Transfusion
Red blood cell transfusions are associated with their own risks and costs [11–14]. The risks of transfusion include acute and delayed hemolytic reactions, febrile nonhemolytic reactions, allergic reactions, viral hepatitis and HIV, transfusion-related acute lung injury (TRALI), sepsis due to bacterial contamination, volume overload (or transfusion-associated circulatory overload [TACO]), and hyperkalemia.
Patients Who Decline Blood Transfusion
Informed consent must be obtained prior to blood transfusion. Patients may decline transfusions for many reasons, most commonly for religious reasons (Jehovah’s Witnesses).
Typically, Jehovah’s Witnesses do not accept whole blood or any of the “four major components” (i.e., red blood cells, platelets, plasma, and white blood cells). Many Jehovah’s Witnesses also believe that blood should not be taken out of the body and stored for any length of time, and do not accept preoperative autologous blood donation.
Patients who decline whole blood transfusion may or may not decide to accept certain medical therapy such as blood subfractions, recombinant coagulation factors, and autologous blood so long as it maintains a continuous circuit with their body.
When caring for any patient who declines blood transfusion, it is important to respect the patient’s decisions, establish a working relationship, maintain confidentiality, review the patient’s understanding and personal position on medical therapy, and develop an appropriate blood management plan including a clear course of action if the worst-case scenario were to occur, and document carefully [15].
Most of the strategies used for patients who decline blood transfusions are the same that are used for all patients to reduce the need for blood transfusion [16, 17]. Erythropoiesis-stimulating agents (see discussion below) and hemostatic agents (coagulation factors, antifibrinolytics, desmopressin, etc.) have more limited roles in the management of perioperative anemia.
If there is a question whether care can be provided for such a patient, a referral should be considered. The Society for the Advancement of Blood Management, which is not affiliated with Jehovah’s Witnesses, also maintains a list of hospitals in the United States with bloodless medicine and surgery programs (http://www.sabm.org).
Erythropoiesis-Stimulating Agents
Recombinant human erythropoietin (epoetin alfa) is FDA approved to reduce the need for blood transfusions in patient undergoing elective, noncardiac, nonvascular surgery.
The benefit of epoetin alfa must be weighed against the potential risks of this therapy (death, myocardial infarction, stroke, deep vein thrombosis [DVT], and tumor progression).
Depending on the timing of surgery, epoetin alfa may be given as 300 U/kg per day beginning 10 days before surgery, on the day of surgery, and for 4 days after surgery or it can be given as 600 U/kg once weekly 21, 14, and 7 days prior to surgery and on the day of surgery. Reticulocyte count will increase in the first few days. Hemoglobin increase varies but can be expected to rise by at least 1–2 g/L prior to surgery. Ferrous sulfate 325 mg PO daily should be given with epoetin alfa.
Due to increased risk of DVT, DVT prophylaxis is recommended if epoetin alfa is given.
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