The World Health Organization indicates that every second someone in the world needs a blood transfusion. Blood transfusions therefore save many lives every year, and patients can die when they don’t receive a transfusion when necessary. However, transfusions also carry certain risks, and therefore should not be performed unless really necessary.
In recent years, a lot of emphasis has been put on this second consideration, which has been more broadly rebranded as “patient blood management” (PBM). PBM is a worthwhile effort, but should be evidence-based and not based on other considerations, be it religious (e.g., refusing of an allogenic blood transfusion as a Jehovah Witness) or commercial (e.g., receiving sponsorships by commercial companies who promote RBC replacing products).
It is therefore important that transfusion guidelines are of high quality, and based on the best scientific evidence. Our analysis of the quality of the most widely used transfusion guidelines, using an internationally used tool (AGREE II), indicates that guidelines recommending red blood cell transfusion as of Hb levels of 7 to 8 g/dL are based on high quality evidence, whereas the more recent guidelines recommending red blood cell transfusion only at Hb thresholds of ≤6 g/dL are not based on solid evidence.
The methodological robustness of the published transfusion guidelines is variable and has room for improvement. Furthermore, guideline developers and reviewers should always be transparent about conflicts of interest, whether religious or commercial, which was, based on other available information, not always the case in these guidelines.
Van Remoortel H1, De Buck E1, Dieltjens T1, Pauwels NS1, Compernolle V1,2, Vandekerckhove P1,2,3.[expand title=”Show Affiliations”]
- BelgianRed Cross-Flanders, Mechelen, Belgium.
- Faculty of Medicine, University of Ghent, Ghent, Belgium.
- Department of Public Health and Primary Care, Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium.
Recent literature suggests that more restrictive red blood cell (RBC) transfusion practices are equivalent or better than more liberal transfusion practices. The methodologic quality of guidelines recommending more restrictive transfusion thresholds and their underlying scientific evidence is unclear. Therefore, we aimed to evaluate the quality of the development process of red blood cell transfusion guidelines and to investigate the underlying evidence of guidelines recommending a more restrictive hemoglobin (Hb) threshold.
STUDY DESIGN AND METHODS:
Via systematic literature screening of relevant databases (NGC, GIN, Medline, and Embase), red blood cell transfusion guidelines recommending a more restrictive Hb level (<6, <7, or <8 g/dL) were included. Four assessors independently evaluated the methodologic quality by scoring the rigor of development domain (AGREE II checklist). The level of evidence served as a reference for the quality of the underlying evidence.
The methodologic quality of 13 red blood cell transfusion guidelines was variable (18%-72%) but highest for those developed by Advancing Transfusion and Cellular Therapies Worldwide (72%), the Task Force of Advanced Bleeding Care in Trauma (70%), and the Dutch Institute for Healthcare Improvement (61%). A Hb level of less than 7 g/dL (intensive care unit patients) or less than 8 g/dL (postoperative patients) were the only thresholds based on high-quality evidence. Only four of 32 recommendations had a high-quality evidence base.
Methodologic quality should be guaranteed in future RBC transfusion guideline development to ensure that the best available evidence is captured when recommending restrictive transfusion strategies. More high-quality trials are needed to provide a stronger scientific basis for RBC transfusion guidelines that recommend more restrictive transfusion thresholds.
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