Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.
JAMA. 2023 Nov 21;330(19):1892-1902. doi: 10.1001/jama.2023.12914.
Red blood cell transfusion is a common medical intervention with benefits and harms.
To provide recommendations for use of red blood cell transfusion in adults and children.
Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed.
For adults, 45 randomized controlled trials with 20 599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence).
It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.
红细胞输注是一种常见的医疗干预措施，具有益处和危害。
为成人和儿童提供红细胞输注的使用建议。
遵循了可靠指南标准，包括使用推荐评估、制定和评估方法，管理利益冲突，并明确价值观和偏好。对随机对照试验的系统评价证据进行了审查。
对于成年人，45 项涉及 20599 名参与者的随机对照试验比较了基于血红蛋白的限制性输血阈值（通常为 7 至 8g/dL）与 9 至 10g/dL 的宽松输血阈值。对于儿科患者，7 项涉及 2730 名参与者的随机对照试验比较了各种限制性和宽松输血阈值。对于大多数患者群体，结果提供了中等质量的证据表明，限制性输血阈值不会对患者重要结局产生不利影响。建议 1：对于血流动力学稳定的住院成年患者，国际小组建议采用限制性输血策略，当血红蛋白浓度低于 7g/dL 时考虑输血（强烈推荐，中等确定性证据）。根据大多数试验中使用的限制性策略阈值，对于接受心脏手术的患者，临床医生可以选择 7.5g/dL 的阈值，对于接受骨科手术或患有心血管疾病的患者，选择 8g/dL 的阈值。建议 2：对于患有血液系统和肿瘤疾病的住院成年患者，小组建议采用限制性输血策略，当血红蛋白浓度低于 7g/dL 时考虑输血（有条件推荐，低确定性证据）。建议 3：对于血流动力学稳定且无血红蛋白病、紫绀性心脏疾病或严重低氧血症的危重症儿童和有发生危重症风险的儿童，国际小组建议采用限制性输血策略，当血红蛋白浓度低于 7g/dL 时考虑输血（强烈推荐，中等确定性证据）。建议 4：对于血流动力学稳定的先天性心脏病儿童，国际小组建议根据心脏异常和手术修复阶段设定输血阈值：7g/dL（双心室修复）、9g/dL（单心室姑息治疗）或 7 至 9g/dL（未经矫正的先天性心脏病）（有条件推荐，低确定性证据）。
在为个体患者做出输血决策时，考虑整体临床情况和输血替代疗法是良好的实践。
