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Invited Commentary |

Determining When Patients Need Transfusions

Samuel A. Tisherman, MD1
[+] Author Affiliations
1R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland, Baltimore
JAMA Surg. 2015;150(10):956. doi:10.1001/jamasurg.2015.1710.
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Blood transfusions save lives but carry risks, including immunosuppression, infections, and transfusion reactions. For stable patients, a restrictive transfusion strategy (transfusions for a hemoglobin [Hb] level of <7 g/dL [to convert to grams per liter, multiply by 10.0]) is safe, possibly beneficial, and saves money.13

Are there other parameters that should be considered for transfusion? Previous work4 suggested that a change in the Hb (ΔHb) level from baseline to nadir of 50% or more in patients who underwent cardiac surgery was associated with worse outcomes. In this issue of JAMA Surgery, Spolverato et al5 have expanded this concept to patients who are undergoing gastrointestinal procedures. They studied 4 groups based on whether the ΔHb level was less than 50% or 50% or greater and whether the nadir Hb level was less than 7 g/dL or 7 g/dL or greater. Patients with a nadir Hb level of 7 g/dL or greater and a ΔHb level of less than 50% rarely needed transfusions and had good outcomes. In contrast, patients with a nadir Hb level of less than 7 g/dL were frequently given transfusions and had an increased risk of adverse outcomes. The patients of interest were those who maintained a nadir Hb level of 7 g/dL or greater despite a ΔHb level of 50% or more. They had a high risk of complications but also seemed sicker at baseline than patients with a lower ΔHb level. This finding alone does not justify transfusion. A patient’s ΔHb may just be a summative marker of preoperative risk factors and perioperative blood loss, yet the current data justify further study of ΔHb.

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