Transfusion in Asymptomatic Patients with a Cardiac History

[SLUser11]

Hi,

I am curious what the up-to-date practices are regarding threshold for transfusing asymptomatic patients with a history of cardiac disease. I'm familiar with some of the older literature (pre-2008), but I've fallen off the critical care bus at this point, and I was having a hard time finding straight answers in the literature.

For those of you active in the ICU, when you have a patient who is status post non-cardiac surgery, and they are asymptomatic and overall doing well, is there a number that triggers transfusion under your care? What is the value, and does that value change based on other factors such as age (>80) or type of surgery. What literature do you base your decisions on? What about for medical ICU patients?

I know that the pendulum initially swung toward restrictive transfusion, and I'm unsure if the pendulum is swinging back. I think it's clear that patients without a cardiac history can tolerate significant anemia, but I've never been as certain with the more at-risk population. Obviously the risks of transfusion don't go away, but I wondered if the benefits go up.

I promise that this isn't a trap, or a setup for an argument, etc. I've just hit a dead end on my lit search, and I don't have a clear answer yet.

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[jdh71]

Hi,

I am curious what the up-to-date practices are regarding threshold for transfusing asymptomatic patients with a history of cardiac disease. I'm familiar with some of the older literature (pre-2008), but I've fallen off the critical care bus at this point, and I was having a hard time finding straight answers in the literature.

For those of you active in the ICU, when you have a patient who is status post non-cardiac surgery, and they are asymptomatic and overall doing well, is there a number that triggers transfusion under your care? What is the value, and does that value change based on other factors such as age (>80) or type of surgery. What literature do you base your decisions on? What about for medical ICU patients?

I know that the pendulum initially swung toward restrictive transfusion, and I'm unsure if the pendulum is swinging back. I think it's clear that patients without a cardiac history can tolerate significant anemia, but I've never been as certain with the more at-risk population. Obviously the risks of transfusion don't go away, but I wondered if the benefits go up.

I promise that this isn't a trap, or a setup for an argument, etc. I've just hit a dead end on my lit search, and I don't have a clear answer yet.

From the MICU perspective we're pretty stingy with blood. We'll transfuse if <7.0 and in the setting of ACS will transfuse <10.0 to 10.0

 

[PMPMD]

Hi,

I am curious what the up-to-date practices are regarding threshold for transfusing asymptomatic patients with a history of cardiac disease. I'm familiar with some of the older literature (pre-2008), but I've fallen off the critical care bus at this point, and I was having a hard time finding straight answers in the literature.

For those of you active in the ICU, when you have a patient who is status post non-cardiac surgery, and they are asymptomatic and overall doing well, is there a number that triggers transfusion under your care? What is the value, and does that value change based on other factors such as age (>80) or type of surgery. What literature do you base your decisions on? What about for medical ICU patients?

I know that the pendulum initially swung toward restrictive transfusion, and I'm unsure if the pendulum is swinging back. I think it's clear that patients without a cardiac history can tolerate significant anemia, but I've never been as certain with the more at-risk population. Obviously the risks of transfusion don't go away, but I wondered if the benefits go up.

I promise that this isn't a trap, or a setup for an argument, etc. I've just hit a dead end on my lit search, and I don't have a clear answer yet.

Similar to JDH , a generic "cardiac history" does not change my transfusion threshold. Active myocardial ischemia does. I don't change my threshold based on age or history of surgery.

 

[SLUser11]

From the MICU perspective we're pretty stingy with blood. We'll transfuse if <7.0 and in the setting of ACS will transfuse <10.0 to 10.0

Similar to JDH , a generic "cardiac history" does not change my transfusion threshold. Active myocardial ischemia does. I don't change my threshold based on age or history of surgery.

I used the same practice as a resident, and I remember reading an article (? Crit Care Medicine) that showed restrictive transfusion policies were safe in patients with CAD. However, looking back on the literature recently, I've only been able to find the big studies that excluded these patients.

Anyway, thanks for the reply.

 

[Hernandez]

as above, H/o CAD doesn't change my threshold to 10gm, unless they're actively bleeding or having active ischemia,

 

[Stitch]

From the MICU perspective we're pretty stingy with blood. We'll transfuse if <7.0 and in the setting of ACS will transfuse <10.0 to 10.0

This generally true for the PICU as well. Most studies have shown a consistent increase in mortality/morbidity associated with increased transfusions and I think the trend is to tolerate lower and lower hemoglobins if asymptomatic. The exception in my world is that most of my cardiac patients are some variant of a single ventricle. Mixers we keep at a crit of 40 pre op, but that's a whole different ball game.