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“Blood transfusion is not harmless. It’s not chicken soup.”

Although blood transfusions are routinely given in the surgical and nonsurgical setting, the decision to transfuse should be carefully thought out and based on clinical versus real-world indicators, according to Maureane Hoffman, MD, PhD. These clinical indicators, while clearly defined, become nebulous when translated into real-world practice. Basing this perspective on her experience as Director of the Blood Bank and Hematology Laboratories at the Durham VA Medical Center in North Carolina, Dr. Hoffman believes that while transfusion may be life-saving at times, there is the potential for adverse effects, especially if the procedure is not clearly warranted.

The possible side effects with which they have been associated include clinical error resulting in misidentification of blood product or patient, transfusion-related acute lung injury, and bacterial contamination of blood products. Moreover, a significant body of literature suggests that certain patient cohorts, including the critically ill, should not be transfused unless there is a good indicator to do so. In light of this evidence, clinicians should be circumspect in their decision to transfuse and consider clinical criteria: oxygen-carrying capacity, clotting factor activity, fibrinogen level, platelet function, cardiopulmonary reserve, and rate and magnitude of current and anticipated blood loss. When indicated, adjunct or alternative therapies should be considered for patients, including local measures to reduce or prevent blood loss, or prohemostatic agents such as small molecular weight inhibitors of the fibrinolytic system.

Although transfusion triggers and hemoglobin levels are delineated in guidelines to aid clinicians in their decision to transfuse, guidelines are broad, and when applied to real-world practice, there is a tendency for clinicians to transfuse for laboratory values solely. These values only provide an incomplete picture, as patients with the same values can have different needs for transfusion. It becomes the clinician’s responsibility to evaluate the patient’s clinical situation in light of guidelines but base the decision to transfuse on a multiplicity of factors.

While such a decision is a complex one, involving guidelines and laboratory values, in Dr. Hoffman’s view, ultimately, it is simply a matter of clinical judgment.


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