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Parameters for Blood Transfusion in MDS

Panelists:Rami S. Komrokji, MD, Moffitt Cancer Center; Ellen K. Ritchie, MD, New York Presbyterian Hospital; Mikkael A. Sekeres, MD, MD, Cleveland Clinic; Jamile M. Shammo, MD, FASCP, FACP, Rush University Medical Center
Published: Wednesday, Jul 06, 2016


Transcript:

Mikkael A. Sekeres, MD, MS:
I wonder what your transfusion parameters are for red blood cells and platelets, irrespective of other comorbidities. Rami, what do you use?

Rami S. Komrokji, MD: For platelets, I think we usually go down to less than 10. Like when their platelets are less than 10, we transfuse unless there are bleeding events or other factors. For red blood cell transfusion, I think I really individualize those based on the patients we just described. If somebody is really asymptomatic with 8 grams and able to do everything on a daily basis, I may not transfuse them. Somebody who cannot walk around at home—even if their hemoglobin is 8.5, and you give them blood, and they feel better, and they’re able to function—I change it. I think the general rule is, we say hemoglobin less than 8, but I really find this is very valuable from one patient to the other, and I don’t think we can set a certain number for every patient. Then, whether we transfuse them two units or only one unit every time, I think there’s some push now from the blood banks to try to minimize transfusions even to one unit. And, I think that’s even individualized. There are some patients, they get one unit, and they become functional. So, I always tells the patients we are going to try it, see where you are, and after a while, we figure out a level where they feel it’s impacting their daily activities. If it does not, I am more willing to let their hemoglobin go lower without transfusing them if they don’t feel impact on their daily activity.

Mikkael A. Sekeres, MD, MS: And that one unit is part of the Choosing Wisely campaign, as well, right? So, we tend to do the same thing. What are your parameters, Ellen?

Ellen K. Ritchie, MD: There are a lot of institutional pressures on our parameters because of supply. So, we really try not to give platelets unless it’s 10000 or less. We try not to give transfusion of packed cells unless it’s 7.5 or less. That being said, patients who have a comorbid illness, like severe heart failure, who really cannot be functional at 7.5, we transfuse them to the level that they need to be able to function. The purpose of our transfusion is to make patients have a functional life, so, if you’re not able to do that, then there really is no point. We really talk to individual patients about the level that they need in order to be functional. That being said, in a place like New York City, where there is a huge demand, we always have to watchful of that, there is limited supply.

Mikkael A. Sekeres, MD, MS: How about you, Jamile?

Jamile Shammo, MD: I have a comparable cutoff, less than 7 g/dL for hemoglobin and less than 10000 for platelets. But I think the problem is, when you try to estimate symptomatic anemia, it’s very difficult because 90% of the United States population is probably fatigued independent of their hemoglobin. It tends to be a little bit difficult, but I try to also individualize. Someone with heart disease is probably an 8. And we had a discussion, too, about the consequences of transfusion. The patients need to know that we’re trying to avoid iron overload, and especially that could be relevant in people who have low-risk disease. So, once they understand why you are being a little bit more cautious with transfusion, they’re probably a little bit more on board with that, and they can also participate in that decision, do I or don’t I need that unit today?

Mikkael A. Sekeres, MD, MS: Our parameters are hemoglobin of 8 and platelet count of 10,000 as well. I will tell you, part of the education that we’ve undertaken is that in the setting of a lot of studies that have shown that in the intensive care units, you should use a hemoglobin cutoff of 7, that this is an outpatient older population which is very different. We’ve been able to successfully make that case for a hemoglobin of 8 as opposed to a hemoglobin of 7 or 7.5. But that did take some education within our institution, and we can see how our parameters vary even among the four of us who practice MDS every single day. So, there is a lot of variability around the country.

Transcript Edited for Clarity
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Transcript:

Mikkael A. Sekeres, MD, MS:
I wonder what your transfusion parameters are for red blood cells and platelets, irrespective of other comorbidities. Rami, what do you use?

Rami S. Komrokji, MD: For platelets, I think we usually go down to less than 10. Like when their platelets are less than 10, we transfuse unless there are bleeding events or other factors. For red blood cell transfusion, I think I really individualize those based on the patients we just described. If somebody is really asymptomatic with 8 grams and able to do everything on a daily basis, I may not transfuse them. Somebody who cannot walk around at home—even if their hemoglobin is 8.5, and you give them blood, and they feel better, and they’re able to function—I change it. I think the general rule is, we say hemoglobin less than 8, but I really find this is very valuable from one patient to the other, and I don’t think we can set a certain number for every patient. Then, whether we transfuse them two units or only one unit every time, I think there’s some push now from the blood banks to try to minimize transfusions even to one unit. And, I think that’s even individualized. There are some patients, they get one unit, and they become functional. So, I always tells the patients we are going to try it, see where you are, and after a while, we figure out a level where they feel it’s impacting their daily activities. If it does not, I am more willing to let their hemoglobin go lower without transfusing them if they don’t feel impact on their daily activity.

Mikkael A. Sekeres, MD, MS: And that one unit is part of the Choosing Wisely campaign, as well, right? So, we tend to do the same thing. What are your parameters, Ellen?

Ellen K. Ritchie, MD: There are a lot of institutional pressures on our parameters because of supply. So, we really try not to give platelets unless it’s 10000 or less. We try not to give transfusion of packed cells unless it’s 7.5 or less. That being said, patients who have a comorbid illness, like severe heart failure, who really cannot be functional at 7.5, we transfuse them to the level that they need to be able to function. The purpose of our transfusion is to make patients have a functional life, so, if you’re not able to do that, then there really is no point. We really talk to individual patients about the level that they need in order to be functional. That being said, in a place like New York City, where there is a huge demand, we always have to watchful of that, there is limited supply.

Mikkael A. Sekeres, MD, MS: How about you, Jamile?

Jamile Shammo, MD: I have a comparable cutoff, less than 7 g/dL for hemoglobin and less than 10000 for platelets. But I think the problem is, when you try to estimate symptomatic anemia, it’s very difficult because 90% of the United States population is probably fatigued independent of their hemoglobin. It tends to be a little bit difficult, but I try to also individualize. Someone with heart disease is probably an 8. And we had a discussion, too, about the consequences of transfusion. The patients need to know that we’re trying to avoid iron overload, and especially that could be relevant in people who have low-risk disease. So, once they understand why you are being a little bit more cautious with transfusion, they’re probably a little bit more on board with that, and they can also participate in that decision, do I or don’t I need that unit today?

Mikkael A. Sekeres, MD, MS: Our parameters are hemoglobin of 8 and platelet count of 10,000 as well. I will tell you, part of the education that we’ve undertaken is that in the setting of a lot of studies that have shown that in the intensive care units, you should use a hemoglobin cutoff of 7, that this is an outpatient older population which is very different. We’ve been able to successfully make that case for a hemoglobin of 8 as opposed to a hemoglobin of 7 or 7.5. But that did take some education within our institution, and we can see how our parameters vary even among the four of us who practice MDS every single day. So, there is a lot of variability around the country.

Transcript Edited for Clarity
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