Open-access Prophylactic blood transfusion prior to elective invasive procedures

INTRODUCTION

In Brazil, approximately 3.3 million blood transfusions are performed annually, of which 62.4% correspond to packed red blood cells (PRBCs), 17% to platelet concentrates (PC), and 13% to fresh frozen plasma1. The use of blood products (BPs) is one of the most common interventions in clinical practice and can save lives when indicated.

In both developed and developing countries, inappropriate prescription of blood components occurs in up to 36% of cases2. The rational prescription of transfusion therapies is essential due to limited resources and growing demand3. Moreover, several studies have shown that aggressive correction of anemia, thrombocytopenia, and coagulopathies does not necessarily result in better clinical outcomes4.

These factors show the importance of individually tailoring the indications and establishing evidence-based transfusion programs5. However, several international medical guidelines still recommend the prescription of BP based on low-quality studies or expert opinion6,7.

In this study, a narrative review of the literature was conducted regarding the evidence for the prescription of BP prophylaxis for elective invasive procedures in clinically stable patients with anemia, thrombocytopenia, or coagulopathies.

The included studies were classified according to the quality of the scientific evidence following the 2011 Oxford Center for Evidence-Based Medicine recommendations (Table 1)8.

Table 1
Oxford Centre for Evidence-Based Medicine levels of evidence according to the study design.

CENTRAL VENOUS CATHETER PUNCTURE-RELATED TRANSFUSION

Evidence regarding the use of blood components prior to central venous catheter (CVC) puncture in patients with blood dyscrasias is scarce. Most international guidelines recommend performing thrombocytopenia and international normalized ratio (INR) correction before the puncture but at variable cutoff points7,9. Nevertheless, classic coagulogram parameters (i.e., prothrombin time, INR, and platelet count) have been poor predictors of bleeding-related complications after CVC puncture10.

A meta-analysis including 4,387 CVC insertions revealed a 5.1% risk of bleeding complications. The efficacy of blood transfusions in preventing these complications could not be determined due to the high heterogeneity and low methodological quality of the studies11.

ESOPHAGOGASTRODUODENOSCOPY

In clinical practice, esophagogastroduodenoscopy (EGD) plays an essential role in the diagnosis and treatment of severe digestive bleeding. This is a heterogeneous clinical context, which may involve patients with or without hemodynamic instability, coagulation disorders, and/or thrombocytopenia.

Based on low-quality evidence, the American Society for Gastrointestinal Endoscopy recommends a minimum value of 20′103 platelets/mm3 to perform EGD in patients at low risk of bleeding and 50′103 platelets/mm3 in those at high risk12. Meanwhile, the British guidelines recommend performing EGD with platelet reserve in patients with less than 50–80′103 platelets/mm313. However, two systematic reviews demonstrated that the existing evidence is insufficient to establish a cutoff point for performing EGD in thrombocytopenic patients and that the current recommendations are based on expert opinion14,15.

Some randomized controlled trials (RCTs) evaluated the transfusion of PRBCs in patients with upper gastrointestinal bleeding and showed lower mortality associated with the use of restrictive strategies (transfusion to maintain Hb 7–8 g/dL)16. The European Society of Gastrointestinal Endoscopy guideline corroborates this strategy recommending Hb values between 7 and 9 g/dL17.

As for coagulopathy, no study demonstrated the risk of a new bleeding event in patients with elevated INR (2.5 or higher) or the use of anticoagulants18. Despite this, a cohort indicates that performing early EGD (<24 h) is safe in patients after partial INR correction, with a similar risk to patients with no coagulopathies19. The International Consensus Group recommends the correction of coagulopathies in advance due to the benefits of early EGD and low evidence of complications, provided this does not delay endoscopy20.

BRONCHOSCOPY

Bronchoscopy is a well-established complementary method for investigating respiratory system pathologies, including bronchoalveolar lavage, lung parenchyma biopsy, and therapeutic procedures. The incidence of hemorrhagic complications after bronchoscopy is approximately 0.44%21.

According to the latest guideline of the American Association of Blood Banks, bronchoscopy can be safely performed in patients with a platelet count ≥20′103/mm3. This recommendation is mainly based on observational studies with limited sample sizes22. Despite this, a recent cohort study observed a low rate of bleeding complications in 1,711 cancer patients with thrombocytopenia, including those with a platelet count <20′103/mm3. Approximately, 45% of the patients with 10–20′103 platelets/mm3 did not receive prophylactic PC transfusion, and even so, there was no significant difference in bleeding complications23. In the case of levels <10′103 platelets/mm3, PC transfusion before the procedure is plausible due to the high risk of spontaneous bleeding10.

RENAL BIOPSY

A major complication associated with renal biopsy is hemorrhagic bleeding, occurring in approximately 0.6–4.9% of cases24. Some of the risk factors for post-biopsy bleeding are as follows: female sex, advanced age, elevated INR, hypertension, and increased baseline creatinine levels25,26. The use of ultrasound in clinical practice allowed the use of open biopsies in some specific cases, as well as CT-, laparoscopic-, or transjugular-guided biopsies.

The use of BPs, especially PRBCs, tends to be more strongly influenced by pre-procedure baseline hemoglobin values rather than by the decrease in hemoglobin levels during the biopsy, the presence of perinephric hematoma, or the need for post-procedure surgical approach27. In a large meta-analysis of randomized clinical trials, Salpeter et al. do not recommend routine blood transfusion after renal biopsy because of increased mortality, higher incidence of acute myocardial infarction, pulmonary edema, and bacterial infections28. However, the cutoff point for blood transfusion in these patients is controversial, and there are no major RCTs on the use of blood concentrates before or after this procedure27.

Regarding platelet transfusion, the thrombocyte level decrease is associated with the development of symptomatic hematoma29. In a retrospective study, Simard-Meilleur et al. demonstrated that the risk of this complication is inversely proportional to the serum platelet level, being 11% in patients with >200′103 platelets/mm3 and 40% in those with levels <100′103 platelets/mm329.

LIVER BIOPSY

The most severe complications of liver biopsies are intraperitoneal hemorrhage, hemobilia, and hematoma formation. The risk of clinically relevant bleeding complications that result in hemodynamic compromise or require some form of intervention ranges from 0.01 to 0.5%30,31.

Both organ dysfunction and hepatosplenomegaly as a result of chronic liver diseases may result in blood dyscrasias, either by INR change or by platelet destruction and dysfunction. Thus, the American Association for the Study of Liver Diseases recommends the correction of thrombocytopenia to serum levels below 50–60′103 platelets/mm332. Regarding INR, the Society of Interventional Radiology defines its cutoff point for performing biopsy as an INR ≤1.5–1.8 and <2.5 for the general population and for patients with chronic liver disease (CLD), respectively33.

In the largest RCT evaluating the performance of percutaneous liver biopsy in patients with advanced CLD, the HALT-C indicated an increased risk of post-procedure bleeding in patients with platelet counts ≤60′103/mm3 (5.3% versus 0.4%; p<0.001) and INR≤1.334. However, this study excluded thrombocytopenia <50′103/mm3, and no patients with INR>1.5 experienced bleeding events.

FINAL ANALYSIS

This study found few and sometimes contradictory data on the indication of blood component transfusion before invasive procedures. Most published studies correspond to observational studies with heterogeneous results and several methodological limitations.

This study found a significant inconsistency in recommendations between the guidelines evaluated and also regarding the evidence available in the literature, indicating that such recommendations are based on expert opinion.

Table 2 shows a synthesis of the main studies, their recommendations, recommended cutoff values for platelet count and INR, and data on the quality of evidence. Figure 1 presents the final recommendations based on these results.

Table 2
Synthesis of evidence levels and recommendations for studies evaluating prophylactic blood transfusion and/or bleeding risk related to elective invasive procedures.
Figure 1
Recommendations for prophylactic blood transfusion prior to main elective invasive procedures.

CONCLUSIONS

Few studies evaluated the indications of prophylactic blood transfusion for bleeding complications in patients with anemia, thrombocytopenia, or coagulopathies. The recommendations of international guidelines do not always reflect critical analyses of the available scientific evidence and should be reviewed and applied in clinical practice with caution.

  • Funding: This work was funded by the Secretaria de Saúde do Estado de Pernambuco as a part of the Medical Residency Program Grant.

REFERENCES

  • 1 Silva DLQ, Brito KNP, Ferreira PHG, dos Santos APG. Caderno de informação: sangue e hemoderivados. Brasília: Ministério da Saúde; 2017.
  • 2 Sharif M, Saxena A, Singh S, Manchala S, Jafri N. Blood component transfusion in a tertiary care hospital. Indian J Pediatr. 2020;87(5):339-44. https://doi.org/10.1007/s12098-020-03186-2
    » https://doi.org/10.1007/s12098-020-03186-2
  • 3 Mohammed AD, Ntambwe P, Crawford AM. Barriers to effective transfusion practices in limited-resource settings: from infrastructure to cultural beliefs. World J Surg. 2020;44(7):2094-9. https://doi.org/10.1007/s00268-020-05461-x
    » https://doi.org/10.1007/s00268-020-05461-x
  • 4 Franchini M, Marano G, Mengoli C, Pupella S, Vaglio S, Muñoz M, et al. Red blood cell transfusion policy: a critical literature review. Blood Transfus. 2017;15(4):307-17. https://doi.org/10.2450/2017.0059-17
    » https://doi.org/10.2450/2017.0059-17
  • 5 Sadana D, Pratzer A, Scher LJ, Saag HS, Adler N, Volpicelli FM, et al. Promoting high-value practice by reducing unnecessary transfusions with a patient blood management program. JAMA Intern Med. 2018;178(1):116-22. https://doi.org/10.1001/jamainternmed.2017.6369
    » https://doi.org/10.1001/jamainternmed.2017.6369
  • 6 Bodenham A, Babu S, Bennett J, Binks R, Fee P, Fox B, et al. Association of Anaesthetists of Great Britain and Ireland: safe vascular access 2016. Anaesthesia. 2016;71(5):573-85. https://doi.org/10.1111/anae.13360
    » https://doi.org/10.1111/anae.13360
  • 7 Patel IJ, Davidson JC, Nikolic B, Salazar GM, Schwartzberg MS, Walker TG, et al. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol. 2012;23(6):727-36. https://doi.org/10.1016/j.jvir.2012.02.012
    » https://doi.org/10.1016/j.jvir.2012.02.012
  • 8 Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C. Oxford Centre for Evidence-Based Medicine 2011 levels of evidence; 2011. [cited on Feb. 15, 2021]. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence
    » https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence
  • 9 Bachowski G, Borge D, Brunker PAR, Eder A, Fialkow L, Fridey JL. A Compendium of Transfusion Practice Guidelines. 3rd ed. Chicago, IL, USA: American National Red Cross; 2017.
  • 10 Kumar A, Mhaskar R, Grossman BJ, Kaufman RM, Tobian AA, Kleinman S, et al. Platelet transfusion: a systematic review of the clinical evidence. Transfusion. 2015;55(5):1116-27. https://doi.org/10.1111/trf.12943
    » https://doi.org/10.1111/trf.12943
  • 11 Cabrini L, Pappacena S, Mattioli L, Beccaria P, Colombo S, Bellomo R, et al. Administration of BP to prevent bleeding complications associated with central venous catheter insertion in patients at risk: a systematic review. Br J Anaesth. 2017;118(4):630-4. https://doi.org/10.1093/bja/aex060
    » https://doi.org/10.1093/bja/aex060
  • 12 ASGE Standards of Practice Committee, Ben-Menachem T, Decker GA, Early DS, Evans J, Fanelli RD, et al. Adverse events of upper GI endoscopy. Gastrointest Endosc. 2012;76(4):707-18. https://doi.org/10.1016/j.gie.2012.03.252
    » https://doi.org/10.1016/j.gie.2012.03.252
  • 13 Andreyev HJ, Davidson SE, Gillespie C, Allum WH, Swarbrick E. Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer. Gut. 2012;61(2):179-92. https://doi.org/10.1136/gutjnl-2011-300563
    » https://doi.org/10.1136/gutjnl-2011-300563
  • 14 Razzaghi A, Barkun AN. Platelet transfusion threshold in patients with upper gastrointestinal bleeding: a systematic review. J Clin Gastroenterol. 2012;46(6):482-6. https://doi.org/10.1097/MCG.0b013e31823d33e3
    » https://doi.org/10.1097/MCG.0b013e31823d33e3
  • 15 Tong MC, Tadros M, Vaziri H. Endoscopy in neutropenic and/or thrombocytopenic patients. World J Gastroenterol. 2015;21(46):13166-76. https://doi.org/10.3748/wjg.v21.i46.13166
    » https://doi.org/10.3748/wjg.v21.i46.13166
  • 16 Kheiri B, Abdalla A, Osman M, Haykal T, Chintalapati S, Cranford J, et al. Restrictive versus liberal red blood cell transfusion for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. J Thromb Thrombolysis. 2019;47(2):179-85. https://doi.org/10.1007/s11239-018-1784-1
    » https://doi.org/10.1007/s11239-018-1784-1
  • 17 Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2015;47(10):a1-46. https://doi.org/10.1055/s-0034-1393172
    » https://doi.org/10.1055/s-0034-1393172
  • 18 Nagata N, Sakurai T, Moriyasu S, Shimbo T, Okubo H, Watanabe K, et al. Impact of INR monitoring, reversal agent use, heparin bridging, and anticoagulant interruption on rebleeding and thromboembolism in acute gastrointestinal bleeding. PLoS One. 2017;12(9):e0183423. https://doi.org/10.1371/journal.pone.0183423
    » https://doi.org/10.1371/journal.pone.0183423
  • 19 Thomopoulos KC, Mimidis KP, Theocharis GJ, Gatopoulou AG, Kartalis GN, Nikolopoulou VN. Acute upper gastrointestinal bleeding in patients on long-term oral anticoagulation therapy: endoscopic findings, clinical management and outcome. World J Gastroenterol. 2005;11(9):1365-8. https://doi.org/10.3748/wjg.v11.i9.1365
    » https://doi.org/10.3748/wjg.v11.i9.1365
  • 20 Barkun AN, Almadi M, Kuipers EJ, Laine L, Sung J, Tse F, et al. Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the International Consensus Group. Ann Intern Med. 2019;171(11):805-22. https://doi.org/10.7326/M19-1795
    » https://doi.org/10.7326/M19-1795
  • 21 Facciolongo N, Patelli M, Gasparini S, Agli LL, Salio M, Simonassi C, et al. Incidence of complications in bronchoscopy. Multicentre prospective study of 20,986 bronchoscopies. Monaldi Arch Chest Dis. 2009;71(1):8-14. https://doi.org/10.4081/monaldi.2009.370
    » https://doi.org/10.4081/monaldi.2009.370
  • 22 Kaufman RM, Djulbegovic B, Gernsheimer T, Kleinman S, Tinmouth AT, Capocelli KE, et al. Platelet transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2015;162(3):205-13. https://doi.org/10.7326/M14-1589
    » https://doi.org/10.7326/M14-1589
  • 23 Faiz SA, Jimenez CA, Fellman BM, Huk T, Jazbeh S, Haque SA, et al. Incidence of bleeding complications with flexible bronchoscopy in cancer patients with thrombocytopenia. J Bronchol Interv Pulmonol. 2019;26(4):280-86. https://doi.org/10.1097/LBR.0000000000000590
    » https://doi.org/10.1097/LBR.0000000000000590
  • 24 Trajceska L, Severova-Andreevska G, Dzekova-Vidimliski P, Nikolov I, Selim G, Spasovski G, et al. Complications and risks of percutaneous renal biopsy. Open Access Maced J Med Sci. 2019;7(6):992-5. https://doi.org/10.3889/oamjms.2019.226
    » https://doi.org/10.3889/oamjms.2019.226
  • 25 Shidham GB, Siddiqi N, Beres JA, Logan B, Nagaraja HN, Shidham SG, et al. Clinical risk factors associated with bleeding after native kidney biopsy. Nephrology (Carlton). 2005;10(3):305-10. https://doi.org/10.1111/j.1440-1797.2005.00394.x
    » https://doi.org/10.1111/j.1440-1797.2005.00394.x
  • 26 Manno C, Strippoli GF, Arnesano L, Bonifati C, Campobasso N, Gesualdo L, et al. Predictors of bleeding complications in percutaneous ultrasound-guided renal biopsy. Kidney Int. 2004;66(4):1570-7. https://doi.org/10.1111/j.1523-1755.2004.00922.x
    » https://doi.org/10.1111/j.1523-1755.2004.00922.x
  • 27 Whittier WL, Sayeed K, Korbet SM. Clinical factors influencing the decision to transfuse after percutaneous native kidney biopsy. Clin Kidney J. 2016;9(1):102-7. https://doi.org/10.1093/ckj/sfv128
    » https://doi.org/10.1093/ckj/sfv128
  • 28 Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med. 2014;127(2):124-31.e3. https://doi.org/10.1016/j.amjmed.2013.09.017
    » https://doi.org/10.1016/j.amjmed.2013.09.017
  • 29 Simard-Meilleur MC, Troyanov S, Roy L, Dalaire E, Brachemi S. Risk factors and timing of native kidney biopsy complications. Nephron Extra. 2014;4(1):42-9. https://doi.org/10.1159/000360087
    » https://doi.org/10.1159/000360087
  • 30 Alvaro D, Caporaso N, Giannini EG, Iacobellis A, Morelli M, Toniutto P, et al. Procedure-related bleeding risk in patients with cirrhosis and severe thrombocytopenia. Eur J Clin Invest. 2021:e13508. https://doi.org/10.1111/eci.13508
    » https://doi.org/10.1111/eci.13508
  • 31 Boyum JH, Atwell TD, Schmit GD, Poterucha JJ, Schleck CD, Harmsen WS, et al. Incidence and risk factors for adverse events related to image-guided liver biopsy. Mayo Clin Proc. 2016;91(3):329-35. https://doi.org/10.1016/j.mayocp.2015.11.015
    » https://doi.org/10.1016/j.mayocp.2015.11.015
  • 32 Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD, American Association for the study of liver diseases. Liver biopsy. Hepatology. 2009;49(3):1017-44. https://doi.org/10.1002/hep.22742
    » https://doi.org/10.1002/hep.22742
  • 33 Davidson JC, Rahim S, Hanks SE, Patel IJ, Tam AL, Walker TG, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions-Part I: Review of Anticoagulation Agents and Clinical Considerations: Endorsed by the Canadian Association for Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe. J Vasc Interv Radiol. 2019;30(8):1155-67. https://doi.org/10.1016/j.jvir.2019.04.016
    » https://doi.org/10.1016/j.jvir.2019.04.016
  • 34 Seeff LB, Everson GT, Morgan TR, Curto TM, Lee WM, Ghany MG, et al. Complication rate of percutaneous liver biopsies among persons with advanced chronic liver disease in the HALT-C trial. Clin Gastroenterol Hepatol. 2010;8(10):877-83. https://doi.org/10.1016/j.cgh.2010.03.025
    » https://doi.org/10.1016/j.cgh.2010.03.025
  • 35 van de Weerdt EK, Peters AL, Goudswaard EJ, Binnekade JM, van Lienden KP, Biemond BJ, et al. The practice of platelet transfusion prior to central venous catheterization in presence of coagulopathy: a national survey among clinicians. Vox Sang. 2017;112(4):343-51. https://doi.org/10.1111/vox.12498
    » https://doi.org/10.1111/vox.12498
  • 36 Müller MC, Arbous MS, Spoelstra-de Man AM, Vink R, Karakus A, Straat M, et al. Transfusion of fresh-frozen plasma in critically ill patients with a coagulopathy before invasive procedures: a randomized clinical trial (CME). Transfusion. 2015;55(1):26-35. https://doi.org/10.1111/trf.12750
    » https://doi.org/10.1111/trf.12750
  • 37 Weigand K, Encke J, Meyer FJ, Hinkel UP, Munder M, Stremmel W, et al. Low levels of prothrombin time (INR) and platelets do not increase the risk of significant bleeding when placing central venous catheters. Med Klin. 2009;104(5):331-5. https://doi.org/10.1007/s00063-009-1070-2
    » https://doi.org/10.1007/s00063-009-1070-2
  • 38 Abu-Sbeih H, Ali FS, Coronel E, Chen HC, Wang X, Lum P, et al. Safety of endoscopy in cancer patients with thrombocytopenia and neutropenia. Gastro Endosc. 2019;89(5):937-49.e2. https://doi.org/10.1016/j.gie.2018.12.004
    » https://doi.org/10.1016/j.gie.2018.12.004
  • 39 Nandagopal L, Veeraputhiran M, Jain T, Soubani AO, Schiffer CA. Bronchoscopy can be done safely in patients with thrombocytopenia. Transfusion. 2016;56(2):344-8. https://doi.org/10.1111/trf.13348
    » https://doi.org/10.1111/trf.13348
  • 40 Carr IM, Koegelenberg CF, Groote-Bidlingmaier F von, Mowlana A, Silos K, Haverman T, et al. Blood loss during flexible bronchoscopy: a prospective observational study. RES. 2012;84(4):312-8. https://doi.org/10.1159/000339507
    » https://doi.org/10.1159/000339507
  • 41 Chen T, Estrella M, Fine D. Predictors of kidney biopsy complication among patients with systemic lupus erythematosus. Lupus. 2012;21(8):848-54. https://doi.org/10.1177/0961203312439334
    » https://doi.org/10.1177/0961203312439334

Publication Dates

  • Publication in this collection
    19 Nov 2021
  • Date of issue
    Sept 2021

History

  • Received
    08 June 2021
  • Accepted
    16 June 2021
location_on
Associação Médica Brasileira R. São Carlos do Pinhal, 324, 01333-903 São Paulo SP - Brazil, Tel: +55 11 3178-6800, Fax: +55 11 3178-6816 - São Paulo - SP - Brazil
E-mail: ramb@amb.org.br
rss_feed Acompanhe os números deste periódico no seu leitor de RSS
Acessibilidade / Reportar erro