Blood transfusion: rethinking who, what and when

Dr Rebecca HowmanConsultant Haematologist

9th October 2014

Blood transfusion practice

• Blood is unique treatment

– It’s a gift: voluntary donors

– It’s complex:Australian Red Cross Blood ServiceTGAhospitalslaboratoriesclinicianspatients

Evolution of transfusion

Transfusion practice in 21st century

Transfusion guidelines from NHMRC

• >100 g/L transfusion prob not good• <70 g/L transfusion prob good• 70-100 g/L …you decide

“If you have decided the patient needs one unit, then you might as well give two”“You need a blood transfusion.”….”Do I?”

Transfusion for anaemia in non-bleeding (or “stabilised recently bleeding”) patient

• We have assumed for too long that transfusion is safe, beneficial and free

• In anaemic patients– ?does an increase in Hb equate to improved patient

symptoms, improved patient outcomes– ?at what threshold is the clinical benefit– ?is there any harm

Perils of anaemia

Perils of transfusion

Anaemia increases risk of death

OR for each 10g/L decrease 2.1 (1.7-2.6)No sig interaction between Hb and CVS disease (p-0.09)

Risk of death in those who refuse Tx

Overall median days from lowest Hb to death 2d (range 0-22, IQR 1-8)

Perils of blood transfusion

Why transfuse?

• Patients are transfused to treat symptoms, reduce morbidity and mortality, and improve quality of life

• Delivery of oxygen to tissue is the primary function of the RBC…transfusion must be to improve tissue oxygen delivery (not oxygen carrying capacity).

• Other reasons for transfusion (volume expansion, support for blood pressure) are not promoted

Poor O2 dissociation

• Normal RBC P50 26mmHg

• Stored RBC quickly loses 2,3 DPG, by 48-96h storage, 2,3 DPG virtually zero (P50 6-11mmHg)

• Transfused blood has such a high affinity that it does not release O2, may well pull O2 from tissues

• Transfused blood will begin 2,3 DPG repletion after rewarming…by 24 hours levels are still <50% normal

Red cell membrane changes

Immune modulation• Transfusion attenuates immune response

– Improve renal allograft survival– Reduce risk of recurrent spontaneous abortion– Reduce severity of autoimmune disorders– Increase cancer recurrence– Increase peri-operative infections– Increase multi-organ failure

• Mechanisms?– Reduction in CD8 T-cell function and number– Altered CD4 number– NK cell number and function– Macrophage-mediated– Cell mediated responses

Recognition of risks of blood transfusion

• Risks of blood transfusion go beyond transmission of infection, fever, incomptability reactions etc

• Blood transfusion is associated with worse patient outcomes – Increased post-operative infection (immune modulation)– Increased length of stay– Increased thrombosis rate– Increased cancer recurrence– Increased mortality in short term

Blood Budget

• Blood is freely given but it is not free!• $350 per unit red cells from ARBCS• $650-1000 per unit = administration,

transport, hospital costs

• Future (2016)– blood budget is to be devolved to hospitals

Patient Blood Management (PBM)

The timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss in an effort to improve patient outcome.

PBM in WA• 3.9% hospital separations in 2012-2013 were associated with a

transfusion

• DoH in WA has been implemented Patient Blood Management– FH 2008– SCGH mid-2012 – RPH, KEMH 2013

• PBM staff provide – education regarding risks and benefits of transfusion– advocate alternatives to transfusion e.g. IV iron– initiate and advocate for hospital policies that support the appropriate use of

blood and blood products– develop innovations such as paediatric tubes, Rotem, etc

Single unit transfusion policy at SCGH

Why give 2, when 1 will

do?•In many instances a transfusion of one unit of red cells will be sufficient to improve symptoms

• A second unit should only be prescribed following review of the patient

3165

4967

2863

3923

Reduction of 1044 units

(21%) transfused

Comparison of pre- and post-single unit policy

1707

2065

1227

646

231172

Comparison of pre- and post-single unit policy

360

233

956

54724%

reduction

43% reduction

Comparison of pre- and post-single unit policy

Overall “value”

• Cost savings: significant– $361,570 saved (RBC price)– $2-3.6 million (total transfusion price)

• Patient outcomes….???– Length of stay– Infection rate– Readmission rates

What can you do instead? Go to PBM intranet site

• Intravenous iron– iron carboxymaltose (1000mg given over 15 mins)

• on hospital formulary for IV lounge, AAU• cost PBS $317 per 500mg

– iron polymaltose (1000mg given over 5 hours)• $150 per 500mg

• Oral iron (specify formulation)– FGF, Ferrogradumet, Ferrograd C, Ferro-f-tab

• Non-iron anaemia– end consult (haem, renal, general med)

Transfusion Sample Collection

Results & Strategies

Sample collection Errors August 2014

• Governed by National Guidelines for Pre-Transfusion Pathology requirements– National Pathology Accreditation Advisory Council (NPAAC)– Australia and New Zealand Society of Blood Transfusion

guidelines

Following collection and before leaving the patient, the sample tube(s) must be legibly labelled with the: Patient’s family name, first name in full Hospital record number or date of birth Date & time of collection Signature [or initials] of the collector”

Sample collection & labelling requirements

Strategies

• 3 policy posters • Correct Completion of Transfusion Request Forms• Rhyme poster as a reminder to check for date, time and

signature• Policy rationales

• Education sessions– Session with ED nurses– Have competition for medical staff

• Suggest recommendations on how transfusion services can improve services for staff

1st Poster 2nd Poster

3rd Poster

• Checklists for trolleys– SCGH Checklist for Specimen Collection

• Group & Screen and Crossmatch Blood Samples