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Transfusion Practice, Policy and Prevention

Transfusion Practice, Policy and Prevention. Andrew Bernard, MD Associate Professor of Surgery Section on Acute Care Surgery Department of Surgery Co-Chair, UK Transfusion Safety/Quality Committee. Trauma Surgery  Acute Care Surgery. Objectives.

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Transfusion Practice, Policy and Prevention

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  1. TransfusionPractice, Policy and Prevention Andrew Bernard, MD Associate Professor of Surgery Section on Acute Care Surgery Department of Surgery Co-Chair, UK Transfusion Safety/Quality Committee

  2. Trauma Surgery  Acute Care Surgery

  3. Objectives • Understand current evidence and best practice for RBC transfusion • Know UK policies on transfusion • Outline anemia prevention strategies

  4. No disclosures.

  5. Transfusion Practice Morbidity of RBC Transfusion Background Recommendations

  6. Effect of blood transfusions on subsequent kidney transplants. Opelz G, Sengar DP, Mickey MR, Terasaki PI. Transplant Proc 1973; 5:253-9. 792 Citations

  7. Effect of Restrictive versus Liberal RBC Transfusion Regimens in Critically Ill PatientsHebert PG et.al. NEJM 1999;340(6):409-17 Prospect randomized study of Critically Ill Patients (“TRICC” study-Transfusion Requirements in Critical Care) 838 patients with Hgb < 9.0 Randomized to: Restrictive regimen Transfused if hemoglobin < 7.0, maintained at 7-9 Liberal regimen Transfused if < 10.0, maintained 10-12 22% Hospital Mortality 28% Hospital Mortality

  8. Hebert, Tinmouth and Corwin. Chest 2007; 131: 1583

  9. Vincent, et al (146 European ICUs; 3534 patients) Logistic Regression Analysis for Mortality OR • Transfusion 1.37 • SOFA score 1.3 • APACHE II score 1.1 • Age 1.01 (NS) • Hgb 1.04 (NS) JAMA 2002; 288(12): 1499-1507

  10. Stored Blood for Transfusion Napolitano, L.M. and H.L. Corwin, Efficacy of red blood cell transfusion in the critically ill. Critical Care Clinics, 2004. 20(2): p. 255-268.

  11. Stored PRBCs behave in this manner! Anemic patients with NL RBCs can at least behave in these ways

  12. What hgb do you need? Critical Hematocrit And O2D

  13. Policy New UK Guidelines for Transfusion Massive Transfusion Protocol Getting Blood for Direct Admits Using Uncrossmatched Blood

  14. UK Healthcare2010 Guide for Blood Component TransfusionJuly 2010 PRBC’s Hct < 21% + symptoms/signs of inadequate oxygen delivery FFP INR ≥ 1.5 or PTT ≥ 46sec + active bleeding and can’t be corrected by Vitamin K Platelets <50,000 during and for 24 hours following surgery <10,000 in non-bleeding patient Cryoprecipitate Fibrinogen <100 mg/dl

  15. So Hgb 7 is the trigger? “trigger to begin thinking about it.”

  16. Rationale and Purpose of new (lower) threshold. • Rationale • Many risks associated with transfusion • Little evidence that transfusion above this threshold improves outcome in normal and many critically ill patients • Considerable evidence that more liberal threshold may compromise outcome. • Purpose • Improve patient outcomes • Conserve valuable resources • Save money for institution

  17. Historical Perspective 1988- Perioperative RBC Transfusions, NIH Consensus Development Statement: • SUGGESTED Hgb = 7 ! • But most compromised on Hgb = 8

  18. CCCTG. Hebert et al. NEJM 1999;340. Napolitano et al. Crit Care Med. 2009;37.

  19. Indicators for Considering RBC Transfusion(in absence of continued bleeding) Normovolemic anemia (Hgb≤7) WITH signs or symptoms of inadequate oxygen delivery Pape, A., et al: Blood Transfus 7:250-8, 2009 Napolitano et al. Critical Care Medicine 2009;37:3124-3157

  20. What are signs or symptoms of inadequate oxygen delivery? Signs ScvO2 < 70% [nl=80%] (central line) SvO2 < 65% [nl=75%] (PA catheter) Low cerebral or tissue oximetry Base deficit – ABG Lactic acidosis - lab ST changes - EKG ↓ LV contractility by trans esoph echo SYMPTOMS Mental status alteration Dyspnea Chest pain New arrhythmias Tachycardia (not from hypovolemia) Pape, A., et al: Blood Transfus 7:250-8, 2009 Napolitano et al. Critical Care Medicine 2009;37:3124-3157

  21. Possible EXCEPTIONS to Hb=7 CNS Neurologic injury/disease Leal-Noval SR,et al. Intensive Care Med 2006;32:1733-40. Smith MJ,et al. Crit Care Med 33:1104-8. 2005. Acute MI or Acute Coronary Syndrome Wu WC et al NEJM 2001;345:1230-6. NICU Sick premature babies Decreased hematologic reserve Risk of intraventricular hemorrhage. Bell, EF, Strauss, R.Pediatrics. 2005;115:1685-91. Septic shock With low ScvO2 Rivers, E. NEJM 2001; 345:1368-77.

  22. More Possible EXCEPTIONS to Hb=7 Hematologic disease Selected patients with chronic anemia Bone marrow failure Myelosuppressive/myeloablative therapy Infiltrative bone marrow disease Pediatric cardiac surgery

  23. HEMOGLOBIN = 7Implemented in the following Medical Institutions • Brigham and Women’s Boston • UAB • U Iowa • U Kansas • U Penn • Good Samaritan Hospital

  24. 1 RBC Preferable to 2 (in hemodynamically stable anemic patients) Consider 2nd unit based upon Hb/hct and physiology. Blood Transfus 2009;7:106-110.

  25. UK’s Blood Management Program PHASE I - Sept. 1, 2010 • Hb ≤ 7 • Pts ≤ 45 • Healthy PHASE II - Jan. 1, 2011 • All ages and categories • Exceptions noted in this presentation. • Other evidenced based exceptions will be considered.

  26. Hypothesis: Pre-ICU MTP (FFP after 6 units PRBC) is inadequate for correcting coagulopathy.

  27. What does the bottom of the blood transfusion form say?

  28. Trauma Transfusion-Orders for Uncrossed

  29. Trauma Transfusion-Frig not Cooler

  30. Prevention Avoiding unnecessary tests Using the lowest volume to run the test Avoiding waste Using smaller tubes

  31. Patients aren’t bleeding… ..but we’re transfusing. Walsh TS, et al. Transfusion 2004;44 (October):1405.

  32. Evidence Indicates: • Pediatric tubes: • Reduce phlebotomy volume • Reduce transfusions • Blood conservation devices • Reduce phlebotomy volume • Reduction in lab testing: • Reduces phlebotomy volume • Reduces transfusions

  33. Phlebotomy Volume in ICU 61-70cc/day (2oz, ¼ cup) Corwin HL et al. Chest 1995;108:767-71.

  34. 1. Only Perform Necessary Draws Add tests to blood in the lab.

  35. 2. Use the Lowest Volume Per Draw

  36. 3. Minimize Waste/Flush-The Safe Set (aka ‘Cell Saver’) • 100 patients • Less blood drawn and discarded (6 vs 96cc) • Higher Hgb in Safe Set group (1.2g/dl, p<0.0001 on day 9) • Discarded blood volume predicted Hgb decrement • No difference in transfusions Peruzzi WT et al. Crit Care Med 1993;21:501-6.

  37. Blood Conservation Devices in ICU • Blood ‘waste’ at UK (Pam Branson): • 3 day stay  1-1.5 units of waste • Safe Set can be used with a central line • Standard a-line set- $8 • Safe Set- $18 • Can you reinfuse flush otherwise? • Most nursing literature says ‘no’ • UK Nursing policy: ‘Discard’ Peruzzi WT et al. Crit Care Med 1993;21:501-6.

  38. Why not use smaller tubes? Standard instruments cannot accommodate pediatric tubes.

  39. 4. Use small-volume tubes. • New tubes: • Hemograms (2.0 vs 3.0 ml) • Coags (1.8 vs 2.7 ml)

  40. Does 1ml matter? More than 200 liters of blood annually.

  41. Summary • Transfusion carries risk • Indication must be: • Appropriate • Documented • Threshold if healthy: 7g/dl • Dose: 1 unit • Policies in place to protect patients • Strategies to prevent anemia work

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