Longer Hospital Stays and Higher Hospital Charges

Increased Morbidity and Mortality

New Dangers in Banked Blood

Shrinking Blood Supplies

Increased Risk of Infection and Other Complications

Bacterial Infection

Other Complications

Lack of Standards and Wide Variation in RBC Transfusion Practice

Lack of Guidelines to Reduce Exposure to Blood Transfusion

Positive Effects of Blood Avoidance

Cases

Blood product transfusion was associated with a 2.5-fold (95% CI 2.1-3.1) increased mortality, 3.7 day (95% CI 2.1-3.1 ) increase in hospital length of stay, and a 7120 dollars (95% CI 6472 dollars-7769 dollars) increase in total charges compared to patients that did not receive Any Transfusion. This data can be used by providers in discussions with patients regarding the risks for transfusion and in identifying patients in whom strategies to reduce transfusions should be evaluated. (J Gastrointest Surg. 2002 Sep-Oct;6(5):753-62. Preoperative predictors of blood transfusion in colorectal cancer surgery)

Allogeneic, but not autologous, blood transfusion(s) were associated in a dose-dependent manner with longer hospital stays and higher costs… Multiple linear regression analyses demonstrated that the number of units of allogeneic blood transfused, rather than surgeon and type of surgery, was the most statistically significant predictor of length of stay and hospital charges. (Semin Hematol. 1997 Jul;34(3 Suppl 2):34-40. Allogeneic transfusion and infection: economic and clinical implications)

Recognition that allogeneic transfusion associated immunomodulation can increase morbidity in allogeneically transfused individuals has become a major concern for those involved in transfusion medicine (Vox Sang. 1998;74 Suppl 2:315-9 I mmunomodulatory effects of allogeneic blood transfusions)

Blood product transfusion was associated with a 2.5-fold (95% CI 2.1-3.1) increased mortality, 3.7 day (95% CI 2.1-3.1) increase in hospital length of stay, and a 7120 dollars (95% CI 6472 dollars-7769 dollars) increase in total charges compared to patients that did not receive Any Transfusion. This data can be used by providers in discussions with patients regarding the risks for transfusion and in identifying patients in whom strategies to reduce transfusions should be evaluated. (J Gastrointest Surg. 2002 Sep-Oct;6(5):753-62. Preoperative predictors of blood transfusion in colorectal cancer surgery)

Using data reported in the literature, we estimate that the death rate from allogeneic transfusion-related postoperative infection and cancer recurrence combined (215 deaths with 1% causality to 21,500 with 100% causality) may exceed the death rate due to all other transfusion risks combined. (Semin Hematol. 1997 Jul;34(3 Suppl 2):34-40. Allogeneic transfusion and infection: economic and clinical implications)

Despite the increased application of aseptic techniques for blood collection and the preparation of platelet concentrates, morbidity and mortality arising from the transfusion of bacterially contaminated allogeneic platelet products persist. (Transfus Med Rev. 2004 Jan;18(1):11-24. Improving the bacteriological safety of platelet transfusions)

Records of the transmission of bacterial infections by transfusion date back to the beginning of organized blood banking. Despite tremendous strides in preventing viral infection through careful donor screening and viral testing, there has been little improvement in reducing the risk of bacterial sepsis (Vox Sang. 2004 Apr;86(3):157-63. Transfusion-transmitted bacterial infection: risks, sources and interventions)

In the US, bacterial contamination is considered the second most common cause of death overall from transfusion (after clerical errors) with mortality rates ranging from 1:20000 to 1:85000 donor exposures. Estimates of severe morbidity and mortality range from 100 to 150 transfused individuals each year. (Hematology (Am Soc Hematol Educ Program). 2003;:575-89. Bacterial contamination of blood components: risks, strategies, and regulation: joint ASH and AABB educational session in transfusion medicine.)

The most common transfusion-associated infectious risk in the United States today is bacterial contamination of platelet components. Bacterial contamination is estimated to occur at an incidence of 1:1000 to 1:3000 in platelet units, with severe episodes estimated to occur in about one sixth of contaminated products. (Arch Pathol Lab Med. 2004 Mar;128(3):279-81. Bacterial contamination of platelet units: a case report and literature survey with review of upcoming American Association of Blood Banks requirements)

When patients are transfused, several possible adverse effects may occur in the transfused patient even though quality testing indicates no potential problem. These adverse events include infectious complications, hemolytic reactions, anaphylaxis, urticaria, circulatory overload, transfusion-associated graft-versus-host disease, chills and fever, immunomodulation, and transfusion-related acute lung injury (TRALI ). ( Clin Lab Sci. 2004 Summer;17(3):133-5. Transfusion-related acute lung injury (TRALI).)

Blood transfusions carry the risk of complications, including the transmission of disease, immunomodulation, and hemolytic and non-hemolytic reactions. (Mt Sinai J Med. 2002 Jan-Mar;69(1-2):83-7. Strategies for minimizing the use of allogeneic blood during orthopedic surgery)

Blood transfusion is associated with a 35-percent greater risk of serious bacterial infection and a 52-percent greater risk of pneumonia. Postoperative infections are costly. The risk of bacterial infection may be the most common life-threatening adverse effect of allogeneic blood transfusion. (Transfusion. 1999 Jul;39(7):694-700. Risk of bacterial infection associated with allogeneic blood transfusion among patients undergoing hip fracture repair)

Two studies in this week's issue of THE LANCET highlight the public-health implications of blood transfusion as a possible route for infection by the prion protein responsible for variant Creutzfeldt-Jakob disease (vCJD). (Lancet website)

The SHOT report of 1998/99 described 252 reports for the 12-month period. 1 A summary is shown in Table 1. The full SHOT report analyses these incidents and makes recommendations designed to prevent some of them, particularly the frequently reported problem of incorrect blood component transfusion. This annual report serves to highlight the risks associated with the transfusion of blood components and strengthens the argument for the use of alternative approaches where possible. ( Hospital Pharmacist Vol 7 No 5 p118-123 - May 2000 Special Features)

There is significant institutional variation in critical care transfusion practice, many intensivists adhering to a 100g/l threshold, and opting to administer multiple units despite published guidelines to the contrary. There is a need for prospective studies to define optimal practice in the critically ill ( Crit Care Med. 2003 Dec;31(12 Suppl):S672-7. Variation in red cell transfusion practice in the intensive care unit: a multicentre cohort study)

Variation in patients receiving plasma and platelet transfusions among institutions was determined in part by prophylactic transfusions. We conclude that blood component usage for coronary artery bypass grafts differs widely among institutions. The variability in use of these components is accounted for in part by unnecessary transfusions in otherwise routine, uncomplicated coronary artery bypass graft procedures. (JAMA. 1991 Jan 2;265(1):86-90. The variability of transfusion practice in coronary artery bypass surgery)

"Trigger hemoglobin" was the lowest hemoglobin recorded before transfusion or recorded at any time during the week before or after surgery for patients who were not transfused. RESULTS: There was considerable variation in transfusion among hospitals postoperatively (range 31.2% to 54.0%, P = 0.001). Trigger hemoglobin also varied considerably among hospitals. In unadjusted analyses, four of nine teaching and two of nine non-teaching hospitals had postoperative transfusion rates significantly higher than the reference (teaching) hospital, while one non-teaching hospital had a lower rate. In an analysis controlling for trigger hemoglobin and multiple clinical variables, one of nine teaching and four of nine non-teaching hospitals had rates higher than the reference hospital, while four teaching hospitals and one non-teaching hospital had lower rates. CONCLUSIONS: The apparent pattern of variation of transfusion among hospitals varies according to how one adjusts for relevant patient characteristics. ( Am J Med. 1998 Sep;105(3):198-206. How you look determines what you find: severity of illness and variation in blood transfusion for hip fracture)

The specific hospital significantly affects red cell and component transfusion practice in coronary artery bypass graft surgery: a study of five hospitals ( Transfusion. 1998 Feb;38(2):122-34)

This study assessed variation in red cell transfusion practice among adult patients hospitalized with ulcer disease (ULCER), and those undergoing coronary artery bypass grafting (CABG), hip surgery (HIP), or total knee replacement (KNEE). There is substantial interhospital variation in the proportion of patients transfused and number of units transfused in the four conditions studied. (Med Care. 1995 Nov;33(11):1145-60. Variation in the use of red blood cell transfusions. A study of four common medical and surgical conditions)

The long-term ICU population receive a large number of blood transfusions. Phlebotomy contributes significantly to these transfusions. There is no clear indication for a large number of the blood transfusions given. Many blood transfusions appear to be administered because of an arbitrary "transfusion trigger" rather than a physiologic need for blood. Blood conservation and adherence to transfusion guidelines could significantly reduce RBC transfusion in the ICU. ( Chest. 1995 Sep;108(3):767-71. RBC transfusion in the ICU. Is there a reason?)

 From October 1990 until September 1991 data were collected in the 43 hospitals from patients undergoing one of six elective surgical procedures. The results obtained from interim analysis (70% of expected data) of patients with total hip replacement revealed differences in the frequency of homologous blood transfusion between hospitals and also regional differences between different countries. There was great variation in the use of alternative programs for reduction or even avoidance of homologous blood transfusion between hospitals. (Infusionsther Transfusionsmed. 1993 Jun;20 Suppl 2:12-5. Blood replacement in elective surgery: results of the Sanguis Study)

Previous studies have identified disconcerting differences in transfusion practices among physicians. (Med Care. 1992 Dec;30(12):1083-96. Variation in a medical faculty's decisions to transfuse. Implications for modifying blood product utilization)

This survey documented a significant variation in transfusion practice patterns among pediatric critical care practitioners with respect to the threshold hemoglobin concentration for red blood cell transfusion. The volume of packed red blood cells given was not adjusted to the hemoglobin concentration. ( Pediatr Crit Care Med. 2002 Oct;3(4):335-40. Survey on transfusion practices of pediatric intensivists)

From October 1990 until September 1991 data were collected in the 43 hospitals from patients undergoing one of six elective surgical procedures. The results obtained from interim analysis (70% of expected data) of patients with total hip replacement revealed differences in the frequency of homologous blood transfusion between hospitals and also regional differences between different countries. There was great variation in the use of alternative programs for reduction or even avoidance of homologous blood transfusion between hospitals. (Infusionsther Transfusionsmed. 1993 Jun;20 Suppl 2:12-5. Blood replacement in elective surgery: results of the Sanguis Study)

Our hospital is a center for bloodless medicine and surgery (CBMS). It is one of 56 such centers located in the United States. The mission of the center is to provide surgical and medical treatment without the administration of blood or blood-related products. Patients' rights to autonomy and self-determination are respected. Development of the CBMS program required the writing and implementation of specific guidelines, developing standards of care, revising existing policies and procedures, and educating staff members. The CBMS program is multifaceted and multidisciplinary. (AORN J. 1998 Jan;67(1):144-52, Bloodless medicine and surgery)

These results suggest that even complex open heart operations can be performed without homologous transfusion by optimally applying available blood conservation techniques. More generalized application of these measures may increasingly allow "bloodless" operations in all patients . (J Am Coll Surg. 1997 Jun;184(6):618-29. Open heart operations without transfusion using a multimodality blood conservation strategy in 50 Jehovah's Witness patients: implications for a "bloodless" surgical technique)

Comprehensive risk factor-based application of multiple blood conservation measures in an optimized, integrated, and algorithmic manner can significantly decrease bleeding and need of allogeneic transfusion in coronary artery bypass grafting in a safe and cost-effective manner (Ann Thorac Surg. 1998 Jan;65(1):125-36. Comprehensive multimodality blood conservation: 100 consecutive CABG operations without transfusion)

A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction and unstable angina. (N Engl J Med. 1999 Feb 11;340(6):409-17. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care)

Therapeutic options, including blood-conservation tools, minimization of phlebotomy, erythropoietic agents, and investigational oxygen-carrying agents, may be alternatives to red blood cell transfusions in critically ill patients with anemia.

Improved clinical outcomes may result from techniques that minimize allogeneic blood use or its immunologic effects (e.g., autologous transfusion or other blood-sparing approaches in surgery, leukodepletion of allogeneic blood, and the use of growth factors [eg, epoetin alfa]). (Semin Hematol. 1997 Jul;34(3 Suppl 2):34-40. Allogeneic transfusion and infection: economic and clinical implications)

Blood management in orthopedic surgery is no longer an option; it is a requirement. The combination of patient desire to avoid transfusion, increasing evidence of multiple risks, decreasing blood supplies, and increasing costs mandate attention. This article addresses the balance of risk versus benefit in blood transfusion and presents a perioperative plan of blood management for patients undergoing orthopedic surgery. ( Current concepts and issues in blood management.Orthopedics. 2004 Jun;27(6 Suppl):s643-51.)

Hospitals Have Reduced Blood Use by Initiating a Blood Conservation Programs

Fairview , Ohio
After factoring in avoided transfusion-related expenses, Fairview officials estimate that the institution saved $450,000 in 2003 and have set a goal of further reducing blood usage by 10% in 2004 (CABMS Executive 2003 Report Summary). Despite the savings, hospital officials acknowledge that the BMSP initially increased use of several other costly items, namely fresh frozen plasma (FFP) and anemia drugs such as Procrit and Ferrlecit. However, as clinicians became accustomed to the new program, Procrit usage fell somewhat, and Fairview officials have set a goal to reduce FFP transfusions by 15% in 2004.

St Vincent Charity, Ohio

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