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PubMed2005

A provincial program of blood conservation: The Ontario Transfusion Coordinators (ONTraC).

PURPOSE: Although often life-saving, blood transfusions are associated with significant risk to the patient and escalating costs to the blood system and hospital. Transfusions are often given unnecessarily. Blood conservation represents the use of alternatives to transfusion. The ONTraC program attempts to enhance transfusion practice outside the blood transfusion laboratory, promote blood conservation in surgery patients, and reduce allogeneic red cell use. METHODS: In the first such large scale program, funding was obtained from the Ontario MOHLTC for a Transfusion Coordinator in 23 Ontario hospitals selected based on blood utilization and geography. At specific time periods, detailed anonymized information was collected in a defined number of all consecutive patients admitted for the three designated surgical procedures: knee arthroplasty (N=approximately 1200 at each time point), abdominal aortic aneurysm (AAA; N=300 at each time) and coronary artery bypass graft (CABG) surgery (N=300 at each time point). RESULTS: Considerable inter-institutional variation was observed in the proportion of patients and amount of blood transfused. At the 12 month analysis, most, although not all, hospitals had decreased use of allogeneic blood and there was an overall 24% reduction in blood use in patients undergoing knee surgery, 14% in AAA and 23% in CABG. In addition to reduction in proportion of patients transfused, transfused patients received fewer units of allogeneic blood. Patients who did not receive allogeneic transfusions had significantly lower postoperative infection rates (p<0.05) and length of stay (p<0.0001); multivariate analysis showed that allogeneic transfusion was an independent predictor of increased length of stay. Eighteen-month analysis indicates even greater reduction in allogeneic transfusion. The main measures of blood conservation employed were preoperative autologous donation and education, with recent increasing use of erythropoietin and the cell saver. These measures have been demonstrated to be very effective in avoiding allogeneic transfusion. CONCLUSIONS: The ONTraC have become leaders locally, nationally and internationally in blood conservation. The reduction in allogeneic transfusion associated with the implementation of the ONTraC program represents important savings in costs associated with blood components, hospital stay and work in transfusion laboratories and nursing units, as well as enhancing patient satisfaction and safety.

Blood Preservation↗

PubMed1996

Changing patterns of red blood cell transfusion in very low birth weight infants.

OBJECTIVE: Anemia develops in increasing numbers of critically ill very low birth weight (VLBW) infants who survive the neonatal period, and they receive multiple red blood cell (RBC) transfusions. Despite their need for prolonged medical treatment, we hypothesized that VLBW infants presently receive fewer RBC transfusions as a result of the growing awareness of transfusion risks and improvement of neonatal care. METHODS: RBC transfusion practices and clinical outcomes in infants with birth weights of 1.5 kg or less were analyzed retrospectively in three selected years: 1982, before awareness of the human immunodeficiency virus; 1989, before surfactant availability; and 1993, before erythropoietin approval. RESULTS: Progressive declines in RBC transfusions, donor exposures, and transfusion volumes occurred concurrently with decreases in morbidity and mortality rates. Transfusions per infant (mean +/- SD) declined from 7.0 +/- 7.4 in 1982 to 5.0 +/- 5.8 in 1989 to 2.3 +/- 2.7 in 1993 (p < 0.001). This decline was associated with a decrease in pretransfusion hematocrit (33.6% +/- 2.8% in 1982, 34.2% +/- 3.7% in 1989, and 29.8% +/- 5.1% in 1993; p < 0.001). The distribution of RBC transfusions given by week of life among study years did not change; 70% of RBC transfusions were given within the first 4 weeks, when infants are sickest. Although the percentage of VLBW infants weighing more than 1 kg at birth and never receiving any RBC transfusions increased with time (17% in 1982, 33% in 1989, and 64% in 1993), more than 95% of infants weighing 1 kg or less in all years received transfusions. CONCLUSIONS: Overall administration of neonatal transfusions has decreased markedly, most likely because of multiple factors. Because most RBC transfusions are given to infants weighing 1 kg or less in the first weeks of life, therapeutic strategies should focus on this group of VLBW infants during this critical period. The temporal changes observed in transfusion patterns emphasize the importance of including concurrent controls in future studies evaluating transfusion interventions.

Erythrocyte Transfusion↗

PubMed1998

Variations in blood transfusions among newborn intensive care units. SNAP II Study Group.

OBJECTIVES: Very low birth weight (< 1500 g) infants frequently require packed red blood cell transfusions, and transfusion rates vary among neonatal intensive care units (NICUs). We analyzed transfusions and compared outcomes among NICUs. STUDY DESIGN: In a 6-site prospective study, we abstracted all newborns weighing < 1500 g (total = 825) born between October 1994 and September 1995. Transfusion frequency and volume and phlebotomy number were analyzed by site and adjusted for birth weight and illness severity. We compared rates of intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, growth, and length of stay between the high and low transfuser NICUs. RESULTS: Sites differed significantly in mean birth weight, illness severity, number of transfusions, pretransfusion hematocrit, blood draws, and donor number. Multivariate adjustment for these risks showed that the highest transfusing NICU transfused an additional 24 cc/kg per baby during the first 14 days and 47 cc/kg per baby after 15 days, relative to the lowest transfusing NICU. The presence of arterial catheters increased the frequency of blood transfusions. The rates of intraventricular hemorrhage, necrotizing enterocolitis, and bronchopulmonary dysplasia were not higher in the 2 lowest transfusing NICUs, nor were there differences in 28-day weight gain or length of stay. CONCLUSIONS: Major differences in transfusion practices for very low birth weight infants exist among NICUs. Because clinical outcomes were no different in lower transfuser NICUs, it is likely that transfusion and phlebotomy guidelines could result in fewer transfusions, fewer complications, and reduced cost.

Anemia, Neonatal↗

PubMed1997

The effect of intrauterine transfusion on fetal bilirubin in red cell alloimmunization.

OBJECTIVE: To evaluate the change in fetal serum bilirubin levels in response to intrauterine transfusion for red cell alloimmunization. METHODS: The records of 37 patients who underwent more than one intrauterine transfusion were reviewed. The following indices were extracted: pre- and post-transfusion fetal hematocrit, total and direct serum bilirubin, reticulocyte count, Kleihauer-Betke test results, volumes of intravascular and intraperitoneal transfusions, and the source used for transfusion. The data were compared for interval 1 (transfusion 1 to 2) and interval 2 (transfusion 2 to 3). The rates of change in bilirubin, reticulocyte count, and percent fetal cells on the Kleihauer-Betke test were defined as the differences between the initial values of one transfusion and the initial values of the next transfusion divided by the number of days between transfusions. Analysis of variance, sign-rank test, and linear regression analysis were used when appropriate. P < .05 was significant. RESULTS: The median number of intrauterine transfusions for each patient was 3 (range 2-8). Gestational ages ranged from 22 to 37 weeks. Total bilirubin remained above the 97.5 percentile for gestational age in all but five patients. There was a significant decrease in reticulocyte count and fetal cells on the Kleihauer-Betke test, and an increase in hematocrit with serial intrauterine transfusions. Bilirubin increased significantly after the first intrauterine transfusion (3.9 versus 5.0 mg/dL) and remained elevated thereafter. CONCLUSION: Fetal total serum bilirubin remains elevated with repeated intrauterine transfusions in fetal alloimmunization. Total bilirubin should not be used to evaluate fetal hematologic responses to the transfusions.

Adult↗

PubMed1996

Patients' attitudes regarding out-of-hospital blood transfusion.

BACKGROUND: While the administration of blood transfusions outside of the hospital has become more prevalent, little is known about patients' attitudes regarding this practice. STUDY DESIGN AND METHODS: Twenty-nine adult patients who regularly received blood transfusions in a hospital's outpatient clinic and had never received home transfusions were surveyed. Linear analogue and categorical monetary scales were used to evaluate their responses to a series of questions. RESULTS: At the time of the survey, 27 study participants (93%) did not want home transfusions, and 21 (72%) thought home transfusions posed a greater risk than hospital based transfusion. More than half (56%) of the participants were unwilling to pay more for a home transfusion for themselves than for an outpatient hospital-based transfusion. Participants were willing to pay more for a home blood transfusion for a hypothetical patient requesting transfusions at home. The lack of available transportation and poor patient health were identified as important factors in determining how much more they would be willing to pay for transfusions at home. CONCLUSION: While blood transfusions at home may become more accessible, many patients may prefer to receive their transfusions in the hospital, probably because home transfusions are thought to pose a greater risk. A patient's health and the availability of transportation were determined to be important factors in decisions about how much more money to spend for transfusions at home than for those in an outpatient hospital setting.

Adult↗

PubMed1998

Nationwide survey of home transfusion practices.

BACKGROUND: Limited information exists on home transfusion practices. STUDY DESIGN AND METHODS: In 1995, a survey requesting data for 1994 was sent to 1273 American Association of Blood Banks (AABB) institutional members and 113 non-AABB home health care agencies that provide out-of-hospital transfusions. RESULTS: Of 943 respondents, 102 provide blood to a home transfusion program, 37 provide blood and run a home transfusion program, and 13 run a home transfusion program only, for a total of 152 (16%) with some involvement in home blood transfusions. Most of the 50 respondents with a home transfusion program are licensed by their state and accredited by the Joint Commission on Accreditation of Healthcare Organizations. All respondents have written policies for home transfusion, and 90 percent require a signed informed-consent document before initiating transfusions in the home. Most have policies requiring that there be a second adult and a telephone in the home, that the home be deemed safe for transfusion, that the patient's physician be readily available, and that the patient have had prior transfusions. The most common component issued by the blood providers was red cells, followed by platelets. White cell-reduced components were always provided by 36 percent of respondents. The most common patient diagnosis was cancer. Home transfusions were provided primarily by registered nurses. Only 14 percent of respondents indicated that the medical director of the blood bank is responsible for approving a patient for home transfusion. A posttransfusion visit is performed by 46 percent of respondents. CONCLUSION: Although most facilities have policies for the administration of home transfusions, there remains marked heterogeneity among blood providers and transfusionists regarding home transfusion practices.

Adult↗

PubMed2001

Blood transfusion costs by diagnosis-related groups in 60 university hospitals in 1995.

BACKGROUND: Transfusion services are frequently challenged to initiate efforts to reduce blood transfusion costs. One approach is to analyze blood transfusion costs for individual medical and surgical Diagnosis-Related Groups (DRGs). Rank ordering of DRGs by transfusion costs and interinstitutional comparisons of these costs may lead to the selection of DRGs for further analysis of the process of blood transfusion. STUDY DESIGN AND METHODS: Common DRGs (n = 486) that were related to discharges in 1995 were analyzed from 60 university hospital members of the University HealthSystems Consortium (UHC). Cost data were tabulated by using cost-to-charge ratios reflecting all aspects of blood transfusion-related costs of participating institutions. RESULTS: Of these 486 DRGs, 471 had identifiable mean blood costs, and 34 had median blood costs, mostly for surgical conditions. Transfusion costs represented a small proportion (< or = 1%) of total hospitalization costs for most DRGS: Nonetheless, millions of dollars were spent on blood transfusion, and for the most expensive DRGs, the costs ranged from 5.0 to 8.6 percent of total hospitalization costs. Transfusion costs are more variable for the DRGs with the lowest transfusion costs than for those with the highest transfusion costs. CONCLUSION: Members of the UHC may utilize such analyses to identify surgical or medical diagnoses with transfusion costs at variance with the group norm. These DRGs could then be targeted for further evaluation of components contributing to high costs, for possible alterations in physician or clinical laboratory practices. Considering those conditions with the highest cumulative transfusion costs (e.g., BMT, liver transplant, acute leukemia, and cardiothoracic procedures), changes in transfusion practices that affect these particular patient categories may have a significant impact on global blood transfusion costs.

Blood Transfusion↗

PubMed2000

Immunological aspects of blood transfusions.

Donor selection based on blood group phenotypes, and blood processing such as leukocyte-depletion, gamma-irradiation or washing to remove plasma, are approaches for therapeutic or preventive use to manage the immunological complications of transfusion. Indications for specific components are prescribed in guidelines provided by (inter)national Transfusion Societies. Although the use of guidelines and protocols is in line with modern medicine, these can create a state of tension with the political sense of values to improve the viral safety of blood products and with the commercial exploitation of pooled plasma-products.A century of blood transfusion therapy has facilitated cancer treatment and advanced surgical interventions. The transfusion product has improved progressively, although mostly in response to disasters such as wars and AIDS. Every blood transfusion interacts with the immune system of the recipient. There are, however, very few quantitative figures to estimate the consequences. This review is based on the available literature on the clinical consequences of transfusion induced immunization and modulation. To a large degree the clinical consequences of transfusion induced immune effects are still a mystery.A blood transfusion is a medical intervention, which in many cases remains experimental with respect to the benefit/risk ratio. Ideally, this uncertainty should be communicated to patients and every transfusion included in a study. Such studies preferentially should be randomized because the perceived need for transfusion is associated with clinical conditions with a worse prognosis than those that do not receive transfusion. This difference may mask the interpretation of the transfusion effect. Since the blood supply services in almost all Western countries have been reorganized and nationalized, or at least operate to national quality standards, the measurement of risk: benefit of transfusion, whether political or evidence-based, needs to be reconsidered. Differences in emphasis and responsibilities between transfusion providers and transfusion prescribers will drive the providers to political and liability criteria - ever safer products - that will increase hospital costs with undetermined clinical benefits.

Blood Grouping and Crossmatching↗

PubMed1998

Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study. Institutions of the Multicenter Study of Perioperative Ischemia Research Group.

BACKGROUND: An estimated 20% of allogeneic blood transfusions in the United States are associated with cardiac surgery. National consensus guidelines for allogeneic transfusion associated with coronary artery bypass graft (CABG) surgery have existed since the mid- to late 1980s. The appropriateness and uniformity of institutional transfusion practice was questioned in 1991. An assessment of current transfusion practice patterns was warranted. METHODS: The Multicenter Study of Perioperative Ischemia database consists of comprehensive information on the course of surgery in 2,417 randomly selected patients undergoing CABG surgery at 24 institutions. A subset of 713 patients expected to be at low risk for transfusion was examined. Allogeneic transfusion was evaluated across institutions. Institution as an independent risk factor for allogeneic transfusion was determined in a multivariable model. RESULTS: Significant variability in institutional transfusion practice was observed for allogeneic packed red blood cells (PRBCs) (27-92% of patients transfused) and hemostatic blood components (platelets, 0-36%; fresh frozen plasma, 0-36%; cryoprecipitate, 0-17% of patients transfused). For patients at institutions with liberal rather than conservative transfusion practice, the odds ratio for transfusion of PRBCs was 6.5 (95% confidence interval [CI], 3.8-10.8) and for hemostatic blood components it was 2 (95% CI, 1.2-3.4). Institution was an independent determinant of transfusion risk associated with CABG surgery. CONCLUSIONS: Institutions continue to vary significantly in their transfusion practices for CABG surgery. A more rational and conservative approach to transfusion practice at the institutional level is warranted.

Blood Component Transfusion↗

PubMedDate not supplied

Blood transfusion in burns: what do we do?

Over 11 million units of blood are transfused yearly in the United States. Although blood transfusion is common in burns, data are lacking on appropriate transfusion thresholds. The purpose of the study was to identify current burn center physician blood transfusion practices. A 30-question survey of blood transfusion practices was developed and sent to burn center directors. The survey assessed demographics, burn experience, and blood transfusion thresholds. Physicians were asked to list factors affecting their blood transfusion thresholds and then to give their blood transfusion threshold for patients based on age and percent burn. The final section presents three case scenarios with alterations in one physiological parameter to assess the effect on transfusion thresholds. A total of 55 of the 180 surveys (31%) were returned. Mean number of burn beds was 15.7 +/- 1.4, with 264 +/- 25 burn admissions per year. The respondents had been in burn care for 15.9 +/- 1.4 years. Their mean hemoglobin transfusion threshold was 8.12 +/- 1.7 g/dl. The most frequent reasons for transfusion were ongoing blood loss (22%), anemia (20%), hypoxia (13%), and cardiac disease (12%). Inhalation injury influenced the decision to transfuse blood in 34%. The hemoglobin level below which respondents would transfuse blood increased with increasing TBSA burn, history of cardiac disease, acute respiratory distress syndrome, and age. Blood transfusion thresholds in burns vary based on burn percentage, age, and presence of cardiac disease. To date, no standard of care exists for blood transfusions in burns. Future prospective studies are needed to determine the appropriate use of blood in burns.

Adolescent↗

PubMed1996

Evaluation of platelet function using the in vitro bleeding time and corrected count increment of transfused platelets. Comparison between platelet concentrates derived from pooled buffy coates and apheresis.

The functional capacity of transfused platelets was evaluated with in vitro bleeding time (IVBT) and corrected count increment (CCI) in order to compare platelet concentrates (PCs) derived from pooled buffy coats (BC-PCs) with PCs collected by apheresis (A-PCs). The suspension medium in the BC-PCs was 30% CPD plasma and 70% of an additive solution (containing sodium and potassium chloride, sodium citrate and phosphate, mannitol), and in the A-PCs the medium was 100% CPD plasma. IVBT was evaluated using a Thrombostat 4000/2. BC-PC and A-PC were transfused 57 and 41 times, respectively to 36 patients with chemotherapy-induced thrombocytopenia. PCs transfused within 2 days of donation were considered fresh, and those transfused within 3-5 days were considered stored. IVBT was determined before, as well as 10-30 min and 24 h after transfusion; CCI was determined 10-30 min and 24 h after transfusion. The median pretransfusion IVBT value was 486 s. It was measurable in 21 of 98 (21%) of the transfusions, i.e. below the cutoff limit of 486 s. Ten to 30 min after transfusion, the IVBT showed a measurable reduction in 90% of the transfusions with fresh BC-PCs, 92% of those with fresh a-PCs, 63% of those with stored BC-PCs and 79% of those with stored A-PCs. After 24 h, the corresponding values were 63% for fresh BC-PCs, 50% for fresh A-PCs, 26% for stored BC-PCs and 38% for stored A-PCs. The median value of CCI 10-30 min after transfusion was 20 for fresh BC-PCs, 17 for fresh A-PCs, 16 for stored BC-PCs and 14 for stored A-PCs. The difference in IVBT between fresh and stored BC-PCs was significant (p = 0.032), unlike that between fresh and stored A-PC. After 24 h the corresponding values were 7 for fresh BC-PCs, 4 for fresh A-PCs, 4 for stored BC-PCs and 3 for stored A-PCs. When all transfusions with fresh PCs (BC-PCs + A-PCs) were compared with all transfusions with stored PCs, a statistical difference was demonstrated in both CCI (p = 0.027) and IVBT (p = 0.043). Spearman's rank correlation coefficient (rs) was -0.41 between CCI and IVBT < 486 s 10-30 min after transfusion, and -0.55 between the posttransfusion platelet count and IVBT, indicating a relatively poor correlation between CCI and IVBT, and a slightly better correlation between platelet count and IVBT. In conclusion, BC-PCs showed a slightly higher CCI and a better response in IVBT than A-PCs. No statistical difference was demonstrated between BC-PCs and A-PCs transfused within 2 days after donation, with respect to function and recovery in vivo. BC-PCs stored for 3 days or more showed about the same CCI and IVBT as stored A-PC but significantly lower CCI and higher IVBT than fresh BC-PCs. This may indicate that the preparation and/or storage conditions were not optimal. IVBT seems to be a useful possibility to test the in vivo behavior of transfused platelets.

Adolescent↗

PubMed2003

Bacterial contamination of blood components: risks, strategies, and regulation: joint ASH and AABB educational session in transfusion medicine.

Bacterial contamination of transfusion products, especially platelets, is a longstanding problem that has been partially controlled through modern phlebotomy practices, refrigeration of red cells, freezing of plasma and improved materials for transfusion product collection and storage. Bacterial contamination of platelet products has been acknowledged as the most frequent infectious risk from transfusion occurring in approximately 1 of 2000-3000 whole-blood derived, random donor platelets, and apheresis-derived, single donor platelets. 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. Concern over the magnitude and clinical relevance of this issue culminated in an open letter calling for the "blood collection community to immediately initiate a program for detecting the presence of bacteria in units of platelets." Thereafter, the American Association of Blood Banks (AABB) proposed new standards to help mitigate transfusion of units that were contaminated with bacteria. Adopted with a final implementation date of March 1, 2004, the AABB Standard reads "The blood bank or transfusion service shall have methods to limit and detect bacterial contamination in all platelet components." This Joint ASH and AABB Educational Session reviews the risks, testing strategies, and regulatory approaches regarding bacterial contamination of blood components to aid in preparing practitioners of hematology and transfusion medicine in understanding the background and clinical relevance of this clinically important issue and in considering the approaches currently available for its mitigation, as well as their implementation. In this chapter, Drs. Hillyer and Josephson review the background and significance of bacterial contamination, as well as address the definitions, conceptions and limitations of the terms risk, safe and safety. They then describe current transfusion risks including non-infectious serious hazards of transfusion, and current and emerging viral risks. In the body of the text, Dr. Blajchman reviews the prevalence of bacterial contamination in cellular blood components in detail with current references to a variety of important studies. He then describes the signs and symptoms of transfusion-associated sepsis and the sources of the bacterial contamination for cellular blood products including donor bacteremia, and contamination during whole blood collection and of the collection pack. This is followed by strategies to decrease the transfusion-associated morbidity/mortality risk of contaminated cellular blood products including improving donor skin disinfection, removal of first aliquot of donor blood, pre-transfusion detection of bacteria, reducing recipient exposure, and pathogen reduction/inactivation. In the final sections, Drs. Vostal, Epstein and Goodman describe the regulations and regulatory approaches critical to the appropriate implementation of a bacterial contamination screening and limitation program including their and/or the FDA's input on prevention of bacterial contamination, bacterial proliferation, and detection of bacteria in transfusion products. This is followed by a discussion of sampling strategy for detection of bacteria in a transfusion product, as well as the current approval process for bacterial detection devices, trials recommended under "actual clinical use" conditions, pathogen reduction technologies, and bacterial detection and the extension of platelet storage.

Bacterial Infections↗

PubMed1996

[Clinical studies on autologous blood transfusion].

To study the present status of blood transfusion in head and neck surgery, we investigated recent cases of intraoperative transfusion in our department. In addition, we present our autologous blood transfusion cases, presently involved in an ongoing clinical trial for patients with head and neck cancer in our department which began in 1989. 1. Investigation of intraoperative blood transfusion cases There were 37 cases of intraoperative blood transfusion among 677 cases who underwent surgery under general anesthesia during the period from May, 1991 to December, 1993. We divided these 37 cases into three groups according to the amount of intraoperative blood loss: less than 600ml (10 cases), more than 600ml and less than 1200ml (11 cases), and more than 1200ml (16 cases). Average amounts of intraoperative blood transfusion in each group were 195ml, 475ml and 780ml, respectively. As we noted that most of these 37 cases received a blood transfusion of less than 800ml, the majority needing intraoperative blood transfusion during head and neck surgery are potential candidates for autologous blood transfusion. Therefore, we have promoted autologous blood transfusion for intraoperative blood transfusion in head and neck surgery. Thus, the patients undergoing intraoperative autologous blood transfusion increased to seven annually as of 1994. 2. Clinical studies on autologous blood transfusion Among 677 cases of head and neck surgery conducted during a six year period (1989-1994), we experienced ten cases of autologous blood transfusion. For the prevention of anemia due to repeated blood withdrawal, we administered an iron preparation. Patients who preoperatively showed a low value of Hb (less than 11g/ dl) received intravenous drip infusion of erythropoietin. Since some patients selected for autologous blood transfusion, who also received neo-adjuvant chemotherapy and preoperative radiotherapy, exhibited a generally chronic anemia status, an iron preparation and erythropoietin should be preoperatively administered in combination.

Adolescent↗

PubMed2005

Storage and transfusion of infected autologous blood or components: a survey of North American laboratories.

CONTEXT: Many patients request that autologous blood or components be collected and available for use during scheduled surgical or invasive medical procedures to avoid exposure to human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) from allogeneic transfusions. Some patients from whom autologous blood is collected are themselves infected with HIV, HBV, or HCV. However, unlike HIV-, HBV-, or HCV-infected allogeneic blood and components, which must be excluded from the community blood supply, infected autologous blood and components are allowed to be stored in hospitals and transfused back to the patients (autologous donors) from whom the blood was collected. Although the transfusion of HIV-, HBV-, or HCV-infected autologous blood or components does not present a risk to the autologous donor, such a transfusion presents a risk to other patients, considering that at least 1 in every 25,000 transfusions are administered to the wrong individual. OBJECTIVE: To determine if hospital transfusion services store and/or transfuse autologous blood or components infected with HIV, HBV, and/or HCV. DESIGN: An educational enhancement subsection of a College of American Pathologists Proficiency Testing Survey (J-C 2003) assessed transfusion service practices for storing and/or transfusing HIV-, HBV-, and HCV-infected autologous blood and components. SETTING AND PARTICIPANTS: A total of 4251 participants were asked whether they stored and/or transfused autologous blood or components and whether these stored blood products included those that were infected with HIV, HBV, or HCV. RESULTS: Of the 4251 survey respondents, 3561 provided data regarding their autologous blood and component storage and/or transfusion practices. A total of 2988 participants reported that they store and/or transfuse autologous blood or components. A total of 2390 respondents reported that they do not test autologous donations collected in their own institution for evidence of infection with HIV, HBV, or HCV. Most survey participants reported that even if an autologous donation is tested and found to be infected they would still be willing to store and transfuse the blood component, according to which agent was causing the infection: HIV (n = 1867), HBV (n = 2158), or HCV (n = 2233). CONCLUSION: Most North American hospitals do not test autologous blood donations that they collect in their own institution for evidence of infection with HIV, HBV, or HCV, leading to the conclusion that infected autologous blood components are being stored and transfused. Even when autologous donations are tested and found to be infected with HIV, HBV, or HCV, most North American hospitals would be willing to store and/or transfuse the infected autologous blood components.

Blood Banks↗

PubMed2001

Red blood cell transfusion practices in very low birth weight infants in 1990s postsurfactant era.

The purposes of this study are (1) to evaluate the practice of red blood cell transfusions in very low birth weight (VLBW) infants (between 501 to 1500 g) during the postsurfactant era of the 1990s; and (2) to evaluate if there is a decreasing trend in red cell transfusions in the 1990s. Database and medical records of VLBW infants admitted to the neonatal intensive care unit (NICU) between January 1990 and December 1995 at Scott & White Clinic, Temple, Texas, were reviewed. Five hundred twenty-seven infants were admitted to the NICU, excluding 5 infants that were transferred out for possible cardiac surgery or for other reasons. Fifty one (9.7%) of these infants died prior to discharge. Hence, data from 476 survivors were reviewed for red blood cell (RBC) transfusions. Transfusions were given at the discretion of the attending neonatologist. None of the infants received erythropoietin. Of the 476 infants, 289 (61%) received RBC transfusions during the hospital stay, with 2.7+/-3.6 transfusions per infant with a volume of 40.5+/-50.4 mL/kg. Smaller infants required significantly more transfusions compared to larger infants when divided into 250-g subgroups. No statistically significant difference was noted in the number of RBC transfusions per infant or number of infants transfused during the 6-year period from year to year. We conclude that VLBW infants in the 1990s postsurfactant era required 2.7 RBC transfusions per infant, on average, with the smallest infants requiring the most transfusions. These data will be helpful to counsel mothers in preterm labor regarding the need of transfusions for each birth weight category. Red cell transfusion practice has not changed over this 6-year period in the 1990s. Additional measures such as erythropoietin or even stricter transfusion criteria may be necessary to decrease transfusions further. However, safety of such measures should be carefully evaluated.

Erythrocyte Transfusion↗

PubMed2003

Should we reconsider triggers for red blood cell transfusion?

Very few randomized controlled trials on the benefits of red blood cell (RBC) transfusions in humans have been published. Consequently, most clinical practice guidelines remain based on expert opinion, animal studies and the limited human trials available. In the absence of definitive outcome studies, numerous theoretical arguments have been put forward either to support or to condone the classic transfusion threshold of 10 g/dL. However, the limited data available from randomized controlled trials suggest that a restrictive transfusion strategy (transfusion threshold between 7 and 8 g/dL) is associated with decreased transfusion requirements, that overall morbidity (including cardiac morbidity) and mortality, hemodynamic, pulmonary and oxygen transport variables are not different between restrictive and liberal transfusion strategies and, finally, that a restrictive transfusion strategy is not associated with increased adverse outcomes. In fact, a restrictive strategy may be associated with decreased adverse outcomes in younger and less sick critical care patients. The majority of existing guidelines conclude that transfusion is rarely indicated when the hemoglobin concentration is greater than 10 g/dL and is almost always indicated when it falls below a threshold of 6 g/dL in healthy, stable patients or more in older, sicker patients. In anesthetized patients, this threshold should be modulated by factors related to the dynamic nature of surgery, such as uncontrolled hemorrhage, coagulopathy, etc. Since transfusions are administered to correct inadequate oxygen delivery, whether global or regional, reliable monitors of tissue oxygenation will be required to study the benefits (or lack thereof) of RBC transfusions. The quest for a universal transfusion trigger, the holy grail of transfusion medicine, must be abandoned. All RBC transfusions must be tailored to the patient's needs, at the moment the need arises. In conclusion most published recommendations are appropriate but their conclusions are limited, as they are commensurate with existing knowledge. Reliable monitors to guide transfusion therapy and well conducted trials to determine optimal transfusion strategies are required.

Acute Disease↗

PubMed1994

Blood transfusions: for the thermally injured or for the doctor?

BACKGROUND: Because of the inherent risks of blood transfusions, including the transmission of viral and other infectious diseases, it is important to re-evaluate blood transfusion policies. METHODS: The present study compared the results of a new selective transfusion policy in which patients were not transfused unless their hemoglobin levels went below 6-6.5 g/dL versus our previous routine transfusion policy in which the hemoglobin levels were routinely maintained at 10 g/dL. The selectively transfused group consisted of 14 patients with a mean +/- SD burn size of 28% +/- 11%, while the routinely transfused group consisted of 38 clinically comparable patients with a mean burn size of 26% +/- 12%. RESULTS: The patients managed by selective transfusion received fewer transfusions (2.1 +/- 1.7 units) during their hospital stay than patients transfused routinely (7.4 +/- 7.6 units) (p < 0.007) and were less likely to receive maintenance transfusions (4 of 29 total units versus 116 of 282 total units) (p < 0.004). No adverse hemodynamic or other adverse effects related to limiting blood transfusions in the selectively transfused group was noted. CONCLUSION: Routinely transfused patients, on average, received over 5 units more blood than the selective group without any apparent clinical benefit. Thus, the results of this pilot study support a policy of selective blood transfusions in burn patients.

Adolescent↗

PubMed2000

Influence of perioperative blood transfusion on the prognosis of patients with gastric cancer receiving anticancer chemotherapy.

BACKGROUND: The deleterious effect of blood transfusions on survival has been reported in patients with cancers of various organs. However, it remains unclear whether there is any adverse effect of blood transfusion when the patients are administered anticancer drugs after surgery for gastric cancers.METHODS: Data from patients with gastric resection for advanced gastric cancer were retrospectively analyzed to determine the influence of perioperative blood transfusion on the survival rate. All patients were administered anticancer drugs (mitomycin C [MMC] and tegafur-uracil [UFT]). Sixty-nine (33%) of 208 patients received blood transfusion perioperatively, while 139 patients (67%) did not receive transfusion. Multivariate analysis of clinicopathologic prognostic factors, including blood transfusion, was performed. Lymphocyte subsets were measured to investigate the immunosuppressive effect of blood transfusion.RESULTS: The 5-year survival rate was 48.8% in the 69 transfused patients and 66.9% in the 139 non-transfused patients ( P < 0.01). Cox's multiple regression analysis showed that, when patients received anticancer drugs, perioperative blood transfusion was not a significant factor affecting survival after the gastric cancer surgery. However, the CD4/CD8 ratio at 3 months after the surgery was significantly lower in the transfused group than in the non-transfused group.CONCLUSION: Blood transfusion did not affect the survival of operated patients who received postoperative adjuvant chemotherapy. However, the finding that the ratio of CD4/CD8 after surgery was significantly higher in the non-transfused group than in the transfused group supports the notion that transfusion causes broad-spectrum immunosuppression.

Journal Article↗