Blood Transfusion

1. Blood transfusion: rethinking
who, what and when
Dr Rebecca Howman
Consultant Haematologist
9th October 2014

2. Blood transfusion practice
• Blood is unique treatment
– It’s a gift: voluntary donors
– It’s complex:
Australian Red Cross Blood Service
TGA
hospitals
laboratories
clinicians
patients

3. Evolution of transfusion

4. 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?”

5. 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

6. Perils of
anaemia
Perils of
transfusion

7. Anaemia increases risk of death

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

10. Risk of death in those who refuse Tx

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

13. Perils of blood transfusion

14. 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

15. 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

16. Red cell membrane changes

17. 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

18. 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

19. 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

21. 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.

23. 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

24. 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

25. Comparison of pre- and post-single unit policy
3165
4967
2863
3923
Reduction of
1044 units
(21%)
transfused

26. Comparison of pre- and post-single unit policy
1707
2065
1227
646
231
172

27. Comparison of pre- and post-single unit policy
360
233
956
547
24%
reduction
43%
reduction

28. 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

29. 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)

30. Transfusion Sample
Collection
Results & Strategies

31. Sample collection Errors
August 2014

32. Sample collection & labelling
requirements
• 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”

33. 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

34. 1st Poster 2nd Poster

35. 3rd Poster

36. • Checklists for trolleys
– SCGH Checklist for Specimen Collection
• Group & Screen and Crossmatch Blood Samples