Impact of national transfusion indicators on appropriate blood usage in critically ill patients

Plasma transfusion in the intensive care unit

BACKGROUND

Current guidelines discourage prophylactic plasma use in non-bleeding patients. This study assesses global plasma transfusion practices in the intensive care unit (ICU) and their alignment with current guidelines.

STUDY DESIGN AND METHODS

This was a sub-study of an international, prospective, observational cohort. Primary outcomes were in-ICU occurrence rate of plasma transfusion, proportion of plasma events of total blood products events, and number of plasma units per event. Secondary outcomes included transfusion indications, INR/PT, and proportion of events for non-bleeding indications.

RESULTS

Of 3643 patients included, 356 patients (10%) experienced 547 plasma transfusion events, accounting for 18% of total transfusion events. A median of 2 (IQR 1, 2) units was given per event excluding massive transfusion protocol (MTP) and 3 (IQR 2, 6) when MTP was activated. MTP accounted for 39 (7%) of events. Indications of non-MTP events included active bleeding (54%), prophylactic (25%), and pre-procedure (12%). Target INR/PT was stated for 43% of transfusion events; pre-transfusion INR/PT or visco-elastic hemostatic assays (VHA) were reported for 73%. Thirty-seven percent of events were administered for non-bleeding indications, 54% with a pre-transfusion INR < 3.0 and 30% with an INR < 1.5.

DISCUSSION

Plasma transfusions occurred in 10% of ICU patients. Over a third were given for non-bleeding indications and might have been avoidable. Target INR/PT was not stated in more than half of transfusions, and pre-transfusion INR/PT or VHA was not reported for 27%. Further research and education is needed to optimize guideline implementation and to identify appropriate indications for plasma transfusion.

Appropriateness of Allogeneic Red Blood Cell Transfusions in Non-Bleeding Patients in a Large Teaching Hospital: A Retrospective Study

In hemodynamically stable patients, both anemia and red blood cell (RBC) transfusion may be detrimental to patients; hence, a decision regarding RBC transfusion should be based on thorough risk-benefit assessment. According to hematology and transfusion medicine organizations, RBC transfusion is indicated when recommended hemoglobin (Hb) triggers are met, and symptoms of anemia are present. The aim of our study was to examine the appropriateness of RBC transfusions in non-bleeding patients at our institution. We performed a retrospective analysis of all RBC transfusions performed between January 2022 and July 2022. The appropriateness of RBC transfusion was based on the most recent Association for the Advancement of Blood and Biotherapies (AABB) guidelines and some additional criteria. The overall incidence of RBC transfusions at our institution was 10.2 per 1000 patient-days. There were 216 (26.1%) RBC units appropriately transfused and 612 (73.9%) RBC units that were transfused with no clear indications. The incidence of appropriate and inappropriate RBC transfusions were 2.6 and 7.5 per 1000 patient-days, respectively. The most frequent clinical situations when RBC transfusion was classified as appropriate were: Hb < 70 g/L plus cognitive problems/headache/dizziness (10.1%), Hb < 60 g/L (5.4%), and Hb < 70 g/L plus dyspnea despite oxygen therapy (4.3%). The most frequent causes of inappropriate RBC transfusions were: no Hb determination pre-RBC transfusion (n = 317) and, among these, RBC transfused as a second unit in a single-transfusion episode (n = 260); absence of anemia sings/symptoms pre-transfusion (n = 179); and Hb concentration ≥80 g/L (n = 80). Although the incidence of RBC transfusions in non-bleeding inpatients in our study was generally low, the majority of RBC transfusions were performed outside recommended indications. Red blood cell transfusions were evaluated as inappropriate mainly due to multiple-unit transfusion episodes, absence of anemia signs and/or symptoms pre- transfusion, and liberal transfusion triggers. There is still the need to educate physicians on appropriate indications for RBC transfusion in non-bleeding patients.

Related Factors of Anemia in Critically Ill Patients: A Prospective Multicenter Study

Anemia is common in critically ill patients; almost 95% of patients admitted to intensive care units (ICUs) have hemoglobin levels below normal. Several causes may explain this phenomenon as well as the tendency to transfuse patients without adequate cause: due to a lack of adherence to protocols, lack of supervision, incomplete transfusion request forms, or a lack of knowledge about the indications, risks, and costs of transfusions. Daily sampling to monitor the coagulation parameters and the acid-base balance can aggravate anemia as the main iatrogenic factor in its production. We studied the association and importance of iatrogenic blood loss and other factors in the incidence of anemia in ICUs. We performed a prospective, observational, multicenter study in five Spanish hospitals. A total of 142 patients with a median age of 58 years (IQI: 48-69), 71.83% male and 28.17% female, were admitted to ICUs without a diagnosis of iatrogenic anemia. During their ICU stay, anemia appeared in 66.90% of the sample, 95 patients, (95% CI: 58.51-74.56%). Risk factors associated with the occurrence of iatrogenic anemia were arterial catheter insertion (72.63% vs. 46.81%, p-value = 0.003), venous catheter insertion (87.37% vs. 72.34%, p-value = 0.023), drainages (33.68% vs. 12. 77%, p-value = 0.038), and ICU stay, where the longer the stay, the higher the rate of iatrogenic anemia (p-value < 0.001). We concluded that there was a statistical significance in the production of iatrogenic anemia due to the daily sampling for laboratory monitoring and critical procedures in intensive care units. The implementation of patient blood management programs could address these issues.

Use of red blood cells in Danish intensive care units: A population-based register study

BACKGROUND

Red blood cell (RBC) transfusion is common in the intensive care unit (ICU). Recent trials have shown that a restrictive transfusion strategy is safe in most patients, and recent guidelines recommend such a strategy in most ICU patients. It is unknown if this has translated into a change in clinical practice.

METHODS

We conducted a population-based register study of RBC transfusions in ICUs in the Danish Capital Region between 1st of January 2011 and 31st of December 2016 by linking data from the regional blood bank and the Danish Intensive Care Database. We used crude data and run- and control-charts to analyse changes in the number of RBC transfusions.

RESULTS

We included 27 835 ICU admissions of which 6936 received 40 889 RBC units. The crude use was 36.2 RBC units per one-hundred patient bed-days in 2011 vs 29.8 in 2016. The run-chart analysis did not confirm a change in the total use of RBC units in all ICUs combined, and we observed no change in the proportion of transfused patients or in the use of RBCs among transfused patients. Sensitivity analyses showed decreased use of RBC units in two general ICUs, and a reduced use of RBC units among medical ICU patients.

CONCLUSIONS

In this population-based register study, we did not with certainty observe changes over time in the use of RBC transfusions in all patients in all ICUs in the Danish Capital Region. A reduction in RBC use may have occurred in some general ICUs and in medical ICU patients.

Red blood cell transfusion policy: a critical literature review

The issue of the most appropriate red blood cell transfusion policy has been addressed by a number of randomised controlled trials, conducted over the last decades, comparing the effects on patients' outcome of restrictive blood transfusion strategies (transfusing when the haemoglobin concentration is less than 7 g/dL to 8 g/dL) vs more liberal ones (transfusing when the haemoglobin concentration is less than 9 g/dL to 10 g/dL) in a variety of clinical settings. In parallel, various systematic reviews and meta-analyses have tried to perform pooled analyses of the data from these randomised controlled trials and their results have been utilised by scientific societies to provide recommendations and guidelines on red blood cell transfusion thresholds. All these aspects will be critically discussed in this narrative review.

[Appropriate use of red blood cell transfusion in the emergency department before and after a specific protocol]

The purpose of this study was to assess appropriateness of red blood cell (RBC) transfusion in the emergency department before and after a specific protocol.

METHODS

A retrospective monocenter study was realized during two six-month periods at the emergency unit. A protocol based on the French national guidelines (HAS) in 2014 was set up between the two periods. All the adult patients, except in a context of massive transfusion, were included in the study. The principal criteria analysed was the rate of appropriate transfusion.

RESULTS

Ninety-five patients were included during the first period (group 1) and 98 during the second one (group 2). The rate of appropriateness was the same in the two groups (81% for the group 1 and 81.6% for the group 2). The inappropriate indications were more frequent with older patients (74.6 ± 15.2 years in the group 1 and 79.5 ± 8.5 in the group 2, P=0.01) and patients suffering from a stable coronary artery disease (18.5% in the group 1 and 38.9% in the group 2, P=0.008).

CONCLUSION

The rate of appropriate red blood cells transfusion, already high at the beginning of the study, could not be significantly improved with the institution of a specific protocol. It is necessary to continue medical training.

Appropriate use of red blood cell transfusion in emergency departments: a study in five emergency departments

BACKGROUND

Transfusion of blood components continues to be an important therapeutic resource into the 21^st century. Between 5 and 58% of transfusions carried out are estimated to be unnecessary. According to several studies, at least 20% of packed red blood cell transfusions (RBCT) are administered in hospital emergency departments (ED), but few data are available about the appropriateness of RBCT in this setting. This multicentre, cross-sectional observational study aims to assess the appropriateness of RBCT indications and transfused volumes in patients who attend ED.

MATERIALS AND METHODS

The study cohort is made up of consecutive consenting adult patients (≥18 years old) who received RBCT in ED over a 3-month period and for whom relevant clinical data were collected and analysed.

RESULTS

Data from 908 RBCT episodes (2±1 units per transfused patient) were analysed. RBCT was considered appropriate in 21.4% (n=195), with significant differences according to RBCT indication (p<0.001), hospital level (p<0.001) and prescribing physician (p=0.002). Pre-transfusion haemoglobin level (Hb) negatively correlated with RBCT appropriateness (r=-0.616; p<0.01). Only 72.4% of appropriate RBCT had a post-transfusion Hb assessment (n=516). Of these, 45% were considered to be over-transfused (n=232), with significant differences according to RBCT indication (p=0.012) and prescribing physician (p=0.047). Overall, 584/1,433 (41%) of evaluable RBC units were unnecessarily transfused.

DISCUSSION

The appropriateness of RBCT in ED is similar to other hospital departments, but the rate of over-transfusion was high. These data support the need for a reassessment after transfusion of each RBC unit before further units are prescribed. In view of these results, we recommend that physicians should be made more aware of the need to prescribe RBCT appropriately in order to reduce over-transfusion.

A Systematic Review and Meta-Analysis of the Clinical Appropriateness of Blood Transfusion in China

The issue of the clinical appropriateness of blood transfusion has become a focus of transfusion medicine worldwide. In China, irrational uses of blood have often been reported in recent years. However, to date there lacks a systematic review of the rational uses of blood. This study aimed to determine the clinical appropriateness of blood transfusion in China. We searched PubMed, Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database, WanFang Database, and Chinese BioMedical Literature Database, and the retrieval cut-off date was June 31, 2015. SPSS 17.0 and MetaAnalyst 3.13 were employed as the statistics tools in this review. A pooled rate of clinical inappropriateness of transfusion was analyzed by DerSimonian-Laird method. In this study, a total of 39 observational studies were included, which related to 75,132 cases of blood transfusion. According to the meta-analysis results, the overall incidence of clinical inappropriateness of transfusion in China was estimated to be 37.3% (95% confidence interval [CI] [32.1, 42.8]). The subgroup analyses revealed that the pooled rates of clinical inappropriateness of transfusion of plasma, red blood cells (RBCs), cryoprecipitate, and platelets were 56.3% (95% CI [45.8, 66.2]), 30.9% (95% CI [27.1, 35.0]), 25.2% (95% CI [13.2, 42.7]), and 14.1% (95% CI [8.8, 21.9]), respectively. However, the pooled incidence of inappropriateness of transfusion in operative departments was 47.5% (95% CI [36.8, 58.3]), which was significantly higher than that in nonoperative departments, 25.8% (95% CI [18.7, 34.4], P < 0.05). The overall rates of inappropriate use were 36.7% (95% CI [30.2, 43.6]) in major cities and 37.5% (95% CI [31.2, 44.3]) in other cities, respectively; there was no statistically significant difference (P > 0.05). In conclusion, China has suffered from a disadvantage in the clinical appropriateness of blood transfusion, especially in plasma and RBC use. In future, comprehensive measures should be implemented in order to improve the clinical appropriateness of blood transfusion.

Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues.

Critical evaluation of justifications for the transfusion of red blood cells: the reality of a government emergency hospital

BACKGROUND

Blood products and derivatives are indispensable resources in medical therapies. However, it is important to note that the number of donations is far from ideal. Despite constant campaign efforts, a deficit of 1 million units is expected by 2030.

OBJECTIVES

To determine the adequacy of the indications for red blood cell transfusion in an emergency hospital in Alagoas.

METHODS

This was a cross-sectional observational study conducted at the Alagoas Blood Center. Of a total of 2936 red blood cell transfusion requests in 2009, 334 were randomized and compared with transfusion parameters described in the literature (primary variable). After analysis, the transfusion requests were categorized as adequate, inadequate or inconclusive. This last group included all red blood cell transfusion requests with insufficient clinical information, rendering their classification as adequate or inadequate impossible. The secondary variable involved the reasons for red blood cell transfusion. A 95% confidence interval was used in the statistical analysis.

RESULTS

Forty-seven (14.07%) requests were adequate and 30 (8.98%) were inadequate. Most of the requests were classified as inconclusive (76.94%). The main indications for transfusion were upper gastrointestinal bleeding (26.95%), anemia (46.71%), hypovolemia/hypovolemic shock (10.78%) and sepsis/septic shock (3.29%).

CONCLUSION

It was not possible to reach a conclusion on the adequacy of the indication for transfusion in most of the cases. Therefore, it is important to adopt a transfusion protocol, rigorously analyze blood bank requests, to provide awareness campaigns on the rational use of blood and to implement strategies to use blood products more effectively.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?» All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

Red blood cell transfusion in non-bleeding critically ill patients with moderate anemia: is there a benefit?

PURPOSE

This study was undertaken to investigate the efficacy of red blood cell transfusion (RBCT) at reversing the deleterious effects of moderate anemia in critically ill, non-bleeding patients.

METHODS

This was a retrospective, pair-matched (ratio 1:1) cohort study. Non-bleeding critically ill patients with moderate anemia (nadir hemoglobin level between 70 and 95 g/l), admitted to the ICU over a 27-month period, were included. Anemic patients were included upon meeting five matching criteria of having the same nadir hemoglobin (±5 g/l), APACHE II score (±5), SOFA score (±2), admission diagnostic group, and age (±5 years). Outcome events occurring over the whole ICU stay and after RBCT were collected. After hospital discharge, all patients had a 2-year follow-up period.

RESULTS

Two hundred fourteen non-transfused anemic patients (NTAPs) were successfully matched with 214 transfused anemic patients (TAPs). In addition to the matching criteria, at baseline, both groups were homogenous with respect to multiple comorbidities. Compared with TAPs, NTAPs showed significantly lower rates of hospital mortality (21 vs.13 %, respectively; p < 0.05) and ICU re-admission (7.4 vs. 1.9 %, respectively; p < 0.05). Additionally, NTAPs had significantly lower rates of nosocomial infection (12.9 vs. 6.7 %, respectively; p < 0.05) and acute kidney injury (24.8 vs. 16.7 %, respectively; p < 0.05). Similar results were obtained in subgroup analysis where only more anemic patients (68 matched pairs) or patients with cardiovascular comorbidities (63 matched pairs) were considered.

CONCLUSIONS

RBCT does not improve the clinical outcome in non-bleeding critically ill patients with moderate anemia.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: "Does this particular AABT reduce the transfusion rate or not?" All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.