Appropriate Use Of Blood Products Research Articles

300 Intraoperative Thresholds for Transfusion During Burn Surgery

Abstract Introduction Burn injury is associated with significant morbidity. Deep partial thickness or full thickness burns require surgical excision and skin grafting. This process results in significant blood loss and frequently requires blood transfusions. There is scarcity in published literature addressing intraoperative blood transfusion requirements. The relationship between blood product volume and patient characteristics has not been clearly defined. The enhanced ability to predict blood transfusion requirements would allow for improved allocation of blood products and safer overall operations. Methods This is a retrospective review conducted at a large academic burn center. Inclusion criteria are adult patients admitted between December 2019 and August 2020 with burns requiring surgical excision. Prisoners, children, and non-operative burns were excluded. Operative cases requiring blood product administration were compared to cases that did not require transfusion. Two-tailed student’s t-tests were conducted with p < 0.05 considered significant. Results There were 103 total patients who underwent a total of 217 operations. Forty-eight percent (n=104) of cases required blood transfusion. As detailed in the table, the transfusion group had significantly increased percent total body surface area (TBSA) burn, along with longer hospital and ICU lengths of stay (LOS). Operatively, this group underwent more tissue excision (approximately 15% TBSA compared to 5%) with longer case lengths, coupled with higher estimated blood loss and a lower preoperative hemoglobin. Interestingly, the median time for the initiation of packed red blood cell transfusion was six minutes after incision. Conclusions The average estimated blood loss in cases resulting in transfusion was 907±462mL (with a median of 800mL) compared to 467±398mL estimated blood loss in the non-transfused group. Expected blood loss along with parameters such as planned area of excision (which was approximately three times greater in transfused patients) and severity of burn injury can guide the surgeon in anticipating perioperative administration of blood products. Future directions include stratification of blood volume administration by %TBSA, operative time, LOS, and percent excision. Applicability of Research to Practice The ability to predict blood product requirements preoperatively coupled with the incorporation of perioperative parameters can assist in the judicious and appropriate use of blood products during burn operations.

Optimizing Utilization of Blood Products in the Hematologic Malignancy Clinic: Less Is More.

There are no universal guidelines for blood product transfusions in patients with hematologic malignancies (HMs). Excess utilization of platelet and RBC transfusion in patients with HM increases the cost of care and likelihood of adverse events. We aim to decrease the total number of transfused units and multiunit orders of platelets and RBCs in the HM clinic by 25% from March 2020 to December 2020. A multidisciplinary, interprofessional team was formed. Baseline rates of blood product utilization were determined using Qlik Analytic software. Strategies to improve utilization were developed, and three interventions were initiated. Data were collected on monthly intervals. Data for total number of platelet and RBC units ordered, total multiunit orders, average number of units ordered per encounter, and pretransfusion hemoglobin thresholds were collected from May 2019 to December 2020. Through our Plan-Do-Study-Act cycles from March 2020 to December 2020, the total number of platelet transfusion orders per month decreased from 164 to 98, multiunit platelet orders decreased from 63 to 2, and the average number of platelet transfusions per encounter decreased from 1.62 to 1.03. The total number of RBC transfusion orders decreased from 172 to 141, multiunit RBC orders decreased from 25 to 16, and the average number of RBC transfusions per encounter decreased from 1.21 to 1.18. Implementation of our multidisciplinary interventions led to more appropriate use of blood products in the outpatient setting. Ongoing efforts are underway to continue to improve utilization in the inpatient and outpatient setting.

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English

Establishing a hospital transfusion management system promotes appropriate clinical use of human albumin in Japan: a nationwide retrospective study

BackgroundDespite international recommendations to establish hospital transfusion management systems to promote appropriate use of blood products, the general efficacy of establishing such systems has not been proven. This study aimed to validate the effect of establishing such systems for promoting the appropriate use of human albumin.MethodsIn this retrospective observational study, we used a Japanese Diagnosis Procedure Combination (DPC) database from fiscal year 2012 to 2016, which included inpatient records from approximately 1200 hospitals for payment processes in the national medical insurance system. From this existing database, containing approximately 8 million inpatient records per year, we selected patients with emergency due to “bleeding,” “sepsis,” and “burn injury,” by using the International Classification of Diseases and Injuries 10th revision (ICD-10) codes, and hospitals that had one or more patients for each disease group in each fiscal year. We conducted multivariable logistic regression analysis to estimate the relationship between human albumin administration and the state of the hospital transfusion management system. We evaluated temporal trends of mortality rate and length of stay as an indicator of care quality.ResultsOverall, 139,853 eligible patients admitted to 682 hospitals were selected. The results of the multivariable logistic regression analysis show that patients who were admitted to hospitals with an established hospital transfusion department introducing good practice criteria of blood products were less likely to be administered human albumin compared with those who were admitted to hospitals not introducing it, by approximately 30% for each of the three disease groups; adjusted odds ratios (95% confidential intervals) were 0.70 (0.59–0.83), 0.75 (0.69–0.81), and 0.71 (0.58–0.87) in the “bleeding,” “sepsis,” and “burn injury” groups, respectively. The temporal trends evaluation shows that there were no increasing trends of mortality rate and average length of stay against decreasing trends of human albumin administration in any disease groups.ConclusionsEstablishing a hospital transfusion department responsible for promoting appropriate clinical use of blood products could reduce human albumin administration for critically ill patients without loss of care quality. These findings provide support for policy makers and hospital managers to consider establishing such systems.

Haemovigilance In Australia

The underlying principle of haemovigilance is patient safety. Haemovigilance plays an important role in transfusion medicine by provision of valuable data on transfusion related adverse events. Undesirable and unexpected events provide useful information to further enhance safety by preventing recurrence. There is a role for haemovigilance in managing the appropriate use of blood products.

Association Between Adverse Clinical Outcomes After Coronary Artery Bypass Grafting and Perioperative Blood Transfusions.

Bleeding is a serious complication of coronary artery bypass grafting that often leads to blood transfusion. Approximately 50% of patients who have the surgery receive blood products, and blood transfusions play a role in adverse outcomes after the surgery. To examine the association between perioperative blood transfusion and postoperative adverse outcomes in patients undergoing coronary artery bypass grafting. A systematic review of the literature, via the matrix method of quality evaluation, was conducted. PubMed, CINAHL, and Science Direct databases for 2000 through 2016 were searched. Inclusion criteria were articles published in English and original research related to clinical outcomes of blood transfusion after coronary artery bypass grafting. Seventeen articles were included in the review. Mortality, both short- and long-term, was significantly higher in transfusion patients than in nontransfusion patients. Patients with transfusion of red blood cells had higher resource utilization and more complications, including infection, pneumonia, renal failure, graft occlusion, and atrial fibrillation, than did nontransfusion patients. An association exists between red blood cell transfusions and adverse clinical outcomes for patients undergoing coronary artery bypass grafting. Transfusion of red blood cells is sometimes unnecessary, may be injurious, and should be used cautiously. Even a single-unit increase in perioperative red blood cell transfusions can have a significant adverse impact on outcomes. Individual benefits and risks should be weighed before transfusion to avoid adverse outcomes. Transfusion guidelines should be reviewed to include the latest evidence to guarantee the most appropriate use of blood products.

The ABCs of transfusion for hematologists

"Guidelines for the use of red blood cell products, platelet transfusion concentrates and fresh frozen plasma based on scientific evidence" was published by the Japan Society of Transfusion Medicine and Cell Therapy. Each transfused blood product carries a certain risk of an acute or late adverse event. Hematologists must be familiar with transfusion-associated adverse events, such as transfusion-related acute lung injury, transfusion-associated circulatory overload, post-transfusion graft-versus-host disease, transfusion-transmitted viral infection, etc. Thus, these guidelines should be followed for the appropriate use of blood products according to trigger values and indications for transfusion.

Obstetric hemorrhage and safe blood for transfusion in Ethiopia: the challenges of bridging the gap.

Obstetric hemorrhage is a leading cause of maternal death in sub-Saharan Africa, and the shortage of blood for transfusion is a contributory factor. In Ethiopia, the National Blood Bank Service continues to be confronted with challenges in its efforts to ensure the availability of blood for health care facilities. This paper reviews the available data on the contribution of obstetric hemorrhage to maternal mortality and examines the current status of the blood supply in Ethiopia. We reviewed the published literature and data from the Ethiopian Federal Ministry of Health. To assess the status of the current blood supply, we applied the five cornerstones of a safe and effective blood donor service advocated by the World Health Organization. Our review indicates that there are insufficient national data on the prevalence of obstetric hemorrhage and the contribution of blood supply shortage to maternal death. Also, transfusion safety may be compromised by inadequate testing of donated blood and ineffective hospital transfusion policies. To overcome the shortage of blood to treat obstetric hemorrhage, the first step is to evaluate the demand and supply gap by acquiring comprehensive data on the current status of the blood supply and the prevalence of obstetric hemorrhage in Ethiopia. Subsequent steps would include the implementation of transfusion policies, the optimization of whole blood collection, ensuring quality-assured testing of donated blood, and the implementation of transfusion guidelines for the appropriate use of blood products. Strategies for long-term, viable solutions to maintain an adequate blood supply should be simultaneously developed.

Computerised decision support systems to promote appropriate use of blood products.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effect of computerised decision support systems (DSSs) on transfusion practice.

A Third of Perioperative Blood Transfusions in the ICU Does Not Follow Guideline Recommendations - A Retrospective Analysis

Objective: This study evaluates the relevance of transfusion guidelines for clinical transfusion practice. Background: There is little data available on current practice related to appropriate use of blood products. Recent data suggest incorrect use and over transfusion in Europe. In Germany, indications for transfusion and administration of blood products are strict and detailed. However, in clinical practice, alignment of transfusion guidelines to clinical situations seems to be difficult for physiciansespecially in complex diseases and severity such as in critical care. We hypothesized that significant practice variability exists with regard to guidelines adherence in critically ill. Materials and methods: Data sets of transfused patients from a surgical intensive care unit of a university center retrospectively were analyzed over a 12 month period. Indications for blood products were compared with guidelines focusing on numbers of ordered and administered units as well as transfusion triggers. Results: In total, during the study period, 450 packed red cells (PRC, 249 orders), 454 fresh frozen plasma (FFP) (201) and 43 platelet units (PC) (29) were given to 89 patients. The mean number of administered PRC was 5.8+/-6.6 (mean +/- SD) units. Double units were administered in 57.4%. Discordant to actual guidelines, 75 (30.12%) PRC`s, 79 (39.30%) FFP's and 9 (31.03%) of PC orders were given without indication. Fresh frozen plasma was administered in ineffective dosage in 83.6% (mean 7.3 ml/kg body weight), platelet transfusion despite intact platelet function in 30.2% and beyond platelet counts of 100 000/μl in 60%. Conclusion: Detailed guidelines for transfusion of blood products were not followed in daily practice in a third of all applications. The reasons for malcompliance are key for improvement.

Transfusion medicine in practice.

The safety and stability of the supply of blood products must be ensured for appropriate blood transfusion therapy. Various security measures need to be taken and a balanced blood donation system should be maintained by the Japanese Red Cross Society. Based on such a system, each institute needs to establish a proper management protocol and to assure adequate use of blood products, as well as creating measures to deal with adverse events associated with blood transfusion. The system for preventing transfusion errors is particularly essential. For appropriate use of blood products, the "Guideline for the Use of Blood Products" should be followed, and unnecessary use should be avoided. These are prerequisites for error-free treatment of patients. In this educational lecture, major points in performing blood transfusion in clinical practice, such as proper indications for the use of blood products associated with patient conditions or trigger levels, and important points as well as contraindications when using blood products, such as the speed of administration, will be discussed.

The revision of the European blood directives: A major challenge for transfusion medicine

AimUsing both patient-focused and donor-focused perspectives, to review the current EU blood directives, in order to derive proposals, in principle, for what should evolve during the revision process of these directives. MethodsReview of the EU blood directives in the light of scientific literature, related reports from the Directorate General Health and Consumers (DG SANTÉ), and from the Council of Europe (CoE). ResultsThe analyses led us to present the main following proposals: developing voluntary unpaid donations: the directives should consider taking into consideration ethically acceptable forms of compensation consistent with altruistic donation (including plasma donations for fractionation); current expertise: more extensive utilization of the expertise of blood establishments and their consultants should be considered; donor selection: an evidence-based approach for basing donor deferral criteria on sound scientific evidence should be promoted; donor reactions: measures to prevent donor reactions and to make donations safer for the donors should also be included; quality control: The quality control requirements should relate to the Council of Europe Blood Guide specifications: these should become minimum standards (as is the case with monographs of the European Pharmacopeia), facilitating regular update of blood component lists and related specifications and compliance with the specifications; haemovigilance: because of reporting difficulties (e.g. lack of number of blood products transfused), the effectiveness of haemovigilance has so far been limited. This should lead appropriate bodies to investigate alternative or complementary ways to help improve patient safety, taking into consideration, in principle, patient blood management and the appropriate use of blood products. Furthermore, donor vigilance, which is still absent from the current directive should be included in a revised directive. ConclusionsThese proposals for revising the current EU blood directives (if taken into account and given appropriate regulatory formulation) should help to optimize patient safety and donor care, progress the compliance with the ethical principles for donors and improve the efficiency of the healthcare systems dedicated to transfusion medicine.

Quality use of blood products

Blood products are a valuable resource, derived from altruistic donations. They undergo high-cost screening and modification to decrease the risk of transfusion-transmitted infection. Although blood products have achieved a high level of safety, significant risks associated with transfusion remain. To avoid unnecessary transfusions, patient blood management involves optimising red cell mass, minimising blood loss, and optimising physiological tolerance of anaemia. A circumspect approach to prescribing blood products is recommended. Regular patient assessment in conjunction with judicious laboratory testing are the primary considerations in the decision to transfuse. Evidence-based guidelines for the appropriate use of blood products have been released by the National Blood Authority.

Improving appropriateness of blood utilization through prospective review of requests for blood products: the role of pathology residents as consultants.

To evaluate the effectiveness of prospective review of orders for fresh-frozen plasma (FFP) and platelets in reducing blood-product use, and of the effectiveness of preparing pathology residents to serve as clinical consultants. At our 572-bed tertiary-care hospital, we developed guidelines for the use of blood products in collaboration with a variety of departments. For patients whose condition(s) met generally accepted criteria, we identified trigger points to allow for quick release by blood bank staff of blood products. For patients whose condition(s) did not meet the applicable criteria, the on-call pathology resident reviewed the medical record of that patient to determine whether there were any extenuating circumstances; consulted with the ordering physician and attending pathologist, as needed; and advised the house staff on appropriate use of blood products. We evaluated the change in use of blood products between the years 2009 and 2012 to assess the effectiveness of the program. We observed a decrease of 38.8% and 31.4% in the use of FFP and platelets, respectively (29.7% and 21.1%, respectively, when normalized for the number of discharges). If projected to the national level, this improvement would translate to an annual cost reduction of approximately $130 million. Prospective review of orders for blood products can significantly improve use of these products, thereby reducing risk to patients and avoiding unnecessary healthcare costs. The involvement of pathology residents in the prospective review process provides an excellent opportunity for their training as laboratory consultants.

The 2013 update of the "Seville Document": a Spanish multidisciplinary alliance for patient blood management.

The 2013 update of the "Seville Document": a Spanish multidisciplinary alliance for patient blood management.

Thromboelastography and thromboelastometry and the management of intra-operative transfusion therapy in massively bleeding patients.

Dear Sir, I have read with interest the letter “Intra-operative transfusion management: the usefulness of point-of-care coagulation monitoring” by Feltracco et al1. Severe bleeding and coagulopathy as a result of massive transfusion are serious clinical conditions that are associated with high mortality. Since the first description in 1948, thromboelastography (TEG) and thromboelastometry (ROTEM) have been successfully used as a point-of-care tests as they are capable of providing a robust and cheap snapshot of haemostasis at the bedside. The study of visco-elastic properties of clots carried out through TEG and ROTEM is being increasingly used to guide transfusion strategies in patients with massively bleeding. TEG and ROTEM are easy to use by non-laboratory personnel as point-of-care tests in peri-operative and emergency settings. They produce rapid graphical and numerical results of the haemostatic status and are able to detect the anticoagulant effect of acidosis, hypothermia or hyperthermia, as they can be performed at temperatures between 22 °C and 42 °C. Finally, they are able to detect and quantify the underlying cause of coagulopathy, such as thrombocytopenia, clotting factor deficiency, heparin effect, hypofibrinogenaemia, and hyperfibrinolysis2. The test is carried out on a sample of whole blood and helps the clinicians to assess the cause of bleeding so that they can initiate the relevant transfusion or pharmacological therapy for coagulation problems resulting from clinical conditions such as trauma, surgery or potential disseminated intravascular coagulation. Notwithstanding their increased use to guide transfusion therapy the role of TEG and ROTEM remain controversial, and the role of the Sonoclot analyser currently seems even more limited, at least for managing transfusion therapy. A recently published Cochrane review had the objective of systematically assessing the benefits and harm of a TEG- or ROTEM-guided transfusion strategy in randomised trials involving patients with severe bleeding3. There is a lack of evidence that a TEG- or ROTEM-guided strategy improves, compared with standard treatment, morbidity or mortality in patients with severe bleeding. A statistically significant effect on the amount of bleeding was detected but the “analyses on the proportion of patients transfused with red blood cells, fresh-frozen plasma (FFP) and platelets did not show a statistically significant reduction”. However, the “analyses on the proportion of patients receiving both FFP and platelets did show a statistically beneficial reduction (RR 0.39, 95% CI 0.27 to 0.57, I2=0) when applying TEG or ROTEM. The true value of these analyses is unclear due to limited amounts of data and lack of a significant reduction in the amount of transfused FFP or platelets when examined separately”. These results call for further studies that are well designed and correctly powered to increase the level of evidence on the efficacy of these point-of-care devices in increasing the appropriate use of blood products. Furthermore, these devices can be really advantageous only when appropriately trained personnel are available, also in peri-operative and emergency settings. In fact, adequate and continuous training of non-laboratory personnel in charge of carrying out the tests and a thorough knowledge of good laboratory practice are really the essential requirements for producing reliable results, regardless of where the test is performed. In addition, an accredited external quality assessment programme and internal quality control system must be established4. For the above reasons the recently issued SIMTI guidelines did not include any recommendations on the routine use of TEG or ROTEM5. Despite the non-inclusion of TEG/ROTEM in the SIMTI guidelines, there is a more than reasonable expectation that, in the near future, the study of visco-elastic properties of clot will provide a higher level of evidence showing that TEG/TOGEM is a suitable method for guiding appropriate transfusion management of patients with massive bleeding. However, these point-of-care tests will express all their potential and be really cost-effective and efficacious in providing reliable results to guide transfusion strategy only in skilled hands and provided that validation of the technique, periodic competency assessments and good laboratory practice are ensured4, also outside the laboratory setting.

Blood Products and the Phases of Perianesthesia Care—Reviewing the Implications

Perianesthesia nurses often provide care for patients who have received blood products. Over the years, great advances in the safety and technology around blood products have occurred, yet transfusions are not without risk. Because 50% of blood transfusions are administered in the surgical setting, the perianesthesia nurse must know the indications and potential adverse reactions. The perianesthesia nurse has an important role in supporting appropriate use of blood products, which can be a scarce resource at times. By knowing indications, benefits, and risks of transfusion, the nurse can better advocate for the patient's needs. Additionally, with this knowledge, the nurse is able to support patient education and ensure that consent obtained is informed in nature. In this article, the commonly used blood products, potential adverse reactions, and methods to reduce transfusion errors are being reviewed. Ideally, nurses should be provided a periodic review on blood products and transfusion safety to maintain knowledge, competency, and an acceptable comfort level overall. Ongoing education can be an effective means to expand knowledge of the health care provider and improve patient safety and outcomes.

Blood Product Transfusion: Does Location Make a Difference?

Early blood product administration during acute blood loss may improve outcomes, yet blood product transfusion for anemia of critical illness has been associated with increased mortality. After major burn injury, patients have two sources of anemia: massive acute blood loss during excision and insidious losses in the intensive care unit (ICU). The purpose of this study was to assess the relationship between the administration of fresh frozen plasma (FFP), platelets, and cryoprecipitate and outcomes in children with major burn injury. This was a retrospective review of children admitted with >20% TBSA burn from 2006 to 2009. Parameters measured included demographics, injury characteristics, operations, blood product transfusions, and outcomes. A total of 143 children received a mean of 3342 ± 283 ml blood. Nonsurvivors had larger burns (62.1 ± 4.6% vs 41.0 ± 1.5% TBSA, P < .001) and received similar amounts of packed red blood cells (PRBCs) during hospitalization (12.8 ± 2.4 units vs 10.9 ± 1.0 units, P = .5) than survivors. Nonsurvivors received more total units of FFP during hospitalization than survivors (8.0 ± 1.7 units vs 3.1 ± 0.4 units, P < .0001) because of the FFP units transfused in the ICU (5.5 ± 1.2 units vs 1.1 ± 0.2 units, P < .0001). The overall FFP:PRBC transfusion ratio in survivors was 1:4, whereas mean FFP:PRBC volume ratio in nonsurvivors was 3:4 (P < .0001). Nonsurvivors received more platelets (3.4 ± 1.0 units vs 0.50 ± 0.1 units, P < .001) and cryoprecipitate (1.9 ± 0.9 units vs 0.3 ± 0.1 units, P < .001) than survivors, both in the operating room and in the ICU. Blood product use in children with severe burns is associated with increased mortality. Appropriate use of blood products may need to be different in the operating room (massive acute hemorrhage) vs the ICU (ongoing red cell senescence).

Cardiac Surgery and the Appropriate Use of Blood Products in Trinidad and Tobago

The frequency of open heart surgery procedures that are performed in Trinidad and Tobago has increased since procedures began being performed at the Eric Williams Medical Science Complex in 1993, and by 2006, over 200 cases per year were being performed nationally. This increase in cardiac surgery within the region poses additional clinical challenges that are related to the use of blood products, such as adding to the burden of already limited blood bank resources, the high cost of blood product screening, and the risks of transfusion-related diseases and potential bleeding complications.

TRALI risk reduction: Donor and component management strategies

Transfusion-related lung injury (TRALI) occurs in approximately 1 in 5,000 transfusions and may cause considerably more morbidity and mortality that is not recognized in clinical practice. Based on the current understanding of the etiology of TRALI, blood centers have implemented or are evaluating various donor and component management strategies in an effort to mitigate the risk of TRALI. Many cases of TRALI are likely caused by antibodies to leukocyte antigens (HLA or HNA) in blood components. Approximately 10 to 20% of female blood donors with a history of pregnancy and 1 to 5% of male blood donors harbor these antibodies. Alternatively, TRALI may be mediated by other bioactive lipids or substances that accumulate during storage and cause a reaction when transfused to susceptible patients. The complex interplay among various donor-, component-, and patient-related factors underlying TRALI guarantees that effective prevention will not be a single or simple intervention but rather will require a multifaceted approach. Perhaps, the most important risk reduction strategy is the effort to ensure appropriate use of blood products and eliminate unnecessary transfusions. Blood collection agencies, however, have more proximate control over donor selection and component management than transfusion practice. AABB has provided some guidance on deferring donors implicated in TRALI and minimizing the preparation of high plasma volume components from donors who have anti-leukocyte antibodies or are at increased risk of leukocyte alloimmunization. Blood centers have taken various approaches to mitigate the risk of TRALI, and the possible benefit and the inherent limitations of the current strategies will be reviewed.