SINGLE UNIT TRANSFUSIONFOR RED BLOOD CELL TRANSFUSION

Based on the Patient Blood Management Guidelines

Every ONE matters

WHY GIVE 2 WHEN 1 WILL DO….TOWARD A MORE RESTRICTIVE RED CELL TRANSFUSION APPROACH

Objectives

Discuss Patient Blood Management Guidelines

Discuss the reasons for single unit blood transfusions.

To provide resource material in the form of a wikispace and hard copy for the doctor to refer to.

WHY GIVE 2 WHEN 1 WILL DO…PATIENT BLOOD MANAGEMENT GUIDELINES (PBM)

What are the Patient Blood Management guidelines?

Evidence-based blood management guidelines that are a summary of recommendations and practice points developed by the National Blood Authority and is based on systematic reviews. The Medical model is the third in a series of six modules

Why have a Patient Blood Management Guidelines?

The Patient Blood Management Guidelines were introduced in 2012 to improve clinical outcomes by avoiding unnecessary exposure to blood components.

Transfusion is a live tissue transplant and not without associated risks

WHY GIVE 2 WHEN 1 WILL DO…PATIENT BLOOD MANAGEMENT GUIDELINES (PBM)

Why have a Patient Blood Management Guidelines?

Blood products are a scarce resource and will only become more scarce with the ageing population.

Economic costs – about $1 Billion per year in plus the added costs.

http://www.blood.gov.au/pbm-module-3

PBM MODULE 3- SYSTEMATIC REVIEW QUESTIONS Box 2.1 Systematic review questions Questions 1 – 5 are relevant to all six modules of these guidelines; Question 6 is

specific to medical transfusion (i.e. to this module). • Question 1 – In medical patients, is anaemia an independent risk factor

for adverse outcomes? (Aetiological question) • Question 2 – In medical patients, what is the effect of RBC transfusion

on patient outcomes? (Interventional question) • Question 3 – In medical patients, what is the effect of non-transfusion

interventions to increase Hb concentration on morbidity, mortality and need for RBC blood transfusion? (Interventional question)

• Question 4 – In medical patients, what is the effect of FFP, cryoprecipitate, fibrinogen concentrate, and/or platelet transfusion on patient outcomes? (Interventional question)

• Question 5 – In medical patients, at what INR (PT/APTT) for FFP, fibrinogen level for cryoprecipitate and platelet count for platelets concentrates should patients be transfused to avoid risks of significant adverse events? (Interventional and Prognostic question)

• Question 6 – In specific regularly and chronically transfused patients, at what Hb threshold should patients be transfused to avoid adverse outcomes? (Interventional question)

APTT, activated partial thromboplastin time; FFP, fresh frozen plasma; Hb, haemoglobin; INR, international

WHY GIVE 2 WHEN 1 WILL DO…PATIENT BLOOD MANAGEMENT GUIDELINES

www.blood.gov.au www.blood.gov.au/pbm-guidelines

WHY GIVE 2 WHEN 1 WILL DO…SINGLE UNIT TRANSFUSION

WHO The stable, normovolaemic adult inpatient who does NOT have clinically significant bleeding with symptoms of anaemia

Haemoglobin as defined in the Patient Blood Management Guidelines www.blood.gov.au/patient-blood-management

WHY GIVE 2 WHEN 1 WILL DO

This does not include the chronically transfused such as patients with MDS. According to the Patient Blood Management Guidelines;

“…there is no evidence to guide clinicians on the Hb threshold for transfusion in patients with MDS and chronic anaemia. Further studies are needed to assess the benefit of transfusion in this population”

http://www.blood.gov.au/pbm-module-3

“EVERY ONE MATTERS”

WHAT Transfuse one unit, then reassess the patient for clinical symptoms before transfusing another

Every unit is a new clinical decision

Base decision on patient symptoms, not only on haemoglobin

SINGLE UNIT TRANSFUSIONWHY It is important to align practice with the national Patient Blood Management GuidelinesTransfusion may be an independent risk factor for

increased morbidity, mortality and length of stay.Potential harm from transfusion is dose dependentTransfusion is a live tissue transplant

The British Committee for Standards in Haematology (2012). Guidelines on the Administration of Blood Components. Addendum to Administration of Blood Components, August 2012 pdf. http://www.bcshguidelines.com/4_HAEMATOLOGY_GUIDELINES.htmlCarson JL et al. 2012. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion – Cochrane Review. Cochrane Database of Systematic Reviews 2012: Issue4 Hofmann A, Farmer S, Shander A. 2011. Five Drivers Shifting the paradigm from Product-focused Transfusion Practice to Patient Blood Management” The Oncologist 2011;16(suppl 3):3-11Hofmann, A et al. 2012. Strategies to preempt and reduce the use of blood products: an Australian perspective. Curr Opin Anesthesiol 2012, 25:66-73.

THREE REASONS WHY EXCESSIVE TRANSFUSION IS A PROBLEMReason 1:

Each transfusion increases the risk of nosocomial infection increases other morbidities

Analysis of 11,963 patients after CABG surgery showed that perioperative RBC transfusion was associated with a dose-dependent increased risk of postoperative cardiac complications, serious infection, renal failure, neurologic complications, overall morbidity, prolonged ventilator support, and in-hospital mortality.

Koch CG et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med 2006, 34: 1608-1616.

THREE REASONS WHY EXCESSIVE TRANSFUSION IS A PROBLEM

Reason 2:

Transfusion requirements after cardiac surgery (TRACS) study prospectively demonstrated the safety of a restrictive strategy of red blood cell (RBC) transfusion in patients undergoing cardiac surgery. Also reported: the higher the number of transfused RBC, the higher was the number of clinical complications.

Hajjar LA et al. Transfusion requirements after cardiac surgery: the TRACS randomised controlled trial. JAMA, 304:1559-1567.

THREE REASONS WHY EXCESSIVE TRANSFUSION IS A PROBLEM

Reason 3:

Transfusion associated circulatory overload (TACO) is among the high risk adverse effects of red cell transfusion (up to 1 in 100 per unit transfused).

National Blood Authority, 2012. Patient Blood Management Guidelines: Module 2 - Perioperative. Appendix B, Table B.2.Transfusion Risks in perspective.

WHY GIVE 2 WHEN 1 WILL DO….TOWARD A MORE RESTRICTIVE TRANSFUSION APPROACH

How are these guidelines relevant to you?

Practice Points 4.4 (Red Cells and Cancer)

RBC transfusion should not be dictated by a Hb concentration alone, but also base on the assessment of the clinical status of the patient

When indicated, the transfusion of a single unit of red cells, followed by clinical reassessment to determine the need for further transfusion, is appropriate.

http://www.blood.gov.au/pbm-module-3

HOW IS THIS RELEVANT TO YOU IN THE ONCOLOGY/HAEMOTOLOGY SETTING?

Refer to the Handouts from the Patient Blood Management Guidelines;

1. Effect of anaemia on outcomes (3.1.4) 2.Effect of RBC on outcomes (3.2.4) 3. What is the effect of non-transfusion

interventions to increase Hb concentration. (3.3.1)

Red cell Transfusion in the chronically transfused (3.3.1) Myleodysplastic syndrome (3.3.6)

Assessment of patient after red blood cell transfusion (p.68)

SINGLE UNIT TRANSFUSION GUIDELINE

Benefits: Safer, evidence based transfusion

PLUS: Reduced risk of non-infectious adverse events Reduced demand on limited blood supply Reduced risk from new infectious agents

Every ONE matters

RESEARCH QUESTIONS AND OTHER THOUGHTS….

The NBA states that there is currently no strong evidence –base underpinning treatment and dosing with blood products.

The number 1 research priority area identified by the NBA is to ensure the use of blood and blood products is appropriate, eg in chronically transfused patients, there is currently no evidence to guide clinicians.

Patient Education….to educate and shift patient thinking that they will automatically be transfused with two units (or three or four…)

Transfuse One Unit

Re-assess the patient

Don’t increase the RISKS

if NO BENEFIT

EVERY ONE MATTERS