Programs Blood Watch - improving transfusion medicine for patients in NSW
Blood Myths There are many myths in medicine about blood transfusions. We commonly hear statements such as, "blood helps my patient get out of hospital sooner" or "blood improves healing". It is also a myth that blood is free.
There is a perception that blood is safer than ever, and whilst this might be the case in regards to transmissible viruses such as HIV, Hepatitis or vCJD, the rate of adverse events from human error, incompatibility reactions, and bacterial contaminations are significant. There is now increasing evidence for immunomodulatory effects following transfusion.
We can no longer ignore the facts about blood and blood transfusion.
Blood, it's safer than it's ever been
Bacterial contamination, incompatibility reaction and transfusion-related acute lung injury (TRALI) are still the most common and most immediately dangerous complications of blood transfusion.
Residual Infectious Risks of Transfusion in Australia:-
Bacterial Sepsis August 2007
Agent and testing standard Window Period (Days) Estimate of residual riskper unit HIV (antibody + RNA) 9 Less than 1 in 10 million HCV (antibody + RNA) 5.4 Less than 1 in 10 million HBV (HBsAg) 38 Approximately 1 in 660 000 HTLV I & II (antibody) 51 Less than 1 in 10 million CMV (antibody negative) 46 Approximately 1 in 127 000 CMV (untested /WBC filtered) N/A Risk of recipient infection approximately 2.5% Variant Creutzfeldt-Jakob Disease (vCJD) [No testing] Possible. Not yet reported in Australia. Malaria (antibody) N/A 1 in 4.9 millionto 1 in 10.2 million
Reference: ARCBS Blood Component Information Booklet, 2006
Non-Infectious Risks of Transfusion in Australia
(Per unit transfused unless specified)
Haemolytic reactions Morbidity Mortality Acute 1: 12 000to 38 000 1: 600 000to 1.5 million Delayed 1: 1 000to 12 000 1: 1.25 million Anaphylaxis - IgA deficiency 1: 20 000to 50 000 Fluid overload / cardiac failure 1: 100 to 700 per patient TRALI 1: 5 000to 100 000 1: 5 million TA-GVHD Morbidity rare 90% cases fatal
Reference: ARCBS Blood Component Information Booklet 2006
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- Blood Myth 1: Blood, it's safer than it's ever been - PDF ~820kb
A blood transfusion will get my patient home sooner
There is emerging evidence that patients transfused after surgery stay longer in hospital and have more infections following discharge.
The CRIT Study
The CRIT Study shows that RBC transfusions are independently associated with longer ICU and hospital length of stay and increased mortality. Overall there were more complications in the patient cohort and the number of RBC units transfused was an independent predictor of worse clinical outcome.
Objectives: To quantify the incidence of anemia and red blood cell (RBC) transfusion practice in critically ill patients and to examine the relationship of anemia and RBC transfusion to clinical outcomes Design: Prospective, multiple center, observational cohort study of intensive care unit (ICU) patients in the United States. Enrolment period was from August 2000 to April 2001. Patients were enrolled within 48 hrs of ICU admission. Patient follow-up was for 30 days, hospital discharge, or death, whichever occurred first. Setting: A total of 284 ICUs (medical, surgical, or medical-surgical) in 213 hospitals participated in the study. Patients: A total of 4,892 patients were enrolled in the study. Measurement and Main Result: The mean hemoglobin level at baseline was 11.0 +/- 2.4 g/dL. Hemoglobin level decreased throughout the duration of the study. Overall, 44% of patients received one or more RBC units while in the ICU (mean, 4.6 +/- 4.9 units). The mean pretransfusion hemoglobin was 8.6 +/- 1.7 g/dL. The mean time to first ICU transfusion was 2.3 +/- 3.7 days. More RBC transfusions were given in study week 1; however, in subsequent weeks, subjects received one to two RBC units per week while in the ICU. The number of RBC transfusions a patient received during the study was independently associated with longer ICU and hospital lengths of stay and an increase in mortality. Patients who received transfusions also had more total complications and were more likely to experience a complication. Baseline hemoglobin was related to the number of RBC transfusions, but it was not an independent predictor of length of stay or mortality. However, a nadir hemoglobin level of â€¹9 g/dL was a predictor of increased mortality and length of stay. Conclusions:
Anemia is common in the critically ill and results in a large number of RBC transfusions. Transfusion practice has changed little during the past decade. The number of RBC units transfused is an independent predictor of worse clinical outcome.
Reference: The CRIT Study: Anemia and blood transfusion in the critically ill- Current clinical Practice in the United States - Corwin, Howard L. Gettinger, Andrew. Pearl, Ronald G. Fink, Mitchell P. Levy, Mitchell M. Abraham, Edward. MacIntyre, Neil R. Shabot, M Michael. Duh, Mei-Sheng. Shapiro, Marc J.Critical Care Medicine 32(1):39-52, 2004 Jan.
The Koch et al 2006 Study
The Koch et al 2006 Study of blood transfusions during cardiac surgery concluded that there was:-
- a dose-dependent relationship between reductions in functional recovery for the patient and an increase in the units of red blood cells transfused.
- a "persistently negative, risk-adjusted effect on health-related quality of life after cardiac surgery that extends well beyond initial hospitalisation".
Background: Although red blood cell transfusion has been associated with an increase in early morbid outcomes and reduced long-term survival after cardiac surgery, its relationship to functional quality of life after surgery has not been previously explored. Our objective was to investigate the relationship between perioperative red blood cell and component transfusion and functional health-related quality of life 6 to 12 months after cardiac surgery. Methods: Of 12,536patients undergoing cardiac surgical procedures between May 1995 and January 1999, 7,321completed a self-administered Duke Activity Status Index (DASI) survey preoperatively and least one follow-up survey at nominally 6 or 12 months postoperatively. The influence of baseline DASI, preoperative risk factors, clinical status, laboratory values, operative events, and postoperative morbidities on follow-up DASI were examined with ordinal regression modeling. Results: After adjustment for preoperative DASI, demographic, cardiac and noncardiac comorbidity, type of surgery, postoperative complications, and interval between follow-up DASI, during which patients continued to improve (p < 0.0001), postoperative functional status after cardiac surgery was incrementally worse the more perioperative red cells (p < 0.0001)and platelets (p = 0.02) that had been transfused. Conclusions: Red blood cell and platelet transfusion have an unintended persistently negative risk-adjusted effect on health-related quality of life after cardiac surgery that extends well beyond initial hospitalization. Reductions in functional recovery paralleled increasing units of red blood cells transfused.
Reference: Persistent effect of red cell transfusion on health-related quality of life after cardiac surgery - Koch, Colleen Gorman. Khandwala, Farah. Li, Liang. Estafanous, Fawzy G. Loop, Floyd D. Blackstone, Eugene H. in Annals of Thoracic Surgery. 82(1):13-20, 2006 Jul.
What the Experts say
"A wide range of sophisticated (and resource-consuming) interventions are in place which are generally successful in dealing with the risk from known viral agents. However, newly emergent viral risks can usually only be addressed after they have been shown to transmit and after tests have been developed." - J. Barbara
Reference: Why 'Safer than Ever' May Not Be Quite Safe Enough in Transfusion Medicine and Hemotherapy, 2004;31 (Suppl. 1):2-10
"It is the emerging and the re-emerging that keep us humble." - H. J. Alter
Reference: Emerging, re-emerging and submerging infectious threats to the blood supply in Vox Sanguinis - (2004);87(Suppl. 2): S56-S61. Department of Transfusion Medicine, Warren Grant Magnuson Clinical Center, Bethesda, USA
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- A blood transfusion will get my patient home sooner - PDF ~477kb
Blood transfusions improve healing
Current, emerging evidence shows that patients who receive blood transfusions are at greater risk of transfusion associated adverse outcomes such as infection, kidney failure, lung injury or death.
The Taylor et al Study
This 2006 study on red cell transfusions and nosocomial infections in critically ill patients concluded that infection rate was higher in those patients transfused compared to those who weren't. Mortality and length of stay (intensive care unit and hospital) were significantly higher in transfused patients, even when corrected for illness severity.
Reference:Red blood cell transfusions and nosocomial infections in critically ill patients - Taylor, Robert W. MD, FCCM; O'Brien, Jacklyn RN; Trottier, Steven J. MD, FCCM; Manganaro, Lisa RN; Cytron, Margaret RN; Lesko, Mary F. RN, BSN; Arnzen, Kimberly RN; Cappadoro, Carla RN, MSN; Fu, Min MS, MBA; Plisco, Michael S. MD; Sadaka, Farid G. MD; Veremakis, Christopher MD in Critical Care Medicine, Volume 34, Issue 9 September 2006
Key studies in surgical infection rates
Surgery - The evidence
Joint replacement and orthopaedic infection rates
Site Number Not Transfused Transfused Montreal1 1 206 8.4% 14% Austria2 308 6.9% 12% Hip (UK)3
Higher morality in transfused group
Minor Wound - 1 068 1.9% 2.0% Major Wound 0.6% 0.9% Spain4 Deep Seated Wound OR 12x
Source: Dr Stephen O'Mara, Blood Culture: Why do we need to improve transfusion practice? - Presentation, Staff Specialist Haematologist, Hunter New England Area Health
Objectives: To assess the risk of postoperative infection associated with blood transfusion in patients who undergo primary total hip arthroplasty. Setting: Victoria General Hospital, Halifax, (a tertiary-care centre). Patients: All patients who underwent primary total hip replacement between 1990 and 1995 (N = 1206). Interventions: Hip replacement with or without perioperative blood transfusion. Outcome Measures: The rate of postoperative infection, the number of blood transfusions, patient age and sex, duration of surgery and the surgeon who performed the procedure. Victoria General Hospital medical records, the transfusion services record and the Dalhousie University Hip Study databases were integrated and analysed using a standard statistical package. Results: The incidence of infection postoperative was 9.9% overall, 8.4% in patients receiving no transfusion, and 14% in those receiving homologous transfusion (p = 0.035). There were no infections in the 11 patients who received an autologous blood transfusion. Significant predictors of postoperative infection were sex, age and duration surgery; these were not confounding variables multivariate analysis). Neither the operating surgeon nor the blood product transfused affected the infection rate. Conclusions:
These findings suggest an increased risk of postoperative infection in patients who undergo primary hip replacement and receive homologous blood transfusions perioperatively.
Reference 1: Is homologous blood transfusion a risk factor for infection after hip replacement? - Steinitz, D. Harvey, E J. Leighton, R K. Petrie, D P. inCanadian Journal of Surgery 44(5):355-8, 2001 Oct.
Reference 2 - Austria
Background: This study was designed to obtain data on the incidence of postoperative infection in patients undergoing elective orthopedic surgery and receiving white blood cell (WBC)-filtered blood components prepared according to current standards. Study Design and Methods: A total of 308 consecutive orthopedic patients who opted for preoperative autologous blood donation (PAD) for primary unilateral hip and knee replacement surgery were enrolled in a prospective observational study of the incidence of postoperative infection. Patients with contraindications for PAD or with any infectious disease were not included in the study. To identify probably confounding factors, differences between patient groups were analyzed first. Identified factors, which differed between groups, and variables describing blood supply were further tested in uni- and multivariate logistic regression analysis for their independent influence on development of postoperative infection. Infection rates were compared on the basis of actual transfusion groups. Results:
Of the 308 study patients, 101 were not transfused, 85 received their PAD, 100 received allogeneic WBC-filtered red blood cells (RBCs), and 22 were given autologous RBCs and additionally allogeneic WBC-filtered RBCs. Overall the infection rate was 6.82 percent (21/308). Infection rates varied significantly between transfusion groups (no transfusion, 6.9%; autologous RBCs, 1.2%; allogeneic WBC-filtered RBCs, 12.0%; both transfusion types, 4.6%; p = 0.03). Allogeneic recipients showed significantly more infections compared to autologous recipients (p = 0.0053). Multivariate regression analysis confirmed transfusion of allogeneic WBC-filtered RBCs as an independent variable predicting postoperative infection (odds ratio, 23.65; confidence interval, 1.3-422.1; p = 0.01).
Conclusion: Differences in postoperative infection rates between allogeneic and autologous recipients are still observable, although universal WBC filtration has been introduced into clinical practice.
Reference 2: Risk for postoperative infection after transfusion of white blood cell-filtered allogeneic or autologous blood components in orthopedic patients undergoing primary arthroplasty - Petra Innerhofer; Anton Klingler; Christian Klimmer; Dietmar Frie1; Walter Nussbaumer in Transfusion, Volume 45, Number 1, January 2005 , pp. 103-110(8)
To assess whether allogeneic blood transfusion in the perioperative period is associated with changes in mortality or complication rates in patients undergoing surgical treatment for hip fracture (proximal femoral fracture).
Retrospective case-control series, all patients followed up for 1 year or until death.
District General Hospital in Peterborough, UK.
Three thousand six hundred twenty-five consecutive patients admitted and operated for hip fracture (proximal femoral fracture) during July 1989 to January 2002 (151 months); 1068 (29.9%) received a perioperative allogeneic blood transfusion.
Main Outcome Measures:
Thirty- 120-, and 365-day mortality, deep and superficial wound infection rates.
Overall mortality for all patients at 1 year post fracture was 28.2% (1007 patients). Transfusion was associated with a statistically significant increase in mortality from 120 days onward after hip fracture. However, when this was adjusted with a statistical regression model for baseline characteristics and confounding variables, this difference became statistically insignificant (P = 0.17). Infection rates in the transfusion group were 2.0% for superficial infection and 0.9% for deep infection compared with 1.9% and 0.6%, respectively, in the non-transfusion group. These figures were not statistically significantly different. Other complications of deep venous thrombosis, chest infection, and congestive cardiac failure showed no statistically significant increase in those patients who received transfusion.
Our data suggest that transfusion is not associated with a change in mortality or infection rates in the hip-fracture.
Reference 3: Is perioperative blood transfusion a risk factor for mortality or infection after hip fracture? - Johnston P, Wynn-Jones H, Chakravarty D, Boyle A, Parker MJ. Journal of Orthopaedic Trauma, VOL 20; NUMB 10, 2006, pages 675-679.
Reference 4 - Spain
Background: Postoperative infections result from the interactions of bacteria, the surgical technique, and host defence mechanisms. Thus, identifying single determinant factors has proved difficult. Magnitude of the risk: In a recent survey of 2,809 colorectal resections, transfusion was the single most powerful risk factor for postoperative infection. In patients undergoing primary hip or knee prosthesis insertion, the transfusion of allogeneic blood increased the risk of a deep-seated infection by a factor of 12. Mechanisms:
Several host defence mechanisms are impaired by blood products. The initial hypothesis incriminated the transfused white blood cells, but this paradigm has since been challenged. The effects of free serum iron, the blood storage time, and the presence in stored blood of bioactive substances such as inhibitors of metalloproteinase-1 may also be important.
It is worth pursuing efforts to emphasize autologous blood transfusion and the reinfusion of shed blood as blood conservation strategies, as these practices reduce the risk of infectious complications.
Reference 4: Blood Transfusions and Postoperative Infections in Patients Undergoing Elective Surgery - Antonio Sitges-Serra, Joan J. Sancho Insenser, Estela Membrilla in Surgical Infections 2006, Vol 7 (supplement 2): s-33-s-35.
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- Blood transfusions improve healing - PDF ~936kb
Autologous blood (pre-donated) is risk-free
Pre-donated autologous transfusion is not risk-free and there are a variety of adverse events associated with this practice.
Reference: Wood, EM & Yomotovian, RA - Adverse Consequences of Autologous Transfusion Practice in Popovsky MA - ed. Transfusion Reactions, 3rd Edition, Bethesda MD: AABB Press, 2007.
Although preoperative autologous blood donation is employed in elective surgery, this is declining because of the increasingly safe allogeneic blood supply. However, it continues to be used because of the public's perception of allogeneic blood risks and increasing blood shortages. Patients may donate a unit of blood (450 +/- 45 ml) as often as twice weekly, up to 72 hours before surgery. Preoperative autologous blood is most beneficial in procedures that cause significant blood loss. It has been determined that preoperative autologous blood donation is poorly cost-effective; the use of this procedure must be based on evidence that it is safe and of value for the patient.
Reference: Autologous blood donation - Goodnough LT. Crit Care. 2004;8 Suppl 2:S49-52. Epub 2004 Jun 14
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- Autologous blood (pre-donated) is risk-free - PDF ~703kb
Blood, it's free anyway
The Australian Red Cross Blood Service collects 900,000 red cell donations per year however it remains an inherently limited resource. In Australia only the donors give their blood for free. What happens thereafter is not free.
Understanding the costs associated with blood products requires sophisticated knowledge about transfusion medicine and is attracting the attention of clinical and administrative healthcare sectors worldwide.
To improve outcomes, blood usage must be optimized and expenditures controlled so that resources may be channelled toward other diagnostic, therapeutic, and technological initiatives. Estimating blood costs, however, is a complex undertaking, surpassing simple supply versus demand economics. Shrinking donor availability and application of a precautionary principle to minimize transfusion risks are factors that continue to drive the cost of blood products upward.
Recognizing that historical accounting attempts to determine blood costs have varied in scope, perspective, and methodology, new approaches have been initiated to identify all potential cost elements related to blood and blood product administration. Activities are also under way to tie these elements together in a comprehensive and practical model that will be applicable to all single-donor blood products without regard to practice type (e.g., academic, private, multi- or single-centre clinic). These initiatives, their rationale, importance, and future directions are described.
Reference: Estimating the cost of blood: past, present, and future directions - Shander A, Hofmann A, Gombotz H, Theusinger OM, Spahn DR. in Best Practice Research Clinical Anaesthesiology 2007 Jun;21(2):271-89
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- Blood, it's free anyway - PDF ~618kb