Researchers seek clearer guidelines for red blood cell transfusions

SAN DIEGO — Nearly half of red blood cell transfusions are not given based on suggested guidelines, according to results of a cross-sectional survey conducted at three Jerusalem hospitals and presented at the ASH Annual Meeting and Exposition.

The findings highlight the need for clearer guidelines and better understanding of clinical decision-making, researchers wrote.

“As part of an initiative to improve the quality of red blood cell (RBC) transfusion practice, we performed this study to examine RBC transfusion practices by patient- and admission-related characteristics,” Shoshana Revel-Vilk, MD, MSc, pediatric hematologist/oncologist at Hadassah Hebrew University Medical Center, and colleagues wrote.

As part of ASH’s participation in the Choosing Wisely campaign in 2013, the society recommended to transfuse the minimum number of units of RBCs required to relieve symptoms of anemia or to return the patient to a safe hemoglobin range.

Based on a high volume of observed RBC use, Revel-Vilk and colleagues evaluated transfusion practices in the following hospital departments: general and adult intensive care; internal medicine; orthopedics; hematology; and cardiothoracic surgery. Exclusion criteria included patients who underwent liver transplants, patients with solid tumors, those who required more than six transfusions, and those who received transfusions during surgery.

Researchers grouped orthopedic and cardiothoracic departments together as surgical departments and compared them with all other nonsurgical departments.

Off-protocol RBC transfusion was defined as patients who received more than one RBC unit consecutively or transfusion given to nonbleeding, nonactive cardiac patients with hemoglobin levels greater than 8 g/dl.

Revel-Vilk and colleagues evaluated data from 584 RBC transfusions given to 302 patients (mean age, 67 years; 53.6% women). The mean number of transfusions per patient was 1.9 (± 1.3); 52.6% of patients received one transfusion. Two patients received eight transfusions.

Nearly all patients (96.4%; n = 291) had at least one underlying medical condition, such as hypertension (48.3%), heart disease (44.7%), malignancy (33.1%), nephrology conditions (32.1%) or pulmonary disease (32.1%). Nearly half (47%; n = 142) of patients took antithrombotic therapy.

Of the 584 RBC transfusions, 85.3% (n = 498) were given in nonsurgical departments, and 42.3% (n = 247) were given to patients who underwent invasive procedures or surgeries during their admission, of which 55.5% (n = 137) were considered major operations (eg, open laparotomy or open heart). Pretransfusion hemoglobin level was greater than 8 gr/dl in 39.2% (n = 229) of transfusions, and more than 1 RBC unit was given consecutively in 16.4% (n = 96) of transfusions.

The prevalence of off-protocol RBC transfusion was 48.1%, and the mean age of patients who received off-protocol RBC transfusion was higher than those who received it on protocol (67.8 years vs. 60.7 years; OR = 1.02; 95% CI, 1.01-1.03). Off-protocol RBC transfusion was more common in surgical departments than nonsurgical departments (OR = 7.4; 95% CI, 3.7-14.7).

Among patients who underwent invasive procedures or surgeries, major operations were associated with higher likelihood for off-protocol RBC transfusion than minor procedures (OR = 1.7; 95% CI, 1.1-2.8).

Off-protocol RBC transfusion was not related to presence of underlying malignancy, heart disease, nephrology conditions or pulmonary disease. However, it was more common among patients who took antithrombotic therapy (OR = 1.7; 95% CI, 1.2-2.4). Pretransfusion recording of patients’ blood pressure, pulse rate and saturation were not associated with off-protocol RBC transfusion.

“Although clinical considerations, such as underlying disease or patients’ pretransfusion signs, may explain nonadherence to guidelines, no clear pattern was observed in the current study to support this explanation,” Revel-Vilk and colleagues wrote. – by Chuck Gormley

Reference:

Revel-Vilk S, et al. Abstract 1003. Presented at: ASH Annual Meeting and Exposition; Dec. 3-6, 2016; San Diego.

Disclosure: Researchers report no relevant financial disclosures.