Elsevier

The Lancet

Volume 381, Issue 9880, 25–31 May 2013, Pages 1845-1854
The Lancet

Series
Concepts of blood transfusion in adults

https://doi.org/10.1016/S0140-6736(13)60650-9Get rights and content

Summary

Recent progress has been made in the identification and implementation of best transfusion practices on the basis of evidence-based clinical trials, published clinical practice guidelines, and process improvements for blood use and clinical patient outcomes. However, substantial variability persists in transfusion outcomes for patients in some clinical settings—eg, patients undergoing cardiothoracic surgery. This variability could be the result of insufficient understanding of published guidelines; different recommendations of medical societies, including the specification of a haemoglobin concentration threshold to use as a transfusion trigger; the value of haemoglobin as a surrogate indicator for transfusion benefit, even though only changes in concentration and not absolute red cell mass of haemoglobin can be identified; and disagreement about the validity of the level 1 evidence for clinical practice guidelines. Nevertheless, institutional experience and national databases suggest that a restrictive blood transfusion approach is being increasingly implemented as best practice.

Introduction

Every year, 24 million blood components are transfused in the USA and 3 million in the UK, and transfusions happen in more than 10% of all hospital stays that include a procedure.1 Of the 39 million hospital discharges in the USA, 5·8% (2·3 million) are associated with blood transfusion.2 Although blood transfusions are believed to be lifesaving, this hypothesis has never been proven in a prospective controlled clinical trial. Thus, the relative benefit–risk ratio of a blood transfusion is an important bedside discussion for patients' informed consent.3

The use of blood has been affected by inherent risks,4 costs,5 and inventory constraints.6 The annual reports of transfusion fatalities by the Serious Hazards of Transfusion (SHOT) scheme in the UK and the US Food and Drug Administration (FDA) Center for Biologics Evaluation and Research7 in the USA show that transfusion-related deaths seem to be falling.8 In 2011, 69 fatalities among transfusion recipients were reported in the USA and eight in the UK, of which 30 (43%) in the USA and two (25%) in the UK were definitely attributed to transfusion. Since the establishment of the French haemovigilance network in 19949 and SHOT in the UK in 1996, transfusion-related acute lung injury (TRALI) has been the most common cause of mortality and morbidity associated with transfusion. Between 2007 and 2011 in the USA, TRALI caused the highest number of reported fatalities (43%), followed by haemolytic transfusion reactions (23%) attributable to non-ABO blood group (13%) or ABO (10%) incompatibilities.8 The number of deaths related to TRALI has decreased, atributable to initiatives reducing procurement of plasma and platelets from female donors. In view of the known risks and potential for unknown risks of blood in relation to the poorly quantifiable benefit of blood transfusions, the safest blood transfusion is the one not given.10, 11, 12

Awareness of the risks, costs, and effect on blood inventory has stimulated much interest in both institution-based and national Patient Blood Management initiatives—eg, the National Blood Transfusion Committee in England and AABB Patient Blood Management in the USA.3, 13 These initiatives have led to an increased focus on evidence-based transfusion practices, minimisation of blood loss, and optimisation of patient red blood cell mass, which can each lead to improved patient outcomes. However, the decision to transfuse a patient is not always straightforward. No well-defined clinical criteria are available to show the ideal moment to start transfusion treatment,14 and the haemoglobin concentration alone poorly shows acute changes in either red blood cell mass (defined as anaemia) or plasma volumes. No one numerical laboratory value can serve as an absolute indicator of the need for transfusion15 without the context of clinical or patient variables such as risk factors, comorbidities, vital signs, and the rate of anaemia onset (acute vs chronic).16

Section snippets

Reasessment of the transfusion trigger

Moderate anaemia has few associated symptoms because of substantial compensatory mechanisms that preserve oxygen transport in the setting of a reduced concentration of haemoglobin. Important physiological compensatory mechanisms are increased blood flow caused by decreased blood viscosity, increased oxygen unloading to tissues because of increased concentration of red cell diphosphoglycerate, maintenance of blood volume attributable to increased plasma volume, and redistribution of blood flow.16

Blood use

Both the paediatric78 and adult hospital3 at Stanford University Medical Center, CA, USA, have reduced blood use by using the computerised physician order entry process for blood transfusions. The haemoglobin concentration threshold for blood transfusions decreased after clinical effectiveness teams introduced physician education and clinical decision support in July, 2010, via best practices alerts and electronic physician order entry. Figure 2 shows a subsequent analysis of trends in blood

Treatment with platelets

Prophylactic platelet transfusions did not become standard practice for haematology, oncology, and stem-cell transplant patients receiving intensive treatment until the 1970s. The use of platelets has become more common since then, and the number of platelet concentrates issued in England rose by 8·3% between April, 2011 and March, 2012.82 However, although platelet transfusions have improved the management of patients with severe thrombocytopenia, three main areas of controversy remain:83 what

Treatment with plasma

National guidelines exist in many countries and are broadly similar in their recommendations for use of plasma (table 526,60,64–68). Recommendations for plasma transfusion are: active bleeding before surgery or an invasive procedure in patients with acquired deficiencies of one or more coagulation factors, as shown by abnormalities in the standard coagulation tests; immediate correction of vitamin K deficiency or reversal of warfarin anticoagulant effect in patients with active bleeding;

Patients with trauma

Haemorrhage is responsible for almost 50% of deaths occurring within 24 h of traumatic injury and for up to 80% of intraoperative trauma mortalities.95, 96, 97 Blood component support before and after control of massive haemorrhage is critical in these scenarios. Traditionally, resuscitation has been initiated with large volumes of crystalloid, accompanied by treatment with red blood cells.98 Plasma, platelets, and cryoprecipitate are then supplemented on the basis of laboratory values and at

Conclusions

Blood transfusions carry risks, and are expensive, and blood supply is scarce. As a result, blood use and transfusion outcomes are under renewed scrutiny by health-care institutions, regulatory agencies, and accreditation organisations.3, 12, 108 Additionally, professional societies are well positioned to incorporate blood transfusion outcomes as quality indicators in their own guidelines and recommendations.109 Physicians and hospital departments of quality and cost-effectiveness should

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