Introduction of a Single Unit Transfusion

Policy

Patient Blood Management Pilot

2014

Introduction

• Patient Blood Management• The Safety of Blood – SHOT data• Single unit blood transfusion policy• Causes of anaemia• Alternatives to blood• Case studies

Changing Transfusion Practice

• Patient Blood Management (PBM) is a National and International initiative in Blood Transfusion

• To give blood transfusions appropriately and effectively on an individual patient basis

Blood safety

• SHOT Report 2013• 22 deaths

– Avoidable, delayed or undertransfused (5)– Transfusion-related Acute Lung Injury (1)– Post Transfusion Purpura (1)– Haemolytic Transfusion Reaction (1)– Transfusion-associated circulatory

overload (12)– Incorrect Blood Component Transfused (1)– Unclassified complication of transfusion (1)

Annual SHOT Report 2013

Blood safety• 143 Major Morbidity

– Acute transfusion reactions (76)– Transfusion-associated circulatory overload

(34)– Incorrect blood component transfused (6)– Haemolytic transfusion reactions (8)– Transfusion-related acute lung injury (9)– Anti-D errors (1)– Transfusion-transmitted infections (0)– Avoidable, delayed or undertransfusion (7)– Unclassifiable complications of transfusion (1)– Transfusion-associated dyspnoea (1)

Annual SHOT Report 2013

TACO

• The International Society of Blood Transfusion (ISBT) definition states that TACO includes any 4 of the following that occur within 6 hours of transfusion– Acute respiratory distress– Tachycardia– Increased blood pressure– Acute or worsening pulmonary oedema– Evidence of positive fluid balance

Annual SHOT Report 201

TACO - Case Study• 78 year old female, weight 63.3kg• Admitted to Emergency Department unwell

and feeling faint• Vial signs normal• Hb 59g/L, microcytic blood picture – likely

iron deficiency• 2 units RBC ordered by ED doctor• First unit commenced at 14:12• Patient transferred to acute medical unit

TACO - Case Study• During ward round an additional 2 units RBC

prescribed• After 270ml of 4th unit patient developed

massive pulmonary oedema and left ventricular failure

• Baseline obs – pulse 98, BP 120/75mmHg• Reaction obs – pulse 82, BP 152/111mmHg• Admitted to ITU and received CPAP and

furosemide• Patient died

Annual SHOT Report 2013

Calculating dose

• Transfusing a volume of 4ml/kg will typically give a Hb rise of 10g/L and should only be applied as an approximation for a 70-80kg non-bleeding patient

Annual SHOT report 2012.British Committee for Standards in Haematology: Addendum to Administration of Blood Components. 2012.

Calculating dose

National Comparative Audit of Blood Transfusion - 2011 Audit of the use of blood in adult medical patients, part 2

Correlation between body weight and Hb increment

Errors in Transfusion

Annual SHOT Report 2013

Single Unit Transfusions

• For stable non-bleeding patients• Investigate causes of anaemia – Iron,

B12, folate investigations• Only transfuse if the patient is

symptomatic• Transfuse a single unit and reassess the

patient for symptoms of anaemia (Hb)• Only transfuse second unit if patient

symptomatic

National Audit

National Comparative Audit for Blood Transfusion of Medical Use of Blood

•Red cells transfused; 65% were 2 units, 15% were 3 units and 6% were 4 units•Transfusion in cases with possible reversible anaemia (20%)•Transfusion above the Hb threshold defined by the audit algorithm (29%)•Over-transfusion (33%)

• Transfusion to more than 20g/L above threshold

Date of download: 9/9/2013Copyright © 2012 American Medical

Association. All rights reserved.

From: Outcomes Using Lower vs Higher Hemoglobin Thresholds for Red Blood Cell Transfusion

JAMA. 2013;309(1):83-84. doi:10.1001/jama.2012.50429

30-Day mortality was evaluated in 4975 patients included in 11 of 19 trials. Adapted from Analysis 3.2 in Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst

Rev. 2012;4:CD002042. doi: 10.1002/14651858.CD002042.pub3

Figure Legend:

Evidence

• Multicentre randomised controlled trials demonstrate that a restrictive approach to RBC transfusion decreases transfusions without increasing mortality or adverse events (Herbert et al 1999, Carson et al 2011, Villanueva 2013)

• Single unit policy reduces the number of transfusions and therefore reduces the risk to the patient (Berger et al 2012)

Evidence• WA PBM program introduced in a tertiary hospital in 2008; 26%

reduction in RBC transfusions and 16% reduction in PLT transfusions over three years (Leahy 2013)

Reference Findings implementing restrictive/single unit policy

Yerrabothala et al (2014)

The total number of red blood cells transfused/1000 patient days decreased from 60.8 to 44.2 and the

proportion of 2-unit transfusions decreased from 47% to 15%

Berger et al (2012)

Reduced red cell usage by 25% with no evidence of more severe bleeding or reduction in survival in patients

receiving intensive chemotherapy or stem cell transplantation.

Royal Oldham Hospital, UK (HTC verbal report, 2014)

Indicates a reduction in red cell usage of 10.4% last quarter (2.5% last year) and platelet usage by 16.8%

Causes of anaemia

• Why is your patient anaemic?– Iron Deficiency– B12 Deficiency– Folate Deficiency

• Test for these before transfusion

Blood results

Royal College of Pathologists of Australia- Common sense pathology 2004

Alternatives to Blood

• Ferrous sulphate supplements• IV Iron• B12 injections• Folate supplementation

Triggers

Table from Handbook of Transfusion Medicine

4th Edition

Indications for Transfusion

National Blood Transfusion Committee -Indication codes for Transfusion

Symptomatic Anaemia•Fatigue•Breathless at rest•Chest pains/Palpitations•Faint

Patient Assessment

Consent for Transfusion

• SaBTO - 2011• Valid consent for blood transfusion should be

obtained and documented in the patient's clinical record by the healthcare professional

• There should be a standardised information resource for clinicians indicating the key issues to be discussed by the healthcare professional when obtaining valid consent from a patient for a blood transfusion

Single Unit Project

• Audit• Education• Prospective collection of data• Regular review• Feedback• Multidisciplinary team

Case Study 1

• Female, 83 • Admitted to Marjory Warren with new

diagnosis of PE• Background of LRTI • Long smoking history• Aiming for sats of 85-92% on room

air

Case Study 1

• Hb 05/06/14 – 86 g/L

• Medical notes - 9/6/14 12:28 states ‘Hb 8.6 – likely to be adding to hypoxia. Plan:- transfuse 2 units’

• Sats –

• Hb 09/06/14 12:27 – 100 g/L

Case Study 1

• Nursing notes 10/6/14 00:13 state ‘NIC contacted 888.’ ‘They came up to the ward and said they had checked Hb which was 10 and not for blood transfusion tonight’

• 10/06/14 09.57– Sats 93% on RA. Patient feels well, comfortable at rest, no pain, denies SOB

• 10/6/14 Hb 101 11:35 am

Case Study 1

• 10/06/14 – Patient transfused 2 units of blood (Units collected 9:55 and 14:31)

• No Hb check or documented review between units

• Medical notes 11/06/14 09:40 - ‘Chronic iron deficiency anaemia – transfused 2 units 11/06’

Case study 1

• Hb 11/06/14 – 132 g/L• No evidence of haematinic tests

performed – B12/Folate/Fe• Patient macrocytic

• Discharged with daily dose of ferrous sulphate

Case Study 2

• Female, 76, weight 59.2kg• Admitted on 07/04/2014 to Oliver

Ward with SOB, non-productive cough and chest tightness.

• History of COPD. RCA managed with stents.

• July 2014 - Bilateral PE on warfarin

Case Study 2

• 12/07/14 - Patient lost blood from cannula following fall. No physical injury noted

• 13/07/14 17:22 - Hb 88g/L• 13/07/14 19:37 - Hb trending 101 – 94 –

88, day team to investigate drop in Hb• 14/07/14 07:54 - Hb 80• 14/07/14 13:42 - (Physiotherapy) Current

medical issues: SOB, ongoing chest pain, hypotensive last 2 days, dropping Hb

Case Study 2

• 14/07/14 – 2 units red cells authorised. No documented symptoms of anaemia.

• Unit 1 collected 21:49 • Unit 2 collected 02:11• 15/07/14 05:41 – unable to sleep due

to transfusion monitoring

Case Study 2

• 15/07/14 07:45 – pyrexic this morning. Temp pre-transfusion 37.2 and post transfusion 38.4. Advised to give paracetamol and monitor patient

• 15/07/14 12:45 - Hb 119g/L

Any Questions?

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