Introduction of a
Single Unit
Transfusion Policy
Patient Blood Management
Pilot 2014
Introduction
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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 nonbleeding patient
Annual SHOT report 2012.
British Committee for Standards in Haematology: Addendum to Administration
of Blood Components. 2012.
Calculating dose
Correlation between body weight and Hb increment
National Comparative Audit of Blood Transfusion - 2011
Audit of the use of blood in adult medical patients, part 2
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
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
Figure Legend:
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
Date of download: 9/9/2013
Copyright © 2012 American Medical
Association. All rights reserved.
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
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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
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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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