PRBC Transfusions Medicine Floors
Michael Cho, MD
Internal Medicine, PGY-3
July 19, 2013
“If the hemoglobin is less than 8,
transfuse 2 units PRBC.”
Transfusion Thresholds
Target
Population
RBC usually
indicated
CAP
(1998)
ASA
(2006)
STS
(2007)
SCCM
(2009)
SIMTI
(2011)
AABB
(2012)
General
Perioperative
(general)
Cardiac
Surgery
Critically Ill
Perioperative
(general)
Stable
Hospitalized
Hgb < 6
Hgb < 6
Hgb < 6
Hgb < 6
Hgb < 7
post-op
Hgb < 7 for
ventilated,
trauma or
stable cardiac
Higher if risk
of end organ
ischemia
Hgb < 8 acute
coronary
syndrome
Hgb 6-10 if
hypoxia
CAP: College of American Pathologists.
ASA: American Society of Anesthesiologists.
STS: Society of Thoracic Surgeons.
SCCM: Society of Critical Care Medicine.
SIMTI: Italian Society of Transfusion Medicine and Immunohaematology.
AABB: American Association of Blood Banks.
Hgb 6 - 8 if
risk factors
Hgb ≤ 7
critically ill
Hgb ≤ 8 surgical
patients, or
patients with
pre-existing
cardiovascular
disease when
symptoms are
present
Blood Transfus. 2012.0195-12: 1-11.
American Red Cross Guidelines
TRANSFUSE FOR:
• SYMPTOMATIC anemia
• CLINICAL ASSESSMENT, not
just a lab value
• SINGLE UNIT, except acute
hemorrhage
PRBC Transfusions Internal Medicine
Study Period: 12/2012
20
16
17
16
15
Where: Tower Hospital
Patients: 37 patients with 52
transfusion orders
10
5
3
0
PRBC transfused: 101 units
Time to 1st Transfusion: 4.1 days
Transfusion Orders by Diagnosis
PRBC units transfused per order
3
2.3
2
1.9
2.0
1.4
1
0
All
ESRD
GIB
NS
TRANSFUSION HEMOGLOBIN LEVELS
11
10.1
10
9.7
9.8
9.8
9.6
9.6
9.5
9.6
9.4
9
8.7
8.4
8.3
7.9
8
ADMISSION
PRE-TRANSFUSION
7.4
POST-TRANSFUSION
7.3
7.3
DISCHARGE
7
6
5
ALL
ESRD
GIB
NOT SPECIFIED
Conversion
1 unit of PRBC increases Hemoglobin by 1
Internal Medicine PRBC Transfusions
All Patients
10
9
9.67
8.66
9.82
+2+2
8
7.44
7
6
5
Admission
Pre
Post
Discharge
Inpatient PRBC Transfusions – All Services
ONE YEAR - May 2012 to April 2013
• Total patients: 2,288
• Total cases: 2,748
• Total pRBC units transfused: 10,770
• Units transfused per order: 2.1
• Units transfused per case: 3.9
• Cost for each unit pRBC with labs: $356
• Total direct cost (labs & blood): $3,800,000
Patient Blood Management
PBM is a patient-centered, evidence-based approach to
preventing avoidable transfusions and ensuring the safe
and efficient use of blood components when necessary.
• Early diagnosis and treatment of anemia using
pharmaceutical interventions rather than transfusion
• Strict transfusion triggers
• Minimizing blood loss during hospitalization
• Healthcare worker education
In 2007, Eastern Maine Medical Center, a 411 bed facility,
began a Patient Blood Management program.
Patient Blood Management Results
Potential Savings from
Patient Blood Management
• PRBC transfused annually: 10,770 units
• Total annual direct cost: $3,830,000
• PRBC transfused after PBM with potential
60% reduction: 4,300 units
• Revised total annual direct cost: $1,530,000
• Potential annual savings: $2,300,000
INDIRECT COSTS
•
•
•
•
•
•
•
•
•
Allergic reaction and hives
Fever
Transfusion-associated circulatory overload (TACO)
Transfusion-related acute lung injury (TRALI)
Bloodborne infections
Acute immune hemolytic reaction
Delayed hemolytic reaction
Iron overload
Graft-versus-host disease
Patient Outcomes
Restrictive transfusions lead to either no change or
improved patient outcomes when compared to liberal
transfusion strategies.
STUDIES
• ICU patients. TRICC. NEJM 340 (6): 409-417.
• Anemic post-operative hip surgery patients. FOCUS.
NEJM 365 (26): 2453-2462.
• Acute Upper GI Bleed. NEJM 368 (1): 11-21.
Special Thanks:
Lloyd Rucker, MD
Minh-Ha Tran, MD
Bindu Swaroop, MD
Maggie Macari-Hinson, RN, MSN, CCM
Eric Belen, MBA