Running head: BLOOD TRANSFUSION GUIDELINES
Blood Transfusion Guidelines – Evidence Based Practice
Jamie McGuire
Wright State University
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Evidenced Based Transfusion Guidelines
Introduction
The purpose of this paper is to review current research and clinical guidelines regarding
the transfusion threshold when using packed red blood cells (RBC) in the acute care setting. Use
of blood transfusions or RBC’s has become one of the most common clinical interventions
utilized by providers (Robak, 2012). Understanding the potential adverse effects associated with
use of RBC’s is vital to protecting patients and delivering appropriate ethical care. Adverse
effects associated with blood transfusion include infectious disease transmission, circulatory
overload, pulmonary edema, myocardial infarction, stroke, thromboembolism, renal failure,
hemorrhage, confusion, transfusion – related acute lung injury, hemolytic reactions, and
increased length of hospital stays (Robak, 2012).
Research demonstrates that clinical
consequences can be reduced by the use of restrictive transfusion strategies while improving
overall mortality when compared to liberal use of blood products (Carson et. al, 2012). Thus,
providers should be up to date on the current evidence based strategies when making clinical
decisions regarding the use of packed RBCs.
Significance of Problem
It is estimated approximately 15 million units of RBC’s are transfused annually in the
United States (Carson et. al, 2012). Ultimately blood transfusions are utilized in the presence of
anemia. There are a variety of causes and disease processes associated with anemia. As defined
by the World Health Organization anemia is defines as a hemoglobin level less than 13 g/dl in
men and 12 g/dl among women (McEvoy & Shander, 2013). Anemia is an epidemic that effects
approximately 25% of the world’s population and over 50% of the hospital population, with as
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high as 75% of the elderly hospital patients (McEvoy & Shander, 2013). There are a variety of
etiologies associated with anemia including nutritional deficiencies, erythropoietin deficiencies,
hemolysis, coagulation abnormalities, and blood loss (McEvoy & Shander, 2013). Patients may
present with a clearly identified source such as acute blood loss or may have a mixed picture
requiring further work up. The highest rates of anemia are associated with chronic kidney
disease (35.4%), cancer (32%), and chronic cardiac disease (18%) (McEvoy & Shander, 2013).
Although blood transfusions can save lives there are associated adverse reactions that can
be fatal. RBC transfusion is the most common intervention associated with anemia, with greater
than 33% of ICU patients receiving a transfusion during their stay, this percentage doubles with a
length of stay of seven days (Kumar, Thapliyal, Coshic, & Chatterjee, 2013). The American
Medical Association, Joint Commission, and the Centers for Medicare and Medicaid Services
joined in identifying that RBC transfusions are one of the top five overused procedures in
medicine (McEvoy & Shander, 2013).
The Joint Commission recently introduced the
appropriateness of blood transfusions when measuring quality outcomes of hospitals (McEvoy &
Shander, 2013).
Discussion of Problem Consequences
Transfusion of blood and or blood products can be life sustaining but providers and
patients need to be aware of the consequences and associated adverse outcomes. The risks of
adverse outcomes vary among patient populations and are influenced by existing co-morbidities,
etiology of anemia, amount of blood transfused, and frequency of transfusion needs.
For
example, repeated transfusions in the presence of chronic conditions can lead to iron overload
resulting in end-organ damage (McEvoy & Shander, 2013).
The most common adverse
outcomes associated with use of RBC’s demonstrated in the research studies includes
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transfusion-related acute lung injury (TRALI), transfusion associated circulatory overload
(TACO), and transfusion-related immunomodulation (TRIM) (McEvoy & Shander, 2013).
TRIM leads to increased nosocomial infections and increased cancer recurrence (McEvoy &
Shander, 2013).
There is an associated 40% increase in thirty-day morbidity and as high as 67% increase
in six-month mortality among patients receiving RBC transfusion (Kumar, Thapliyal, Coshic, &
Chatterjee, 2013). Furthermore, there is an overall increase in healthcare cost and demands
associated with transfusing blood and the treatment of related adverse outcomes. Providers rely
upon the current research and recommendations to identify when the risk of anemia outweighs
the potential for adverse outcomes.
Treatment Issues
There is limited quality evidence assessing the benefit versus harm of various transfusion
practices due to the lack of consistency throughout the country (Kumar, Thapliyal, Coshic, &
Chatterjee, 2013). The Patient Safety Science and Technology Summit (2013) identified the
need to align hospitals to address the overuse of blood transfusions (McEvoy & Shander, 2013).
Identifying when to implement a liberal or restrictive transfusion policy can be tricky for
providers given the variety of etiologies of anemia in the presence of other disease processes.
Certain subgroups of patient disease processes need further research to identify thresholds for
transfusion recommendations (Carson et. al, 2012).
Patients diagnosed with coronary artery disease (CAD) have been identified as a
subgroup that might benefit from a higher hemoglobin threshold, especially those diagnosed with
ischemic heart disease (Carson et. al, 2012). In this case oxygen delivery by RBCs to the heart
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may be reduced secondary to the obstructive process of CAD thus, there is an associated higher
mortality rate with the use of restrictive transfusion guidelines (Carson et. al, 2012).
Previous liberal transfusion guidelines were utilized in training of providers to promote
improved ventilator weaning and decreased hospital length of stay, cost, and decreased ventilator
associated pneumonia.
Education is needed to reduce the provider trigger response for blood
transfusions (McEvoy & Shander, 2013).
Concerns
Inappropriate use of RBC’s can lead to risk of adverse events, increased health care costs,
increased length of hospital stays, and an increase in morbidity and mortality.
Although
restrictive RBC transfusion guidelines have been released by the American Association of Blood
Banks (AABB) and supported by numerous organizations such as the American Society of
Hematology, Society for Critical Care Medicine, American College of Physicians, and governing
bodies such as The Joint Commission and the Centers for Medicare and Medicaid Services,
implementation of such recommendations remains inconsistent world wide (Kumar, Thapliyal,
Coshic, & Chatterjee, 2013). Consistency among providers is needed to produce high quality
evidence to develop clinical recommendations and practice guidelines (Kumar, Thapliyal,
Coshic, & Chatterjee, 2013).
Studies have demonstrated that clinicians continue to make
transfusion decisions every day based on incomplete evidence and continue to hold a transfusion
trigger mentality (Carson et. al, 2012).
Further concern when attempting to achieve consistency across the country is raised
when considering the practice setting, availability of resources, patient needs and preferences,
and the quality of research supporting the use of alternative agents (Robak, 2012). Currently
research in ongoing to develop evidence based plasma transfusion practice guidelines (Robak,
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2012). Other practice changes such as proactive use of intravenous iron therapy, smaller volume
phlebotomy tubes, and use of point of care or noninvasive hemoglobin (McEvoy & Shander,
2013).
Daily labs are a major source of unnecessary blood loss among intensive care units
(McEvoy & Shander, 2013).
Providers need to be proactive in identifying risks of anemia,
alternative treatment options, and minimize labs unless appropriate.
Additional concerns have been raised by researchers as to the accuracy of transfusion
reaction reporting among providers. The true incidence of transfusion reactions is difficult to
determine due to lack of knowledge of reactions, early identification, and prevention (Kumar,
Thapliyal, Coshic, & Chatterjee, 2013). This adds to the need for education among providers to
promote hemovigilance and improved patient outcomes.
Relevant Research
The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation)
methodology was utilized in terms of benefits, harms, and clinical outcomes to develop the
current transfusion guidelines (Carson et. al, 2012).
The strength of the guideline
recommendation is graded based on the quality of evidence, the trade off of benefit versus harm,
variability patient and practice preferences, and whether the intervention makes use of
appropriate resources (Robak, 2012). A systematic review of literature was completed and
included the Cochrane, CENTRAL, MEDLINE, EMBASE, and SCI-EXPAND databases
(Carson et. al, 2012). The review included randomized, controlled trials in which the transfusion
groups were identified as “trigger” or “threshold” (Carson et. al, 2012). The primary outcomes
in the systematic review were the proportion of patients receiving transfusions and secondary
outcomes included illness associated with the transfusion, length of hospital stay, and the amount
of blood transfused (Carson et. al, 2012). Restrictive transfusion protocols were considered to
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have threshold hemoglobin of less than of seven g/dl while liberal protocols had a threshold of
less than ten g/dl.
In summary, the evidence reviewed included nineteen trials (n= 6264 patients) with a
reduction by 39% of patients being transfused on a restrictive protocol when compared to those
transfused based on a liberal protocol (Carson et. al, 2012). Use of the restrictive transfusion
protocol demonstrated lower associated mortality rates at 30 days (RR, 0.85 [95% CI, 0.7 to
1.03]) (Carson et. al, 2012).
Several recognized trials were reviewed to assess the use of restrictive versus liberal
transfusion protocols in the subgroup of patients with existing cardiovascular disease. The
FOCUS trial resulted in no difference of functional recovery, mortality, or further complications
(Carson et. al, 2012).
Further research evaluated the risk for development of myocardial
infarction with in this subgroup and use of restrictive versus liberal transfusion strategies. The
FOCUS and TRICC trials demonstrated conflicting findings between both groups (Carson et. al,
2012). Thus the recommendation provided for this subgroup is considered of moderate quality
and weak in its strength (Carson et. al, 2012).
Additional studies were reviewed to support the use of restrictive transfusion protocols.
The focus of these studies was to identify the frequency and type of potential adverse transfusion
reactions to assist providers in prevention and early identification (Kumar, Thapliyal, Coshic, &
Chatterjee, 2013). After completing a retrospective review of reported transfusion reactions,
Kumar and colleagues found that the most common type of reaction reported was allergic in
nature (55.1% with n=108). This was followed by febrile, non-hemolytic reactions (35.7%,
n=70), and an overall frequency of reactions reported of 0.05% (198 out of 380,658) in the cases
reviewed (Kumar, Thapliyal, Coshic, & Chatterjee, 2013). The report of this study demonstrated
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concern of underestimated findings based upon poor reporting among providers (Kumar,
Thapliyal, Coshic, & Chatterjee, 2013).
Marik and colleagues completed a systemic review of 45 cohort studies to examine the
association between transfusion of RBC’s and adverse outcomes among the critically ill
population (McEvoy & Shander, 2013). In 42 of the 45 studies reviewed the risk of transfusion
outweighed the overall benefit of transfusion (McEvoy & Shander, 2013).
Findings included
RBC transfusions were an independent predictor of mortality, nosocomial infection, multi-organ
dysfunction, and acute respiratory distress syndrome (McEvoy & Shander, 2013).
The Cochrane review (2012) of transfusion thresholds sought out to compare the clinical
outcomes of patients receiving a restrictive versus liberal transfusion protocols (Carson, Carless,
& Hebert, 2012). This review included nineteen randomized control trials that included 6234
patients. The use of RBC’s was reduced by 39% among patients included in the restrictive group
(risk ratio (RR) 0.61, 95% confidence interval (CI) 0.52 to 0.72) (Carson, Carless, & Hebert,
2012). Additionally, the volume of units used within the restrictive group was reduced by an
average of 1.19 units (95% CI 0.53 to 1.85 units) (Carson, Carless, & Hebert, 2012). A
significant reduction in hospital mortality (RR 0.77, 95% CI 0.62 to 0.95) was demonstrated
among the restrictive group (Carson, Carless, & Hebert, 2012).
Role of the Adult Gerontological Acute Care Nurse Practitioner in Relation to the Problem
The adult gerontological acute care nurse practitioner (AG-ACNP) holding a current
certificate of authority and certificate to prescribe (CTP) or CTP- Externship may prescribe
blood products as stated in their standard care agreement as a physician initiated or physician
consulted intervention (Ohio Board of Nursing, 2011). It is importance for the AG-ACNP to be
current on current research and evidence based practice (EBP) guidelines. Use of EBP allows
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the AG-ACNP the ability to incorporate current research into their daily practice (Facchiano &
Snyder, 2012). We practice in an ever changing and evolving environment, it is the
responsibility of the provider to demonstrate and practice in a manner in which the patient
receives the best practice to promote quality clinical outcomes (Facchiano & Snyder, 2012). The
AG- ACNP plays an important role in educating peers, nursing staff, and patients. Given the
latest research studies, utilization of restrictive transfusion protocols improves patient outcomes,
length of stay, and mortality.
Conclusion
Overuse of RBC’s continues to be an issue within the acute care setting. Practitioners
commonly use the hemoglobin alone in determining the need for transfusion; however, most
guidelines emphasize using patient symptoms in addition to serum findings (Carson et. al, 2012).
Advancement in technology used to screen blood donors with advanced immunohematological
techniques in antibody identification has improved thus decreasing the risk of infectious
complications and febrile non-hemolytic reactions (Kumar, Thapliyal, Coshic, & Chatterjee,
2013). With said improvements, the non-infectious complications have become more apparent
and studied (Kumar, Thapliyal, Coshic, & Chatterjee, 2013). The purpose of evidence-based
guidelines for blood transfusion is to guide providers care based on reliable and quality research
findings (Robak, 2012). Multiple studies have been completed with evidence to support the use
of restrictive transfusion protocols. Proper use of the restrictive transfusion protocol improves
patient outcomes, reduces overall mortality, and improves costs associated with inpatient care
and staff resources.
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References:
Carson J., Carless P., & Hebert P., (2012). Transfusion thresholds and other strategies for
guiding allogeneic red blood cell transfusion. Cochrane Database of Systematic
Reviews 2012, Issue 4. Art. No.: CD002042.
DOI:10.1002/14651858.CD002042.pub3.
Carson, J., Grossman, B., Kleinman, S., Tinmouth, A., Marques, M., Fung, M., &
Djulbegovic, B. (2012). Red Blood Cell Transfusion: A Clinical Practice
Guideline From the AABB. Annals Of Internal Medicine, 157(1), 49-58.
Facchiano, L., & Snyder, C. (2012). Evidence-based practice for the busy nurse
practitioner: Part one: Relevance to clinical practice and clinical inquiry process.
Journal Of The American Academy Of Nurse Practitioners, 24(10), 579-586.
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care hospital: A preliminary step towards hemovigilance. Asian Journal Of
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intensive care unit: Causes, risks, costs, and new strategies. American Journal Of
Critical Care, 22(6), eS1-eS14. doi:10.4037/ajcc2013729
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