Despite evidence-based transfusion practice, 40 percent of ICU patients receive transfusions, which account for 7 to 8 percent of the national blood supply.

Anemia is highly prevalent in ICUs that use restrictive transfusion triggers. The impact of anemia on functional recovery after intensive care requires investigation.

The patient should be assessed for anaesthesia in the standard manner. Non-consent, inability to comply with the anaesthetist's instructions as, for example, a result of deafness or mental incapacity, inability to lie¯at, allergy to local anaesthetics, lack of i.v. access, or excessive uncontrollable anxiety are absolute contraindications to Sub-Tenon's anaesthesia. The procedure should be explained to the patient to allay anxiety and assist the anaesthetist in carrying out the block.

Safety concerns combined with the greatly increased costs and difficulties of maintaining the blood supply are major considerations for transfusion services. Previous local surveys demonstrated that hospital blood use at our hospital could be improved. Excessive cross-matching, unnecessary transfusion and high return rates of unused blood were commonplace. Transfusion practice was audited over a 3-month period. An education package with guidelines for transfusion was delivered to all clinician groups within the hospital, over the following 9 months. The audit was repeated exactly 1 year later at the same time period. During the second audit, inpatient hospital numbers increased by 1.02% (from n = 7262 to n = 7336) but no differences in length of stay, cardiovascular morbidity or mortality were demonstrated. Twenty percent (n = 254, 2002; n = 316, 2001) fewer patients received blood, and the number of red cell packs used reduced by 19% (from n = 1093 to n = 880). Total number of patients transfused reduced from 4.4% to 3.5% which, as an absolute difference, is a reduction of 0.9% (CI 0.3-1.5, P = 0.006). The audit, guideline and education package had a major impact on red cell use within the hospital with no adverse effects. Blood use can be improved by the implementation of a suitable education package and guideline. If it is possible to replicate the results of this education programme nationwide, the effect on blood use, with subsequent savings and enhanced patient safety could be significant.

About 29% of patients admitted to Scottish ICUs had documented IHD, which was associated with small adjustments to Hb transfusion triggers. In response to scenarios, clinicians believe that patients with IHD require higher transfusion triggers than are observed in practice.