Adherence to blood product transfusion guidelines—An observational study of the current transfusion practice in a medical intensive care unit

Abstract

Background Blood transfusions though life‐saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the ‘Choosing Wisely campaign’. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost. Objectives In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre‐transfusion haemoglobin (Hb) ≥7 g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions. Methods We conducted a retrospective observational study in a 64‐bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N = 957) requiring packed red blood cell transfusion between January 2015 and December 2015. Results In total, 3140 units were transfused with a mean pre‐transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty‐four (30%) transfusion events occurred with a pre‐transfusion Hb ≥7 g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre‐transfusion Hb ≥7 g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11–3.88; p = 0.02) and LOS in patients with chronic blood loss (β1.8.26, 95% CI 4.09–12.43; p < 0.01). Conclusion A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.

The impact of red blood cell transfusion practices on inpatient mortality in variceal and non‐variceal gastrointestinal bleeding patients: a 20‐year US nationwide retrospective analysis

“…[5][6][7][8] This recommendation remains based on low-quality evidence and is currently a conditional recommendation per recently published American College of Gastroenterology society guidelines. 9 Therefore, PRBC transfusion practices remain poorly defined and are highly variable in practice, [10][11][12] and many patients with upper GI bleeding are inappropriately transfused. 13 From a pathophysiological standpoint, over-transfusion is likely to be of greatest concern in patients with variceal upper GI bleeding due to its resultant increase in portal pressure, which in turn may cause re-bleeding.…”

Relevance of pre-existing anaemia for patients admitted for acute coronary syndrome to an intensive care unit: a retrospective cohort analysis of 7418 patients

“…Furthermore, transfusion practice changed over the last decade, and the general approach has become more restrictive compared with the years 2014 and 2015. 38 , 39 …”

Severe bleeding in the ICU

“…The mortality was increased in the group of patients with a pretransfusion Hb at least 7 g/dl who received RBCs for acute blood loss and the length of stay was longer in patients receiving transfusions for chronic blood loss. The data point out the potential of clinical and economic improvements by guideline adherence [8 ▪▪ ].…”

“…Today's most practiced transfusion triggers published by Hébert et al in 1999 recommend an Hb threshold for RBC transfusions of 7 g/dl and a target concentration of 7–9 g/dl [2]. Although the body of evidence, which supports this strict transfusion guideline is substantial and still growing [3–7], a recent observational study by Sadana et al [8 ▪▪ ] has shown that about 30% of administered RBC transfusions in an ICU were not compliant with these guidelines. The mortality was increased in the group of patients with a pretransfusion Hb at least 7 g/dl who received RBCs for acute blood loss and the length of stay was longer in patients receiving transfusions for chronic blood loss.…”