Image: A hospitalized patient receiving a blood transfusion (Photo courtesy of the US National Institute of Health).
Although blood transfusion is a lifesaving therapy for some patients, transfusion has been named one of the top five overused procedures in hospitals in the USA.
As unnecessary transfusions only increase risk and cost without providing benefit, improving transfusion practice is an effective way of promoting high-value care. Most high-quality clinical trials supporting a restrictive transfusion strategy have been published in the past five to 10 years, so the value of a successful patient blood management program has only recently been recognized.
Experts at the Johns Hopkins Medical Institutions (Baltimore, MD, USA) and their colleagues analyzed data from randomized clinical trials comparing blood transfusion approaches and endorse recommendations for blood transfusions that reduce blood use to improve patient safety and outcomes. The clinical trials that were examined compared so-called liberal versus restrictive blood transfusions. Liberal transfusions are those given to patients with hemoglobin values of 9 to 10 g/dL, of blood volume, while restrictive transfusions are those given to patients with 7 to 8 g/dL. Many of the clinical trials examined by this team used the number of patients who died within a 30- to 90-day window post-transfusion as a measure of patient outcome.
Of the more than 8,000 patients included in eight clinical trials that were reviewed, there was no difference in mortality between liberal or restrictive transfusions. One clinical trial found an increased mortality associated with liberal transfusion, and occurrence of blood clots was increased in the liberal cohort in a study that involved traumatic brain injury patients. The team also found that the largest randomized trials reduced the amount of blood used by 40% to 65%. Earlier this year, the results of a four-year project to implement a blood management program across the Johns Hopkins Health System, reducing blood use by 20% and saving more than USD 2 million on costs over a year.
Stable adult patients, including critically ill patients, with hemoglobin levels of 7 g/dL or higher should not be transfused. Patients undergoing orthopedic or cardiac surgery, or patients with underlying heart disease with hemoglobin levels of 8 g/dL or higher should not be transfused. Patients who are stable and not actively bleeding should be transfused with a single unit of blood and then reassessed.
Steven M. Frank, MD, professor of anesthesiology and the lead investigator, said, “In summary, there is no benefit in transfusing more blood than necessary and some clinical trials actually show harm to patients. All this does is increase risks and cost without adding benefit.” The study was published on November 20, 2017, in the journal JAMA Internal Medicine.
Johns Hopkins Medical Institutions