Can we safely restrict transfusion in trauma patients?

PURPOSE OF REVIEW

Transfusion of red blood cells in the trauma patient can be lifesaving. The question is how much and when? It is important to weigh the risks and benefits of red blood cell transfusions, as well alternatives to transfusion as these products are not benign.

RECENT FINDINGS

We explore the evidence, and provide the rationale for current and future red blood cell transfusion strategies within a framework of prehospital and hospital care of the trauma patient. We also describe how red blood cell transfusion trends are changing in trauma, discuss alternatives to red blood cell transfusion and present evidence from randomized controlled trials that support a lower transfusion trigger.

SUMMARY

Optimal transfusion practice and use of alternatives in trauma is a rapidly expanding and important area of research. Strong clinical evidence derived by future randomized controlled trials in the area of transfusion triggers as well as transfusion alternatives is required to determine their roles in clinical practice.

What's happening - Scotblood 2006 advances in immunetolerance, information technology, microarrays and pathogen inactivation in transfusion medicine

This commentary on Scotblood meeting aimed to provide a highlight on four areas of new development in blood transfusion medicine, based on the abstracts provided by the invited speakers. Dr. Jerard Seghatchian would like to express his sincere thanks to Prof. Robin Fraser, Chairman of the Scotblood Organising Committee, and Dr. Hagop Bessos, chairman of the Scotblood Programme Sub-Committee, for inviting him to attend this event and providing him with the essential material for this report.

Transfusion medicine in Norway: new problems and new opportunities

During 2005 Norwegian Transfusion Medicine has faced some new problems, sought new solutions and gained strength. Interactions with the public and the health authorities have been important issues for consideration, which are discussed below.

[Blood transfusion and ethics: new questions]

Chairman to the French Institutional Review Board, Professor Didier Sicard raises blood donation issues from an ethical standpoint. The contaminated blood scandal focused on the necessity of reducing transfusion risks and regarded blood safety as an ethical mandatory requirement, a debatable subject to deal with. The author proposes to reconsider the nature of unpaid blood donations while advising not to scorn the remunerated gift when such is the case. As for the use of blood, he questions the solutions based on a zero risk perspective, in particular an excessive auto-transfusional practice or a restrictive use of blood, lately regarded as essential. Starting from the blood donation concern this article leads us to think over both our society's fears and the precautionary principle abuses.

[Blood transfusion in the European Union: current status and future challenges]

Blood transfusion is developing rapidly in the European Union. Though a compromise between technocrats, lobbies and blood transfusion professionals, the new specific EU directive (2002/98/EC) was a major step forward. In the future, blood transfusion in the EU must be centered on medical, scientific and social criteria, within a sound ethical and non commercial framework. Attention must be paid to the needs of patients and blood donors alike. The EuroNet-TMS survey is highly informative in this respect. National transfusion systems are extremely heterogeneous, ranging from public services to profit-oriented organizations. The approach to donors varies from one country and culture to another Some member states prescribe 2.5 times more blood products than others. Likewise, prevention and haemovigilance strategies are highly variable, with no attempt at harmonization.

Transfusion practice in massively bleeding patients: time for a change?

BACKGROUND AND OBJECTIVES

We identified some fatal cases where massively bleeding patients received inadequate transfusion therapy. The aim of this study was to review and evaluate the transfusion practice in acutely multitransfused patients.

MATERIALS AND METHODS

Patients receiving > 10 units of red blood cells (RBC) within 24 h of admission and 30 blood components within 7 days of admission were reviewed.

RESULTS

Thirty-nine patients were identified, 13 of whom were inadequately transfused (IT) and had a higher mortality (12/13) than adequately transfused (AT) patients 13/26 (P = 0.013). Ten of 13 IT patients developed a microvascular bleed compared to four of 26 in the AT group (P = 0.001) and had a lower platelet count upon arrival at the intensive care unit (40 x 10(9)/l vs. 80 x 10(9)/l, P = 0.024).

CONCLUSIONS

An early balanced transfusion therapy is vital in massively bleeding patients, and a pro-active approach from the blood bank is warranted. We have introduced an acute transfusion package (ATP) consisting of 5 RBC, 5 FFP and 2 PC units, indicated in massively bleeding patients, securing a balanced transfusion therapy.

North American pretransfusion testing practices, 2001-2004: results from the College of American Pathologists Interlaboratory Comparison Program survey data, 2001-2004

CONTEXT

Pretransfusion testing of whole blood and red blood cell recipients is regulated by the federal government under the authority of the Clinical Laboratory Improvement Amendments of 1988. Regulated tests include determination of ABO group, Rh D type, antibody detection, antibody identification, and crossmatching. A wide variety of methods and reagents are available for these regulated tests. During 2001-2004, the College of American Pathologists (CAP) Interlaboratory Comparison Program (Proficiency Testing) J-Survey collected data from more than 4000 laboratories regarding their pretransfusion testing practices. Those data are presented in this report.

OBJECTIVE

To assess current testing practices for ABO grouping, Rh D typing, antibody detection, and crossmatching in North America.

DESIGN

Data collected for the CAP Interlaboratory Comparison Program (Proficiency Testing) J-Survey were analyzed for trends in laboratory testing practice during 2001- 2004. The data were grouped for analysis by peer group (testing method used) for ABO grouping, Rh D typing, antibody detection, and crossmatching and then analyzed. SETTING, PATIENTS, OR OTHER PARTICIPANTS: Subscribers to the CAP Interlaboratory Comparison Program Transfusion Medicine J-Series.

RESULTS

The most common testing schemes used in North America during 2001-2004 are as follows: ABO grouping (most laboratories perform tube testing: 97.6% in 2000 and 91.1% in 2004); Rh D typing (most laboratories perform tube testing: 97.7% in 2001 and 91.1% in 2004); antibody detection (most laboratories perform tube testing: 69.7% in 2001 and 55% in 2004, most frequently with the low ionic strength solution anti-human globulin [AHG] method, 48.3% in 2001 and 39.9% in 2004; as of 2004 slightly more laboratories use the gel AHG method [42%] than the low ionic strength solution AHG tube method); crossmatching for alloimmunized patients (most laboratories perform tube testing using a low ionic strength solution AHG method; 55.8% in 2001 and 47.6% in 2004); and crossmatching for nonalloimmunized patients (tube testing using an immediate spin method; 42% in 2001 and 40.4% in 2004).

CONCLUSIONS

Most North American laboratories currently favor tube methods when performing ABO grouping, Rh typing, antibody screening, and crossmatching. However, there has been a significant increase in the use of gel-based methods in recent years, especially for antibody detection and crossmatching. Data collection and data analysis of CAP Interlaboratory Comparison Program Survey results allow for assessment of laboratory proficiency and provide insights into current North American practice trends in pretransfusion compatibility testing.

Clinical results of Perftoran application: present and future

Clinical experience of Perftoran (commercial drug of low concentrated perfluorocheminal emulsion) applications is presented in some statistical data and in brief analysis of clinical trials and following clinical studies described in the Russian scientific literature. Observed data allow us to suppose that Perftoran facilitates oxygen delivery together with remaining red blood cells at blood replacements and will have more wider area for application than just a blood substitute. Its infusion alleviates symptoms of ischemia at different types of occlusion vessels disease, improves grafting in plastic surgery, diminishes inflammation and prevents rejection of transplants, activates detoxication functions of liver, inhibits retro-virus infection development. Local PF applications is able to accelerate wounds and ulcers healing.

Blood and marrow transplantation compensation: perspective in payer and provider relations

The high cost per patient of hematopoietic cell transplantation (HCT) causes this therapy to be the focus of much controversy, given the competing societal demands to provide all possible therapy to preserve life while simultaneously limiting global health care expenditures. Treatment and eligibility decisions for HCT often are heavily scrutinized by both governmental and private payers and not simply determined by physicians, facility providers, and the patient. In an effort to control costs, payers have administrative infrastructure to review resource utilization by these patients. Additionally payers have developed payment methodologies, usually in the form of a case rate payment structure, that place facilities and physician providers of HCT at financial risk for adverse patient financial outcomes in an effort to promote optimal utilization and selection of patients for HCT. As providers enter into such financial risk arrangements with payers, the providers need to understand the true cost of care and be able to identify predictable and unpredictable outlier risks for the financial consequences of medical complications. HCT providers try to protect themselves from excessive financial risk by having different payment rates for different types of transplant, eg, autologous versus HLA or genotypically matched related versus HLA mismatched transplants. Because at certain times in the HCT process risk is more unpredictable, HCT providers require different payment system strategies for the different time periods of care such as evaluation, pre-transplant disease management, harvesting, and cell processing, as well as short- and long-term follow-up. Involvement by clinicians is essential for this process to be done well, especially given the rapid changes technological innovation brings to HCT. Constant dialogue and interaction between providers and payers on these difficult financial issues with HCT is essential to preserve patient access to this potentially lifesaving therapy.

Reducing the Amount of Blood Transfused

BACKGROUND

Transfusion services have used various techniques to reduce blood product utilization. Given the potential adverse effects of transfusions and the resources consumed in implementing strategies to reduce transfusions, there is a need to understand their effectiveness. Therefore, we performed a systematic review of the literature to examine the effectiveness of behavioral interventions to reduce blood product utilization.

METHODS

We identified all relevant articles through the use of electronic searches of MEDLINE and EMBASE, as well as hand searches of review articles and personal files. The electronic searches included articles published between January 1966 and May 2003. The searches included the terms blood transfusion, plasma exchange, guidelines, education, practice patterns, and professional practice. The outcomes of interest were the number of units transfused and the proportion of patients who received transfusions.

RESULTS

Nineteen studies examining the effectiveness of single (guidelines, prospective audits, retrospective audits, and reminders) or multifaceted interventions in reducing red blood cell, platelet, plasma, cryoprecipitate, and albumin transfusions met the inclusion criteria. Eighteen studies demonstrated a relative reduction in the number of units given (range, 9%-77%) or the proportion of patients receiving transfusions (range, 17%-79%). The reported reductions were qualitatively similar for the different blood products studied. No particular intervention or combination of interventions appeared more effective in reducing utilization.

CONCLUSIONS

Behavioral interventions, including simple interventions, appear to be effective in changing physician transfusion practices and reducing blood utilization. Appropriately designed clinical trials are still needed to determine the relative effectiveness of different interventions to change practices.

Changing the paradigm for transfusing the anemic patient in an acute care environment

Blood is a precious and vital resource in medicine. Its importance in maintaining human life is second only to the oxygen it transports. Nearly 300,000 blood product transfusions occurred in Kentucky last year. While donor attrition from the pool is inevitable, recruiting efforts have resulted in an overall stable donor population in the state over the last five years. Roughly 5% of community members who are eligible to donate do so each year. Despite our effort to constantly recruit new donors, there is evidence to suggest that clinicians are less than rigorous in their efforts to conserve and to be accountable for this precious human product. For example, the indications for blood transfusions are often not documented in up to a third of the cases, and arbitrary transfusion "triggers" are often the criteria used to justify transfusion rather than the patient's clinical condition. Recent development of evidence-based criteria for prevention and treatment of anemia combined with technological advances suggest that a major paradigm shift in the clinical use of red cells is warranted.

Current issues in transfusion medicine in Norway

Important current issues in transfusion medicine in Norway are discussed. Current patient legislation specifically defines blood donors as patients, and blood and blood products are defined as drugs. Donor selection is controversial, especially deferral of all persons born in, or having lived for more than one year in areas with high prevalence of infections that are transmitted by blood. The threshold for becoming a blood donor is high, but registered donors donate frequently, e.g. 2,4 whole blood donations per year on average. Some blood banks have specialized in multicomponent aphereis technology, in particular collection of two units of red cells.