Evaluation of the appropriateness of blood and blood product transfusion using preset criteria

Utilization of frozen plasma, cryoprecipitate, and recombinant factor VIIa for children with hemostatic impairments: An audit of transfusion appropriateness

BACKGROUND

Blood transfusions and fractionated products are not without risk and may lead to acute and long-term adverse events. The objective of this study was to evaluate the appropriateness of usage of frozen plasma (FP), cryoprecipitate (CRYO), and recombinant factor VIIa (rVIIa) in a pediatric setting.

METHODS

All orders for FP, CRYO, and rVIIa were prospectively audited over 6 weeks. Data collected included demographics, laboratory values, indication, and adverse reactions. The appropriateness of each order was independently evaluated using adjudication criteria rated by two hematologists.

RESULTS

Two hundred sixty-five products were ordered; 67% of the orders were issued to operating rooms or intensive care units. The most common indication for all products was cardiac surgery. FP was ordered as fluid replacement (15/215; 7%) to correct abnormal coagulation tests (23/215; 11%) and for patients with minor or no bleeding (111/242; 46%). FP was more likely to alter the international normalized ratio (INR) if the INR was over 2.0 (P < 0.0001). The rate of inappropriate products was judged as FP 19%, CRYO 21%, and rVIIa 91%.

CONCLUSION

FP, CRYO, and rVIIa are most commonly used in the operating room and intensive care units. FP was often used for fluid resuscitation and for patients with mild to no bleeding. FP was only effective in lowering the INR when the INR was over 2.0. Use of rVIIa was rarely ordered for an appropriate indication. Results of this study inform its readers where trials of pediatric transfusion should be performed to clarify how these products should be used in clinical practice.

Use of blood transfusion at the end of life: does it have any effects on survival of cancer patients?

BACKGROUND

Treatment of anemia is an important issue in the palliative care setting. Blood transfusion is generally used for this purpose in supportive care. However the place of blood transfusion in terminally ill cancer cases is less far established.

OBJECTIVE

We aimed to outline the use of transfusions and to find the impact of blood transfusion on survival in patients with advanced cancer and very near to death.

DESIGN

Patients dying in 2010-2011 with advanced cancer were included in the study. We retrospectively collected the data including age, type of cancer, the duration of last hospitalisation, ECOG performance status, Hb levels, transfusion history of erythrocytes and platelets, cause and the amount of transfusion. The anaemic patients who had transfusion at admission were compared with the group who were not transfused. Survival was defined as the time between the admission of last hospitalisation period and death.

RESULTS

Three hundred and ninety eight people with solid tumours died in 2010-2011 in our clinic. Ninety percent of the patients had anemia at the time of last hospitalisation. One hundred fifty three patients had erythrocyte transfusion at admission during the last hospitalisation period (38.4%). In the anaemic population the duration of last hospitalisation was longer in patients who had erythrocyte transfusion (15 days vs 8 days, p<0.001).

CONCLUSIONS

Patients who had blood transfusion at the end of life lived significantly longer than the anaemic patients who were not transfused. This study remarks that blood transfusions should not be withheld from terminal cancer patients in palliative care.

Audit of pediatric transfusion practices in a tertiary care hospital

OBJECTIVE

To perform a retrospective audit of transfusion practices, in order to study the appropriate and inappropriate usage of different blood components in pediatric population.

METHODS

The present study, conducted over a period of 3 mo analyzed all the episodes of transfusions and divided them into appropriate and inappropriate according to the type of blood components, the requesting departments and the clinical indication of transfusion. Data was reviewed according to the British Committee for Standards in Hematology and American Association of Blood Bank guidelines.

RESULTS

A total of 2,145 units of hemocomponents were transfused to children, including 1,181 units of red cell concentrates, 566 units of platelet concentrates/platelet rich plasma, 118 units of whole blood and 280 units of fresh frozen plasma in 1,819 episodes. Appropriate usage of blood components was 59.65%. Whole blood was most appropriately transfused (82.9%). Appropriate indications outnumbered inappropriate requisitions in Department of Pediatric Medicine (70.38 %), Nursery (82.54 %) and Thalassemia day care centre (55.63%). Red cell concentrate was most appropriately indicated in anemias (73.14%) and inappropriately in cases of surgeries (53.6%). Platelets were used more appropriately in all clinical indications. Whole blood was transfused most appropriately (100%) in double venous exchange therapy. Most appropriate indication of fresh frozen plasma usage was coagulopathy (42.57%).

CONCLUSIONS

As the appropriate usage (59.65%) of blood components was low in the present study, regular auditing of transfusion practices from time to time is indicated. This not only helps guide their judicious use but also serves to evaluate and decrease their inappropriate usage.

Assessment of Intraoperative Blood Loss during Oral and Maxillofacial Surgical Procedures in a Nigerian Tertiary Health Care Center

Background. Reports on estimated amount of blood loss in maxillofacial surgical procedures will guide clinicians through units of blood required for each procedure. The aim of the study was to assess the amount of blood loss and duration of surgery. Methods. All cases of maxillofacial surgical procedures done under GA in the MFU theatre, from January 2007 to December 2013, were included in the study. Pre- and postoperative haematocrit values, number of units of whole blood requested and used, amount of blood loss, and duration of surgery were recorded. Results. 139 patients were analyzed, of which 75 (54.0%) were males and 64 (46.0%) were females. Fifty-six (40.3%) cases involved soft tissues. Eighty-three cases involved hard tissues. Age range was 2 months to 78 years; mean ± (SD) was 21.3 ± (18.5) years. Isolated unilateral cleft lip had the lowest mean value of estimated blood loss of 10.4 ± 10.8 mLs and also the lowest duration of surgery of 58 (76) minutes. There was no significant relationship between both parameters for cleft lip. Fractures of the mandible had mean blood loss of 352 mLs and duration was 175 min. Conclusion. In this study, there was significant relationship between estimated blood loss and duration of surgery for mandibular and zygomatic complex fractures.

A survey of resident physicians' knowledge concerning transfusion medicine in Shiraz, Iran

OBJECTIVE

The knowledge of physicians concerning blood transfusion has a significant impact on the optimal use of blood and blood products. The aim was to survey their knowledge regarding this area and identify whether additional training is required.

MATERIAL AND METHODS

This cross-sectional study was conducted on all 1(st) year resident physicians at Shiraz University of Medical Sciences, Iran in 2011. The questionnaire solicited information on demographic variables, knowledge regarding transfusion medicine, education and experience regarding blood transfusion.

RESULTS

The mean total knowledge score regarding transfusion medicine was 15.44 ± 3.3 (7-25) out of 29. Only about one-fourth (27.4%) replied correctly to over 60% of questions. The mean score of knowledge was higher among residents who stated that they received special training regarding blood transfusion in their medical courses (P < 0.01). Seventy-five percent of residents believed that they had received insufficient education and 97.8% believed that they need additional training.

CONCLUSION

The results reflect the uncertainties among resident physicians regarding blood transfusion. It has been suggested that a special transfusion medicine educational program should be added to the medical education curriculum.

An assessment of the necessity of transfusion during pancreatoduodenectomy

INTRODUCTION

Perioperative transfusion of packed red blood cells (PRBC) has been associated with negative side effects. We hypothesized that a majority of transfusions in our series of patients who underwent pancreaticoduodenectomy (PD) were unnecessary. A retrospective analysis was performed to determine whether transfusions were indicated based on pre-determined criteria, and the impact of perioperative transfusions on postoperative outcomes was assessed.

METHODS

Our prospectively maintained database was queried for patients who underwent PD between 2004 and 2011. 200 patients were divided into Cohort 1 (no transfusion) and Cohort 2 (transfusion). Rates of various graded 90-day postoperative complications were compared. Categorical values were compared according to the Common Terminology Criteria for Adverse Events. All cases involving intraoperative blood transfusion were reviewed for associated blood loss, intraoperative vital signs, urine output, hemoglobin values, and presence or absence of EKG changes to determine whether the transfusion was indicated based on these criteria.

RESULTS

There were 164 patients (82%) in Cohort 1 (no transfusion) and 36 patients (18%) in Cohort 2 (transfused). Both groups had similar demographics. Patients in Cohort 2 had lesser median preoperative values of hemoglobin (12.3 vs 13.1, P = .002), a greater incidence of vein resection (33% vs. 16%, P = .021), longer operative times (518 vs 440 minutes, P < .0001), a greater estimated blood loss (850 vs. 300 mL, P < .001), and greater intraoperative fluid resuscitation (6,550 vs. 5,300 mL, P = .002). Ninety-day mortality was similar between the 2 groups (3% vs 1%, P = .328). Patients in Cohort 2 (transfused) had increased rates of delayed gastric emptying (36% vs. 20%, P = .031), wound infection (28% vs. 7%, P = .031), pulmonary complications (6% vs. 0%, P = .032), and urinary retention (6% vs. 0%, P = .032). A greater incidence of any complication of grade II severity (67% vs. 35%, P = .0005) or grade III severity (36% vs. 17%, P = .010) was also noted in Cohort 2. Of the 33 intraoperative transfusions, 15 (46%) did not meet any of the predetermined criteria: intraoperative hypotension (<90/60 mmHg), tachycardia (>110 beats per minute), low urine output (<10 mL/hour), decreased oxygen saturation (<95%), excessive blood loss (>1,000 mL), EKG changes, and low hemoglobin (<7.0 g/dL).

CONCLUSION

Perioperative transfusions among patients with PD were associated with increased rates of various postoperative complications. A substantive portion (∼46%) of perioperative transfusions in this patient population did not meet predetermined criteria, indicating a potential opportunity for improved blood product use. Further prospective studies are required to determine whether the implementation of these criteria may a positive impact on perioperative outcomes.

An audit of fresh frozen plasma usage in a tertiary trauma care centre in north India

Fresh frozen plasma (FFP) transfusion is a crucial part of management of trauma patients. There is a paucity of literature about the audit of appropriateness of FFP use in trauma patients. To evaluate and analyze the appropriateness of FFP transfusion practices for trauma patients. Prospectively compiled blood bank records of FFP transfusion practices over a period of 4 months from Augusts'08 through Deember'08 were retrospectively analyzed for 207 patients. The number of FFP units used in all these trauma patients were evaluated a propos the cause of injury, departments, type of surgery, presence of coagulopathy, bleeding, massive transfusion, length of hospital stay and patient outcome. Trauma scores such as Glasgow coma score and injury severity score were also calculated to estimate the severity of injury. The appropriateness of FFP transfusion was assessed according to the guidelines drafted by the College of American Pathologists. FFP transfusion for patients experiencing active bleeding, micro vascular bleeding, coagulopathy and/or massive transfusion, was deemed appropriate. Patients receiving FFP were categorized and individually correlated with the outcome. The influences of other variables which affect patient outcome were excluded using stepwise multivariate logistic regression analysis. p value < 0.05 were considered to be statistically significant. A total of 207 trauma patients were included in the study, 183 (88.4 %) males and 24 (11.6 %) females. The FFP use among neurosurgery patients was 46.9 %, general surgery patients 40.6 % and orthopedics 12.6 %. Appropriate use of FFP was 49.5 % according to the CAP guidelines. Trauma patients who required FFP as a part of treatment were categorized as; Patients who had bleeding alone (n = 40), bleeding with coagulopathy (n = 16), and coagulopathy alone (n = 43), and further correlated with the outcome and were found statistically insignificant. The prevalence of appropriate use of FFP at trauma centre was 49.5 %. The FFP use by neurosurgery:orthopedics:general surgery was 5:1:4. The highest appropriate FFP use was by Neurosurgery department (50.5 %). Assessing the pattern of usage and rate of misuse of FFP units, allows us to establish required strategies to improve the state of affairs.

Concurrent audit of fresh frozen plasma: experience of a tertiary care hospital

Fresh frozen plasma (FFP) transfusion is among the highest risk of all blood component transfusions and also the most inappropriately used blood component. All these factors have impact on safety, economy, and work burden.

OBJECTIVE

To assess the utilization of FFP in a tertiary care hospital.

METHODS

Concurrent audit was conducted manually over the period of 4 months from April 2010 to July 2010. Patient's age, sex, clinical diagnosis, indication for FFP transfusion, and coagulation profile were noted. Data were analysed and episodes of transfusion were divided into appropriate and inappropriate. Requests were further classified according to the requesting department, clinical diagnosis, and coagulation profile.

RESULTS

A total of 1763 units of FFP were transfused to 560 patients in 877 episodes of requisition. Out of 877 episodes, about 686 (78.2%) requests were found to be inappropriate. Highest number of FFP requisitions was received from department of paediatrics and paediatric surgery (580 episodes). Most inappropriate requests were received from the department of orthopaedics (88.9%) and paediatrics (80.17%). The most common indication for FFP transfusion was surgical/traumatic bleeding/massive transfusion (40.9%) in which 68.5% requests were inappropriate. Out of 686 inappropriate episodes, the most common cause was in setting of normal or mildly altered coagulation profile irrespective of bleeding status of patient.

DISCUSSION

Inadvertent use of FFP is a major problem and guidelines are not strictly adhered to. Concurrent audit of FFP use needs to be done to make appropriate interventions to prevent misuse of this valuable commodity.

Rational use of blood components - an audit

OBJECTIVES

The present study was designed to study appropriateness of use of the blood components in pediatric and neonatal wards.

DESIGN

It was an observational study conducted in a tertiary care institute. The patients were selected from various pediatric subsections over a period of six months.

MATERIALS AND METHODS

All the patients below 12 years of age, who received blood components in any of the pediatric subsections including general pediatric wards, pediatric intensive care unit, pediatric hematology section, neonatal intensive care unit and pediatric surgery ward were included in the study. Each transfusion episode was assessed to decide whether it satisfied the predetermined criteria.

RESULTS

Of the total 184 episodes of blood component transfusions, 153 (83.1%) episodes were appropriate and 31 (16.9%) episodes were inappropriate. Among these, fresh frozen plasma transfusions had highest inappropriate [18/41 (58%)] episodes followed by packed red cell transfusions [11/110 (35.5%)] and platelet transfusions [2/5 (6.45%)]. There was no inappropriate episode of cryoprecipitate transfusion.

CONCLUSIONS

The present study reinforces the importance of blood audit in the clinical setting. Judicious implementation of guidelines for use of various blood products may help decrease the inappropriate use of blood components.

Audit of the clinical use of fresh-frozen plasma in Umbria: study design and results of the pilot phase

BACKGROUND

Fresh-frozen plasma (FFP) is unanimously recognised by international guidelines as the blood component of choice for the management of acute haemorrhage when accompanied by disorders of haemostasis, for disseminated intravascular coagulation in the presence of haemorrhage, for rare bleeding disorders when specific clotting factor concentrates are not available and for thrombotic thrombocytopenic purpura. The literature, however, reports a high percentage of inappropriate requests for FFP. This article presents the results of a pilot study of clinical auditing of the use of FFP in the Region of Umbria (Italy).

METHODS

This study was based on the examination of the requests for FFP made in April 2006 to four Immunotransfusion Services (ITS) in Umbria and of the clinical records of the patients receiving transfusions. The following indicators were identified and evaluated: completeness of the request, appropriateness of the indication and the dose, completeness of the records in the clinical charts, adverse events, in-hospital morbidity and mortality, efficacy of the treatment (evaluated by analysing the changes between pre- and post-transfusion coagulation test results) and, as an indicator of the process, the correspondence between data in the paper request form and in the computerised database. The data were extracted from the ITS databases, from the paper request forms and from the patients' clinical records.

RESULTS

Two hundred and twenty-one requests (615 units of FFP) for 109 patients and 92.8% of the related clinical records were examined. The patients were admitted in medical (22.9%), surgical (51.4%) and critical care units (25.7%). In 50.7% of the cases, the completeness of the data in the individual requests was good (65-80% of the fields filled in). The indication was appropriate in 31.5% of the requests evaluated (56.1% of the total), with no difference related to different requesters. The dosage was appropriate in 62.7% of the requests evaluated (62% of the total). A comparison of pre- and posttransfusion laboratory data showed a significant correction of pathological values (p=0.02) only for the International Normalised Ratio (INR).

CONCLUSIONS

Critical areas that should be targeted by interventions to improve plasma usage are those related to the appropriateness of the indication, the completeness of the data entered in the request forms and the data recorded in the clinical charts.

Tuscan study on the appropriateness of fresh-frozen plasma transfusion (TuSAPlaT)

INTRODUCTION

The considerable increase in the consumption of fresh-frozen plasma (FFP) recorded in 2002 in the Region of Tuscany made it necessary to check the appropriateness of the use of this blood component in all transfusion facilities in the Tuscan network.

MATERIALS AND METHODS

From July 1, 2003 to December 31, 2005, the Regional Blood Transfusion Coordinating Centre carried out an audit on the clinical use of FFP in the 40 structures included in the Tuscan transfusion network. The study had two complementary parts: a review of guidelines on the use of FFP and the involvement of Hospital Transfusion Committees in evaluating the outcome of the audit and in the consequent local policy decisions and in educating clinicians.

RESULTS

The data from all 40 of the regional transfusion structures were analysed. The audit, which was initially retrospective, gradually became prospective. The percentage clinical use of FFP decreased, compared to 2002, in each of the 3 years of the study: a) 2003: - 8.92%; b) 2004: - 2.11%; c) 2005: -1.97%. The inappropriate requests for plasma decreased from 27% to 22.7% of the total. It was possible to classify the inappropriate requests for plasma on the basis of homogeneous, regionally defined criteria. The most frequent inappropriate indication (60.7% of the total) was the use of plasma in the case of haemorrhage in patients with a normal PT and/or PTT or unavailable results. Each hospital revised its own guidelines between 2004 and 2005 and the Hospital Transfusion Committees set up appropriate educational and behavioural interventions.

CONCLUSIONS

The capacity of transfusion facilities to make data on the use of blood components available systematically and continuously is an essential feature of clinical governance; systematic clinical auditing increases the level of appropriate behaviours in the transfusion sector, contemporaneously contributing to self-sufficiency in transfusion products, and may direct research towards those clinical settings at greatest risk of inappropriate use of transfusion therapy with FFP.

Adequacy of physician documentation of red blood cell transfusion and correlation with assessment of transfusion appropriateness

CONTEXT

A major function of the hospital transfusion service is to assess the appropriateness of blood transfusion. Inadequate documentation of transfusions may hamper this assessment process.

OBJECTIVE

To correlate the level of physician documentation of transfusion with the ability to justify transfusion.

DESIGN

Retrospective review of red blood cell transfusions in adult patients in 2 hospital facilities during 1-week audit periods of each month from April 2001 to March 2003. Assessment forms were used to classify the level of physician documentation of transfusions into 3 groups: adequately, intermediately, and inadequately documented. Transfusions were deemed justified or not via comparison with hospital transfusion guidelines.

RESULTS

There were 5062 audited red blood cells transfused to 2044 adult (> or = 18 years) patients. Medical records from 154 patients transfused with 257 units of red blood cells during 172 transfusion events were reviewed after initial screenings of hemoglobin/hematocrit values failed to justify the transfusions. Nine percent of adequately documented, 50% of intermediately documented, and 73% of inadequately documented transfusion events could not be justified. Transfusion events with suboptimal (intermediate and inadequate) documentation accounted for 49% of all medical record-reviewed transfusion events and 62% could not be justified. The correlation between inadequate documentation and failure to justify transfusion was significant (P < .001), as was the correlation between suboptimal documentation and failure to justify transfusion (P = .03).

CONCLUSIONS

There is a significant correlation between suboptimal documentation and failure to justify transfusions. Educating clinicians to improve documentation along with appropriate indications for transfusions may enhance efficiency of blood utilization assessment and lead to reduced rates of unjustifiable transfusions.

Medical staff attitudes: views and positions regarding blood transfusion to terminally ill cancer patients

Blood transfusion is a widely used supportive treatment of cancer patients, most of whom are anemic. In the particular subset of cancer patients that undergoes chemotherapy, blood transfusion is viewed as an essential part of supportive care. However, the place of blood transfusion in anemic terminally ill cancer patients is far less established. There are no well-defined blood transfusion guidelines ("transfusion trigger") for these patients. Hence, transfusion decisions are greatly influenced by the personal views of the medical team. Therefore, a mail survey of 500 physicians (from several specialties) and nurses was initiated to assess their personal opinions on this topic. The overall response rate was relatively high (70%). There was broad agreement that blood transfusions, as a rule, should not be withheld from terminal cancer patients. On the other hand, only nurses were of the opinion that these patients should be transfused "as usual." Significantly, there was but a slight majority (53% of participants) that was of the opinion that transfusions to these patients do not prolong suffering. There emerged a short list of agreed-on suggestions for blood transfusion--namely, Hb level < or = 7 mg/dL, active bleeding (acute and/or occult), functional deterioration of the patient, presence of anemia resulting from chemotherapy, anginal symptoms, dyspnea, and worsening congestive heart failure. The agreed-on suggestions for transfusions in terminally ill cancer patients may serve as a reasonable physician standard for this complex clinical, medical-legal, and emotional issue.

The Appropriateness of Red Blood Cell Transfusions in the Peripartum Patient

OBJECTIVE

Despite published guidelines, numerous studies have consistently shown that a significant proportion of red blood cell (RBC) transfusions are unnecessary. The purpose of this study was to evaluate the reasons for and the appropriateness of RBC transfusions in the peripartum patient.

METHODS

We reviewed all RBC transfusions given to peripartum inpatients at Sunnybrook and Women's College Health Sciences Centre in Toronto, Ontario, Canada between April 1994 and July 2002. Appropriateness of RBC transfusion was ascertained using current hospital transfusion guidelines.

RESULTS

We identified 33,795 obstetrics-related admissions. In 218 admissions (0.65% of all admissions), an RBC transfusion was given to 216 women. There were 83 vaginal deliveries, 94 deliveries by cesarean, and 42 operations (for ectopic pregnancies or dilatation and curettage). A total of 779 RBC units were transfused (median, 2 units per woman; range, 1-32), most commonly for postpartum bleeding (34% of cases). There were 16 adverse events from transfusion recorded. According to guidelines, 248 of the transfused RBC units (32%) were not appropriate. In addition, in 24 patients (11%) the mean corpuscular volume on admission to the hospital for delivery was less than or equal to 80 fL.

CONCLUSION

A significant proportion of RBC transfusions given to peripartum women are inappropriate. Educational programs that promote adherence to transfusion guidelines might help reduce exposure to RBC transfusion. Aggressive oral and intravenous iron therapy might have prevented transfusion in 11% of the women in the cohort who were possibly iron deficient.

Assessment of intraoperative blood transfusion practice during elective non-cardiac surgery in an Indian tertiary care hospital

BACKGROUND

We assessed appropriate intraoperative use of whole blood during elective surgery.

METHODS

This prospective observational audit by a team of anaesthetists over 3 months in a multi-speciality tertiary care teaching hospital used strict preset criteria to evaluate the use of blood transfusion during elective surgery by anaesthetists. The criteria used to evaluate the rate of appropriate transfusion were haemoglobin less than 8 g x dl(-1), haemoglobin less than 10 g x dl(-1) in patients with medical co-morbidities and blood loss greater than 20% of blood volume when more than 1000 ml.

RESULTS

The overall rate of appropriate use of blood was 40.7%; it was inappropriate in 19.2% of cases (haemoglobin >11 g x dl(-1)). The primary trigger was low haemoglobin (measured intraoperatively or derived from blood loss). Patients in whom haemoglobin was measured intraoperatively had a significantly higher appropriate use of blood (P<0.05). There was a reduction in blood use over the 3-month audit period (P<0.05).

CONCLUSIONS

Current intraoperative blood use is sub-optimal. Intraoperative haemoglobin estimation is an effective and simple measurement to improve appropriate use of blood. The indication for transfusion should be recorded in the case notes.

Palliative care in a national cancer center: results in 1987 vs. 1993 vs. 2000

In the last few years, palliative care for advanced and terminal cancer patients has undergone considerable evolution. We determined the characteristics of patients admitted to the 4-bed Palliative Care Unit (PCU) of the National Cancer Institute (NCI) of Milan in 1987, 1993 and 2000 to evaluate how our diagnostic and therapeutic approaches have changed over the years. We reviewed the charts of every patient admitted to the PCU in 1987, 1993, and the first ten months of 2000. We recorded demographic data; the primary tumor sites; the main reason for admission; the types of therapies administered (oncologic, analgesic, surgical, neurosurgical analgesic procedures, and supportive therapy); the type and number of cardiological, radiological and endoscopic examinations, as well as specialist consultations; the duration of stay and eventual death on the Unit. There were no significant differences regarding gender, age, primary tumor site and death in hospital of the patients admitted during these years. The time spent in hospital increased over time (P = 0.006). A significant increase was observed in the percentage of patients admitted for supportive therapy (P < 0.001) and investigation concerning the stage of the disease (P < 0.001). There was a significant decrease in admission for invasive analgesic procedures (P < 0.001), as well as for pain diagnosis and/or uncontrolled pain. Uncontrolled pain remained the most frequent reason for admission. Over the years, during hospitalization, 7% to 12% of the patients underwent radiotherapy,1% to 9% had computerized tomography, and 4% to 8% had palliative surgery. More than 50% of the patients received intravenous hydration; a few patients received hypodermoclysis in 1987. Over time, there was a significant increase in "as needed" administration of nonsteroidal anti-inflammatory drugs and a significant reduction in their regular administration (from 24% in 1987 and 1993 to 3% in 2000) (P < 0.001). The use of codeine, tramadol and methadone increased (P < 0.001), whereas the use of oral morphine, buprenorphine and oxycodone decreased in 2000 (P < 0.001). There was a reduction in the use of antidepressants (no significant constant trend) and a significant increase in the use of anticonvulsants, laxatives and pamidronate (P < 0.001). Regularly administered hypnotics decreased in 1993 and increased in 2000 (P < 0.001). Over these years, no significant differences were found in the routes of opioid administration, in route switching and in the mean maximum oral opioid dose (ranging from 108 to 126 mg/day). The percentage of patients undergoing percutaneous cordotomy significantly decreased in 1993 and 2000 (P < 0.001). Over time, there was an increase in requests for specialist consultations, which was significant for neurological, cardiological and oncological consults (P < 0.001). Although the characteristics of the patients admitted to the PCU did not change over these years, there have been significant modifications in our therapeutic approaches, above all in the use of supportive therapy, adjuvant drugs, opioids and neurosurgical invasive procedures. Moreover, a major collaborative interaction with other specialists of the NCI took place with the aim to tailor treatment for each single patient.

A pilot study to assess physician knowledge in transfusion medicine

INTRODUCTION

An assessment of transfusion medicine knowledge and practice in Canada was carried out over a 3-week period.

METHODS

Fifty-five questions were posed to evaluate both basic information on blood and blood products and on clinical use. The form was distributed through the Canadian Society for Transfusion Medicine with designated individuals asked to handle regional distribution. Some used provincial mailing lists, others distributed within each hospital. Approximately, 2000 forms were sent, including 500 in French.

RESULTS

A total of 294 forms were returned; answers were recorded as 'correct', 'incorrect', 'no answer' or with 'added comments'. Overall, 52% of the questions were answered correctly or were answered with qualifying comments. In clinical practice questions, 63% were answered correctly or with qualifying comments. Basic knowledge questions drew correct answers in 37% of the cases. Several issues were answered poorly. The volume of an apheresis plasma unit was correctly estimated by less than 10% of respondents with many understanding the volume (500-600 mL) by as much as 300-400 mL. Anaesthesiologists responded most often (21%); few haematologists participated (4%). Provincial response varied: most were received from Ontario (30%) and British Columbia (22%).

CONCLUSIONS

The answers show that clinical application of transfusion is generally accompanied by a questioning process - it is not entirely by rote. Basic knowledge about products needs improvement.

[Transfusion of fresh frozen plasma (FFP): audit of prescriptions]

OBJECTIVE

To review fresh frozen plasma (FFP) prescriptions and compare their validity to the legal french guidelines (law of the 12/03/91).

STUDY DESIGN

Assessment of all prescriptions has been carried out by a multidisciplinary committee.

PATIENTS

All the adults transfused with FFP over one year in a teaching hospital.

METHODS

Following each head of department's agreement and following a written notice to all prescribers within the hospital to inform them of the undergoing study and its methodological validation by the board of quality experts, each delivery of FFP was followed by a questionnaire addressed to the prescriber. A board of experts then assessed the significance of the prescription in accordance with the legal requirements after reviewing each medical file.

RESULTS

144 prescriptions to 89 patients were assessed: 23% were judged inappropriate by the experts and 6% did not respect the law. The inappropriate transfusions distribute as follows: intensive care patients (73% of which 80% in multiple organ failure (MOF) and 20% in haemorrhagic shock), cirrhotic patients (12%), patients treated with vitamin K antagonists (12%), obstetric patients (3%). Nine percent of the appropriate transfusions were judged in insufficient volume. The hospital mortality rate was 48%. Among prescribers, 59% were not aware of the law.

CONCLUSION

A significant proportion of FFP transfusions is inappropriate. This study, which is the first step of a quality assurance program, will be followed by local recommendations for clinical practice. The current standards of prescribing FFP are more restrictive than those defined in the legal french guidelines.

Monitoring for underutilization of RBC components and platelets

BACKGROUND

Monitoring blood transfusion for overutilization is standard practice at most institutions.

STUDY DESIGN AND METHODS

This study monitored for underutilization of blood transfusion over a 14-month period, by evaluating patients who had Hb levels that were reported to be <5 g per dL or platelet counts <10 x 10(9) per L and who did not receive an RBC or platelet transfusion within 24 hours of the reported results.

RESULTS

During the study period, 24,004 units of RBCs and 3,967 units of apheresis platelets were transfused. There were 148 patients who had a Hb level that was reported to be <5 g per dL or a platelet count reported to be <10 x 10(9) per L and who did not receive a transfusion during the 24 hours after the reporting of these results. In 5 cases, the patients died before the reporting of the low Hb or platelet counts, which precluded the low Hb or low platelet count reports from triggering transfusion therapy. In 8 cases, an underutilization review investigation could not be done, because of the unavailability of patient charts. Of the remaining 135 cases, investigation revealed justifiable reasons for withholding transfusion in 133. In 2 cases, the withholding of transfusion was deemed by peer review to be inappropriate, as the patients should have received a transfusion. Overall, there was one documented underutilization of RBC transfusion therapy during a period when 24,004 units were transfused and one underutilization of platelet transfusion therapy during a period when 3,967 units of apheresis platelets were transfused.

CONCLUSION

Monitoring for underutilization of transfusion therapy fulfills the requirements of the Joint Commission on the Accreditation of Healthcare Organizations: While the underutilization of transfusion therapy did not appear to be a significant problem at this medical center, determining the reasons for withholding transfusions shed light on important patient care-related issues, including preexisting causes of falsely low platelet counts and Hb levels, delays in investigating critical laboratory values, and the need for policies for the treatment of patients who refuse transfusion for personal or religious reasons.

Blood transfusion for treating malarial anaemia

BACKGROUND

Blood transfusion is used in patients with severe malarial anaemia, but risks adverse reactions, transmission of disease, and is complicated to organise in developing countries.

OBJECTIVES

This review evaluates the effects of routine blood transfusion for severe anaemia on death and adverse outcomes in malarious areas.

SEARCH STRATEGY

The Cochrane Controlled Trials Register, African Index Medicus, LILACS, EMBASE and reference lists of relevant articles, and contact with researchers and organizations working in the field.

SELECTION CRITERIA

Randomised and quasi-randomised trials of blood transfusion compared with conservative management in malaria-associated severe anaemia.

DATA COLLECTION AND ANALYSIS

Trials were identified and extracted by a single reviewer (MM) and checked by a second (HS). Inclusion criteria were applied and data were extracted independendtly by both reviewers.

MAIN RESULTS

Two randomised trials of 230 children were included. In the transfusion group, there was a non-significant tendency towards fewer deaths (RR 0.41, 95% CI 0.06 to 2.70), but significantly more severe adverse events (RR 8.60, 95% CI 1.11 to 66. 43). In one trial by Bojang (1997a) respiratory distress was less common and hospital stay was shorter in the transfusion group (WMD 1.9 days, 95% CI 2.4 to 1.3). Subsequent need for urgent blood transfusion was less common in the transfusion group (RR 0.11, 95% CI 0.02 to 0.62). Day 28 packed cell volume was less in the transfusion group (WMD -1.34, 95% CI -2.57 to -0.11). There was no information on HIV or Hepatitis B virus transmission.

REVIEWER'S CONCLUSIONS

There is insufficient data to be sure whether routinely giving blood to clinically stable children with severe anaemia in endemic malarious areas reduces death, or results in higher haematocrit measured at one month.

Variation in red cell transfusion practice in the intensive care unit: a multicentre cohort study

OBJECTIVES: To determine the degree of interinstitutional transfusion practice variation and reasons why red cells are administered in critically ill patients. STUDY DESIGN: Multicentre cohort study combined with a cross-sectional survey of physicians requesting red cell transfusions for patients in the cohort. STUDY POPULATION: The cohort included 5298 consecutive patients admitted to six tertiary level intensive care units in addition to administering a survey to 223 physicians requesting red cell transfusions in these units. MEASUREMENTS: Haemoglobin concentrations were collected, along with the number and reasons for red cell transfusions plus demographic, diagnostic, disease severity (APACHE II score), intensive care unit (ICU) mortality and lengths of stay in the ICU. RESULTS: Twenty five per cent of the critically ill patients in the cohort study received red cell transfusions. The overall number of transfusions per patient-day in the ICU averaged 0.95 +/- 1.39 and ranged from 0.82 +/- 1.69 to 1.08 +/- 1.27 between institutions (P < 0.001). Independent predictors of transfusion thresholds (pre-transfusion haemoglobin concentrations) included patient age, admission APACHE II score and the institution (P < 0.0001). A very significant institution effect (P < 0.0001) persisted even after multivariate adjustments for age, APACHE II score and within four diagnostic categories (cardiovascular disease, respiratory failure, major surgery and trauma) (P < 0.0001). The evaluation of transfusion practice using the bedside survey documented that 35% (202 of 576) of pre-transfusion haemoglobin concentrations were in the range of 95-105 g/l and 80% of the orders were for two packed cell units. The most frequent reasons for administering red cells were acute bleeding (35%) and the augmentation of O2 delivery (25%). CONCLUSIONS: There is significant institutional variation in critical care transfusion practice, many intensivists adhering to a 100g/l threshold, and opting to administer multiple units despite published guidelines to the contrary. There is a need for prospective studies to define optimal practice in the critically ill.

Improving the appropriateness of red blood cell transfusions in patients undergoing orthopedic surgery

Orthopedic surgery is a common procedure among the elderly, and patients are at risk of receiving unnecessary blood transfusions. The goals of this project were to analyze current transfusion practices, identify opportunities for improvement, implement hospital-based quality improvement programs, and measure their impact on transfusion practices. Our aims were to decrease unnecessary transfusions and overall exposure to blood products. Data were abstracted from medical records, at baseline and postintervention. The results demonstrated significant improvements: a 55% decrease in avoidable transfusion events (from 42% to 19%, p < .001) and a decrease in the pre-transfusion hematocrit from a baseline of 29% to 26.9% in the postintervention period (p < .01). The percentage of single unit transfusion events increased from 71.9% to 77.2% (p = .05). These results suggest that the interventions had a significant impact on the use of blood. In the long term, these results should translate into cost savings and improved patient outcomes.

Red blood cell transfusion practices in patients undergoing orthopedic surgery: a multi-institutional analysis

This retrospective review analyzed and compared transfusion practices in patients undergoing orthopedic surgery in five Massachusetts hospitals with current practice guidelines; opportunities for improvement were identified. Patient-specific clinical information and data about transfusion practices were obtained from the medical records of 384 Medicare patients undergoing orthopedic surgery between January 1992 and December 1993. The number of patients who donated autologous blood preoperatively differed significantly among hospitals as did the number of autologous units that were unused. The number of blood units transfused at each transfusion event also differed significantly; some surgeons transfused > or =2 units in the majority of their patients, while others transfused 1 unit at a time. This variation in practice was not explained by differences in patients' clinical status. The mean pretransfusion hematocrit was higher for autologous versus allogeneic blood, suggesting more liberal criteria to transfuse autologous blood. Nearly half of all transfusion events were determined to have been potentially avoidable. Avoidable transfusions were also three to seven times more likely with autologous than with allogeneic blood. Significant inter-hospital differences existed in the number of elective surgery patients exposed to allogeneic blood. The major determinant of allogeneic blood use in these patients was the availability of autologous blood. Each additional autologous blood unit available decreased the odds of allogeneic blood exposure twofold. Differences in intraoperative and postoperative blood salvage use also were noted. These findings indicate that significant variations in practice exist. Comparative data enabled hospitals to identify and target specific areas for improvement.

Computer assisted prospective review of blood product utilization: a large hospital experience

In an effort to assess need to administer blood products, we developed a computer-assisted prospective blood utilization review system. Prior to transfusion, clinical information (from the blood requisition form) and pertinent laboratory data (from the laboratory information system) are checked against approved hospital transfusion guidelines (HTG). If request-review is outside HTG, the blood bank physician is called to review and consult with ordering physician. Of 27,840 requests received in a year period (1995-1996), 1.2% (327) were outside HTG and were physician reviewed. The great majority, 120/160 (88%) of requests for red blood cells (RBC) or whole blood were approved; about 65% of these were approved in patients with cardiorespiratory dysfunction and hemoglobin (Hb) > or = 90 g/L. Slightly more than two-thirds, 84/119 (71%) of platelet concentrate requests reviewed were approved; about 69% of them were approved in patients who were either bleeding or were undergoing an invasive procedure and had platelets > or = 20 x 9/L. Almost four-fifths, 38/48 (79%) of fresh frozen plasma or cryoprecipitate requests reviewed were approved; all in bleeding patients with sepsis and/or disseminated intravascular coagulation. Based on the frequent request for RBC transfusions in patients with cardiorespiratory dysfunction and Hb > or = 90 g/L, we have obtained approval to increase the Hb threshold to < 130 g/L as a means of facilitating measures to increase oxygen delivery.

An audit to assess the impact of a strategy to reduce inappropriate red cell transfusions at Honiara Hospital

A blood transfusion committee was established at Honiara Central Hospital (HCH), a national referral hospital for the Solomon Islands to promote a rational, safe and cost-effective blood transfusion service and to audit the use of blood particularly in the perioperative context. Following the education strategy, a 29.7% reduction in the number of units of blood crossmatched as a proportion of total admissions was achieved as well as a 30.1% reduction in the number of units transfused per 100 operations. The failure of the education strategy to increase the proportion of 'group and hold' requests confirms the need for an integrated approach between the different hospital departments involved to ensure a fully satisfactory result.

Use of red blood cell transfusions in terminally ill cancer patients admitted to a palliative care unit

Anemia is often associated with neoplastic disorders. Blood transfusions are used to alleviate the discomfort of anemic cancer patients. Of 246 terminally ill cancer patients admitted to our palliative care unit from October 1991 to December 1993 (128 women and 118 men), 31 patients (12.6%) (17 men and 14 women; age, 69.5 +/- 12 years) received on average 2.8 units of packed red blood cells (PRBCs) (range, 2-7 units/patient) in 35 separate admissions. PRBCs were transfused in the presence of low hemoglobin (Hb) levels ( < or = 8 g/dL) and/or severe fatigue or dyspnea. Pre-transfusion performance status, cognitive function, dyspnea, and fatigue at rest (evaluated by a four-point scale), complete blood count, serum albumin, and C-reactive protein were determined. The day after transfusion, subjective well-being was recorded as "yes/no" improvement in comparison with the pre-transfusion day. Improved subjective well-being after blood transfusion was reported in 51.4%, without significant relationship to pre-transfusion Hb levels or performance status. The influence of blood transfusion on subjective well-being was not related to the severity of dyspnea or fatigue. Twenty-one patients (60%), including seven with subjective improvement, died during the same hospitalization, a median of 49 days after transfusion. Pre-transfusion Hb level did not differ significantly in patients who benefited and did not benefit from transfusion, whereas time before death was significantly (P < 0.001) shorter in patients who did not benefit. In the discharged patients (40%), the median interval between transfusion and discharge was 13 days and the frequency of subjective improvement in well-being was 78.6%. Our data suggest that two main areas should be investigated, namely the relation between low Hb levels and symptoms and signs in terminally ill cancer patients, and the correct timing for effective blood transfusion. A combination of criteria is needed for effective transfusion; they must include not only Hb levels but also type and severity of anemic symptoms and signs. Furthermore, the identification of reliable prognostic indicators for survival would be useful.

[Transfusion of erythrocyte concentrates. An evaluation in anesthesia and intensive care]

OBJECTIVE

To assess the relevance of perioperative packed red blood cell (PRBC) transfusion practice at the University Hospital of Nice, compared with information from the consensus conference on red blood cell transfusion, held by the French Society of Anaesthesia and Intensive Care (SFAR) and the National Agency for the Development of Medical Evaluation (ANDEM) in December 1993.

STUDY DESIGN

Retrospective case series analysis.

PATIENTS

The study included 240 medical files of surgical patients, transfused in 1994 with PRBC, obtained by drawing of lots following a methodology recommended by ANDEM.

METHOD

A reference list according to the statement of the consensus conference was designed for the various surgical specialities and the ICU in which PRBC had been transfused. It included the clinical and laboratory criteria which justified the transfusion, as well as the various categories of PRBC (phenotyped, cytomegalovirus negative, leukocyte-depleted, etc). Autotransfused PRBC were also considered. The data collected from the medical files of the 240 patients were compared with the reference list.

RESULTS

In 84.6% of patients (203/240), the PRBC transfusion had been decided with reference either only to a haematocrit level below 0.27 or a level between 0.27 and 0.30 associated with clinical evidence of bad tolerance of blood loss, according to the reference list. A lack of compliance with the reference list occurred in 15.4% of patients (37/240), who had been transfused without any reference to a biological criterion. Another non compliance existed in 50% of patients (12/24) transfused with phenotyped PRBC and in 35.3% (6/17) of those transfused with leucocyte-depleted PRBC. An autotransfusion with PRBC had been carried out in 30.4% of patients (75/240).

DISCUSSION

These deviations of transfusion practice from the consensus conference statement, which were more pronounced with phenotyped and leucocyte-depleted PRCB than conventional PRBC, resulted in the edition of a report, with an analysis of the causes of deviations and recommendations for all doctors of our institution prescribing blood transfusions. Another evaluation, extended also to the medical specialities of our hospital and including all blood derivates is planned for 1996.

RBC transfusion in the ICU. Is there a reason?

OBJECTIVE

To evaluate RBC transfusion practice in the ICU.

DESIGN

Retrospective chart review.

SETTING

Multidisciplinary ICU in a tertiary care center.

PATIENTS

All patients admitted to the ICU with a length of stay of greater than 1 week.

RESULTS

A total of 23% of all patients admitted to the ICU had a length of stay of greater than 1 week (19.6 +/- 1.6 days). Of these patients, 85% received blood transfusions (9.5 +/- 0.8 U per patient). These transfusions were not solely a function of acute blood loss. Patients were transfused a constant 2 to 3 U/wk. Patients receiving blood transfusions were phlebotomized on average 61 to 70 mL per day. Phlebotomy accounted for 49% of the variation in amount of RBCs transfused. No indication for blood transfusion was identified for 29% of transfusion events. A low hematocrit (< 25%) was the only identifiable indication in an additional 19% of events. Almost one third of all RBCs transfused were without a clear transfusion indication.

CONCLUSION

The long-term ICU population receive a large number of blood transfusions. Phlebotomy contributes significantly to these transfusions. There is no clear indication for a large number of the blood transfusions given. Many blood transfusions appear to be administered because of an arbitrary "transfusion trigger" rather than a physiologic need for blood. Blood conservation and adherence to transfusion guidelines could significantly reduce RBC transfusion in the ICU.

Inventory management in Sydney Public Hospital Blood Banks

Monitoring the outdating of donated units is one way of assessing the efficiency of blood usage. Inventory management in public hospital blood banks in Sydney was reviewed with the aim of determining factors which lead to the outdating of donor blood. Factors which correlated significantly with increased outdating in hospitals included absence of an effective hospital transfusion committee; high ratio of average inventory: units transfused; fewer than three routine deliveries from the BTS per day; increased time taken for delivery of urgent products; CT values greater than 2:1, premature performance of the crossmatch and prolonged crossmatching holding time. Hospitals were informed of the initial audit results and were alerted to the factors contributing to excessive outdating. They received monthly feedback of individual outdating results compared with overall outdating. After 6 months there was a significant reduction in overall outdating from 5.0 to 0.9% (P < 0.05), which has been maintained for a further 12 months. Changes in inventory management associated with an improvement in overall outdating included: changes in crossmatching practice which increase the effective shelf-life of blood, knowledge of when blood was due to outdate and effective stock rotation.

Transfusion therapy during war and peace in Sarajevo

OBJECTIVE

To investigate surgical blood usage during the siege of Sarajevo.

METHODS

Data on blood usage and pre-transfusion hematocrit (Hct) values from blood transfusion request forms in 250 wartime emergency surgical procedures during August through October 1992 (experimental group), and in 146 peacetime elective surgical procedures (control group) during April through June 1991 at the State Hospital of Sarajevo, were reviewed.

RESULTS

The mean number of blood units transfused per patient (blood usage rate) was 1.13 in the experimental group versus 2.56 in the control group (p < 0.001). During the war, for blood conservation, normovolemic hemodilution was practiced widely. A significantly lower mean pre-transfusion Hct value of 0.21 was observed in the experimental group versus 0.27 in the control group (p < 0.001).

CONCLUSION

Blood-usage rate was lower during emergency surgical procedures in war than during elective surgical procedures in peacetime without apparent adverse patient outcome. This decrease in blood-usage rate in the face of increased numbers of trauma victims was the result of a planned blood-conservation program which included: stringent blood-usage criteria, and widespread implementation of casualty resuscitation using normovolemic hemodilution with colloid and crystalloid plasma substitutes.

Can mandatory pretransfusion approval programmes be improved?

To improve the appropriateness of blood-component prescribing, a mandatory haematologist pretransfusion approval programme of all non-red-cell components was instituted. This was associated with a 33% decrease in the units of fresh frozen plama (FFP) transfused. Platelet transfusions increased but utilization of both platelets and FFP are now the lowest of the six comparable blood transfusion regions in New Zealand. A subsequent concurrent audit, using preset criteria, of FFP, cryoprecipitate and platelet usage over a 3-month period showed that further reductions in blood component usage could still be achieved, despite the continuing pretransfusion approval policy. This audit showed that 33% of FFP and 30% of cryoprecipitate units transfused were inappropriately given, despite prior haematologist approval. Hospital transfusion practices can be improved by mandatory blood-component pretransfusion approval but concurrent auditing of this programme is required to identify and correct continuing inappropriate blood-component prescribing. Haematologists need to agree on blood-component indications prior to instituting a pretransfusion approval programme in order to provide optimal management.

[Transfusion risks: importance of blood surveillance]

Transfusion risks result from the transfusion chain complexity and are due to human errors and limits of screening technics. Causes, mechanisms and manifestations of the main risks are mostly well known. Transfusion risks can be related to the donor, the blood donation or the transfusion act. The mechanisms are immediate or delayed. Environment can be a favorable factor. In France, rates of transfusion risks and the part of risk attributable to the environment are not known with accuracy because of the absence of a mandatory reporting system. The assessment of the existing prevention policies, essential for envisaging new actions, lacks rigour. The setting of means assessment and follow-up of transfusion safety as it was mentioned by the Comity of transfusion safety follow-up (L. Degos, A. Goudeau, R. Salamon) in november 1991, and in the law no. 93-5 of january 4, 1993 would allow the improvement of epidemiologic features of blood donation, blood use and transfusion risks.

Clinicians' satisfaction with a hospital blood transfusion service: a marketing analysis of a monopoly supplier

One of the objectives of the NHS reforms is to improve customer focus within the health service. In a study to assess the quality of customer service provided by the Edinburgh and South East Scotland Blood Transfusion Service a 19 item questionnaire survey of the main clinical users of the service was performed to ascertain their satisfaction, measured on a 5 point anchored scale, with important aspects of the service, including medical consultation, diagnostic services, blood and blood components or products and their delivery, and general satisfaction with the service. Of 122 clinicians in medical and surgical disciplines in five hospitals in Edinburgh, 72 (59%) replied. Fourteen (22%) indicated dissatisfaction with any aspect of the medical consultation service, owing to inadequate follow up of clinical contacts and unsatisfactory routing of incoming calls. Diagnostic services were criticised for the presentation, communication, and interpretation of results. The restricted availability of whole blood, the necessity to order platelets and plasma through the duty blood transfusion service doctor, and the use of a group and screen policy, attracted criticism from a small number of clinicians. Ten of 68 respondents expressed dissatisfaction with delivery of blood and components to the wards and theatres. The findings indicate that the clinicians served by this blood transfusion service are largely satisfied with the service. Changes are being implemented to improve reporting of laboratory results and measures taken to improve liaison with clinicians.

Factors associated with transfusion requirements during treatment for acute myelogenous leukemia

Supportive care is a prerequisite for intensive chemotherapy in leukemic patients. Little has been published about quantitative aspects of red blood cell and platelet transfusions. We evaluated transfusion requirements and factors associated with observed differences in 206 patients undergoing initial induction consolidation chemotherapy for newly diagnosed acute myelogenous leukemia. All patients were treated during a 5-year period in 12 hospitals on a common protocol of the Swiss Study Group for Clinical Cancer Research (SAKK). Protocol 30/85 comprises a double induction and one course of consolidation. Of 206 registered patients, 199 were evaluable; 118 of 199 (59%) patients entered completed all three cycles of chemotherapy. These 118 patients received a median (range) of 18 (3-44) units of red blood cells and 12 (2-61) platelet transfusions during 112 (70-129) days of hospitalization. Patients with a hemoglobin > 10 g/l, platelets > 100 x 10(9)/l, and white blood cell counts < 5 x 10(9)/l at diagnosis received fewer transfusions than patients with less favorable blood counts during the first cycle of chemotherapy (p < 0.05). Patients with FAB subtype M3 received more platelet transfusions during the first cycle. Female patients received more platelet transfusions than male patients. In multivariate analyses the participating center was the most important single factor associated with the number of red cell and platelet concentrates given per patient and cycle (p < 0.05), the number of days in hospital (p < 0.05), and the risk of premature withdrawal from the study. These data define factors associated with transfusion requirements in patients treated for newly diagnosed AML. They include severity and subtype of disease at diagnosis, age and sex of the patients, and the participating institution. Results suggest that medical decision-making varies from center to center. The participating institution is strongly associated with differences in transfusion requirements, hospitalization time, and premature withdrawal from study. Leukemia trials tend to focus on the prospective evaluation of chemotherapy or growth factors. Our results suggest that other variables, such as management strategies, should be included for prospective analysis.

Iron-deficiency anemia: a medically treatable chronic anemia as a model for transfusion overuse

PURPOSE

Transfusion practice in patients with iron deficiency was reviewed.

PATIENTS AND METHODS

During the study period, records of 265 consecutive patients with an unsaturated iron-binding capacity of greater than 53.7 mumol/L were evaluated for possible iron-deficiency anemia.

RESULTS

Two hundred sixty-three patients met the study criteria for iron deficiency. Of these patients, 50 received 1 or more units of red blood cells (RBCs). The transfusion therapy of 12 patients could not be justified; physicians used laboratory results rather than the clinical status of the patients to initiate transfusion therapy. As a result, units of RBCs were transfused to raise the hematocrit to an arbitrarily chosen level. Furthermore, iron therapy was not prescribed for 97 of the 263 iron-deficient patients, including 11 of the patients for whom transfusion was justifiable and 2 patients for whom transfusion could not be justified. Based on records reviewed, no work-up was initiated to identify the cause of iron deficiency in 13 patients, including 4 patients who received transfusions.

CONCLUSION

These findings suggest that the evaluation and treatment of iron deficiency, including transfusion therapy for that condition, may be problematic. In view of the risks of blood transfusion therapy, improvement in transfusion practices for iron deficiency should be emphasized.

Perioperative haemotherapy: I. Indications for blood component transfusion

The practice of transfusion medicine has undergone substantial change over the last decade. Much of the impetus for the change has come from the isolation of human immunodeficiency virus (HIV) and the linkage of HIV transmission to blood transfusion. The purpose of this paper is to collate and review the literature relating to the indications for blood transfusion and provide recommendations for the appropriate utilization of blood products. Peer-reviewed and published studies and reviews relating to aspects of clinical blood transfusion were identified through computer searches and searching of the bibliographies of identified articles. Emphasis was placed on the literature published within the last decade and particularly in the years 1985-91. Material was chosen which was of proved clinical importance and in which findings were consistent among different investigators or different centres. Less emphasis was placed on material reporting new findings of uncertain clinical relevance or findings that were not consistent with majority reports. It is concluded that the only indication for red cell transfusion is to increase the oxygen carrying capacity of the blood and that an adjustment downwards in the haemoglobin concentration at which blood is transfused (transfusion trigger) from the traditional level of 100 g.L-1 is supported by the physiological and clinical data. Perioperative haemoglobin concentrations of 80 g.L-1 are acceptable in otherwise healthy young patients. The transfusion trigger should be adjusted upwards from this in medically compromised patients and in the elderly (greater than 60 yr). Fresh frozen plasma (FFP) is only indicated when there are documented deficiencies of coagulation factors. Platelet concentrates (PC) are indicated for the treatment of clinical coagulopathy resulting from thrombocytopaenia or platelet dysfunction. Routine or prophylactic administration of either FFP or PC after cardiopulmonary bypass or during resuscitation from haemorrhage is not indicated.

Analysis of fresh frozen plasma administration with suggestions for ways to reduce usage

A programme for the daily monitoring of Fresh Frozen Plasma (FFP) usage, combined with continuous education in the correct use of FFP, was started at William Beaumont Hospital in 1985. In 2 years, this had resulted in a 77% reduction in FFP usage. An analysis of the type of cases which received FFP, after the major reduction had occurred, from July, 1985 through June, 1989 is presented. During this time 2,612 units were administered to 873 patients, an average of 54 units per month. According to the accepted criteria established by the Hospital Transfusion Committee, 67% of the transfused units on the medical service were deemed indicated, compared with 54% on the surgical service. Most of the FFP was used to treat patients with liver disease, or receiving coumadin, or undergoing coronary bypass surgery. Conditions which will decrease the need for FFP administration are also presented for consideration. The results indicate that a consistent monitoring and education programme can keep blood and blood component usage at a defensible minimum.