Transfusion of blood and blood products: indications and complications

Red blood cell transfusions are used to treat hemorrhage and to improve oxygen delivery to tissues. Transfusion of red blood cells should be based on the patient's clinical condition. Indications for transfusion include symptomatic anemia (causing shortness of breath, dizziness, congestive heart failure, and decreased exercise tolerance), acute sickle cell crisis, and acute blood loss of more than 30 percent of blood volume. Fresh frozen plasma infusion can be used for reversal of anticoagulant effects. Platelet transfusion is indicated to prevent hemorrhage in patients with thrombocytopenia or platelet function defects. Cryoprecipitate is used in cases of hypofibrinogenemia, which most often occurs in the setting of massive hemorrhage or consumptive coagulopathy. Transfusion-related infections are less common than noninfectious complications. All noninfectious complications of transfusion are classified as noninfectious serious hazards of transfusion. Acute complications occur within minutes to 24 hours of the transfusion, whereas delayed complications may develop days, months, or even years later.     

Survival after blood transfusion

BACKGROUND: Long‐term survival of transfusion recipients has rarely been studied. This study examines short‐ and long‐term mortality among transfusion recipients and reports these as absolute rates and rates relative to the general population. STUDY DESIGN AND METHODS: Population‐based cohort study of transfusion recipients in Denmark and Sweden followed for up to 20 years after their first blood transfusion. Main outcome measure was all‐cause mortality. RESULTS: A total of 1,118,261 transfusion recipients were identified, of whom 62.0 percent were aged 65 years or older at the time of their first registered transfusion. Three months after the first transfusion, 84.3 percent of recipients were alive. One‐, 5‐, and 20‐year posttransfusion survival was 73.7, 53.4, and 27.0 percent, respectively. Survival was slightly poorer in men than in women, decreased with increasing age, and was worst for recipients transfused at departments of internal medicine. The first 3 months after the first transfusion, the standardized mortality ratio (SMR) was 17.6 times higher in transfusion recipients than in the general population. One to 4 years after first transfusion, the SMR was 2.1 and even after 17 years the SMR remained significantly 1.3‐fold increased. CONCLUSION: The survival and relative mortality patterns among blood transfusion recipients were characterized with unprecedented detail and precision. Our results are relevant to assessments of the consequences of possible transfusion‐transmitted disease as well as for cost‐benefit estimation of new blood safety interventions.     

Rationalizing blood management in orthopedics and traumatology

In recent years there has been growing interest in blood conservation and avoidance of transfusion in patients undergoing orthopedic surgery. The benefits of blood transfusion must be considered and evaluated in terms of risk factors relating to the adverse effects of transfusion. A number of strategies are available to reduce the need for blood transfusion. These strategies are maximally effective if combined to span the pre-operative, intra-operative and post-operative periods. Surgical, anesthetic and pharmacological techniques can reduce blood loss during operation and the use of allogenic blood. This article presents current opinions, on the base of contemporary literature, regarding risks of transfusion and several simple techniques that will reduce the need for transfusion in orthopedic procedures.     

Alternatives to blood transfusion.

Blood transfusion therapy in the 21st century continues to present limitations regarding efficacy and risks. Blood management partners optimal blood transfusion therapy with anemia management that incorporates nonblood strategies and techniques. A planned approach to anemia prevention, identification, and treatment can reduce the need for blood transfusion and improve patient outcomes. The use of pharmaceutical agents and tools to minimize blood loss also leads to blood transfusion reduction. Nurses play an integral role in affecting the use of alternatives to blood transfusion. Through assessment, communication, and an understanding of blood management strategies, nurses are patients' front-line innovators in promoting best practices.     

不规则抗体筛查在临床输血中的意义探讨

目的探讨通过抗体筛查和鉴定,发现有临床意义的不规则抗体,以避免不规则抗体引起的溶血性输血反应发生,并选择相合的血液,确保患者输血安全。方法采用微柱凝胶抗人球蛋白法检测978例神经外科择期手术需要输血患者的血清（浆）不规则抗体,结果阳性的标本再送南京市血液中心进行抗体特异性进一步鉴定。对不规则抗体筛查结果进行分析。结果 978例择期手术患者的不规则抗体筛查发现不规则抗体阳性6例,阳性率0.61%。筛检阳性的6例标本经南京市血液中心进行抗体特异性鉴定,发现在6例不规则抗体阳性患者中抗-E 3例、抗-D 1例、抗-cE 2例。对6例不规则抗体阳性患者提示少输或不输血,其中2例未输血,4例输注经南京市血液中心配合型血液,无1例发生溶血性输血反应。结论在输血前对受血者进行不规则抗体筛查可发现有意义的不规则抗体,以及选择和准备相适合的血液,防止溶血性输血反应。这对确保临床输血安全具有重要的意义。     

Epidemiology of blood transfusion

BACKGROUND: Earlier investigations of the epidemiologic attributes of blood transfusion were not based on total community populations. To calculate incidence rates of the transfusion of blood and blood components in the general population and in age- and gender-specific groups, all residents of a United States county who received transfusion(s) from 1989 through 1992 were studied. STUDY DESIGN AND METHODS: The study was a prevalence survey (cross-sectional study) of a well-defined population at a specified time. RESULTS: There was no significant change in blood and blood component utilization from the beginning of 1989 through 1992. The incidence of red cell transfusion was 42.88 units per 1000 population per year in both men and women and varied from 12.08 units per 1000 population per year in those less than 41 years old to 245.24 units per 1000 population per year in the group aged more than 65. A random resident's probability of receiving transfusion(s) in any year was 0.89 percent (0.83% for men and 0.94% for women) and varied from 0.26 to 5.17 percent among the three age groups. The incidence of platelet and fresh-frozen plasma transfusion was 21.24 units per 1000 population per year and 8.64 units per 1000 population per year, respectively. CONCLUSION: Incidence rates of blood transfusion for "causal" planning of blood collections are presented here for the first time. The probability of receiving a transfusion of RBCs in any year rises by 20-fold from the rate in those less than 40 years old to that in those more than 65 years old, who receive 53.3 percent of the red cell units transfused.     

Cost analysis of autologous blood transfusion, using cell salvage, compared with allogeneic blood transfusion

Autologous transfusion is an option infrequently used in the UK, partly because the direct costs are greater than for allogeneic transfusion. An analysis of the cost consequences of substituting autologous for allogeneic blood, by using cell salvage, was undertaken from a hospital perspective. Direct costs were estimated for two different cell salvage devices and sensitivity analysis performed on the key variables.
Allogeneic transfusion may be associated with increased rates of postoperative infection due immunomodulation and immunosuppression. As a result, one of the short-term benefits of autologous transfusion is a possible reduction in length of hospital stay. This was the most important variable affecting the cost of autologous transfusion. Cost equivalence for autologous and allogeneic blood was reached at reductions in hospital stay of between 0.3 and 2 days across a range of variables.
Reductions in length of hospital stay of this magnitude have been reported in several small studies. The results of our cost analysis suggest that autologous transfusion should not be rejected on the grounds of cost and we recommend a large-scale randomized controlled trial of autologous vs. allogeneic transfusion.     

The risks associated with blood and blood product transfusion

Although transfusion of blood and blood products is often of life-saving benefit for the many patients who receive transfusions every year, it is not without considerable risk. Nurses need to be aware of these risks so that they can respond to patient anxiety about transfusion. This article outlines risks associated with transfusion and the measures taken to minimize them. Attention will be focused principally on the two most significant risks: transmission of serious blood-borne infection and the potentially fatal acute immune haemolytic reaction that can occur if patients receive incompatible red cells. Other significant adverse effects will be discussed briefly. Recent initiative aimed at monitoring the incidence of these adverse effects and increasing the safety of blood transfusion will be discussed, with special emphasis on the nurse's role in the transfusion process.     

Towards better blood transfusion – recruitment and training

summary .  Recent national initiatives in blood transfusion safety in the UK have created the need for an expansion in haematologists subspecializing (wholly or in part) in transfusion medicine. In 2008, there are 62 transfusion consultants in the UK, but only 42 are full time, and only 19 have hospital sessions. Despite the need for expansion, recruitment appears difficult. The English blood transfusion service, National Health Service Blood and Transplant (NHSBT), is undergoing major reconfiguration, and the current practice of transfusion training for haematology specialists primarily at blood centres with little or no hospital training is not sustainable or desirable. Delivering a high-quality transfusion programme to haematology trainees is best achieved through an increased emphasis on hospital-based training. Improved research opportunities, joint NHSBT/hospital posts and a separate subspecialty training curriculum may stimulate interest in transfusion medicine.     

临床成分输血分析

目的 通过对临床成分输血的分析,指导临床科室树立现代输血观念,做到科学、合理用血,推广成分输血.方法 分析我院近5年(2001～2005年)临床用血情况及各年度我院临床输血总量、成分输血率和各成分血所占比例.结果 用血量:红细胞、血小板、血浆使用率均逐年上升,全血细胞、白细胞的使用率则逐年下降,与现代国内外输血相比,我院在血浆、冷沉淀、红细胞的使用上还存在着一定的差距和不合理性.结论 通过我院临床成分输血分析,为合理配置成分血提供依据,推广成分输血.     

静脉输血的护理进展

为达到安全输血的目的 ,介绍了输血前的准备、输血速度、血液的保存温度与输注温度及其保证输血快速通畅护理 ,总结了常见输血并发症的防治。     

Perception of blood transfusion risk

Perceptions of risk ultimately drive the responses of individuals and society to risk issues, and transfusion risk is no exception. Surveys of lay people over the past decade indicate that public concern about transfusion safety has remained prevalent, dominated by the ongoing fear of contracting HIV infection. Such perceptions persist despite the acknowledgment that blood transfusion is safer now than in years past. Judgements by the lay public that may, at first glance, seem irrational can often be understood when the heuristics, biases, and models of human judgements of risk are considered. Risk perception research suggests that how lay people perceive risk has less to do with the unidimensional view of risk as a probabilistic expression and more to do with a complex multidimensional construct in which affect, reason, worldviews, trust, and other factors are intertwined. This review summarizes some of the principles of risk perception as applicable to transfusion medicine.     

The societal unit cost of allogenic red blood cells and red blood cell transfusion in Canada

BACKGROUND: There is a dearth of information about the cost of allogenic red blood cells (RBCs) and RBC transfusion in Canada in the aftermath of the Canadian blood system reorganization and the introduction of various safety measures. The unit cost of allogenic RBCs and RBC transfusion in Canada in 1994 was estimated at 152.17 US dollars. The objective of this study was to determine the unit cost of allogenic RBC transfusion in Canada from a societal perspective. STUDY DESIGN AND METHODS: A cost-structure analysis using the cost information from 2001 through 2002 was used. Costs of blood collection, production, distribution, delivery (hospital transfusion service processing and patient administration), transfusion reaction management, and opportunity cost of donor's time were included in the analysis. Canadian Blood Services and Héma-Québec supplied the data for collection, production, and distribution stages. Delivery and transfusion reaction costs were collected from eight hospitals across six Canadian provinces. In-patient costs were assessed for the intensive care unit, emergency, general medicine ward, and operating room. RESULTS: The aggregate mean societal unit cost of RBCs transfused on an inpatient basis in 2002 was 264.81 US dollars (95% confidence interval [CI], 256.29 dollars-275.65 dollars). The mean cost of blood collection, production, and distribution was 202.74 US dollars (95% CI, 199.63 dollars-204.31 dollars), the mean opportunity cost of donor time was 18.21 US dollars (95% CI, 17.11 dollars-21.63 dollars), the mean cost of hospital transfusion service processing was 16.65 US dollars (95% CI, 13.50 dollars-19.79 dollars), of RBC transfusion was 26.92 US dollars (95% CI, 25.33 dollars-28.52 dollars), and of transfusion reaction management was 0.29 US dollars(95% CI, 0.22 dollars-0.36 dollars). There were substantial variations in hospital transfusion service processing and RBC transfusion costs across hospitals. CONCLUSION: The societal unit cost of RBC transfusion has doubled since 1994 to 1995. Further increases in unit costs would be expected as additional safety measures are introduced. This will have important financial implications for treating patient populations that require a high level of RBC transfusions.     

Red blood cell transfusion and outcome in cancer

Oncology services utilize about 15% of the blood transfusion resources in the USA. Red blood cell transfusion is performed immediately before, during or after major surgery to compensate for blood loss and hemodilution. However, a lack of evidence-based guidelines leads to variable transfusion practices among clinicians. The benefits of transfusing blood products are obvious in life-threatening low blood cell counts or bleeding, but it is becoming apparent that deliberate blood transfusion in some cancer patients can trigger negative clinical impacts. This review attempts to provide an overview of the impact of red blood cell transfusion in patients suffering from various types of oncologic pathologies.     

Patient safety and blood transfusion: new solutions

Current risk from transfusion is largely because of noninfectious hazards and defects in the overall process of delivering safe transfusion therapy. Safe transfusion therapy depends on a complex process that requires integration and coordination among multiple hospital services including laboratory medicine, nursing, anesthesia, surgery, clerical support, and transportation. The multidisciplinary hospital transfusion committee has been traditionally charged with oversight of transfusion safety. However, in recent years, this committee may have been neglected in many institutions. Resurgence in hospital oversight of patient safety and transfusion efficacy is an important strategy for change. A new position, the transfusion safety officer (TSO), has been developed in some nations to specifically identify, resolve, and monitor organizational weakness leading to unsafe transfusion practice. New technology is becoming increasingly available to improve the performance of sample labeling and the bedside clerical check. Several technology solutions are in various stages of development and include wireless handheld portable digital assistants, advanced bar coding, radiofrequency identification, and imbedded chip technology. Technology-based solutions for transfusion safety will depend on the larger issue of the technology for patient identification. Devices for transfusion safety hold exciting promise but need to undergo clinical trials to show effectiveness and ease of use. Technology solutions will likely require integration with delivery of pharmaceuticals to be financially acceptable to hospitals.     

Autologous blood transfusion today.

Autologous blood transfusion--the transfusion to a patient of his or her own blood--is increasingly being recognised as a useful adjunct to traditional transfusion practice. The reasons include fears of disease transmission, the potential adverse effects on the recipient's immune system of transfused donor blood, and logistical factors. The three main techniques of autologous transfusion are: (i) pre-deposit, in which patients donate blood over a period of time in preparation for elective surgery; (ii) pre-operative isovolaemic haemodilution, in which blood is removed immediately before surgery and volume replacement is given, the blood being reinfused post-operatively; and (iii) salvage transfusion--the collection of blood shed at surgery or in similar circumstances, which is reinfused immediately or after concentration and purification. All three techniques can help to improve the safety of transfusion and economise on scarce supplies of donor blood.     

Massive blood transfusion therapy

Surgical patients requiring massive blood transfusion therapy present many challenges for the anesthetist. The decision to transfuse homologous banked blood and its components must be weighed against the potential complications that may occur in this form of therapy. A review of metabolic changes that occur in banked blood, the risk of infection, and physiologic derangements that may develop during massive blood transfusion are presented.     

Autologous blood donation and subsequent blood use in patients undergoing total knee arthroplasty

Autologous blood donation is designed to avoid complications from allogeneic blood, leaving units of blood in the general blood supply. It is unclear how efficient these programmes are in accomplishing these goals. It is unclear if autologous donation provokes increased need for any transfusion following surgery and whether it can be avoided in low-risk surgeries. Of 430 patients undergoing unilateral primary knee replacement arthroplasty over 12 months in our hospital, 309 had autologous donations and 121 did not. Of the 121 patients who did not donate, 36% completed surgery without transfusion, whereas only 17% of those who had autologous donations did so (P < 0.05). Age less than 65 years, higher baseline and postoperative haemoglobin levels were associated with lower transfusion rates. Patients who had autologous donations were approximately four times more likely to be transfused. As the number of autologous units donated increased, transfusions following surgery increased. Autologous donation did reduce allogeneic blood transfusions. Therefore, autologous blood donation for unilateral total knee arthroplasty is associated with overall increased transfusion rates, but with reduced need for allogeneic blood, independent of other clinical factors associated with transfusion. Therefore, there is need for reconsideration of these programmes relative to specific surgeries.     

Current status of blood component therapy in surgical critical care

PURPOSE OF REVIEW: The use of blood component therapy, with transfusion of red cells, plasma, and platelets, is common in critical care. New evidence has emerged documenting the risks associated and lack of efficacy or improvement in clinical outcome with blood transfusion for the treatment of anemia in critically ill patients who are hemodynamically stable. RECENT FINDINGS: The safety of a restrictive transfusion strategy (transfuse only if hemoglobin < 7 g/dL) was reported in 1999. Despite compelling evidence from this prospective randomized clinical trial, clinicians have not substantially changed practice regarding blood transfusion in critical care. The recently published CRIT trial reported that the mean pre-transfusion hemoglobin was 8.6 g/dL in this large multicenter trial that examined transfusion practices in critical care in the US. Furthermore, only 19% of hospitals had an institutional blood transfusion protocol. The Surviving Sepsis Campaign guidelines have also recommended blood transfusion only when hemoglobin falls to 7.0 g/dL, following resolution of tissue hypoperfusion and in the absence of significant coronary artery disease or acute hemorrhage. We have an increased understanding of the pathophysiology of the anemia associated with critical care, related to the inflammatory response, downregulation of erythropoietin, and lack of iron availability due to macrophage sequestration. Clinical trials are underway to confirm the efficacy of recombinant erythropoietin in the treatment of critically ill patients with anemia. SUMMARY: Current data regarding blood transfusion thresholds and risks of blood transfusion have not as yet significantly altered practice patterns. Efforts to reduce blood transfusion rates in critically ill patients are required. These strategies will require education, unit and institutional protocols, and reduction of phlebotomy for diagnostic laboratory testing in the intensive care unit. Further investigations regarding anemia in critical care and new treatment and prevention strategies are required.     

加压输血的临床研究

对近年来临床上有关加压输血的方法,如一次性输血器、塑料三通辅助、袖带加压、输液泵等进行综述,提出加压输血器的研制还有待于改善和推广。