A new three-part Lancet Serieson transfusion medicine looks at the effect of the new approach of patient blood management on the use of blood products, transfusion-free alternatives, and better ways of the managing the blood supply to meet increasing demand.
- Blood transfusion still overused during common heart surgery
- Innovative solutions may help solve blood shortage facing developed countries
- Transfusion-free alternatives could improve patient safety and cut costs
Series 1 — Blood transfusion still overused during common heart surgery
Despite a growing body of evidence highlighting the danger of unnecessary blood transfusions, there is still wide variation in the use of transfusions during common heart surgery (and some other non-cardiac surgeries) in the UK, USA, and Canada, according to the first paper in the Lancet Series on transfusion medicine.
"The presumed benefits of blood transfusion are being challenged by the findings of recent trials which show that restrictive transfusion practices are equivalent or better than liberal practices, even for patients with heart disease and the elderly"*, explains Lawrence Goodnough, Series coordinator and Director of the Transfusion Service and Professor of Pathology and Medicine at Stanford University Medical Center in the USA.
"The big question is how best to translate these findings into clinical practice and target them to the right staff group (most transfusions are ordered by junior doctors) and overcome clinicians' resistance to change."*
The lack of consistent recommendations for when a surgical patient should get blood, including little consensus among medical societies about the use of haemoglobin levels (the quantity of red blood cells carrying oxygen in the body) to determine when a transfusion should be given, may explain why practice varies so widely, write the authors.
Another possible reason is that there simply isn't enough good evidence informing blood transfusion guidelines because of the limited number of large, high-quality randomised trials.
About 24 million blood products (red blood cells, fresh-frozen plasma, and platelets) in the USA, and 3 million in the UK, are transfused each year.
An overall fall in the use of red blood cell units in the USA (3% in both 2009 and 2010) and blood use in the UK (nearly 16% between 2001 and 2007 and a further 3% in 2012) over the last few years suggests that a growing number of physicians are transitioning to a more restrictive approach. But according to Goodnough, "Considerable variation remains between hospitals in the reduction of blood use, and national audits of blood components in the UK suggest that overall blood usage could be further reduced without patient safety being compromised."
In the USA, institution-based initiatives to optimise blood use are beginning to have an impact on blood demand. For instance, the adoption of best practice support alerts and electronic order systems at Stanford University Medical Center have successfully reduced transfusion use in children and adults. Similar Patient Blood Management strategies are being implemented in many other hospitals and as national initiatives in some countries including the UK.
But a recent survey of anaesthetists from 1000 north American institutions found that only a fifth reported having an institutional discussion on the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists transfusion guidelines, and just 14% had an institutional transfusion monitoring group.
According to Goodnough, there is still much to do to ensure every transfusion is necessary and appropriate, "Professional societies are well positioned to incorporate blood transfusion outcomes as quality indicators in their own guidelines and recommendations. Physicians and hospital departments of quality and cost-effectiveness should introduce patient blood management initiatives to improve patient safety and clinical outcomes."
Notes to Editors:
*Quote direct from author and cannot be found in text of paper.
Series 2 — Innovative solutions may help solve blood shortage facing developed countries
In less than 10 years, there may not be enough donated blood in developed countries to treat the ageing population. Finding alternative ways of managing the blood supply to meet the 10% projected increase in demand for blood for complex surgical procedures such as joint replacements and cancer therapy is one of the most critical challenges facing transfusion medicine.
In the second Series paper, Lorna Williamson from the UK's NHS Blood and Transplant and Dana Devine from Canadian Blood Services point out that alternative ways of recruiting and retraining future generations of blood donors will be needed, whilst ensuring that every transfusion is necessary and appropriate, and that wastage is minimised.
They propose several key solutions including: harnessing new technology such as Facebook, Twitter, and Spotify to enlist new donors; adapting supply chain solutions from industry to improve blood stock management; and donor and blood compatibility testing to minimise the risk of adverse events and storage-related problems.
In the longer-term, growing large quantities of transfusion products (eg, red cells) from stem cell sources is a possibility, say the authors, but challenges of cost, scaling up, and reproducibility remain to be solved.
Series 3 — Transfusion-free alternatives could improve patient safety and cut costs
The third Series paper discusses how the health risks surrounding blood transfusions and the continued rise in blood costs (estimated transfusion cost of one blood unit is US$700–$1200) are driving the development of alternatives to donated blood. These alternatives are changing the way many patients undergo surgery.
Patients who receive blood have higher rates of infection, kidney failure, lung dysfunction, heart attack, stroke, and death, as well as facing the potential threat of diseases from emerging pathogens such as new variant Creutzfeldt-Jakob disease and West Nile Virus.
New concepts such as patient blood management hold promise for reducing the use of blood products by detecting and treating anaemia before surgery. Strategies include the use of erythropoieitic-stimulating drugs and iron to boost red blood cell production, meticulous surgical techniques to minimise blood loss, more targeted monitoring and treatment of blood coagulation (clotting) with single coagulation factors such as fibrinogen or factor XIII, and harnessing the body's capability to tolerate relatively low haemoglobin levels.
According to Professor Donat R. Spahn from Zurich University Hospital, one of the paper's authors, "Quality indicators measuring patient outcomes (ie, hospital stay, postoperative complications, mortality, and costs) need to be used so that the alternatives to blood transfusion can be more effectively assessed and incorporated into clinical practice."*
Notes to Editors:
*Quote direct from author and cannot be found in text of paper.
Journal
The Lancet