Patient management: Optimization of blood and blood products utilization

Each year about 30 million blood products are transfused in the US; the demand is steady or decreasing, in light of the current economic down turn and improvements patient blood management programs it is expected to stay steady for the near future, however with aging population this trend may reverse (Drackley 2012). Blood and blood products are important parts of treatment in various disorders; however, these products are not without side effects and risks, including death. The indications, appropriateness and risks of blood product transfusions are undergoing evolution and, in general, the evidence points to a more conservative use of these products. In the case of each of the four main blood products, Red cells, Platelets, Plasma and Cryoprecipitate, critical review of outcomes in retrospective studies and a few prospective controlled trials, the evidence has favored restrictive administration of these products. The first randomized controlled trial for the use of red cells in critical care patients strongly favored limiting red cell transfusions to patient with hemoglobin (Hb) levels of <7.0 gm/dL. At the upper end it appears that post-transfusion Hb levels >10.0 gm/dL suggest over-transfusion. Red cell transfusions carry the rare risks of hemolytic transfusion reactions, transmission of infectious agents, transfusion associated acute lung injury (TRALI), transfusion associated circulatory overload (TACO), transfusion related immunomodulatory effect (TRIM), and graft vs. host disease (TA-GVHD); The evidence is strongly in favors of limiting red cell transfusions. Plasma transfusions are generally used in prevention of coagulation abnormalities in cases of massive transfusions, and treatment of coagulation abnormalities due to Warfarin overdose, liver disease, undefined prolongation of prothrombin and partial thromboplastin times and international normalized ratio (INR). An additional use of plasma involves its use as a replacement fluid during plasma exchange procedures for treatment of thrombotic thrombocytopenic purpura. Risks of plasma transfusion are similar to those for red cell transfusions, with TRALI and transfusion associated circulatory overload (TACO) being more frequent. Transfusions of plasma for correction of mild coagulation defects, prior to invasive procedures, likely represent a common miss-use and over-use of plasma. Platelet transfusion practices have undergone controlled randomized trials assessing differences in dose, preparation methods and use. Studies suggest prophylactic and therapeutic transfusion of platelets to patients with platelet counts of <10,000 thousand/cmm. with additional guidelines for transfusions in patients with thrombocytopenia in case of bleeding, invasive procedures and presence of intracranial and eye pathology (Heddle 2009, Triulzi 2012, TRAP 1997). In addition to the risks listed under red cell transfusions, platelet transfusions carry added risk of transmission of bacterial infections. Cryoprecipitate use is limited to replacing fibrinogen and high molecular weight/multimeric von Willebrand factor. We are not addressing the use of coagulation factor concentrates.