Guidelines for blood transfusion The early history of blood transfusion 1628: William Harvey - circulation SCANSECT s Post Graduate Course Saturday the 25th of October 2014 Kjell Titlestad, Klinisk Immunologisk Afdeling, Odense Universitetshospital Jean Baptiste Denis 1667 Sheep blood for transfusion James Blundell 1818 blood transfusion human human. Karl Landsteiner (1868-1943) 1901: Karl Landsteiner AB0-blood group Reuben Ottenberg 1911 Transfusion by AB0 Studies in isoagglutination. I. Transfusion and the question of intravascular agglutination. Ottenberg R. J Exp Med 1911; 13: 425 1
Richard Lewisohn 1915 Introducing sodium citrate as an anticoagulant OH Robertson 1918 Transfusion with preserved red blood cells Transfusion with preserved red blood cells. BMJ 1918; i: 691 Bernard Fantus 1937 Blodets bestanddele Cook County Hospital Blood Bank Fantus, B. The therapy of the Cook County Hospital July 10, 1937 Journal of the American Medical Association reprinted 1984;251:647-649 BLODKOMPONENTER Erytrocytsuspension (SAG-M) Frisk Frosset Plasma (FFP) Trombocytkoncentrat (TC) Guidelines for blood transfusion Why? 2
4500 4000 n u 3500 C3000 B R2500 d 2000 s e 1500 s 1000 n ra T 0 500 Years 1997 1998 1999 2000 2001 2002 2003 2004 2005 4500 its 4000 n u 3500 C3000 B R2500 d 2000 e s 1500 fu s 1000 n ra T 0 500 Years 1997 1998 1999 2000 2001 2002 2003 2004 2005 Patterns of blood use Transfusionspraksis - international variation 70 RBC (U) per 1000 inhabitants 2008 60 50 40 30 20 10 0 Denmark Germany Austria Sweden Belgium USA Finland Norway United Kingdom Australia Netherlands Ireland The collection, testing and use of blood and blood products in Europe (2008) The 2009 National Blood Collection and Utilization Survey Report (USA, data for 2008, Department of Health and Human Services etc.) National Blood Authority, Australia. Annual Report 2007-08 KET 2012 Patterns of blood use Patterns of blood use Congenital and perinatal conditions (P) Pregnancy and childbirth (O) Dis. of the muscles and connective tissue (M) Diseases of the ureto-genital system (N) Infectious diseases A,B) Diseases of the respiratory system (J) Figure 1 FIN DK Figure 1 illustrates transfused RBC-units per thousand inhabitants included in the databases. Non malignant haematological disease (D5-D8) Trauma (S,T,V,X,Y) Diseases of the circulatory system (I) Haematological malignancies (C81-C9) Diseases of the GI-system (K) Other neoplasms (C1-C80, D0-D4) 0,0 1,0 2,0 3,0 4,0 5,0 6,0 7,0 8,0 9,0 Epidemiology of Blood Transfusion in a Danish County Jonas T Madsen, Torben Barington, Kjell Titlestad. Department of Clinical Immunology, Odense University Hospital, Denmark. Background Results The incidences of blood transfusion are low for the age groups 0 19. Females aged 20-49 years seem to have higher incidence of blood use than males of corresponding ages. This This study describes the incidence of In the years between 1997-2006, an average of 4,455 relation is reversed from the 50-59 year group and up, where individual patients received RBC every year. These patients transfusion of red blood cells (RBC) in the males have a higher incidence of blood transfusion. used an average of 25,400 units per year, thus requiring an general population. average of 5.7 units RBC. The authors used The incidence of receiving a blood transfusion during a calendar year is 0.94 percent for the total population of demographic data and Funen (472,349 citizens in 2006). This is an average for the information from the local ten year period, with individual years ranging from 0.87 blood transfusion register 0.99 percent. and diagnosis and Sub grouping according to sex and ten year age groups procedure register in the yields information about incidence of blood transfusion: Danish county of Funen for Incidence of transfusion the years 1997-2006. 10.0 its fu The total number of RBC units used was also studied. The following charts display blood product use by the different age groups for different years. Most blood is used by men aged 70-79. Blood use by female group Blood use by male group Epidemiology of Blood Transfusion in a Danish County (AABB 2008) The incidence of receiving a blood transfusion during a calendar year is 0.94 percent for the total population of Funen (472,349 citizens in 2006). Methods All transfusion data in the county of Funen has been stored electronically since 1997. All sets of transfusion data include the recipient s personal identification number (PIN), which is used for all contacts with public service, including the public health service. Only blood recipients that were citizens of the county of Funen were included in the study. For each year since 1997 we have found the incidence ( risk ) of blood transfusion during the calendar year for different age groups for both sexes. We have calculated the incidence of RBC transfusions for ten year age groups, by finding the number of unique patients transfused each year, and dividing by the total number of citizens in the corresponding age- and gender groups. Percent 8.0 6.0 4.0 2.0 0.0 years Male 0.13 0.06 0.08 0.13 0.350.82 1.83 3.89 6.77 9.34 Female 0.12 0.06 0.26 0.31 0.440.76 1.54 3.25 5.66 8.17 Age group Incidence of blood transfusion to unique patients in one year. Average 1997-2006. Incidence of transfusion is below 0.32 % for citizens 0-39 years old. The incidence increases from 0.35 % in male and 0.44% in female 40 49 year groups, to 9.34 % and 8.17 % in the 90+ year groups. Conclusions This study shows the incidence of blood transfusion for the general population in a county. As expected, the incidence of RBC transfusions increases with age. Until the age of 19, incidence is nearly identical for males and females (few patients actually transfused). In the age groups 20-49 years, the incidence is highest for females, whereas males have the highest incidence in the age groups 50-89. We have shown the average incidence of receiving a RBC unit during a calendar year in the county of Funen to be 0.94 percent. Contact: jonas.madsen@ouh.regionsyddanmark.dk Abstract Title: Epidemiology Of Blood Transfusion In A Danish County; Sequence#: SP113 AABB Annual Meeting & TXPO October 4-7, 2008 KET 2008 3
Transfusion Requirements in Critical Care (TRICC) Variation and overconsumption Does it matter? N Engl J Med 1999; 340(6):409-417. Transfusion requirements in critical care A multicenter, RANDOMIZED, CONTROLLED clinical trial of transfusion requirements in critical care Liberal strategy: 420 patients: transfusions were given when the hemoglobin concentration fell below 10.0 g/dl and hemoglobin conc. were maintained at 10.0-12.0 g/dl Restrictive strategy: 418 patients: transfusions were given when the hemoglobin concentration fell below 7.0 g/dl and hemoglobin conc. were maintained at 7.0 to 9.0 g/dl Transfusion requirements in critical care Results The restrictive strategy decreased the average number of red-cell units transfused by 54 percent and decreased exposure to any red cells after randomization by 33 percent. Transfusion requirements in critical care Transfusion requirements in critical care Results Overall, 30-day mortality was similar in the two groups (18.7 percent vs. 23.3 percent, P= 0.11) The rates were significantly lower with the restrictive transfusion strategy among patients who were: less acutely ill (restrictive 8.7% and liberal 16.1%; P=0.03) less than 55 years of age (restrictive 5.7% and liberal 13.0%; P=0.02) but NOT among patients with clinically significant cardiac disease (20.5% and 22.9%, respectively; P=0.69). 4
Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair (FOCUS) Transfusion Strategies for Acute Upper Gastrointestinal Bleeding A liberal transfusion strategy (N = 1007, a hemoglobin threshold of 10 g/dl), as compared with a restrictive strategy, (N = 1009, symptoms of anemia or at physician discretion for a hemoglobin level of <8 g /dl) did not reduce rates of death or inability to walk independently on 60-day follow-up or reduce in-hospital morbidity in elderly patients at high cardiovascular risk. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding Transfusion Strategies for Acute Upper Gastrointestinal Bleeding Liberal strategi: 460 patienter randomiseret til liberal strategi: RBC-transfusioner når hæmoglobin-koncentrationen (Hgb) falder under 5,6 mmol/l (9 g/dl) Hgb holdes mellem 5,6 og 6,8 mmol/l (11.0-12.0 g/dl) Restriktiv strategi: 461 patienter randomiseret til restriktiv strategi: RBC-transfusioner når hæmoglobin-koncentrationen (Hgb) falder under 4,3 mmol/l (7.0 g/dl) Hgb holdes mellem 4,3 og 5,6 mmol/l (7-9 g/dl) KET 2013 Quality of life (QoL) measurement was measured preoperatively and twice up to 14 days postoperatively using the Functional Status Index (FSI), the Visual Analogue Score (VAS)-Fatigue score, and the Functional Assessment of Cancer Therapy Anemia (FACT-Anemia) subscale RESULTS: A total of 603 patients were evaluated. All patients scored worse postoperatively, but none of the scores correlated with Hb values, neither after correcting for confounding factors. Even more, the changes between preoperative and postoperative Hb levels were not correlated with changes in fatigue scores. CONCLUSION: In hip and knee prosthesis surgery no correlation existed between postoperative Hb levels or acute postoperative decline in Hb values and Quality of life scores 5
Transfusion med erytrocytter til blødende patienter Transfusion med erytrocytter til blødende patienter 9 g/dl 9 g/dl 8 g/dl 6
Transfusion med erytrocytter til blødende patienter 9 g/dl Transfusion med erytrocytter til blødende patienter Less is more 7 g/dl 8 g/dl http://discoverattic.com/products/details/one-word-a-day NATIONAL GUIDELINES FOR BLOOD TRANSFUSION 2007 The purpose of this guidance is to ensure: A consistently high patient safety by use of blood transfusions and to reduce the high consumption of donor blood in Denmark VEJLEDNING OM BLODTRANSFUSION Behandlingsstrategi ved kontrollabel blødning Hæmoglobinkoncentration < 7 g/dl 4,5 mmol/l medfører oftest behov for behandling med erytrocytter. Hæmoglobinkoncentration < 10 g/dl 6,0 mmol/l medfører overvejelse om behandling med erytrocytter til patienter med: svær iskæmisk hjertesygdom, den initiale fase af septisk shock (< 6 timer efter indlæggelse) og akut, alvorlig blødning (fx tab af mere end 30 % af blodvolumenet indenfor 24 timer). Sundhedsstyrelsen: Vejledning om blodtransfusion 2007 www.sst.dk Sundhedsstyrelsen: Vejledning om blodtransfusion - 2007 2007 2013: 22% reduction KET 2012 KET 2013 7
Transfusions per hospitalization Denmark 2008 50% 45% 40% PLATELETS Transfusions per hospitalization Denmark 2008 50% 45% 40% RBC 35% 30% 25% 20% 15% 10% 5% 0% 1 2 3 4 5 6 7 8 9 >9 Hospitalizations plt 31% 23% 11% 9% 5% 4% 2% 2% 1% 11% 35% 30% 25% 20% 15% 10% 5% 0% 1 2 3 4 5 6 7 8 9 >9 Hospitalizations RBC 12% 44% 10% 15% 4% 4% 2% 2% 1% 6% Antal transfusioner (RBC) per indlæggelse OUH 2008 Antal transfusioner (RBC) per indlæggelse OUH 2012 27% 29% Hemoglobin conc. following the last transfusion For patients receiving RBC transfusions, we identified the LAST transfusion and the FIRST hemoglobin concentration thereafter (1 7 days) Hemoglobin conc. following the last transfusion University Hospital 2008 N=3824 Mean: 10.6 g/dl National guidelines: Normal transfusion trigger is 7.2 g/dl (4.5 mmol/l). Transfusions should NOT be given if hemoglobin concentration is above 9.7 g/dl (6.0 mmol/l ). We concluded that guidelines were certainly not followed, if patients hemoglobin concentration were 10.5 g/dl (6.5 mmol/l) or higher. mmol/l 10.5 g/dl 39% OK (?) 61% NOT OK 8
Hemoglobin conc. following the last transfusion University Hospital 2009 Hemoglobin conc. following the last transfusion University Hospital 2010 N=3831 Mean: 10.6 g/dl N=3149 Mean: 10.3 g/dl mmol/l mmol/l 10.5 g/dl 10.5 g/dl 46% OK (?) 54% NOT OK 54% OK (?) 46% NOT OK Hemoglobin conc. following the last transfusion University Hospital 2011 Hemoglobin conc. following the last transfusion University Hospital 2012 N=3684 Mean: 10.1 g/dl N=3676 Mean: 10.1 g/dl mmol/l 10.5 g/dl 10.5 g/dl 60% OK (?) 40% NOT OK 61% OK (?) 39% IKKE OK Sundhedsstyrelsens hjemmeside www.sst.dk VEJLEDNING OM BLODTRANSFUSION Treatment of bleeding in hemodynamically stable patients Hos en blødende patient med stabilt kredsløb erstattes blodtabet initialt med krystalloider og evt. kolloider. Den videre behandling af kontrollabel blødning omfatter RBC,FFP and platelets by the 6 12 principle. Ved pågående blødning hos voksne, dvs. vedvarende transfusionsbehov hos voksne, behandles efter eksempelvis seks erytrocyttransfusioner med: 6 RBC, then FFP and RBC 1:1 Sundhedsstyrelsen: Vejledning om blodtransfusion - 2007 9
VEJLEDNING OM BLODTRANSFUSION VEJLEDNING OM BLODTRANSFUSION Treatment of bleeding in hemodynamically stable patients Den videre behandling af kontrollabel blødning omfatter indgift af FFP og trombocytter, fx efter 6-12 princippet. Ved pågående blødning hos voksne behandles, indtil hæmostase opnås efter cirka 12 erytrocyttransfusioner og seks FFP transfusioner med trombocytter i forholdet: 12 RBC, then Platelets 1 : FFP 5 : RBC 5 Treatment of bleeding in hemodynamically unstable patients Akutte, ukontrollable blødninger kendetegnes ved hæmodynamisk instabilitet, dvs. svigtende kredsløb med utilstrækkelig vævsgennemblødning/-oxygenering og laktatdannelse. Krystalloider anvendes kortvarigt i ventetiden på balanceret blodkomponentbehandling ækvivalent til fuldblod. Der skal straks skiftes til balanceret blodkomponentterapi, hvis en kontrollabel blødning udvikler sig og bliver ukontrollabel. Sundhedsstyrelsen: Vejledning om blodtransfusion - 2007 Sundhedsstyrelsen: Vejledning om blodtransfusion - 2007 VEJLEDNING OM BLODTRANSFUSION Treatment of bleeding in hemodynamically unstable patients Balancerede blodkomponenter gives hos voksne fra den tidligste fase eksempelvis i forholdet: RBC 3 : FFP 3 : platelets 1 Sundhedsstyrelsen: Vejledning om blodtransfusion - 2007 Good Guidelines for blood transfusion 10
www.blood.gov.au www.transfusionguidelines.org.uk/transfusion-handbook 9 g/dl 8 g/dl 7 g/dl 11