Transfusion in sepsis: the controversy continues

sepsis-bullseyeRed blood cell (RBC) transfusion in septic patients remains a controversial topic. The well-known and often quoted article by Rivers et al. in New England Journal of Medicine, 2001, was one of the first to attempt to define a protocol for transfusion along with primary use of fluid resuscitation, vasopressors and inotropic agents.¹ The assumption and hope of incorporating RBC transfusion into what was deemed “Early Goal-Directed Therapy” (EGDT) was that anemic septic patients would acquire an increased O₂ delivery during this critical timeframe. Continue reading

Ringing the “T.A.C.O.” Bell

TACO-graphicHats off and ring the bell for Dr. Alam et al. for their upcoming article “The prevention of transfusion-associated circulatory overload” in Transfusion Medicine Reviews, anticipated in print April, 2013!  This review is outstanding as it guides us through the literature, both past and present, surrounding TACO, its definition, estimated incidence, identifiable risks factors, diagnosis, treatment options, and most importantly preventive strategies. Continue reading

The Importance of Physician Opinion Leaders in Blood Management Programs

March is a great time to talk about physician opinion leaders because March 30th is National Doctors Day. Physicians are clearly a key stakeholder group for appropriate blood use, so their engagement and ownership is essential for the success of comprehensive blood management programs. One of the common concerns I hear from hospital administrators and lab staff seeking to start blood management programs is the lack of active physician participation on their transfusion committees and on their blood management team. While the eventual goal is to have all physicians who order blood products fully bought in, an efficient and effective way to begin the change effort is to target key physician opinion leaders. Continue reading

Is it Time for Goal Directed Management of Gastrointestinal Bleeding?

Gastrointestinal bleeding accounts for more than 450,000 hospitalizations annually in the United States and is a major consumer of blood products.1 Blood transfusions are given to 21- 43% of these patients, and acute upper gastrointestinal bleeding has a mortality rate of 10- 14%.2,3 In our large database, GI bleeding consistently ranks in the top 5 list of patient groups receiving blood products, along with cardiac surgery, orthopedics, oncology, and critical care/ trauma.  In a number of hospitals, GI bleeding is actually the #1 consumer of blood products, which often comes as a surprise to hospital leadership.  For reasons discussed below, this is a high risk/ high volume patient population that needs to have a more proactive and evidence-based approach. Continue reading

The Storage Lesion: The saga continues!

Early this year I discussed the potential implications of the “storage lesion” for RBC transfusions in a previous blog post, The Storage Lesion, Soldier On and Stay Tuned. Several studies were cited and questions put forth that remained with the conclusion to soldier on and stay tuned. Recently there have been publications that provide additional information, which continue to fuel the fire surrounding the controversy of “fresh” vs. “old” blood.  Let’s revisit these original questions and see where the literature is today.

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The Heartbreak of Blood Transfusions – Part II

I have always emphasized the need for multidisciplinary, representative blood utilization committees as part of a comprehensive blood management program.  To that end, it is important to have representation from the “bloody specialties”, including cardiac surgery, orthopedic surgery, anesthesiology, critical care, hospitalists, and hematology-oncology.  Based upon recent trends in the transfusion literature, it has become evident that also involving cardiologists in blood utilization committees as well as blood management teams is essential. Continue reading

The 8 Rights of Transfusion Administration

Nurses have known and upheld the five rights of medication administration for decades. The Transfusion Medicine community quickly and readily adapted these rights to another high volume, high risk hospital procedure: transfusion administration. Recently, the five medication administration rights have been expanded to eight, all of which apply to blood product transfusion: right product; right patient; right dose; right time; right reason; right site; right documentation and right response.1  Continue reading

Some principles of pediatric blood management

We have all heard the phrase “it’s the principle of the thing.” This phrase reminds us that in everything we do, including the clinical management of patients, there are both precedents and principles to guide our decision making processes. The principle of “doing the right thing” should be utilized in pediatric blood management and in making evidence based transfusion decisions. Most of us are familiar with, and may well already be using, a Computerized Provider Order Entry (CPOE) system; which incorporates evidenced based practice (EBP) guidelines in an electronic order entry format. This EBP function is crucial in supporting the clinician’s decision to transfuse, and how much, if any, blood product is appropriate. Decision support systems can also help in areas such as pediatric blood volume management and anemia management. Some pediatric blood conservation centers utilize Electronic Medical Record (EMR) systems to monitor other blood management considerations such as intake and output, utilizing the output feature to monitor lab waste and sampling volumes. The EMR alerts the clinician when, based on the child’s body weight, and a 24-hour time period, the patient has reached maximum blood volume depletion due to sampling. Other centers have created a unique set of guidelines for pediatric lab sampling by which only the amount absolutely indicated is taken, lab tests are batched, and add-ons are encouraged. These strategies work together to promote blood conservation, maintain limited blood volume reserves, and conserve a very precious resource. Continue reading

Risky Business? The Relative Infectious Risks of Blood Transfusion

Every medical intervention has an inherent risk.  Blood transfusion is no exception. Physicians must know the risks versus benefits of therapeutic modalities for each specific patient treated.  Unfortunately, disproportionate emphasis is sometimes placed on the risks and potential infectious complications of transfusion, in part due to transfusion transmitted HIV in the 1980′s.  Continue reading

A Precarious Position

In July, Strategic Healthcare Group will be highlighting information on antiplatelet and anticoagulant medications, both old and new.  The webinar and the Ask-the-Expert segment, will focus not only on the pharmacological mechanisms of these drugs, but the controversies surrounding their benefits, risks and reversal strategies, if available or adequate. Continue reading