1. What Is the Difference Between Blood and Chicken Soup?
Maureane Hoffman, MD, PhD
Professor of Pathology and Immunology
Duke University
Director, Blood Bank and Hematology Laboratories
Durham VA Medical Center
Durham, North Carolina

2. 80 million units donated worldwide yearly1
Transfusion Facts
80 million units donated worldwide yearly1
12.5 million units transfused each year in the United States2
A blood transfusion is the most intimate possible contact with a stranger
1. World Health Organization. Available at
2. Goodnough LT, et al. N Engl J Med. 1999;340:

3. Blood CAN Cause Harm Infectious diseases
Complications resulting from misidentification or clerical error
Transfusion-related acute lung injury
Bacterial contamination
Immunomodulation
Unknown mechanism

4. Infectious Diseases Human immunodeficiency virus risk: 1:2.3 million1
Hepatitis C risk: 1:1.8 million1
Hepatitis B: 78,000 new infections annually, United States2
 Risk of transmission through transfusion of 1 unit of blood, 1:58,000-1:149,0003
Other viral diseases4,5
 West Nile: cases in United States between 2002 and 20064
 Cytomegalovirus: 40%-100% of US population shows prior exposure
by serology5
Malaria: million cases worldwide6
Chagas disease: 1 million new cases annually*6
Prions6
*In humans, confined to South and Central America and Mexico.
1. Busch MP, et al. Transfusion. 2005;45: ; 2. Centers for Disease Control and Prevention. Available at: Accessed March 3, 2008; 3. Goodnough LT, et al. Lancet. 2003;361: ; 4. Centers for Disease Control and Prevention. Available at: Accessed March 3, 2008; 5. Taylor GH. Am Fam Physician. 2003;67: , 526; 6. Snyder EL, et al. Hematology. 2001;

5. Blood CAN Cause Harm Infectious diseases
Complications resulting from misidentification or clerical error
Transfusion-related acute lung injury
Bacterial contamination
Immunomodulation
Unknown mechanism

6. Summary of Transfusion Errors 2000-2003
No. of Cases
FFP = fresh frozen plasma.
Data on file, US Department of Veterans Affairs.

7. Patient Identification Is Critical
Identify at time of phlebotomy
 Ask patient his/her name
 Verify identity with wrist band
 Label tube at bedside
Identify at time of transfusion
 Two people must identify patient and verify match to label on
blood product
If there are ANY discrepancies when blood sample and paperwork arrive at blood bank
 It is 40 times more likely that the wrong patient’s blood is in the tube
than if all identifying information is complete and matches

8. Blood CAN Cause Harm Infectious diseases
Complications resulting from misidentification or clerical error
Transfusion-related acute lung injury
Bacterial contamination
Immunomodulation
Unknown mechanism

9. Transfusion-Related Acute Lung Injury (TRALI)
New acute pulmonary insufficiency occurring during or within 6 hours after transfusion1
Incidence estimated at 1:5000 to :100,000 transfusions1
Most common with FFP and RBC1
Usually resolves within 96 hours with supportive care2
RBC = red blood cells.
1. Toy P, et al. Best Pract Res Clin Anaesthesiol. 2007;21: ;
2. Mariani SM. Medscape Gen Med. 2003;5.

10. Three Hypotheses for TRALI
Antigranulocyte antibodies in donor's plasma (or, less commonly, recipient's plasma)
Biologically active substances in transfused blood
“2-hit" hypothesis
 Recipient granulocytes are primed in vivo, then
transfused antibodies "activate" granulocytes
Toy P, et al. Best Pract Res Clin Anaesthesiol. 2007;21:

11. Blood CAN Cause Harm Infectious diseases
Complications resulting from misidentification or clerical error
Transfusion-related acute lung injury
Bacterial contamination
Immunomodulation
Unknown mechanism

12. Blood CAN Cause Harm Infectious diseases
Complications resulting from misidentification or clerical error
Transfusion-related acute lung injury
Bacterial contamination
Immunomodulation
Unknown mechanism

13. Blood CAN Cause Harm Infectious diseases
Complications resulting from misidentification or clerical error
Transfusion-related acute lung injury
Bacterial contamination
Immunomodulation
Unknown mechanism

14. Transfusion Has Deleterious Effects via Mechanisms We Do Not Understand
A number of studies have found that patients who are on liberal transfusion strategies do WORSE (more morbidity and mortality) than do patients on restrictive transfusion strategies
Corwin HL, et al. N Engl J Med. 2007;356: Hébert PC, et al. Crit Care Med. 2001;29: Raghavan M, et al. Chest. 2005;127:

15. Transfusion Requirements in Critical Care (TRICC)
Prospective, randomized trial that supports causal link between blood transfusion and adverse outcomes among critically ill patients
Hébert PC, et al. N Engl J Med. 1999;340:

16. TRICC, cont’d
838 patients randomized to liberal (threshold Hb = 10 g/dL) or restrictive (Hb = 7 g/dL) transfusion strategy
Cardiac and pulmonary complications increased significantly, and trend existed toward increased mortality in liberal-strategy group (23.3% vs 18.7% in restrictive- strategy group)
Mortality was also significantly increased in younger (<55 years), less-sick patients in liberal-strategy group
Hb = hemoglobin.
Hébert PC, et al. N Engl J Med. 1999;340:

17. Nonetheless.…
Subgroup analysis of patients (N=257) with cardiac disease showed trend (P=0.3) toward increased survival in liberal-strategy group, in spite of increased incidence of pulmonary complications and multiorgan failure
Hébert PC, et al. Crit Care Med. 2001;29:

18. Subsequent Studies: Transfusion Also a Risk Factor for Patients With Cardiovascular Disease
Rao SV, et al. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA. 2004;292:
Yang X, et al. The implications of blood transfusions for patients with non–ST-segment elevation acute coronary syndromes. Results from the CRUSADE National Quality Improvement Initiative. J Am Coll Cardiol. 2005;46:
Published in 2008
Koch CG, et al. Duration of red-cell storage and
complications after cardiac surgery. N Engl J Med.
2008;358:

19. Cardiac Surgery Patients Also Did Worse With Transfusion
Retrospective cohort study utilizing database of adult cardiac surgery patients (N=8598)
No benefit from transfusion for HCT as low as 21% for patients undergoing cardiac surgery
Risk of death within 30 days of surgery almost 6 times greater for patients who received blood
Patients receiving transfusions more likely to experience infections and ischemic complications
HCT = hematocrit.
Murphy GJ. et al. Circulation. 2007;116:

20. Effects Are Long-Lasting….
Cohort study of 10,289 patients who underwent coronary
artery bypass grafting (CABG) between 1995 and 2002
Transfusion of as little as 1 U RBC associated
with decreased 10-year survival after CABG procedure
Koch CG, et al. Ann Thorac Surg. 2006;81:

21. … and There Is Little Evidence of Benefit for Cardiac Surgery Patients
Ischemic complications (myocardial infarction, neurologic and renal injury) were not decreased with blood transfusion regardless of patient’s nadir HCT or comorbidities
Thus, we want to be sure patient really needs transfusion before we give blood products
Murphy GJ, et al. Circulation. 2007;116:

22. Indications for Transfusion
RBC for inadequate oxygen-carrying capacity
Plasma for inadequate clotting factor activity
Cryoprecipitate for fibrinogen and factor VIII/ von Willebrand factor
Platelets for inadequate platelet function

23. Recommendations
Transfusion is rarely indicated when Hb is >10 g/dL and is almost always indicated when Hb is <6 g/dL, especially when anemia is acute
6-10 g/dL: decision to transfuse should be based on patient’s risk for complications of inadequate oxygenation
Ferraris VA, et al. Ann Thorac Surg. 2007;83(suppl 1):S27-S86.

24. Recommendations
Threshold Hb of 7 g/dL has been suggested for postoperative cardiac surgery patients
Ferraris VA, et al. Ann Thorac Surg. 2007;83(suppl 1):S27-S86.

25. The Decision to Transfuse Is a Clinical Judgment That Considers
Patient’s cardiopulmonary reserve (cardiopulmonary disease, hemodynamic indexes, affected by drugs and anesthetics)
Rate and magnitude of blood loss (actual and anticipated)
Oxygen consumption (affected by body temperature, drugs, sepsis, muscular activity)
Atherosclerotic disease (cerebrovascular, cardiovascular, peripheral, renal)

26. Thus….
RBC transfusion trigger should be Hb/HCT at which risks of reduced oxygen-carrying capacity exceed risks of transfusion

27. Platelet Concentrates
Prophylactic platelet transfusion not indicated unless platelet count is <10,000/µL
Platelet count of 50,000/µL is generally adequate for hemostasis during/following minor procedures
Platelet count of 100,000/µL is generally adequate for hemostasis during/following major procedures
Mintz PD, ed. Transfusion Therapy: Clinical Principles and Practice. 2nd ed.
Bethesda, MD: American Association of Blood Banks; 2004.

28. Give FFP if clotting tests are prolonged AND patient is bleeding
Fresh Frozen Plasma
Give FFP if clotting tests are prolonged AND patient is bleeding
We don’t really know what PT and PTT are sufficient for adequate hemostasis, and normal PT and PTT do not guarantee against bleeding
PT = prothrombin time; PTT = partial prothrombin time.

29. Alternatives to Transfusion
Increase RBC production
 Iron supplementation
 Erythropoietin
Local measures
Save patient’s own blood
Prohemostatic agents
Network for Advancement for Transfusion Alternatives is useful:
Goodnough LT, et al. Transfusion. 2003;43:

30. Alternatives to Transfusion
Increase RBC production
Local measures
 Tourniquet
 Embolization
 Fibrin glue/topical thrombin
Save patient’s own blood
Prohemostatic agents
Goodnough LT, et al. Transfusion. 2003;43:

31. Alternatives to Transfusion
Increase RBC production
Local measures
Save patient’s own blood
 Autologous transfusions
 Hemodilution
 Cell saver
Prohemostatic agents
Society for the Advancement of Blood Management is useful:
Goodnough LT, et al. Transfusion. 2003;43:

32. Alternatives to Transfusion
Increase RBC production
Local measures
Save patient’s own blood
Prohemostatic agents
Goodnough LT, et al. Transfusion. 2003;43:

33. Take-Home Messages
Blood transfusion can be bad for your patients
Don’t transfuse unless you are sure that the patient really needs it
There are alternatives to transfusion that should be considered seriously for all types of medical and surgical patients