Blood Transfusion Evidence-Based Blood Therapeutics “7 is the NEW 10” ***INSTRUCTIONS ON HOW TO APPLY IMAGE MASKING***: STEP 1: Insert picture of choice. STEP 2: Make sure inserted picture covers the entire width of the slide by dragging it from the lower right-hand corner handle. STEP 3: Right-click the picture and choose Order > Send to Back. 1

Objectives To implement new parameters for blood transfusion based on evidence-based blood transfusion therapeutics To decrease blood transfusions given to clinically stable patients with Hgb levels > 7g/dl

The “Big” Clinical Question… In critically ill patients, how does a restrictive transfusion strategy (Hgb goal of 7-9 g/dL) compare with a liberal transfusion strategy (Hgb goal of 10-12 g/dL) in decreasing mortality?

The Answer… In critically ill patients, restrictive transfusion (Hgb >7 g/dL) is associated with better survival compared to liberal transfusion strategy with (Hgb >10 g/dL).

Evidence Based Reality PRBC Therapy – “The First Organ Transplant” – is associated with significant risk of harm to patients. Patient harm due to immunomodulation or direct toxicity from blood and blood breakdown products. Transfusion Related Acute Lung Injury (TRALI)/acute pulmonary edema Increased hospital associated bacterial infection rates Increased incidence of acute myocardial infarction/stroke Increased incidence of re-bleeding Higher cancer recurrence rates

Evidence - Based Reality Contamination of products with infectious agent. Viral infection no longer most significant risk Bacterial contamination in platelets 1:2000-1:3000 Mismatch blood

The TRICC Trial ***INSTRUCTIONS ON HOW TO APPLY IMAGE MASKING***: STEP 1: Insert picture of choice. STEP 2: Make sure inserted picture covers the entire width of the slide by dragging it from the lower right-hand corner handle. STEP 3: Right-click the picture and choose Order > Send to Back. 7

The Modern Era of Transfusion Medicine Begins: The TRICC Trial The Transfusion Requirements in Critical Care (TRICC) trial, conducted in Canada from 1994-1997, randomized 838 patients admitted to the ICU without evidence of active bleeding to a restrictive transfusion strategy (transfusion to maintain Hgb >7 g/dL) versus a liberal strategy (transfusion to maintain Hgb ≥10 g/dL). Liberal transfusion group received more transfusions and maintained higher Hgb levels.

The Modern Era of Transfusion Medicine Begins: In-hospital mortality significantly lower for all patients in restrictive group. 30 day mortality significantly lower for all patients in restrictive group. Cardiac complications markedly higher in liberal transfusion group.

The Outcome of TRICC Trial The restrictive transfusion strategy was associated with decreased rate of in-hospital mortality compared to those seen with the liberal transfusion strategy.

TRICC Recommendation: Transfusion goal of 7 g/dL if NO evidence of MI, severe hypoxemia, acute hemorrhage, or ischemic coronary artery disease

The AABB Clinical Recommendations ***INSTRUCTIONS ON HOW TO APPLY IMAGE MASKING***: STEP 1: Insert picture of choice. STEP 2: Make sure inserted picture covers the entire width of the slide by dragging it from the lower right-hand corner handle. STEP 3: Right-click the picture and choose Order > Send to Back. 12

The American Association of Blood Banks (AABB) WHO is AABB (American Association of Blood Banks) A professional, non-profit organization established in 1947 dedicated to the education, formulation of standards, policy and other facets of transfusion medicine. The AABB is responsible for collecting half of the US blood supply and transfusing 80%, and is involved in accrediting transfusion facilities, maintaining a rare donor database, and providing reference labs.

The American Association of Blood Banks (AABB) The AABB developed guidelines to provide clinical recommendations about Hgb concentration thresholds and other clinical variables that trigger RBC transfusions in hemodynamically stable adults and children.

The AABB Clinical Recommendations: The AABB recommends adhering to a restrictive transfusion strategy. In adult and pediatric intensive care unit patients, transfusion should be considered at Hgb concentrations of 7 g/dL or less. In postoperative surgical patients, transfusion should be considered at a Hgb concentration of 8 g/dL or less or for symptoms (chest pain, orthostatic hypotension or tachycardia unresponsive to fluid resuscitation, or congestive heart failure).

The AABB Clinical Recommendations: The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with acute coronary syndrome. The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration.

The New Road ***INSTRUCTIONS ON HOW TO APPLY IMAGE MASKING***: STEP 1: Insert picture of choice. STEP 2: Make sure inserted picture covers the entire width of the slide by dragging it from the lower right-hand corner handle. STEP 3: Right-click the picture and choose Order > Send to Back. 17

Road to the NEW ERA of Blood Transfusion: Development of written evidence – based guidelines for blood product therapy, approved by medical staff Formation of “Blood Therapeutics Committee” Provider education – nursing engagement Clinical decision support tools. Example: critical value calls, order sets reminders

Road to the NEW ERA of Blood Transfusion: Ongoing review of all transfusions to patients with Hgb greater than 7g/dl Educational letters to providers ordering blood product therapy consistent with new guidelines Ongoing feedback based on results Improve measures to avoid anemia Revision of informed consent process and patient education

Appropriate Blood Therapeutics: Lower mortality Lower incidence of Healthcare Associate Harm Decreased length of stay Lower cost per admission Improved blood stewardship

CHSB’s Steps to the NEW Road ***INSTRUCTIONS ON HOW TO APPLY IMAGE MASKING***: STEP 1: Insert picture of choice. STEP 2: Make sure inserted picture covers the entire width of the slide by dragging it from the lower right-hand corner handle. STEP 3: Right-click the picture and choose Order > Send to Back. 21

Hgb: 7 is the new 10 CHSB’s Part: Blood product transfusion is a tissue transplant and is associated with profound physiologic, inflammatory and immunologic effects. PRBC transfusion is inherently risky and significantly increases the risk of death and hospital acquired harm in medically ill and surgical patients.

CHSB’s Part: PRBC transfusion should only be performed in patients with life- threatening hemorrhage or clinically significant or symptomatic anemia where the risk of death or harm to the patient outweighs the known risks. When PRBC transfusion is necessary, the minimum quantity of blood should be transfused – e.g. “Why give two when one will do?”

CHSB’s Part: Evaluation of platelet and plasma component products should be the next phase in improving patient care through appropriate use of blood products as administration of these products also pose significant risk to patients. Avoidance of iatrogenic anemia should become an important component of contemporary blood management programs.

Blood Transfusion Criteria: Exclusion Criteria: Inpatients Patients less than 18 years old Packed Red Blood Cells NICU, Nursery, Pediatrics, Pregnant (based on Medical Service) Postpartum hemorrhage patients (based on Medical Service) Cases with massive transfusion protocol used and/or cases with 4 or more units transfused with 4 hours or less between each unit

Signs and Symptoms of Transfusion Reaction: Complication Signs/Symptoms Treatment Extraneous Febrile transfusion reaction 1 degree rise in temp. May have chills, malaise Supportive – acetaminophen Most common Hemolytic transfusion reaction Fever, chills, pain at the site of reaction, N/V, shock, dark urine STOP the transfusion. Lots of IV fluids +/- diuretics Worst reaction. Often a clerical issue. ABO incompatibility Allergic reaction Urticaria, pruritus, hives, anaphylaxis is rare Symptomatic – antihistamines. DO NOT need to stop transfusion NOTE: they are not actually allergic to blood but secondary to antibodies in blood TRALI (Transfusion Related Acute Lung Injury) Dyspnea, hypoxemia, bilateral chest infiltrates (think ARDS) STOP the transfusion . Airway control, supportive care Most common cause of death associated with transfusion but better prognosis than most ARDS TACO (Transfusion Associated Circulatory Overload) Dyspnea, edema Give blood slowly (over 3-4 hours). Diuretics with transfusion Often occurs in the elderly and chronically anemia

Symptoms of Anemia:

CHSB’s FY 2016 Goal: FY16 Goal: Percent of blood units transfused to patients with a pre-transfusion hemoglobin level of >/= 7 g/dL. (Top decile is <55% transfusions to patients with Hgb >7)

Reference TRICC Hebert PC, et al. "A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care". The New England Journal of Medicine. 1999. 340(6):409-417.

Thank You