PRBC Transfusions Medicine Floors Internal Medicine, PGY-3 Michael Cho, MD Internal Medicine, PGY-3 July 19, 2013

“If the hemoglobin is less than 8, transfuse 2 units PRBC.”

Transfusion Thresholds CAP (1998) ASA (2006) STS (2007) SCCM (2009) SIMTI (2011) AABB (2012) Target Population General Perioperative (general) Cardiac Surgery Critically Ill Stable Hospitalized RBC usually indicated Hgb < 6 Hgb < 7 post-op Higher if risk of end organ ischemia Hgb < 7 for ventilated, trauma or stable cardiac Hgb < 8 acute coronary syndrome Hgb 6 - 8 if risk factors Hgb 6-10 if hypoxia Hgb ≤ 7 critically ill Hgb ≤ 8 surgical patients, or patients with pre-existing cardiovascular disease when symptoms are present Blood Transfus. 2012.0195-12: 1-11. CAP: College of American Pathologists. ASA: American Society of Anesthesiologists. STS: Society of Thoracic Surgeons. SCCM: Society of Critical Care Medicine. SIMTI: Italian Society of Transfusion Medicine and Immunohaematology. AABB: American Association of Blood Banks.

American Red Cross Guidelines TRANSFUSE FOR: SYMPTOMATIC anemia CLINICAL ASSESSMENT, not just a lab value SINGLE UNIT, except acute hemorrhage

PRBC Transfusions Internal Medicine Study Period: 12/2012 Where: Tower Hospital Patients: 37 patients with 52 transfusion orders PRBC transfused: 101 units Time to 1st Transfusion: 4.1 days Transfusion Orders by Diagnosis

1 unit of PRBC increases Hemoglobin by 1 Conversion 1 unit of PRBC increases Hemoglobin by 1

Internal Medicine PRBC Transfusions +2+2

Inpatient PRBC Transfusions – All Services ONE YEAR - May 2012 to April 2013 Total patients: 2,288 Total cases: 2,748 Total pRBC units transfused: 10,770 Units transfused per order: 2.1 Units transfused per case: 3.9 Cost for each unit pRBC with labs: $356 Total direct cost (labs & blood): $3,800,000

Patient Blood Management PBM is a patient-centered, evidence-based approach to preventing avoidable transfusions and ensuring the safe and efficient use of blood components when necessary. Early diagnosis and treatment of anemia using pharmaceutical interventions rather than transfusion Strict transfusion triggers Minimizing blood loss during hospitalization Healthcare worker education In 2007, Eastern Maine Medical Center, a 411 bed facility, began a Patient Blood Management program.

Patient Blood Management Results

Potential Savings from Patient Blood Management PRBC transfused annually: 10,770 units Total annual direct cost: $3,830,000 PRBC transfused after PBM with potential 60% reduction: 4,300 units Revised total annual direct cost: $1,530,000 Potential annual savings: $2,300,000

INDIRECT COSTS Allergic reaction and hives Fever Transfusion-associated circulatory overload (TACO) Transfusion-related acute lung injury (TRALI) Bloodborne infections Acute immune hemolytic reaction Delayed hemolytic reaction Iron overload Graft-versus-host disease

Patient Outcomes Restrictive transfusions lead to either no change or improved patient outcomes when compared to liberal transfusion strategies. STUDIES ICU patients. TRICC. NEJM 340 (6): 409-417. Anemic post-operative hip surgery patients. FOCUS. NEJM 365 (26): 2453-2462. Acute Upper GI Bleed. NEJM 368 (1): 11-21.

Maggie Macari-Hinson, RN, MSN, CCM Special Thanks: Lloyd Rucker, MD Minh-Ha Tran, MD Bindu Swaroop, MD Maggie Macari-Hinson, RN, MSN, CCM Eric Belen, MBA