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

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

3. 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 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 : 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.

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

5. 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

8. 1 unit of PRBC increases Hemoglobin by 1
Conversion
1 unit of PRBC increases Hemoglobin by 1

9. Internal Medicine PRBC Transfusions
+2+2

10. 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

11. 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.

13. Patient Blood Management Results

14. 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

15. 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

16. 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):
Anemic post-operative hip surgery patients. FOCUS. NEJM 365 (26):
Acute Upper GI Bleed. NEJM 368 (1):

17. 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