Minimizing Transfusions to Reduce Cost, Improve Outcomes

Lara C. Pullen, PhD

May 28, 2013

Institutions can manage medical and surgical anemias without blood transfusion. Transfusion alternatives include preoperative strategies and perioperative autologous blood procurement. The ongoing development of transfusion-free options may also soon make it easier to manage the blood supply.

Donat R. Spahn, MD, from University Hospital Zurich in Switzerland, and Lawrence T. Goodnough, MD, from Stanford University in California, published a summary of strategies that can be used to minimize blood transfusion in the May 25 issue of the Lancet. The authors also describe how the cost and risks related to blood transfusions have driven the search for alternatives to blood.

A single blood unit costs approximately US$700 to US$1200. US patients receive transfusions of 24 million blood products (red blood cells, fresh-frozen plasma, and platelets) each year. However, patients who receive blood are at increased risk for infection, kidney failure, lung dysfunction, transfusion reactions, and many other health complications.

The authors suggest that a strategy as simple as the detection and treatment of anemia before surgery may help reduce the use of blood products and the concomitant risk. "Quality indicators measuring patient outcomes (ie, hospital stay, postoperative complications, mortality, and costs) need to be used so that the alternatives to blood transfusion can be more effectively assessed and incorporated into clinical practice," says Dr. Spahn in an accompanying press release.

The article was grouped in a series with 2 other review articles and an editorial. In the first of the accompanying articles, Dr. Goodnough and colleagues describe how a restrictive blood transfusion approach is increasingly recognized as best practice. In the other accompanying article, Lorna M. Williamson, MD, from the National Health Service Blood and Transport in Watford, United Kingdom, and Dana V. Devine, PhD, from the Canadian Blood Services in Vancouver, British Columbia, Canada, describe the logistics and therapeutic potential of using stem cells to grow red cells or platelets.

The articles share the premise that many surgeries, and particularly heart surgeries, are overly reliant on blood transfusion. Although the reliance on transfusion varies widely throughout the United Kingdom, United States, and Canada, in many cases patients are unnecessarily exposed to the danger of blood transfusions. Intrinsic to this exposure is the lack of consistent transfusion recommendations from medical societies.

Benefits of Transfusions Challenged

"The presumed benefits of blood transfusion are being challenged by the findings of recent trials which show that restrictive transfusion practices are equivalent or better than liberal practices, even for patients with heart disease and the elderly," Dr. Goodnough explains in the press release. Although the default use of blood transfusion is now being questioned, however, there are only a limited number of large, high-quality randomized trials on the subject."

In the accompanying comment, he explains the importance of blood management: "Patient blood management encompasses an evidence-based medical and surgical approach that is multidisciplinary (ie, including transfusion medicine specialists, surgeons, anaesthesiologists, and critical care specialists) and multiprofessional (ie, including physicians, nurses, pump technologists, and pharmacists). In this approach, preventive strategies are emphasised to identify, assess, and manage anaemia in medical and surgical patients, including use of pharmacological interventions and the avoidance of unnecessary diagnostic testing to minimise iatrogenic blood loss; to optimise homoeostasis and use of point-of-care testing; and to establish clinical practice guidelines for blood transfusions. With recent development of quality–performance indicators for patient blood management by health-care institutions and accreditation organisations, the accompanying Clinical Series in The Lancet is appropriate and timely, and looks at the effect of patient blood management on three areas of transfusion medicine: blood utilisation, alternatives to blood, and inventory management of the blood supply." .

In the past 5 years, Dr. Spahn has received honoraria or travel support for consulting or lecturing from various companies, including AMGEN GmbH, Baxter AG, Baxter S.p.A., CSL Behring GmbH, Ethicon Biosurgery, Janssen-Cilag AG, Janssen-Cilag EMEA, Novo Nordisk A/S, Octapharma AG, Organon AG, Oxygen Biotherapeutics, Pentapharm GmbH (now tem Innovations GmbH), ratiopharm Arzneimittel Vertriebs-GmbH, Roche Pharma, Vifor Pharma Deutschland GmbH, Vifor Pharma Österreich GmbH, and Vifor. Dr. Goodnough is a consultant for Amgen, Luitpold, Vifor, CSL Behring, Hemocue, and Octapharma. Dr. Williamson has disclosed no relevant financial relationships. Dr. Devine receives research funding from TerumoBCT and Macopharma and is a member of the scientific advisory committee of Fresenius-Kabi Transfusion Technologies and has received speaker fees or travel reimbursement for speaking at various conferences including the International Society for Blood Transfusion, the International Association for Biological Standards, the US FDA Blood Products Advisory Committee, Cellular Therapeutics in Trauma and Clinical Care, and the Fresenius-Kabi Advanced Course on Transfusion Technology, as well as a number of visiting professorships.

Lancet. 2013;381:1791-1792, 1845-1875. Spahn and Goodnough abstract, Goodnough et al abstract, Williamson and Devine abstract, Comment extract

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