Why transfuse two … when one will do?

Author: Douglas Blackall, M.D., MPH, medical director, Oregon Core Laboratory and Oregon Regional Blood Bank

In a September 2021 Pulse article, I wrote about best practices in red cell transfusion, especially in the face of national blood supply shortages. Ideally, transfusion orders should be both restrictive (Hgb<7 g/dL for non-bleeding, symptomatic patients), and single unit (with clinical evaluation and retesting after each transfused unit before ordering additional units). These best practices promote good blood product stewardship and advance patient safety.

In this issue of Pulse, I’d like to introduce a regional performance indicator for red cell transfusion, which will be reported regularly in 2022: the percentage of RBC transfusion orders that are one-unit orders. This data will be filtered by hospital, specialty area and individual provider.

The most effective way to improve single-unit red cell transfusion orders is for providers to consider each unit of red cells as a single transfusion event. The patient’s clinical condition should be carefully assessed in coordination with appropriate laboratory values (hemoglobin and hematocrit). In most circumstances, non-bleeding patients with hemoglobin levels less than 7 will benefit from a single-unit red cell transfusion without incurring the risk that comes with additional units (e.g., volume overload).

Here is an example of a recent case I encountered. A 60-year-old woman was admitted to a Providence hospital with a hemoglobin of 7.2 g/dL. She had experienced lower GI bleeding, but it had resolved. She was mildly symptomatic from her anemia (dizzy on standing and tachycardic). The patient’s provider ordered a 2-unit red blood cell transfusion since the patient was symptomatic, and there was a concern of additional GI bleeding. I believe that a better approach would have been to transfuse a single unit, reassess the patient, and then determine the need for additional units of blood. Why transfuse two when a single unit will do?

The goal of Providence’s new performance indicator is to increase awareness of real-time trends against baseline and established guidelines for health care systems that employ patient blood management principles. The Oregon Regional Transfusion Safety Committee will analyze this key performance indicator and will provide information and education about how to improve practice. This could entail general educational opportunities, as well as specific direction to a provider, practice or specialty area.

While the pandemic has challenged what constitutes best practices in non-emergent care settings, we can anticipate their incorporation into contemporary practices moving forward. Best transfusion practice is no exception.

Thank you for the care you are providing to our patients and thank you for being good stewards of blood products.
 

For more information

If you have questions or would like consultation on transfusion therapy issues, please contact douglas.blackall@providence.org.