AUDIT OF RED BLOOD CELL TRANSFUSION PRACTICE IN THE ITU SETTING Dr J.P.R. Brown, Dr P. Ford Royal Devon and Exeter NHS Foundation Hospital Trust, Exeter, UK Introduction Anaemia & red cell transfusion are common in the ITU. 40% of ITU patients require transfusion. Evidence suggests that a restrictive transfusion strategy is as safe as liberal1. There are clinical risks and financial costs associated with transfusion and an ongoing national shortage of blood bank stores. Closed Arterial Line Sampling Systems At least 4mls of blood per sample from arterial line sampling deadspace is commonly discarded. If reinjected it carries the risk of increased infection or microthromboembolic events. If the conservative assumption of 5 arterial blood gas samples a day are taken from the average ITU patient then 20mls a day can be saved. (Introduction of these devices was found to be cost effective when compared to existing arterial transducer sets) Aim To compare transfusion practice to Royal College of Anaesthetists agreed standards2 and current best evidence. To identify methods of reducing requirements and improving practice. To raise the profile of associated issues. Venous Arterial blood Management Protection Methods Audit standard2 100%: Transfusion trigger 7-8g/dl Post transfusion target 7-9g/dl Prescription of 1 unit at a time to patients with haemoglobin>7g/dl Transfusion trigger 8-9g/dl in patients with history of ACS. Retrospective review of 250 consecutive ITU admissions. History of acute coronary syndrome (ACS), number of units red blood cells transfused, triggering haemoglobin, post transfusion haemoglobin & number of units transfused per episode were recorded. Patients with history of active haemorrhage were excluded. Courtesy of Edwards Lifesciences LLC Potential 50% Reduction in Phlebotomy Reduced Transfusion - Protocol The findings of this audit have been used to formulate a proposed protocol for red blood cell transfusion. Including: Documentation of clinical reasoning as to why transfusion is required. Documentation of triggering & post transfusion haemoglobin. Prescription of single unit and checking of haemoglobin before prescription of additional units, if required. Involvement of senior clinicians in prescription of blood in critically ill patients Results Mean age 63 Mean APACHE II Score 16.2 Mean ITU admission length 3.7days 20% patients admitted received red cell transfusion. 210 units in total were transfused (40% for haemorrhage) 126 units were given in 93 transfusion episodes. Haemoglobin transfusion trigger 7-8g/dl achieved 48% Post transfusion target 7-9g/dl achieved 32% Prescription of 1 unit at a time for patients with Haemoglobin >7 66% Triggering Haemoglobin 8-9g/dl in patients with history of ACS 60% Conclusions Potentially significant reductions are possible if transfusion triggers are adopted. If transfusion triggers had been adhered to there would potentially have been a reduction of 52% on our unit. Transfusion trigger used as the audit standard was conservative compared with available evidence suggesting a lower trigger of <7g/dl could be safely employed. If this target was adhered to transfusion would have been reduced by up to 85%. Prescription of 1 unit at a time would potentially reduce transfusion by up to 26%. There are cost effective methods of reducing the need for blood transfusion that can be simply implemented, especially to reduce phlebotomy. Recommendations Develop and implement transfusion protocol Routine use of slim line blood bottles Closed arterial line sampling systems It highlighted a need for education of current evidence & issues related to transfusion practice. (Education needs to reach outside the ITU environment to prevent unnecessary transfusion prior and after discharge from the unit.) Reduction in Phlebotomy Average phlebotomy loss in an ITU patient is 41mls/day or 762 mls per admission3. The following proposals were made to help reduce this and therefore reduce anaemia and transfusion requirement. Routine use of Slim Line Blood Bottles Assuming that one full blood count, biochemistry and clotting sample are taken a day then a reduction of 9.5mls a day can be made (often more are taken). Potential 50% Reduction in Transfusion References 1. Herbert PC. A multicentre, randomised, controlled clinical trail of transfusion requirements in critical care. New England Journal of Medicine 1999; 6: 409-418 2. http://www.rcoa.ac.uk/docs/ARB-section10.pdf 3. Vincent JL et al. Anemia and blood transfusion in critically ill patients. JAMA 2002; 288: 1499-507 Potential 25% Reduction in Phlebotomy