1. No category

Guidelines for blood transfusion
The early history of blood transfusion
1628: William Harvey - circulation
SCANSECT’s
Post Graduate Course
Saturday the 25th of October 2014
Kjell Titlestad, Klinisk Immunologisk Afdeling, Odense Universitetshospital
KET 2014
Jean Baptiste Denis 1667
James Blundell 1818
• Sheep blood for transfusion
• blood transfusion human – human.
KET 2014
Karl Landsteiner (1868-1943)
1901: Karl Landsteiner AB0-blood group
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Reuben Ottenberg 1911
• Transfusion by AB0
Studies in isoagglutination. I. Transfusion and the question of intravascular agglutination.
Ottenberg R. J Exp Med 1911; 13: 425
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Richard Lewisohn 1915
• Introducing sodium citrate as an anticoagulant
OH Robertson 1918
• Transfusion with preserved red blood cells
Transfusion with preserved red blood cells. BMJ 1918; i: 691
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Blodets bestanddele
Bernard Fantus 1937
• Cook County Hospital Blood Bank
Fantus, B. The therapy of the Cook County Hospital July 10, 1937 Journal of the American Medical Association reprinted 1984;251:647-649
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BLODKOMPONENTER
• Erytrocytsuspension
• Frisk Frosset Plasma
• Trombocytkoncentrat
(SAG-M)
(FFP)
(TC)
Guidelines for
blood transfusion
Why?
KET 2014
2
Transfusionspraksis - international variation
Patterns of blood use
70
RBC (U) per 1000 inhabitants 2008
60
50
40
Ireland
Netherlands
Norway
Finland
USA
Belgium
Sweden
Austria
Germany
10
Denmark
20
Australia
United Kingdom
30
0
The collection, testing and use of blood and blood products in Europe (2008)
The 2009 National Blood Collection and Utilization Survey Report (USA, data for 2008, Department of Health and Human Services etc.)
KET 2014
National Blood Authority, Australia. Annual Report 2007-08
Patterns of blood use
KET 2012
Patterns of blood use
Figure 1
Congenital and perinatal conditions (P)
FIN
DK
Pregnancy and childbirth (O)
Figure 1 illustrates
transfused RBC-units per
thousand “inhabitants”
included in the databases.
Dis. of the muscles and connective
tissue (M)
Diseases of the ureto-genital system
(N)
Infectious diseases A,B)
Diseases of the respiratory system (J)
Non malignant haematological disease
(D5-D8)
Trauma (S,T,V,X,Y)
Diseases of the circulatory system (I)
Haematological malignancies (C81-C9)
Diseases of the GI-system (K)
Other neoplasms (C1-C80, D0-D4)
0,0
Jonas T Madsen, Torben Barington, Kjell Titlestad.
Department of Clinical Immunology, Odense University Hospital, Denmark.
Background
Results
In the years between 1997-2006, an average of 4,455
individual patients received RBC every year. These patients
used an average of 25,400 units per year, thus requiring an
average of 5.7 units RBC.
The authors used
demographic data and
information from the local
blood transfusion register
and diagnosis and
procedure register in the
Danish county of Funen for
the years 1997-2006.
The incidence of receiving a blood transfusion during a
calendar year is 0.94 percent for the total population of
Funen (472,349 citizens in 2006). This is an average for the
ten year period, with individual years ranging from 0.87 –
0.99 percent.
Incidence of transfusion
3,0
4,0
5,0
6,0
7,0
8,0
9,0
The incidences of blood transfusion are low for the age groups
0 – 19. Females aged 20-49 years seem to have higher
incidence of blood use than males of corresponding ages. This
relation is reversed from the 50-59 year group and up, where
males have a higher incidence of blood transfusion.
The total number of RBC units used was also studied. The
following charts display blood product use by the different age
groups for different years. Most blood is used by men aged 7079.
Blood use by female group
Sub grouping according to sex and ten year age groups
yields information about incidence of blood transfusion:
2,0
Epidemiology of Blood Transfusion in a
Danish County (AABB 2008)
Epidemiology of Blood Transfusion in a Danish County
This study describes the incidence of
transfusion of red blood cells (RBC) in the
general population.
1,0
Blood useby malegroup
4500
4500
its 4000
n
u 3500
C 3000
B
R 2500
d
e 2000
s
u 1500
fs
n 1000
ra 500
T 0
1997
1998
1999
2000
2001
2002
s
ti 4000
n
u 3500
C 3000
B
R 2500
d 2000
e
s 1500
fu
s 1000
n
ra 500
T
0
1997
1998
1999
2000
2001
2002
2003
2003
2004
10.0
Years
2005
2004
Years
The incidence of receiving a
blood transfusion during a
calendar year is 0.94 percent for
the total population of Funen
(472,349 citizens in 2006).
2005
All transfusion data in the county of Funen has been stored
electronically since 1997. All sets of transfusion data include the
recipient’s personal identification number (PIN), which is used
for all contacts with public service, including the public health
service.
Percent
8.0
Methods
6.0
Conclusions
4.0
This study shows the incidence of blood transfusion for the
general population in a county. As expected, the incidence of
RBC transfusions increases with age.
2.0
0.0
years
Only blood recipients that were citizens of the county of Funen
were included in the study. For each year since 1997 we have
found the incidence (“risk”) of blood transfusion during the
calendar year for different age groups for both sexes.
We have calculated the incidence of RBC transfusions for ten
year age groups, by finding the number of unique patients
transfused each year, and dividing by the total number of
citizens in the corresponding age- and gender groups.
Male
0.13 0.06 0.08 0.13 0.35 0.82 1.83 3.89 6.77 9.34
Female 0.12
Until the age of 19, incidence is nearly identical for males and
females (few patients actually transfused).
0.06 0.26 0.31 0.44 0.76 1.54 3.25 5.66 8.17
Age group
Incidence of blood transfusion to unique patients in one year. Average
1997-2006.
Incidence of transfusion is below 0.32 % for citizens 0-39 years
old. The incidence increases from 0.35 % in male and 0.44% in
female 40–49 year groups, to 9.34 % and 8.17 % in the 90+
year groups.
In the age groups 20-49 years, the incidence is highest for
females, whereas males have the highest incidence in the age
groups 50-89.
We have shown the average incidence of receiving a RBC unit
during a calendar year in the county of Funen to be 0.94
percent.
Contact: [email protected]
Abstract Title: Epidemiology Of Blood Transfusion In A Danish County; Sequence#: SP113
AABB Annual Meeting & TXPO – October 4-7, 2008
KET 2008
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Transfusion Requirements in
Critical Care (TRICC)
Variation and overconsumption
Does it matter?
N Engl J Med 1999; 340(6):409-417.
Transfusion requirements in critical care
A multicenter, RANDOMIZED,
CONTROLLED clinical trial of
transfusion requirements in critical care
Liberal strategy:
strategy
420 patients: transfusions were given when the
hemoglobin concentration fell below 10.0 g/dl and
hemoglobin conc. were maintained at 10.0 - 12.0 g/dl
Restrictive strategy:
strategy
418 patients: transfusions were given when the
hemoglobin concentration fell below 7.0 g/dl and
hemoglobin conc. were maintained at 7.0 to 9.0 g/dl
Transfusion requirements in critical care
Transfusion requirements in critical care
Results
The restrictive strategy decreased the
average number of red-cell units
transfused by 54 percent
and decreased exposure to any red cells
after randomization by 33 percent.
percent
Transfusion requirements in critical care
Results
Overall, 30-day mortality was similar in the two groups
(18.7 percent vs. 23.3 percent, P= 0.11)
The rates were significantly lower with the restrictive
transfusion strategy among patients who were:
less acutely ill (restrictive 8.7% and liberal 16.1%; P=0.03)
less than 55 years of age (restrictive 5.7% and liberal
13.0%; P=0.02)
but NOT among patients with clinically significant cardiac
disease (20.5% and 22.9%, respectively; P=0.69).
4
Transfusion Trigger Trial for Functional
Outcomes in Cardiovascular Patients
Undergoing Surgical Hip Fracture Repair
(FOCUS)
Transfusion Strategies for Acute Upper
Gastrointestinal Bleeding
A liberal transfusion strategy (N = 1007, a hemoglobin
threshold of 10 g/dl), as compared with a restrictive
strategy, (N = 1009, symptoms of anemia or at physician discretion for a
hemoglobin level of <8 g /dl) did not reduce rates of death or
inability to walk independently on 60-day follow-up
or reduce in-hospital morbidity in elderly patients at
high cardiovascular risk.
KET 2014
Transfusion Strategies for Acute Upper
Gastrointestinal Bleeding
Transfusion Strategies for Acute Upper
Gastrointestinal Bleeding
Liberal strategi:
460 patienter randomiseret til liberal strategi:
RBC-transfusioner når hæmoglobin-koncentrationen (Hgb)
falder under 5,6 mmol/l (9 g/dl)
Hgb holdes mellem 5,6 og 6,8 mmol/l (11.0 - 12.0 g/dl)
Restriktiv strategi:
461 patienter randomiseret til restriktiv strategi:
RBC-transfusioner når hæmoglobin-koncentrationen (Hgb)
falder under 4,3 mmol/l (7.0 g/dl)
Hgb holdes mellem 4,3 og 5,6 mmol/l (7 - 9 g/dl)
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KET 2013
Quality of life (QoL) measurement was measured preoperatively and
twice up to 14 days postoperatively using the Functional Status Index
(FSI), the Visual Analogue Score (VAS)-Fatigue score, and the Functional
Assessment of Cancer Therapy Anemia (FACT-Anemia) subscale
RESULTS: A total of 603 patients were evaluated. All patients scored
worse postoperatively, but none of the scores correlated with Hb values,
neither after correcting for confounding factors. Even more, the changes
between preoperative and postoperative Hb levels were not correlated
with changes in fatigue scores.
CONCLUSION: In hip and knee prosthesis surgery no correlation existed
between postoperative Hb levels or acute postoperative decline in Hb
values and Quality of life scores
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Transfusion med erytrocytter til blødende patienter
≈ 9 g/dl
Transfusion med erytrocytter til blødende patienter
≈ 9 g/dl
≈ 8 g/dl
6
Transfusion med erytrocytter til blødende patienter
Transfusion med erytrocytter til blødende patienter
Less is more
≈ 9 g/dl
≈ 8 g/dl
≈ 7 g/dl
http://discoverattic.com/products/details/one-word-a-day
NATIONAL GUIDELINES FOR BLOOD TRANSFUSION
2007
The purpose of this guidance is to ensure:
VEJLEDNING OM BLODTRANSFUSION
Behandlingsstrategi ved kontrollabel blødning
Hæmoglobinkoncentration < 7 g/dl ≈ 4,5 mmol/l medfører
oftest behov for behandling med erytrocytter.
A consistently high
patient safety by use of
blood transfusions
Hæmoglobinkoncentration < 10 g/dl ≈ 6,0 mmol/l medfører
overvejelse om behandling med erytrocytter til patienter
med:
• svær iskæmisk hjertesygdom,
• den initiale fase af septisk shock (< 6 timer
efter indlæggelse) og
• akut, alvorlig blødning (fx tab af mere end 30 %
af blodvolumenet indenfor 24 timer).
and to
reduce the high
consumption of donor
blood in Denmark
KET 2014
Sundhedsstyrelsen: Vejledning om blodtransfusion – 2007 www.sst.dk
Sundhedsstyrelsen: Vejledning om blodtransfusion - 2007
2007 – 2013:
22% reduction
KET 2014
KET 2012
KET 2014
KET 2013
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Transfusions per hospitalization Denmark 2008
Transfusions per hospitalization Denmark 2008
50%
50%
PLATELETS
45%
RBC
45%
40%
40%
35%
35%
30%
30%
25%
25%
20%
20%
15%
15%
10%
10%
5%
5%
0%
Hospitalizations plt
1
2
3
4
5
6
7
8
9
>9
31%
23%
11%
9%
5%
4%
2%
2%
1%
11%
0%
Hospitalizations RBC
Antal transfusioner (RBC) per indlæggelse
OUH 2008
1
2
3
4
5
6
7
8
9
>9
12%
44%
10%
15%
4%
4%
2%
2%
1%
6%
Antal transfusioner (RBC) per indlæggelse
OUH 2012
29%
27%
Hemoglobin conc. following the last transfusion
Hemoglobin conc. following the last transfusion
University Hospital 2008
For patients receiving RBC transfusions, we
identified the LAST transfusion and the FIRST
hemoglobin concentration thereafter (1 – 7 days)
N=3824
Mean: 10.6 g/dl
National guidelines: “Normal” transfusion trigger is
7.2 g/dl (4.5 mmol/l).
Transfusions should NOT be given if hemoglobin
concentration is above 9.7 g/dl (6.0 mmol/l ).
mmol/l
We concluded that guidelines were certainly not
followed, if patients hemoglobin concentration were
10.5 g/dl (6.5 mmol/l) or higher.
10.5 g/dl
39% OK (?)
61% NOT OK
8
Hemoglobin conc. following the last transfusion
Hemoglobin conc. following the last transfusion
University Hospital 2009
University Hospital 2010
N=3831
Mean: 10.6 g/dl
N=3149
Mean: 10.3 g/dl
mmol/l
mmol/l
10.5 g/dl
46% OK (?)
10.5 g/dl
54% NOT OK
54% OK (?)
46% NOT OK
Hemoglobin conc. following the last transfusion
Hemoglobin conc. following the last transfusion
University Hospital 2011
University Hospital 2012
N=3684
Mean: 10.1 g/dl
N=3676
Mean: 10.1 g/dl
mmol/l
10.5 g/dl
60% OK (?)
10.5 g/dl
61% OK (?) KET 2014
40% NOT OK
Sundhedsstyrelsens hjemmeside www.sst.dk
39% IKKE OK
VEJLEDNING OM BLODTRANSFUSION
Treatment of bleeding in hemodynamically stable patients
Hos en blødende patient med stabilt kredsløb erstattes blodtabet
initialt med krystalloider og evt. kolloider.
Den videre behandling af kontrollabel blødning omfatter
RBC, FFP and platelets
by the 6 – 12 principle.
principle
Ved pågående blødning hos voksne, dvs. vedvarende
transfusionsbehov hos voksne, behandles efter eksempelvis seks
erytrocyttransfusioner med:
6 RBC, then FFP and RBC 1:1
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Sundhedsstyrelsen: Vejledning om blodtransfusion - 2007
9
VEJLEDNING OM BLODTRANSFUSION
VEJLEDNING OM BLODTRANSFUSION
Treatment of bleeding in hemodynamically unstable patients
Treatment of bleeding in hemodynamically stable patients
Den videre behandling af kontrollabel blødning omfatter indgift af
FFP og trombocytter, fx efter 6 - 12 princippet.
Ved pågående blødning hos voksne behandles, indtil hæmostase
opnås efter cirka 12 erytrocyttransfusioner og seks FFP
transfusioner med trombocytter i forholdet:
12 RBC, then Platelets 1 : FFP 5 : RBC 5
Akutte, ukontrollable blødninger kendetegnes ved hæmodynamisk
instabilitet, dvs. svigtende kredsløb med utilstrækkelig
vævsgennemblødning/-oxygenering og laktatdannelse.
Krystalloider anvendes kortvarigt i ventetiden på balanceret
blodkomponentbehandling
ækvivalent til fuldblod.
Der skal straks skiftes til balanceret blodkomponentterapi, hvis en
kontrollabel blødning udvikler sig og bliver ukontrollabel.
KET 2014
Sundhedsstyrelsen: Vejledning om blodtransfusion - 2007
KET 2014
Sundhedsstyrelsen: Vejledning om blodtransfusion - 2007
VEJLEDNING OM BLODTRANSFUSION
Treatment of bleeding in hemodynamically unstable patients
Balancerede blodkomponenter gives hos voksne fra
den tidligste fase eksempelvis i forholdet:
RBC 3 : FFP 3 : platelets 1
KET 2014
Sundhedsstyrelsen: Vejledning om blodtransfusion - 2007
Good Guidelines
for blood transfusion
10
www.blood.gov.au
www.transfusionguidelines.org.uk/transfusion-handbook
9 g/dl
8 g/dl
7 g/dl
11