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2378 Part XIII: Transfusion Medicine Chapter 138: Blood Procurement and Red Cell Transfusion 2379

among others. Until the results of these studies are available, no changes 6. Riley W, Schwei M, McCullough J: The United States’ potential blood donor pool:
to practice should be made based on the available data. Estimating the prevalence of donor exclusion factors on the pool of potential donors.
Transfusion 47:1180, 2007.
7. McCullough J: Transfusion Medicine, 3rd ed. Wiley-Blackwell, Oxford, UK, 2011.
PATIENT BLOOD MANAGEMENT 8. Eder AF, Dy BA, Kennedy JM, et al: The American Red Cross donor hemovigilance
program: Complications of blood donation reported in 2006. Transfusion 48:1809,
2008.
Patient blood management (PBM) is an evidence-based, systematic and 9. Goldman M, Osmond L, Yi QL, et al: Frequency and risk factors for donor reactions in
multifaceted approach to optimizing the care of patients who might an anonymous blood donor survey. Transfusion 53:1979, 2013.
need transfusion. The risks associated with unnecessary transfusions, 10. Goodnough LT, Rednick S, Price TH, et al: Increased preoperative collection of autol-
coupled with the rising cost of blood have helped fuel the growth of ogous blood with recombinant human erythropoietin therapy. N Engl J Med 321:1163,
1989.
PBM efforts. PBM was recently adopted by the World Health Organi- 11. Spivak JL: Recombinant human erythropoietin and its role in transfusion medicine.
zation as the new standard of care, and the AABB has issued guidelines Transfusion 34:1, 1994.
and other tools designed to help hospitals implement a PBM program. 12. Williams AE, Kleinman S, Gilcher RO, et al: The prevalence of infectious disease mark-
ers in directed versus homologous blood donations [abstract]. Transfusion 32:45S,
A comprehensive PBM program includes (1) hospital-wide guidelines 1992.
for evidence-based use of blood components, (2) early assessment and 13. Luten M, Roerdinkholder-Stoelwinder B, Rombout-Sestrienkova E, et al: Red cell con-
correction of preoperative anemia, and (3) application of a variety of centrates of hemochromatosis patients comply with the storage guidelines for transfu-
sion purposes. Transfusion 48:436, 2008.
techniques to minimize perioperative blood loss. 14. Shi PA, Ness PM: Two-unit red cell apheresis and its potential advantages over tradi-
Guidelines for transfusion have been published by multiple med- tional whole-blood donation. Transfusion 39:219, 1999.
ical professional societies, and can serve as a useful starting point for 15. McCullough J, Clay M, Herr G, et al: Effects of granulocyte colony stimulating factor
(G-CSF) on potential normal granulocyte donors. Transfusion 39:1136, 1999.
hospitals; however, the evidence for Hgb thresholds was developed in 16. Herwaldt BL, Linden JV, Bosserman E, et al: Transfusion-associated babesiosis in the
selected patient populations and does not always apply in all clinical United States: a description of cases. Ann Intern Med 155:509, 2011.
situations. Combining evidence with a clinical assessment is necessary 17. Busch MP, Young MJ, Samson SM, et al: Risk of human immunodeficiency virus (HIV)
when deciding if a transfusion is indicated. Adding decision support transmission by blood transfusions before the implementation of HIV-1 antibody
screening. Transfusion 31:4, 1991.
tools into computerized physician order entry systems can remind cli- 18. Dodd RY, Notari EP, Stramer SL: Current prevalence and incidence of infectious disease
86
nicians of guidelines and safety considerations when ordering blood. markers and estimated window-period risk in the American Red Cross blood donor
These systems have been shown to reduce blood use and decrease costs population. Transfusion 42:975, 2002.
associated with transfusions. Auditing transfusion orders may reveal 19. Hebert PC, Wells G, Blajchman MA, et al: A multicenter, randomized, controlled clini-
87
cal trial of transfusion requirements in critical care. N Engl J Med 340(6):409, 1999.
patterns of blood utilization that can be corrected with education. 20. Villanueva C, Colomo A, Bosch A, et al: Transfusion strategies for acute upper gastro-
Preoperative anemia is associated with adverse outcomes in sur- intestinal bleeding. N Engl J Med 368(1):11, 2013.
gery. 88–90 Anemia levels act as an inverted sliding scale, with higher mor- 21. Hebert PC, Yetisir E, Martin C, et al: Is a low transfusion threshold safe in critically ill
patients with cardiovascular diseases? Crit Care Med 29(2):227, 2001.
tality seen in patients with lower preoperative Hgb. The effect of blood 22. Carson JL, Terrin ML, Noveck H, et al: Liberal or restrictive transfusion in high-risk
loss on mortality was also more pronounced in patients with lower ver- patients after hip surgery. N Engl J Med 365(26):2453, 2011.
sus higher preoperative Hgb values. When preexisting comorbidities 23. Hajjar LA, Vincent JL, Galas FR, et al: Transfusion requirements after cardiac surgery:
The TRACS randomized controlled trial. JAMA 304(14):1559, 2010.
and other confounders were considered, preoperative anemia contin- 24. Foss NB, Kristensen MT, Kehlet H: Anaemia impedes functional mobility after hip
ued to be independently associated with adverse outcomes after cardiac fracture surgery. Age Ageing 37(2):173, 2008.
and noncardiac surgery. Even relatively mild preoperative anemia was 25. Foss NB, Kristensen MT, Jensen PS, et al: The effects of liberal versus restrictive trans-
fusion thresholds on ambulation after hip fracture surgery. Transfusion 49(2):227, 2009.
shown to be an independent risk factor for higher early mortality in 26. Desjardins P, Turgeon AF, Tremblay MH, et al: Hemoglobin levels and transfusions
cardiac surgeries, and for 30-day morbidity and mortality in patients in neurocritically ill patients: A systematic review of comparative studies. Crit Care
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undergoing major noncardiac surgery. 90 16(2):R54, 2012.
Given the risks of preoperative anemia, both patients and hospi- 27. Lacroix J, Hebert PC, Hutchison JS, et al: Transfusion strategies for patients in pediatric
intensive care units. N Engl J Med 356(16):1609, 2007.
tals may benefit from a preoperative anemia assessment program for all 28. Rouette J, Trottier H, Ducruet T, et al: Red blood cell transfusion threshold in postsur-
surgical patients. When possible, this assessment should be undertaken gical pediatric intensive care patients: A randomized clinical trial. Ann Surg 251(3):421,
28 days before surgery, to correct anemia with oral iron when possible, 2010.
and IV iron or erythropoietin when necessary and not contraindicated. 29. Willems A, Harrington K, Lacroix J, et al: Comparison of two red-cell transfusion strat-
egies after pediatric cardiac surgery: A subgroup analysis. Crit Care Med 38(2):649,
Hematologists should be consulted for cases of refractory anemia. 2010.
Perioperative blood management is the third pillar of a strong 30. Karam O, Tucci M, Ducruet T, et al: Red blood cell transfusion thresholds in pediatric
patients with sepsis. Pediatr Crit Care Med 12(5):512, 2011.
PBM program. Blood sparing surgical techniques and anesthesiology- 31. Bell EF, Strauss RG, Widness JA, et al: Randomized trial of liberal versus restrictive guide-
based blood conservation tools should be used whenever possible. Min- lines for red blood cell transfusion in preterm infants. Pediatrics 115(6):1685, 2005.
imizing perioperative blood loss reduces the need for RBC transfusion 32. Kirpalani H, Whyte RK, Andersen C, et al: The premature infants in need of transfusion
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and the length of hospital stay. Together the combination of a restric- (PINT) study: A randomized, controlled trial of a restrictive (low) versus liberal (high)
transfusion threshold for extremely low birth weight infants. J Pediatr 149(3):301, 2006.
tive transfusion strategy, preoperative anemia correction and perioper- 33. Whyte R, Kirpalani H: Low versus high haemoglobin concentration threshold for
ative blood management has been shown to reduce RBC transfusions, blood transfusion for preventing morbidity and mortality in very low birth weight
decrease adverse events and reduce hospital costs. 91 infants. Cochrane Database Syst Rev (11):CD000512, 2011.
34. DeBaun MR, Gordon M, McKinstry RC, et al: Controlled trial of transfusions for silent
cerebral infarcts in sickle cell anemia. N Engl J Med 371:699, 2014.
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http://www.who.int/bloodsafety/transfusion_services/en/ 37. Chou ST, Jackson T, Vege S, et al: High prevalence of red blood cell alloimmuniza-
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