BloodProduct_Journal.pdf - Q ualit y M anagement for...

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[ 8 ] CLINICAL LEADERSHIP & MANAGEMENT REVIEW QUALIT Y MANAGEMENT FOR PATIENT SAFET Y Introduction The patient blood management (PBM) initiative is com- posed of multiple steps to minimize overall blood prod- uct use and improve patient safety. Perhaps the most important aspect of PBM for the transfusion medicine community is the focus on proper utilization of blood products. Following published red blood cell (RBC) guidelines and recommendations can prevent unnec- essary transfusions. Adhering to the standard of care regarding the threshold for prophylactic platelet transfu- sions will help avoid over use. Restricting plasma usage to the accepted clinical indications can help to limit inappropriate transfusions. Taken together, these steps will help to ensure proper utilization of blood products and optimize patient care. Red Blood Cells Red blood cells are collected from whole blood (requiring an additional centrifugation step to separate them from the associated plasma and platelets) or apheresis donations. All units are leukoreduced, with a residual white blood cell count of <5 x 10 6 per product. Red blood cells are stored with anticoagulant and additive solution, with an average hematocrit (Hct) of 55-65 percent and an average volume of 300-400 mL. Red blood cells function by transporting oxygen to tis- sues and removing carbon dioxide buildup. Red blood cell products are transfused to restore or increase oxygen carry- ing capacity and subsequently improve tissue hypoxia. He- moglobin (Hgb) and Hct levels are used to estimate the pres- ence and amount of tissue hypoxia that needs to be treated. Blood Product Utilization in the Age of the Patient Blood Management Initiative By Lawrence B. Fialkow, MD
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VOLUME 27 / ISSUE 4 / Q4 2013 [ 9 ] Historically, accepted transfusion practice has followed the 10/30 rule, a belief that a Hgb value of less than 10 g/dL or a Hct value of less than 30 percent indicates a need for RBC transfusion. This traditional 10/30 rule was established by Adams and Lundy 1 during World War II and remained the accepted standard of care for more than 50 years. However, numerous recent studies have supported a more “conservative” transfusion trigger for RBCs. In the Transfusion Requirements in Critical Care (TRICC) trial, Hebert et al. 2 evaluated the effects of transfusing RBCs at a Hgb of 10 g/dL (liberal group) vs. 7 g/dL (restrictive group) in 838 critically ill patients. While patients in the restrictive group used 54 percent fewer RBCs (33 percent received no RBCs at all), no statistically significant difference was observed in 30-day mortality between the two groups (18.7 percent for the restrictive group vs. 23.3 percent for the liberal group, p value=0.11). In fact, numerous variables were lower in the restrictive group compared to the liberal group, including in-hospital mortality (22.2 percent vs. 28.1 percent, p=0.06), inci- dence of myocardial infarction (0.7 percent vs. 2.9 percent, p=0.02), incidence of acute respiratory distress syndrome (7.7 percent vs. 11.4 percent, p=0.06), and incidence of pulmonary edema (5.3 percent vs. 10.7 percent, p<0.01).
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