Effects of a More Restrictive Transfusion Trigger in Trauma Patients

Abstract

Since the Transfusion Requirements in Critical Care trial, studies have shown that acutely ill patients can drift as a low as 5 g/dL. This study reviews a transfusion trigger change to 6.5 g/dL, which we hypothesize will conserve resources and improve quality of care. This is a retrospective chart review at an urban Level I trauma center from January through December 2015 after our trauma service changed the transfusion trigger from 7 to 6.5 g/dL. Outcomes in patients before (TT7) and after (TT6.5) the change in transfusion threshold were then compared. One hundred thirty-one discrete patients were included in this trial, with 285 instances of a hemoglobin of 7 g/dL or less and 178 transfusions. Seventy-two patients were before the change in threshold and 59 after. There was no change in length of hospital stay, ICU stay, ventilator days, mortality, and organ system failure after change in the transfusion threshold. After initiation of a more conservative threshold, 72 units of blood were saved. Decreased transfusion threshold was associated with no worse outcomes associated with decreased resource utilization.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

“…However, high-quality data were only available in cardiac, orthopaedic surgery and critical care patients and no study on acute bleeding in trauma patients was included in the analysis. In a small-sample-size before–after study ( n = 131 patients) in which the transfusion threshold was decreased from 70 to 65 g/L in a trauma centre, no difference was reported in hospital length of stay or organ failure [ 178 ]. Above all, physicians should keep in mind that haemorrhagic shock may be a rapidly evolving situation in which anticipation of transfusion is essential to prevent an excessive decrease in arterial oxygen transport and the decision to transfuse should not be based on haemoglobin levels alone.…”

Passive order auditing associated with reductions in red blood cell utilization: National blood shortage experience

“…5,11,[20][21][22] In addition to conserving inventory, reducing unnecessary transfusions also reduces associated risks and complications. 5,11,17,23 The 2016 Clinical Practice Guidelines from the AABB recommend a pre-transfusion hemoglobin threshold of 7-8 g/dL in most hemodynamically stable adult patients. 24 Lowering the pre-transfusion hemoglobin threshold from 7.0 to 6.5 g/dL or lower in stable, asymptomatic patients, while outside of evidence-based practice, has been proposed as one strategy to conserve RBCs during long-term severe blood supply shortages.…”

“…4 Garland-Kledzik et al showed that reducing the pre-transfusion hemoglobin threshold from 7.0 to 6.5 g/dL in trauma patients was not associated with increased morbidity or mortality but was associated with decreased RBC utilization. 23 At an academic medical center the existing BPA for inpatient locations that previously alerted providers when an order for RBC transfusion was placed on a patient with a pre-transfusion hemoglobin greater than 7.0 g/dL 11 was modified to activate at pre-transfusion hemoglobin greater than 6.5 g/dL. This change was implemented on June 1, 2021 after notification from the medical center's blood supplier of an impending critical RBC shortage, initially expected to last at least through the summer months, that was subsequently extended until 3/1/2022.…”

“…CDS can be an effective tool to complement a patient blood management program 5,11,20–22 . In addition to conserving inventory, reducing unnecessary transfusions also reduces associated risks and complications 5,11,17,23 …”

“…Lowering the pre‐transfusion hemoglobin threshold from 7.0 to 6.5 g/dL or lower in stable, asymptomatic patients, while outside of evidence‐based practice, has been proposed as one strategy to conserve RBCs during long‐term severe blood supply shortages 4 . Garland‐Kledzik et al showed that reducing the pre‐transfusion hemoglobin threshold from 7.0 to 6.5 g/dL in trauma patients was not associated with increased morbidity or mortality but was associated with decreased RBC utilization 23 …”