Evaluation of RBC Transfusion Practice in Adult ICUs and the Effect of Restrictive Transfusion Protocols on Routine Care

Abstract

Objective Research supports the efficacy and safety of Restrictive Transfusion Protocols (RTP) to reduce avoidable red blood cell (RBC) transfusions, but evidence of their effectiveness in practice is limited. This study assessed whether admission to an intensive care unit (ICU) with an RTP reduces the likelihood of transfusion for adult patients. Design Observational study using data from the multi-center, cohort Critical Illness Outcomes Study. Patient-level analyses were conducted with RBC transfusion on day of enrollment as the outcome and admission to an ICU with an RTP as the exposure of interest. Covariates included demographics, hospital course (e.g. lowest hematocrit, blood loss), severity of illness (e.g. SOFA score), interventions (e.g. sedation/analgesia), and ICU characteristics (e.g. size). Multivariable logistic regression modeling assessed the independent effects of RTPs on transfusions. Setting 59 US ICUs. Patients 6,027 adult ICU patients. Interventions None. Measurements and Main Results Of the 59 study ICUs, 24 had an RTP; 2,510 (41.6%) patients were in an ICU with an RTP. The incidence of RBC transfusion among patients with severe (Hct<21%), moderate (Hct: 21–30%), and mild (Hct>30%) anemia in RTP ICUs were 67%, 19%, and 4%, respectively, compared to 60%, 14%, and 2% for those in ICUs without an RTP. Only 27% of transfusions were associated with a hematocrit less than 21%. Adjusting for confounding factors, RTPs independently reduced the odds of transfusion in moderate anemia with an odds ratio of 0.59 (95%CI: 0.36–0.96) while demonstrating no effect in mild (p=0.93) or severe (p=0.52) anemia. Conclusions In this sample of ICU patients, transfusions often occurred outside evidence-based guidelines, but admission to an ICU with an RTP did reduce the risk of transfusion in moderately anemic patients controlling for patient and ICU factors. This study supports the effectiveness of RTPs for influencing transfusions in clinical practice.

Blood manufacturing methods affect red blood cell product characteristics and immunomodulatory activity

“…Red blood cell (RBC) transfusion remains common, particularly in critically ill patients. [1][2][3] However, transfusion of red cell concentrates (RCCs) is independently associated with increased risks of nosocomial infection, organ dysfunction, and death. [4][5][6] Transfusion-related immunomodulation (TRIM) includes both immunosuppressive and inflammatory effects that may in part explain increased risks in patients who receive blood transfusions.…”

Outcomes of red blood cell transfusions prescribed in organ donors by the Digital Intern, an electronic decision support algorithm

“…Adherence to transfusion guidelines is no exception. In a study by Seitz and colleagues, 42% of 59 intensive care units studied reported having restrictive transfusion policies in place that were in line with current AABB guidelines. However, transfusion rates in patients with a Hb level of 7 g/dL or more were as high as 20%, indicating a substantial lack of compliance with the institutional guidelines.…”

Slow and Steady: A Systematic Review of ICU Care Models Relevant to Pediatric Chronic Critical Illness

“…Various adult ICU protocols are shown to streamline acute care and improve patient safety in multiple ways such as, oral care protocols leading to decreased ventilator-associated pneumonia rates, electrolyte replacement protocols reducing time from abnormal laboratory result to electrolyte normalization, and transfusion guidelines reducing the rate of nonevidencebased transfusions. [17][18][19][20][21] While patients with CCI require individualized care, they also have predictable chronic needs that can be proactively managed with protocols.…”