Implementing inpatient, evidence-based, antihistamine-transfusion premedication guidelines at a single academic US hospital

Abstract

Allergic transfusion reactions (ATRs) are a common complication of blood transfusions. Advances in transfusion medicine have significantly decreased the incidence of ATRs; however, ATRs continue to be burdensome for patients and problematic for providers who regularly order packed red blood cells and platelet transfusions. To further decrease the frequency of ATRs, routine premedication with diphenhydramine is common practice and is part of "transfusion culture" in a majority of institutions. In this article, we review the history, practice, and literature of transfusion premedication, specifically antihistamines given the adverse-effect profile. We discuss the rationale and original academic studies, which have supported the use of premedication for transfusions for decades. However, despite the common use of premedication to prevent ATRs, recent literature has not conclusively validated its use. In addition, the existing premedication that is routinely prescribed often causes a number of adverse effects. These findings have motivated the Moores Cancer Center (University of California, San Diego) to change its current transfusion premedication practices, particularly with regard to ATRs and first-generation antihistamines. We outline the preliminary development of an evidence-based and patient-specific approach to transfusion premedication, including the challenges and steps taken to revise inpatient premedication protocols. We plan to expand this protocol to the outpatient setting at a later date. Future efforts require a prospective validation of our presented transfusion premedication guidelines.

A retrospective cost analysis of the frequency and cost of transfusion premedications

“…At our institution, policies are being set in place to reduce routine premedication administration by way of electronic medical record prompts and restrictions. This strategy has been implemented by other institutions with success in decreasing routine use of premedications . Our study underscores the need for large prospective randomized studies to assess the efficacy and adverse effects of this practice and others within transfusion medicine .…”

Rationalised premedication practice for blood product transfusions: A single‐centre quality initiative

“…In the 1950s, several trials explored the use of prophylactic antihistamine. There was some initial success, however, the trials were of poor scientific quality 2,7,17 . As transfusion medicine has progressed, reaction rates have significantly reduced due to a combination of more advanced storage techniques and controls, plasma reduction and use of different coagulant preservative solutions 1,4,7,10,17 .…”

“…[1][2][3][4] ATRs are diagnosed on clinical signs and symptoms with mild reactions exhibiting urticaria with or without pruritus. [5][6][7] Severe ATRs include anaphylaxis with manifestations of systemic involvement such as bronchospasm, facial swelling, hypotension, tachycardia and decreased level of consciousness. 4,5 Following a patient experiencing an initial ATR, pharmaceutical cover may be used prophylactically immediately prior to subsequent transfusions.…”

“…ATRs are diagnosed on clinical signs and symptoms with mild reactions exhibiting urticaria with or without pruritus 5–7 . Severe ATRs include anaphylaxis with manifestations of systemic involvement such as bronchospasm, facial swelling, hypotension, tachycardia and decreased level of consciousness 4,5 .…”

“…The use of IV corticosteroids and IV antihistamines are generally well tolerated in a controlled setting but do have potential risks, particularly in growing children and when used over months to years in line the extended duration of typical childhood cancer treatment regimens. 5,7 In addition to these medications unnecessarily increasing the risk of patient harm, there is an added burden on resources such as consumables and clinicians' time.…”