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Blood Transfusion: New Guidelines Joint Surgery and Anesthesiology Grand Rounds July 2, 2009 Paul Picton MD Lena M. Napolitano MD Andrew Rosenberg MD Perioperative Transfusion Triggers Paul Picton MD MRCP FRCA Assistant Professor Director, Transplant Anesthesia

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blood transfusion new guidelines
Blood Transfusion: New Guidelines

Joint Surgery and Anesthesiology Grand Rounds

July 2, 2009

Paul Picton MD

Lena M. Napolitano MD

Andrew Rosenberg MD

perioperative transfusion triggers

Perioperative Transfusion Triggers

Paul Picton MD MRCP FRCA

Assistant Professor

Director, Transplant Anesthesia

slide3

Changes in cardiac output (A) oxygen extraction (B) oxygen delivery (C) and oxygen consumption (D) as hemoglobin decreases in humans and animals

Klein HG, et al. Lancet 2007; 370:415-426

anemia in healthy awake volunteers
Anemia in Healthy Awake Volunteers
  • Critical hemoglobin threshold unknown in humans
  • At 5 g/dL - VO2 maintained but ST changes (5%) and memory formation impaired
  • At 6 g/dL - decline in cognitive function

Lieberman, et al. Anesthesiology 2000

do nothing study
Do Nothing Study
  • Retrospective study of 300 JW who underwent surgery from 1981 - 1994
  • Even after adjusting for age, cardiovascular disease and APACHE score, odds of death increased by 2.5 times for each gram of Hb below 8 g/dL

Transfusion. 2002 Jul;42(7):812-8

do nothing study6
Do Nothing Study
  • Retrospective study of 300 JW who underwent surgery from 1981 - 1994
  • Even after adjusting for age, cardiovascular disease and APACHE score, odds of death increased by 2.5 times for each gram of Hb below 8 g/dL

Transfusion. 2002 Jul;42(7):812-8

the tricc study
Herbert PC, et al. NEJM 1999

Enrolled 838 euvolemic, anemic, critically ill pts who were admitted to 1 of 25 Canadian ICUs

Patients were stratified according to center and disease severity (APACHE II) and placed into one of two groups

Restrictive group: Transfuse if Hb < 7 and maintain between 7 and 9

Liberal group: Transfuse if Hb < 10 and maintain between 10 and 12

The primary outcome measure was death from all causes in the 30 days after randomization

The TRICC Study
the tricc study9

The TRICC Study

No difference 30 day mortality

In “healthy” (APACHE II < 20)and young(<55yrs)patients

Transfusion increased mortality

Herbert PC, et al. NEJM 1999

the tricc study10
The TRICC Study

5.7% vs 13.0%

8.7% vs 16.1%

Herbert PC, et al. NEJM 1999

the tricc study11
The TRICC Study
  • Average red cell units per patient:

2.6 ± 4.1 vs. 5.6 ± 5.3 (p < 0.01)

  • Average daily Hb concentrations:

8.5 ± 0.7 g/dl vs. 10.7 ± 0.7 g/dl (p < 0.01)

tricc sub group analyses
TRICC Sub Group Analyses

Trauma (n = 203)

McIntyre LA, et al. J Trauma 2004;57:563-568

Moderate to severe head injury (n = 67)

McIntyre LA, et al. Neurocrit Care 2006;05:4-9

Cardiovascular disease (n = 357)

Herbert PC, et al. Crit Care Med 2001; 29(2):227-234

Mechanical ventilation (n = 713)

Hebert PC, et al. Chest 2001 June;119(6):1851.

No difference in outcomes

slide13
“A restrictive red blood cell transfusion

strategy generally appears to be safe in

most critically ill patients with cardiovascular

disease…

with the possible exception of

patients with acute myocardial infarction and

unstable angina.”

crit study
CRIT Study
  • Prospective, multiple center, observational cohort study of 4,892 ICU pts in the US
  • Propensity score matched
  • Designed to examine the relationship of anemia and RBC transfusion with clinical outcomes
  • Almost 95% of patients admitted to the ICU have a Hb level below “normal” by day 3
  • In total, 11,391 RBC units were transfused.
  • Overall, 44% of pts admitted to the ICU received one or more RBC units while in the ICU

Crit Care Med. 2004 Jan;32(1):39-52

crit results
CRIT Results

35% of Blood transfused in patients with Hgb  9

RBC transfusion was independently associated with higher mortality (OR 1.65 CI 1.35-2.03). OR 2.62 if 3-4 units transfused p < 0.0001

The mean pre-transfusion Hb was 8.6 ± 1.7 g/dL

hematocrit versus postop morbidity ischemia

ST

Sx

Hematocrit versus Postop Morbidity & Ischemia

n = 27 high-risk pts undergoing infra-inguinal arterial bypass

Nelson A, Fleischer L, et al. Crit Care Med 1993

slide17
2001
  • Retrospective cohort
  • Cooperative Cardiovascular Project
  • 78,974 patients ≥ 65 yrs acute MI
  • 30 day mortality
slide19
Analysis of 24,112 enrollees in 3 large international trials of patients with acute coronary syndromes
  • Association between transfusion and outcome
  • Cox proportional hazards modeling
  • Main outcome = 30 day mortality

Rao SV et al. JAMA. 2004;292:1555-1562

blood transfusion and clinical outcome in acute coronary syndrome
Blood Transfusion and Clinical Outcome in Acute Coronary Syndrome

Transfusion

Adjusted hazard ratio 3.94

(3.26-4.75)

No Transfusion

Rao SV et al. JAMA. 2004;292:1555-1562

slide21
Meta-analysis of observational studies
  • 45 studies - 272,596 patients
  • Multivariate analysis correcting for age and illness severity
  • Outcome measures:
    • Mortality
    • Infection
    • Multi-organ dysfunction
    • ARDS

Crit Care Med 2008;36(9):2667-74

results
Results

Association between blood transfusion and the risk of death (OR & 95% CI). Pooled OR 1.7 (95% CI 1.4-1.9)

Association between blood transfusion and the risk of infectious complications (OR & 95% CI). Pooled OR 1.8 (95% CI 1.5-2.2)

Crit Care Med 2008;36(9):2667-74

results23
Results

Association between blood

transfusion and the risk of ARDS (OR & 95% CI).

Pooled OR 2.5 (95% CI 1.6-3.3)

Crit Care Med 2008;36(9):2667-74

financial burden
Financial Burden

Millions

Based on data from UMHHC cost accounting system.

Cost includes cost of blood products and allocated

costs of labor

summary
Summary
  • Post op Hct 15 - very high mortality
  • At Hct 18 - cognitive dysfunction in healthy volunteers
  • Utilization of a transfusion trigger 21 (mean Hct 25)- confers survival benefit for those < 55 yrs and those with an APACHE < 20
  • A liberal transfusion policy - trigger 30(mean Hct 32) does not benefit patients on critical care
  • AtHct 27 - ST changes in high risk patients.
summary27
Summary
  • Transfusion may benefit patients during acute coronary syndromes if Hct < 25-29
  • There is only rarely an indication to transfuse ANY patient with a Hct ≥ 30
  • Blood transfusions are not risk free
  • Decreasing transfusion may not only decrease cost but also improve outcome
closing comments
Closing Comments
  • Good prospective data limited to critical care setting
  • Considerable scope for differences in opinion
  • Concerning intra-operative transfusion - best to come to some agreement pre op and remain in communication
  • Give RBC’s as single units when possible
  • Treat the patient not the Hct
univ michigan adult blood transfusion guidelines 2009
Univ. Michigan Adult Blood Transfusion Guidelines: 2009

Lena M. Napolitano MD, FACS, FCCP, FCCM

Professor of Surgery

Division Chief, Acute Care Surgery

Department of Surgery

University of Michigan

Ann Arbor, MI

slide32

Project Overview & Scope Of Work

Blood Utilization lean project work was commissioned by both OCA & Hospital Administration, under the oversight ofDr. Skip Campbell

Team Make-Up

Project Goal: To develop standard policies & practices leading to: improved patient outcomes through the appropriate use of blood products and gain process efficiencies by removing waste and delays in the blood dispensing & administration process

guidelines for blood transfusion prbcs
Guidelines for Blood Transfusion: PRBCs
  • These guidelines are intended to ensure that the most appropriate, efficient and safe use of the blood supply is achieved
  • To establish evidence-based criteria for the transfusion of blood components
  • Every indication for the use of blood products cannot be anticipated
  • These guidelines are not intended to override physician judgement
guidelines for blood transfusion prbcs34
Guidelines for Blood Transfusion: PRBCs
  • Hemodynamically stable anemia without acute coronary syndrome: hemoglobin trigger less than 7 g/dL, with a transfusion goal to maintain hemoglobin 7 – 9 g/dL.
  • Acute hemorrhage with evidence of hemodynamic instability or inadequate oxygen delivery
  • Symptomatic (tachycardia, tachypnea, postural hypotension) anemia (Hb < 10 g/dL) not explained by other causes
  • Chronic Tx-dependent bone marrow syndromes: Hb < 10 g/dL.
  • Transfusion or exchange transfusion for severe sickle syndromes.
  • Hemodynamically stable anemia with ischemic heart disease: current evidence does not support routine transfusion in non-ST segment elevation acute coronary syndromes; although in ST-segment elevation myocardial infarction Tx may be beneficial.
guidelines for blood transfusion prbcs35
Guidelines for Blood Transfusion: PRBCs
  • RBCs should be administered as single units for most operative and inpatient indications (transfuse and reassess strategy) except for ongoing blood loss with hemodynamic instability.
  • Tx decisions are clinical judgments that should be based on the overall clinical assessment of the individual patient. Transfusion decisions should not be based on laboratory parameters alone.
  • Routine premedication is not advised unless the patient has a history of previous transfusion reactions. Premedication has not been shown to reduce the risk of transfusion reactions.
east sccm blood tx guidelines
EAST / SCCM Blood Tx Guidelines

In press.

November 2009

Crit Care Med

risks of blood transfusion
Risks of Blood Transfusion
  • Viral transmission
  • Acute transfusion reactions
  • Immunosuppression
  • Acute inflammatory response

Noninfectious Hazards

Immunosuppression

Infection

decline in hiv hbv hcv risks of transmission via blood tx
Decline in HIV, HBV, HCV Risks of Transmission via Blood Tx

HIV

HCV

1:100

1:1000

1:10,000

1:100,000

1:1,000,000

1:10,000,000

HBV

Risk of Infection per Unit Transfused

1983 1985 1987 1989 1991 1993 1995 1997 1999 2001

Year

Non-A, Non-B Hepatitis

Surrogate Testing

p24 AntigenTesting

HCV and HIVNucleic AcidTesting

Revised DonorDeferral Criteria

HIV AntibodyScreening

HCV AntibodyScreening

Busch MP, et al. JAMA. 2003;289:959-62.

risks of transfusion infectious disease
Risks of Transfusion: Infectious Disease
  • HIV = 1 in 1.8 million
  • HCV = 1 in 1.6 million
  • HBV = 1 in 220,000

HIV = human immunodeficiency virus.

HCV = hepatitis C virus.

HBV = hepatitis B virus.

Busch MP, et al. JAMA. 2003;289:959-62.

serious hazards of transfusion

Transfusion-transmitted

infections

Post-transfusion

purpura

3%

Acute lung injury

6%

8%

Graft vs host

disease

2%

Incorrect blood/

componenttransfused

14%

53%

Delayed

transfusion

reaction

15%

Acute

transfusion

reaction

Based on 366 spontaneously-reporteddeaths/major complications between October 1996 and September 1998 in the UK and Ireland.

Serious Hazards of Transfusion

Williamson LM, et al. BMJ. 1999;319:16-9.

risks of blood transfusion41
Risks of Blood Transfusion

TRALI 1:5,000

HTLV = human T-cell leukemia-lymphoma virus.

Klein HG. Am J Surg. 1995. 170;6A(suppl):21S-26S.

immune effects of blood
Immune Effects of Blood
  • Immunologic effects of autologous and allogenic blood transfusions:
    • Decreased T-cell proliferation
    • Decreased CD3, CD4, CD8 T-cells
    • Increased Soluble cytokine receptor
      • sTNF-R, sIL-2R
    • Increased Serum neopterin
    • Increased Cell-mediated lympholysis
    • Increased TNF-alpha
    • Increased suppressor T-cell activity
    • Reduced natural killer cell activity

TRIM – Transfusion-associated Immunomodulation

McAlister FA, et al, British Journal of Surgery 1998; 85: 171-178

Innerhofer et al. Transfusion 1999 Oct;39(10):1089

blood tx increases risk of postoperative bacterial infection
Blood Tx Increases Risk of Postoperative Bacterial Infection
  • 20 peer-reviewed studies, 1986-2000
  • N = 13,152 (Tx 5215, No-Tx 7937)
  • Association of Blood Tx to Infection
    • Common OR 3.45 (range 1.43-15.15)
    • 17 of 20 studies with p < 0.05
  • Trauma subgroup
    • Common OR 5.26 (range 5.03-5.43)
    • All studies with p < 0.05 (0.005 – 0.0001)
    • Blood Tx associated with greater risk in trauma pts

Hill GE, Minei JP et al. J Trauma 2003;54:908-914

slide44
Prospective cohort study, n=2085
  • Project Impact
  • Nosocomial Infections: 14.3% vs. 5.8%, p < 0.001

Taylor RW et al.

Crit Care Med 2006;

34:2302–2308

slide45
15,592 Cardiovascular operations
  • Infection endpoints bacteremia, SSI
  • 55% of pts received PRBCs, 21% plts, 13% FFP, 3% cryoprecipitate
  • Increased RBC tx associated with increased infection (p < 0.0001), confirmed by logistic regression analysis.

J Am Coll Surg 2006;202:131-138

slide46

Leukoreduction does not diminish tx-associated Microchimerism

Reed W, et al.Semin Hematol 2007:44:24-31

Utter G et al. Transfusion 2006 Nov;46(11):1863-9

stored rbcs
Stored RBCs
  • Decreased RBC deformability
  • Decreased 2,3, DPG
  • Metabolic acidosis
  • Altered oxygen carrying capacity
  • Increased red cell death with increased age of blood (~30% dead)
  • No improvement in oxygen utilization at the tissue level
poor efficacy of blood tx
Poor Efficacy of Blood Tx
  • RBCs stored > 15 days lose deformability and ATP
  • Altered capillary lumen size (decreased cross-sectional diameter) in critically ill patients
  • Increased “stickiness” (adherence) of RBCs to altered endothelium in the microcirculation of critically ill pts.
slide53

Distribution of Transfused Units

by Age of Blood – CRIT Study

60% of Blood transfused is > 20 days old

Percentage of Patients

0 - 10 10 - 20 20 - 30 30 - 40 > 40

Oldest Age of Blood in Days

In Trauma Subset, 68% of blood is > 20 days old

slide55
The median duration of storage was 11 days for newer blood and 20 days for older blood.

Patients who were given older units had higher rates of in-hospital mortality (2.8% vs. 1.7%, P = 0.004), intubation beyond 72 hours (9.7% vs. 5.6%, P<0.001), renal failure (2.7% vs. 1.6%, P = 0.003), and sepsis or septicemia (4.0% vs. 2.8%, P = 0.01).

A composite of complications was more common in patients given older blood (25.9% vs. 22.4%, P = 0.001).

Similarly, older blood was associated with an increase in the risk-adjusted rate of the composite outcome (P = 0.03).

At 1 year, mortality was significantly less in patients given newer blood (7.4% vs. 11.0%, P<0.001).

slide56

Composite Outcome:

In-hospital mortality

And Complications (STS)

age of blood evaluation able able study hypothesis
Age of Blood Evaluation (ABLE)ABLE Study-Hypothesis

The useof fresh red cells as compared to standard issue red cells will lead to significant improvement in morbidity and mortality

  • Age of Blood Evaluation (ABLE) in the
  • resuscitation of critically ill patients
  • International Study, CIHR, NIH, others
  • Projected n = 6800
able something about the design
ABLE……Something about the design?
  • Study Design: Randomized double‑blind controlled clinical trial.
  • Setting: 30 Canadian tertiary care intensive care and trauma units. Additional study sites in the US, UK, Europe and Australia
  • Study Population: 6800 critically ill or trauma victims who require at least one red cell unit within the first 72 hrs of acute care.
the study intervention
The Study Intervention
  • Leukoreduced RBCs
  • ‘Fresh’ RBCs defined as 8 days or less
    • Primarily for feasibility as limited biological rationale for cut-off
  • Control group…standard-issue RBCs (average age of 21 days)
  • Local transfusion guidelines/practices
able what outcomes will we measure
ABLE…What Outcomes will we measure?

Primary outcome: 30-day all cause mortality.

Secondary outcomes:

1) Other mortality rates

2) Organ failure

3) Nosocomial infections

4) Quality of life using the SF-36 and costs of care.

slide61

[1] Vincent JL, Baron JF, Reinhart K, et al. ABC (Anemia and Blood Transfusion in Critical Care ) Investigators. Anemia and blood transfusion in critically ill patients. JAMA 2002;288:1499-1507.

[2] Corwin HL, Gettinger A, Pearl RG, et al. The CRIT Study: Anemia and blood transfusion in the critically ill – current clinical practice in the United States. Crit Care Med 2004;32:39-52.

[3] Shapiro MJ, Gettinger A, Corwin H, Napolitano LM, Levy M, Abraham E, Fink MP, MacIntyre N, Pearl RG, Shabot MM. Anemia and blood transfusion in trauma patients admitted to the intensive care unit. J Trauma 2003;55:269-274.

[4] Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requireemtns in Critical Care investigators, Canadian Critical Care Trials Group. N Engl J Med 1999;340:409-417.

[5] Rao MP, Boralessa H, Morgan C, et al and the North Thames Blood Interest Group. Blood component use in critically ill patients. Anaesthesia 2002 Jun;57(6):530-4.

[6] Palmieri TL, Caruso DM, Foster KN, et al and the American Burn Association (ABA) Multicenter Trials Group. Effect of blood transfusion on outcome after major burn injury: A multicenter study. Crit Care Med 2006 Jun;34(6):1602-7.

blood transfusion and clinical

Studies on RBC transfusion and outcome in ischemic heart disease.

Blood Transfusion and Clinical

Adapted in part from: Gerber DR. Crit Care Med 2008;36(4):1068-1074.

slide64

Studies on RBC transfusion and outcome in ischemic heart disease.

Adapted in part from: Gerber DR. Crit Care Med 2008;36(4):1068-1074.

focus
FOCUS
  • NHLBI
  • Transfusion Trigger for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair
  • N=2600
  • 25 Med Ctrs
  • US, Canada
  • J.L. Carson MD
focus66
FOCUS
  • Inclusion criteria:
    • Undergo surgery for hip fracture
    • Have a history of cardiovascular disease
    • Have a postoperative Hgb < 10 g/dL
  • Randomized to keep Hgb > 10 g/dL or not
  • Tx permitted but not required if Hgb < 8 g/dL
  • Primary outcome is ability to walk 10 feet without human assistance at 60 days
  • Negative outcome is postoperative unstable angina, myocardial infarction or death
  • MI diagnosis based on 4 blood tests, 3 EKGs, medical history
  • Telephoned at 30 and 60 days to determine functional capacity and vital status.
  • Long-term mortality by searching vital statistics registries in U.S. and Canada
slide67
SURGERY Committee
  • Jeff Carson (Chair) Clinical trials and Transfusion Medicine, Robert Wood Johnson Medical School
  • Darrell Triulizi (Co‑Chair) Transfusion Medicine, University of Pittsburgh
  • John Marshall: General Surgery, Univ. Toronto
  • Lena Napolitano: General Surgery, Univ. Michigan
  • Chris Stowell: Transfusion Medicine, Mass General
  • Richard Weiskopf: Anesthesia, UCSF
  • Transfusion Triggers in CAD, Elective Cardiac Surgery
effect of blood transfusion on long term survival after cardiac operation
Effect of Blood Transfusion on Long-Term SurvivalAfter Cardiac Operation
  • 1915 CABG pts
  • After correction for comorbidities and other factors, tx was still associated with a 70% increase in mortality (RR 1.7; 95% CI 1.4 to 2.0; p 0.001).

Engoren MC et al. (MCO, Toledo)

Ann Thorac Surg 2002;74:1180–6

slide69
10,289 CABG pts, 1995 – 2002
  • Perioperative RBC tx is associated with adverse outcome.
  • Attention should be directed toward blood conservation methods and a more judicious use of PRBC.

0

1

2

3-5

≥ 6

Ann Thorac Surg 2006;81:1650 –7

Cleveland Clinic, OH

slide70
Institution-specific protocols should screen for patients at high risk for blood transfusion. Available evidence-based blood conservation techniques include:
    • (1) drugs that increase preoperative blood volume (eg, erythropoietin) or decrease postoperative bleeding (eg, antifibrinolytics)
    • (2) devices that conserve blood (eg, intraoperative blood salvage and blood sparing interventions)
    • (3) interventions that protect the patient’s own blood from the stress of operation (eg, autologous predonation and normovolemic hemodilution)
    • (4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly
    • (5) a multimodality approach to blood conservation combining all of the above

Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Society of Cardiovascular Anesthesiologists Special task Force on Blood Transfusion. Ann Thorac Surg 2007;83:S27-86.

efficacy of blood tx in sepsis
Efficacy of Blood Tx in Sepsis

Zimmerman JL. Use of blood products in sepsis: An evidence-based review. Crit Care Med 2004;32[Suppl]S542-547

early goal directed therapy in the rx of severe sepsis and septic shock
Early Goal-directed Therapy in the Rx of Severe Sepsis and Septic Shock
  • Severe sepsis and septic shock patients (n=263)
    • SIRS and SBP < 90mm Hg or lactate > 4mmol/L
    • Prospective, randomized controlled trial
    • Goal-directed therapy vs. control (standard of care)
  • Goal-directed therapy performed in ER prior to ICU
    • Placement of oximetric CVP line, CVP goal 8-12, ScVO2 > 70%
    • Guidelines for pressor and vasodilators, dobutamine, blood tx
    • Maintained for at least 6 hours

Rivers E et al. NEJM 345(19) November 8, 2001:1368-77

early goal directed therapy in the rx of severe sepsis and septic shock76
Early Goal-directed Therapy in the Rx of Severe Sepsis and Septic Shock
  • Early Goal-directed Therapy resulted in:
  • Reduced In-hospital mortality, 30.5% vs 46.5% (p=0.0009)
  • Higher ScVO2, lower lactate, lower base deficit
  • Early goal-directed therapy provides significant benefits in outcome in patients with severe sepsis and septic shock.

Rivers E et al. NEJM 345(19) November 8, 2001:1368-77

slide77

Validation Study

Multicenter Trial

20 sites

Derek Angus et al.

Univ. of Pittsburgh

ProCESS

Protocolized Care for Early Septic Shock

NIH-sponsored

$8.4 Million

east sccm blood tx guidelines78
EAST/SCCM Blood Tx Guidelines
  • Recommendations Regarding RBC Transfusion in Sepsis
  • Level 1
  • There are insufficient data to support Level 1 recommendations on this topic.
  • Level 2
  • The transfusion needs for each septic patient must be assessed individually since optimal transfusion triggers in sepsis patients are not known and there is no clear evidence that blood transfusion increases tissue oxygenation.
anemia of chronic disease or anemia of inflammation
Anemia of Chronic Disease or“Anemia of Inflammation”
  • Dysregulation of iron homeostasis
  • Impaired proliferation of erythroid progenitor cells
  • Blunted EPO response

Weiss and Goodnough. N Engl J Med. 2005;352(10):1011-1023.

blunted epo response in critically ill
Blunted Epo Response in Critically Ill

Inhibition of EPO gene transcription in renal juxtaglomerular cells

Inflammatory Cytokines

(IL-1, IFN, TNF, TGF)

  • Direct inhibition of RBC production by bone marrow
  • Direct inhibition of the erythroid precursor cell response to erythropoietin
  • Indirect limitation of iron availability by increasing iron sequestration in macrophages.
anemia management protocol
Anemia Management Protocol

40% Reduction in Blood Tx in SICU

Jul-Sep 2006

Oct-Dec 2004

sicu blood utilization
SICU Blood Utilization

Added to Keystone ICU Reports

Jul-Sep 2006

Oct-Dec 2004

sicu blood utilization84
SICU Blood Utilization

Added to Keystone ICU Reports

Jul-Sep 2006

Oct-Dec 2004

slide85

ICU Mortality

2007

3.36%

6.60%

7.21%

O/E 0.71 0.54 0.47 0.41

slide86

Hospital Mortality

2007

5.35%

10.89%

9.67%

O/E 0.74 0.59 0.55 0.56

slide87

Blood Dashboard for Clinical Services - DRAFT

Current Month “Snapshot” of Percent of RBC Transfusions by Pre-Transfusion Hct with “drill-down” to Patient-Level Detail

Trend Report of Percent of RBC Transfusions by Pre-Transfusion Hct

summary88
Summary
  • Anemia is common
  • No evidence that blood tx for treatment of anemia improves outcome
  • Critically ill patients can tolerate Hb levels as low as 7 mg/dL
  • Blood should be transfused for physiologic indications
  • New UMich Blood Tx Guidelines
um carelink support for improved transfusion practice

UM Carelink Support for Improved Transfusion Practice

Andrew Rosenberg MD

Medical Director, UM Carelink

Chief, Critical Care Division Anesthesiology

clinical it supports good decisions best practices institution policies
Clinical IT supports good decisions, best practices & institution policies

For emergency transfusion call Blood Bank

Pre-op requests for PRBCs on standby & OR transfusion NOT part of this process.

UMCL (UM Carelink);

Is the primary method to order blood.

Provides Clinical Decision Support {Alerts}

Serves as a useful clinical database {Queries}

Clinician feedback needed (6-2222, light bulb icon in UMCL)

transfusion alert rule logic
Transfusion Alert Rule Logic

Based on ECCA Transfusion Guidelines

Hemodynamically stable anemia w/out CAD

Transfusion trigger= Hg < 7g/dL

Maintain Hg 7-9g/dL

For PRBC Order set only

1 or 2 units ordered (alert will NOT fire for 3 or more units)

And Hemoglobin > 7g/dL

And/or Hg result >48 hrs old/ Or no Hg result available

And Pt age > 17 yo.

four alert messages
Four Alert Messages

I. Hgb <7 g/dL but last Hgb result > 48 hours.

Request does not meet ECCA Guidelines when ordering 1 or 2 units PRBC

Last HGB is over 48 hours old

HGB: ## g/dL DATE

Confirm HGB before ordering or select override reason to complete order.

II. Hgb> 7g/dL and HGB result < 48 hrs.

Transfusion may not be advised if the HGB is > 7g/dL

III. Hbg > 7 g/dL but HGB result > 48 hrs.

HGB is greater than 7 g/dL and is over 48 hours old.

IV. No Hgb result available

No HGB result on file

override reasons
Override Reasons

Active Bleeding

Cardiovascular disease

Hemoglobinopathy

Hemolysis

Oxygen carrying deficit

Refractory Hypotension

Symptomatic anemia

Attending Physician deems necessary

slide100

Blood Transfusion Ordered

Email Sent To Service Chief

Evidence Based

Annual Review

UMHS – Blood Transfusion Guideline

Order & Compliance Monitoring (Future State Map)

Blood Transfusion Guideline

*RBC Transfusion Trigger = Hemoglobin < 7

*Redefines role/scope of Transfusion Committee to act as oversight body

*Reports Track Compliance To Guideline & Transfusion Volume

Response Review By Transfusion Committee

Response Explanation Submitted To Transfusion Committee

Compliance Report Capture (If Order Is Beyond Trigger)

*Email includes link to patient level data to assist review

House Wide Communication/Education

Carelink Order “Checkpoints”