Literature Review

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Introduction

There has been much debate within the peri-operative environment at a regional New South Wales hospital regarding the management and transfusion of red blood cells. This is why the topic has been selected for further study. The purpose of this paper is to review the literature surrounding the safety of red blood cell (RBC) transfusions, which comes under standard seven of the National Safety and Quality in Health Service Standards (ACSQHC, 2012). It will touch on the complications of RBC transfusion, when to transfuse, the management of blood loss and the impact of RBC transfusion on critically ill patients. The paper will aim to answer the following questions: ‘To transfuse or not to transfuse, do the risks of transfusion outweigh the benefits?’ It will also examine and critically analyse strategies that have been put in place to reduce errors in the administration of blood and also strategies aimed at reducing blood loss and therefore decrease the chance of a patient needing to be transfused. Similarities, differences and omissions of each research article will be examined. The relevance of these issues to the peri-operative environment will be evaluated, and conclusions and recommendations will be made.

In the peri-operative environment, red blood cells transfusions are used to treat haemorrhage and to improve oxygen delivery to tissue. Approximately 85 million red blood cell units are transfused annually worldwide (American Association of Blood Banks, 2012). They are seen to have remarkable health benefits for patients and have undoubtedly saved the lives of thousands of people. Unfortunately, there is considerable risk involved. The leading cause of RBC related mortality is transfusion-related acute lung injury (TRALI), ABO and non-ABO haemolytic transfusion reactions (HTR) and transfusion related sepsis (TAS). Inappropriate or incorrect transfusion of RBC is the most frequent cause for HTR. Errors can arise from donor choice, laboratory and administrative errors, to unnecessary transfusion (Thomas & Holmes, 2011).

WHEN TO TRANSFUSE

Guidelines for blood transfusion all emphasise that blood should be transfused when clear physiologic needs exist (Shander et el, 2012). When a unit of RBC is transfused to a patient, the haemoglobin levels should increase by approximately 10g/L. The Australian and New Zealand Society of Blood Transfusion (2011) and the American Association of Blood Banks (AABB cited in Carson et al, 2012) both recommend lowering the haemoglobin level to 70-80g/L before instigating a transfusion, instead of 100g/L in stable patients. Shander et al (2012) agree with the above guideline and have stated ‘that blood transfusions are generally not indicated in patients with haemoglobin levels of greater than 100g/L’. A randomised multicentre controlled clinical trial conducted by Herbert et al (1999) supports that a RBC transfusion should not be given until the haemoglobin is less than 70g/L. This study was cited in both Sharma et al (2011) and da Silver Junior et al (2012), which makes it a reputable study.

CRITICALLY ILL PATIENTS

An observational study conducted by da Silver Junior et al (2012) investigated the epidemiology and outcomes related to blood transfusion amongst critically ill patients in an intensive care unit, whom were all under a restrictive transfusion regime. The blood transfusion protocol for this unit is that transfusion is only allowed to be given to patients whose haemoglobin levels is less than 70g/L. Patients with cardiovascular disease and low tissue perfusion associated with circulatory shock are an exception and their haemoglobin is to be kept between 70-90g/L. 167 patients were included in this study and were split into two groups: patients who received a blood transfusion and patients who did not receive a blood transfusion. Of these patients 35.3 per cent received a blood transfusion. This study found that the patients who received a RBC...
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