In 2010, blood transfusions were the most common procedures among
hospitalized patients. They are often necessary and life-saving
interventions; however, as blood is neither free nor completely
benign, the overutilization has led many to conclude that when it
comes to blood product administration, “less is more.”
There are substantial monetary costs associated with blood
products. In 2011, researchers estimated an acquisition cost of
$210 per unit of red blood cells (RBCs), $61 per unit of fresh
frozen plasma, and $534 per unit of apheresis platelets.
According to the
American Red Cross, approximately 36,000 units of RBCs,
10,000 units of plasma, and 7,000 units of platelets are used
every day in the U.S. These values equate to an estimated annual
cost of $276 billion for RBCs, $222.6 million for frozen plasma,
and $136 billion for apheresis platelets. Of note, these
estimates are for acquisition alone and the total cost is much
higher. In a
2010 study, researchers estimated that the cost of RBC
transfusion among surgical patients was between 3.2 and 4.8 times
greater than the cost of acquiring the blood.
Stopping the overutilization of blood products saves money, but
more importantly, saves lives. Data from the National Healthcare
Safety Network Hemovigilance Module for 77 facilities between
January 1, 2010 and December 31, 2012 indicate 7.2% of the
reported adverse were severe or life-threatening and 0.1% (n=4)
were fatal. Of the four fatal cases in the study, three were
attributed to transfusion-related acute lung injury (TRALI) and
19 of the 26 cases of TRALI were severe or life-threatening. For
patients in whom blood transfusion is not indicated, these risks
are without sufficient counterbalancing benefit.
TRALI is an acute lung injury associated with transfusion. It
will generally present within four hours of transfusion and is
characterized by hypoxic respiratory distress. The patient with
TRALI may also present with fever, tachycardia, hypertension or
hypotension. Differentiating TRALI from other transfusion related
adverse events such as transfusion associated circulatory
overload (TACO) is based on laboratory values, clinical
presentation and response to specific treatments.
Click here for more information on the differential diagnosis of
While there is no definitive way to predict TRALI, there are ways
to protect your patient from developing this life threatening
reaction to blood product administration. First and foremost, be
sure that the transfusion is warranted. For example, one of the
cases found in the CHPSO database involved a patient who
developed TRALI after receiving a single unit of packed red blood
cells in the operating room. This transfusion reaction may have
been preventable as the patient had a hemoglobin of 12, which
exceeds the recommended thresholds for transfusion.
When transfusion is necessary, keep in mind that TRALI rates are
higher for transfusions of platelets and plasma.
Research indicates that patient related factors which have
been implicated in an increased risk of TRALI include active
infection, recent major surgery, mass transfusion, cytokine
administration, treatment for hematologic malignancies (induction
phase), and cardiovascular disease requiring bypass surgery. An
FDA study of older adults indicates that race, gender,
tobacco use, and certain medical histories increase the odds of
developing TRALI in patients 65 and older.
Carson, J. L., Grossman, B. J., Kleinman, S., Tinmouth, A. T.,
Marques, M. B., Fung, M. K., … & Rao, S. V. (2012). Red blood
cell transfusion: a clinical practice guideline from the AABB.
Annals of internal medicine, 157(1), 49-58. Available at http://www.pac4.ch/Pdf/AnnEAnesth/Transfusion%20AABB.pdf