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Blood Product Administration: Lives and Dollars

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 TRALI.

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.

Resources

Pfuntner, A., Wier, L. M., & Stocks, C. (2006). Most frequent procedures performed in US hospitals, 2010: Statistical Brief# 149. Available at: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb149.pdf

Tobian, A. A., Heddle, N. M., Wiegmann, T. L., & Carson, J. L. (2016). Red blood cell transfusion: 2016 clinical practice guidelines from AABB. Transfusion, 56(10), 2627-2630. Available at https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=Red+blood+cell+transfusion%3A+2016+clinical+practice+guidelines&btnG=

Roback, J. D., Caldwell, S., Carson, J., Davenport, R., Drew, M. J., Eder, A., … & Perkins, J. G. (2010). Evidence‐based practice guidelines for plasma transfusion. Transfusion, 50(6), 1227-1239. Available at http://ether.stanford.edu/Ortho/8%20-%20Plasma%20transfusion.pdf

Kaufman, R. M., Djulbegovic, B., Gernsheimer, T., Kleinman, S., Tinmouth, A. T., Capocelli, K. E., … & Mintz, P. D. (2015). Platelet transfusion: a Clinical Practice Guideline From the AABBPlatelet transfusion: a clinical practice guideline from the AABB. Annals of internal medicine, 162(3), 205-213. Available at http://annals.org/aim/fullarticle/1930861/platelet-transfusion-clinical-practice-guideline-from-aabb

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

Kleinman, S., Caulfield, T., Chan, P., Davenport, R., McFarland, J., McPhedran, S., … & Slinger, P. (2004). Toward an understanding of transfusion-related acute lung injury: statement of a consensus panel. Available at https://deepblue.lib.umich.edu/bitstream/handle/2027.42/73845/j.0041-1132.2004.04347.x.pdf?sequence=1&isAllowed=y

Menis, M., Anderson, S. A., Forshee, R. A., McKean, S., Johnson, C., Warnock, R., … & Kelman, J. A. (2014). Advancing regulatory science. Transfusion. Available at https://www.fda.gov/downloads/BiologicsBloodVaccines/ScienceResearch/UCM438942.pdf

Shander, A., Hofmann, A., Ozawa, S., Theusinger, O. M., Gombotz, H., & Spahn, D. R. (2010). Activity‐based costs of blood transfusions in surgical patients at four hospitals. Transfusion, 50(4), 753-765. Available at: http://www.bs-zh.ch/Media/File/Journal%20Club/Activity-based%20costs%20of%20blood%20transfusions%20in%20surgical%20patients%20at%20four%20hospitals.pdf