You are the Intensivist looking after a 30-year-old male, with no significant past medical history, who has been in the Intensive Care Unit for eight days with severe community acquired pneumonia and septic shock.
Although there are no overt signs of bleeding, his haemoglobin has slowly dropped and is now 65 g/L. He has been recommenced on low dose noradrenaline and you have decided to transfuse one unit of packed cells.
His wife has concerns about the “safety” of this and refuses to consent until she speaks to you.
Outline the key points of your discussion with the patient’s wife, including the pros and cons of, and alternatives to blood transfusion in this context.
Discussion should cover:
Pros:
Cons:
Non-transfusion strategies should be employed
Calman scale of risk useful in this context:
Negligible (less than 1 in a million or dying of lightning strike)
Minimal, Very low, Low (1 in a thousand to 1 in 10000 or dying in a road accident)
High (>1 in 1000)
Additional Examiners’ Comments:
Candidates were not expected to give this much detail and were given credit for valid points not included in the answer template
I love it when they invite you to give less detail.
A "routine transfusion" in this setting is the transfusion which has a "numeric trigger" as opposed to a clinical indication (i.e. the patient is asymptomatic).
Rationale for some sort of strategy
Arguments in support of routine transfusion to a Hb of >70
Arguments against the routine transfusion to a Hb of >70
Practical approach to a questionably indicated transfusion
Alternatives to transfusion
Spahn et al (2013) have done an excellent review of this for Lancet. In summary:
Goodnough, Lawrence T., Jerrold H. Levy, and Michael F. Murphy. "Concepts of blood transfusion in adults." The Lancet 381.9880 (2013): 1845-1854.
Spahn, Donat R., and Lawrence T. Goodnough. "Alternatives to blood transfusion." The Lancet 381.9880 (2013): 1855-1865.
There is also a rescinded document from the NHMRC (2001) which has been used to guide practice: Clinical Practice Guidelines on the Use of Blood Components.
To some extent this document has been superceded by the Australian and New Zealand Society of Blood Transfusion GUIDELINES FOR THE ADMINISTRATION OF BLOOD PRODUCTS.
The Patient Blood Management Guidelines from the National Blood Authority of Australia is another series of documents worth looking at - it contains several important modules which have been reviewed and which act as successors to the 2001 NHMRC guidelines.
Treleaven, Jennie, et al. "Guidelines on the use of irradiated blood components prepared by the British Committee for Standards in Haematology blood transfusion task force." British Journal of Haematology 152.1 (2011): 35-51.
Aoun, Elie, et al. "Transfusion‐associated GVHD: 10 years’ experience at the American University of Beirut—Medical Center." Transfusion 43.12 (2003): 1672-1676.
Heddle, Nancy M., and Morris A. Blajchman. "The leukodepletion of cellular blood products in the prevention of HLA-alloimmunization and refractoriness to allogeneic platelet transfusions [editorial]." Blood 85.3 (1995): 603-606.
Sharma, R. R., and Neelam Marwaha. "Leukoreduced blood components: Advantages and strategies for its implementation in developing countries."Asian journal of transfusion science 4.1 (2010): 3.
Dzik, Walter H. "Leukoreduction of blood components." Current opinion in hematology 9.6 (2002): 521-526.
Corwin, Howard L., and James P. AuBuchon. "Is leukoreduction of blood components for everyone?." JAMA 289.15 (2003): 1993-1995.
Blajchman, M. A. "The clinical benefits of the leukoreduction of blood products."Journal of Trauma-Injury, Infection, and Critical Care 60.6 (2006): S83-S90.
Rosenbaum, Lizabeth, et al. "The reintroduction of nonleukoreduced blood: would patients and clinicians agree?." Transfusion 51.12 (2011): 2739-2743.
Bilgin, Y. M., L. M. van de Watering, and A. Brand. "Clinical effects of leucoreduction of blood transfusions." Neth J Med 69.10 (2011): 441-450.
Australian Red Cross - Blood Service Policy on "The Age of Red Cells"
Hess, John R. "Red cell changes during storage." Transfusion and Apheresis Science 43.1 (2010): 51-59.
Bennett-Guerrero, Elliott, et al. "Evolution of adverse changes in stored RBCs."Proceedings of the National Academy of Sciences 104.43 (2007): 17063-17068.
Hébert, Paul C., et al. "A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care." New England Journal of Medicine340.6 (1999): 409-417.
Carson, Jeffrey L., Paul A. Carless, and Paul C. Hébert. "Outcomes using lower vs higher hemoglobin thresholds for red blood cell transfusion." Jama 309.1 (2013): 83-84.
Lelubre, C., J. L. Vincent, and F. S. Taccone. "Red blood cell transfusion strategies in critically ill patients: lessons from recent randomized clinical studies." Minerva anestesiologica (2016).
Spahn, Donat R., and Lawrence T. Goodnough. "Alternatives to blood transfusion." The Lancet 381.9880 (2013): 1855-1865.