The “sticky” business of “adherence” to transfusion guidelines

Excerpt

Red blood cell, frozen plasma, and platelet transfusions are potentially life-saving therapies for critically ill patients. In fact, transfusion therapy has aided the development and permitted the use of many more aggressive therapies introduced in the past 50 years (i.e., chemotherapy, bone marrow and organ transplantation, heart surgery). However, the adverse effects of transfusion, including increased mortality, have also been recognized in the last 30 years. Thus, either “undertransfusion” or “overtransfusion” could result in adverse clinical outcomes. Therefore, clinicians continue to provide “appropriate” transfusion therapy by avoiding these extremes and balancing the risk–benefit ratio in favor of optimal transfusion practice for each patient. While undertransfusion has not been frequently reported in the literature, global application of transfusion thresholds derived from previous randomized trials in critical care (TRICC) has contributed to lowering transfusion thresholds in critical care patients [1, 2]. Conversely, overtransfusion has received considerable attention. This attention was largely associated with transmission of human immune-deficiency virus (HIV) and hepatitis through blood transfusions. A multifactorial and effective response to this event has led to a marked reduction in transfusion-transmitted viral infections over the last three decades. However, there remain significant “noninfectious” adverse effects associated with transfusions, including transmission of bacterial contaminants, transfusion-associated acute lung injury (TRALI), mistransfusion (transfusion of the wrong blood to the wrong patient), and transfusion-associated circulatory overload (TACO). In addition, there is increasing concern that transfusion, which had once been viewed as a life-saving therapy, may result in increased mortality [3]. Transfusion should thus not be undertaken unless the risks of not receiving the transfusion exceed the risks of its administration. …