Cedars-Sinai Medical Center

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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF March 15, 2013 | Archived Issues

New Guidelines for Blood Transfusions Implemented

With a 200-year history that includes numerous safety advances, blood transfusion is one of medicine's oldest and most widely accepted practices. Yet recent studies have been unable to confirm the practice's benefit for many patients amid mounting evidence that it does more harm than good.

Patients who receive blood transfusions are at risk for adverse reactions that include transfusion-related acute lung injury, transfusion-transmitted infections, fluid overload, allergic reactions and hemolytic transfusion reactions.

Platelet Transfusion Guidelines

Platelet transfusions are the subject of a new alert being piloted on 4 South. Platelet transfusions are used in patients who have leukemia, are undergoing chemotherapy or have taken Plavix or aspirin when they arrive at the hospital bleeding or needing emergency surgery.

A Cedars-Sinai Medicine task force, which studied the appropriateness of blood transfusions, launched the alert, which pops up on CS-Link™ when physicians order platelet transfusions that do not meet the task force guidelines.

The guidelines, which are suggested but not mandated, recommend restricting platelet transfusions to patients with platelet dysfunction or patients with the following platelet counts:

  • Less than 10,000 u/L
  • Less than 20,000 u/L where there is evidence of bleeding, febrile neutropenia, sepsis or recent surgery
  • Less than 50,000 u/L prior to an invasive procedure
  • Less than 100,000 u/L with central nervous system bleeding or before invasive eye or brain surgery

"Evidence is accumulating to show that patients who receive blood transfusions do not have better outcomes, and often do worse, than similar patients who are not transfused," says Ellen Klapper, MD, medical director of Cedars-Sinai's Division of Transfusion Medicine. "Yet blood transfusion remains a standard accepted practice, as much an icon to medicine as apple pie is to America."

To ensure patients are spared the risks of unnecessary blood transfusions, Cedars-Sinai Medicine appointed a multidisciplinary task force which has developed best-practice guidelines in the appropriate use of blood transfusion therapy. The team reviewed published data and the recommendations of nine international bodies to develop guidelines for each blood component.

According to the new guidelines, red blood cell transfusions – the most common type – are appropriate but not mandated for patients with the following conditions:

  • Active bleeding
  • Hematocrit less than or equal to 21 percent or hemoglobin less than or equal to 7g/dL
  • Hematocrit less than or equal to 24 percent or hemoglobin less than or equal to 8g/dL for patients with coronary artery disease
  • Hematocrit less than or equal to 30 percent or hemoglobin less than or equal to 10g/dL for patients with subarachnoid hemorrhage with vasospasm (a serious type of stroke and complications)

The hemoglobin thresholds do not apply to patients experiencing active bleeding or symptoms related to hypoxemia, nor to patients for whom significant blood loss is anticipated, such as in the Emergency Department, operating rooms, procedure rooms or labor and delivery.

The C-S Medicine task force embedded the guidelines in an electronic alert on CS-Link™ that lets physicians know when an order for a red blood cell transfusion does not conform to trigger thresholds. Successfully piloted on three units before it was rolled out hospitalwide earlier this year, the alert does not prevent transfusion orders, but asks that physicians provide the reason they want to override the recommendations.

"These guidelines were developed after review of the best evidence in the literature," says Klapper, who served on the Cedars-Sinai Medicine task force, "but in no way do they replace clinical judgment."

The blood transfusion guidelines are among several best practices developed by Cedars-Sinai Medicine and are being implemented in collaboration with Nursing, Transfusion Medicine and EIS. Cedars-Sinai Medicine is under the direction of Glenn D. Braunstein, MD, vice president for Clinical Innovation.

Blood Transfusion Guidelines - 2013 (PDF)