Five transfusion practices one must avoid

Anemia is common, presenting in approximately one-third of patients undergoing elective surgery. There is often the misconception that anemia is harmless, when, in fact, it is independently associated with significant morbidity and mortality that can be as high as 30-40% in certain patient populations. Treatment of anemia improves patient readiness for surgery, aids in management of comorbid conditions, decreases length of stay and readmission rates, and reduces transfusion risks. Treatment modalities may include nutritional supplementations, such as iron, B12 and folate, changes in medication, management of chronic inflammatory conditions or previously undiagnosed malignancy, or other interventions based on the etiology.

• To avoid iatrogenic anemia, don't order blood tests unless they are clinically indicated or necessary for diagnosis or management.

Up to 90% of patients become anemic by day 3 in the intensive care unit. Although laboratory testing can aid in diagnosis, prognosis and treatment of disease, a significant number of tests are inappropriate or unnecessary. Anemia secondary to iatrogenic blood loss causes an increased length of stay and mortality. Increased phlebotomy for laboratory testing also increases the odds for transfusion and its associated risks. Unnecessary laboratory testing adds to the cost of care through laboratory test charges and also by increasing downstream costs due to unnecessary interventions, prescriptions, etc. Thus the judicious use of laboratory testing is recommended, and testing should not be performed in the absence of clinical indications.

• Avoid plasma transfusion if there is neither active bleeding nor laboratory evidence of coagulopathy especially when antifibrinolytic drugs are available to minimize surgical bleeding.

Antifibrinolytic pharmacologic therapy has been shown to reduce blood loss and transfusion requirements in orthopedic and cardiovascular surgeries. Early administration of tranexamic acid, specifically within three hours, in trauma and obstetric hemorrhage significantly reduces mortality and bleeding.

• To manage surgical bleeding, use antifibrinolytic drugs (e.g., tranexamic acid) rather than blood transfusion when possible. Avoid transfusion when antifibrinolytic drugs are available to minimize surgical bleeding.

Antifibrinolytic pharmacologic therapy has been shown to reduce blood loss and transfusion requirements in orthopedic and cardiovascular surgeries. Early administration of tranexamic acid, specifically within three hours, in trauma and obstetric hemorrhage significantly reduces mortality and bleeding.

• In nonemergent settings, avoid transfusion when other treatments are available. Discuss alternative strategies during the informed consent process.

Avoid transfusion, outside of emergencies, when alternative strategies are available as part of informed consent; make discussion of alternatives part of the informed consent process.

Informed choice/consent regarding transfusion and other effective methods should be standardized and consistently delivered. Throughout the world, there is wide variation among medical practitioners and hospitals with regard to medical knowledge about the true risks of transfusion, alternatives to transfusion, and the delivery of this information to patients. Outside of the truly emergent clinical situation, transfusion should be avoided or limited when other interventions are available. Alternative strategies include, but are not limited to pharmacologic agents, cell salvage, normovolemic hemodilution and minimally-invasive surgical techniques.

For further reference log on to:

http://www.choosingwisely.org/clinician-lists/sabm-avoid-transfusion-when-alternative-strategies-are-available/