7: Effective transfusion in surgery and critical care
- Transfusion of blood according to evidence-based guidelines improves patient safety and conserves precious blood supplies.
- The decision to transfuse should be based on clinical assessment as well as laboratory tests.
- The use of red cells in surgery has decreased but audits show many transfusions are inappropriate and there is wide variation in practice between clinical teams.
- Patient blood management programmes to improve surgical transfusion work across primary and secondary care and focus on:
- preoperative optimisation
- minimising blood loss at surgery
- avoiding unnecessary transfusion after surgery
- using blood conservation techniques (e.g. intraoperative cell salvage) and transfusion alternatives (e.g. antifibrinolytic drugs) where appropriate.
- Restrictive red cell transfusion strategies are safe in a wide variety of surgeries and in critical care patients.
- In the haemodynamically stable, non-bleeding patient transfusion should only be considered if the Hb is 80 g/L or less. A single red cell unit (or equivalent weight-related dose in children) may be transfused and the patient reassessed.
- Most invasive surgical procedures can be carried out safely with a platelet count above 50×109/L or international normalised ratio (INR) below 2.0.
- Successful transfusion support in major haemorrhage depends on the rapid provision of compatible blood, a protocol-driven multidisciplinary team approach and excellent communication between the clinical team and transfusion laboratory.
- The benefit of routinely transfusing fresh frozen plasma (FFP) in a fixed ratio to red cells (‘shock packs’) in traumatic haemorrhage is still uncertain but the CRASH-2 trial has proven that early administration of tranexamic acid reduces mortality.
- A restrictive red cell transfusion policy may be appropriate in many patients with acute upper gastrointestinal haemorrhage.
Blood transfusion can be life-saving and is a key component of many modern surgical and medical interventions. However, blood components are expensive, may occasionally have serious adverse effects and supplies are finite. Avoiding unnecessary and inappropriate transfusions is both good for patients and essential to ensure blood supplies meet the increasing demands of an ageing population. Clinical assessment, rather than laboratory test results, should be the most important factor in the decision to transfuse and evidence-based guidelines should be followed where available.
Surgical blood use in the UK has fallen by more than 20% since 2000, at least in part due to the various Better Blood Transfusion initiatives and increasing evidence for the benefits of restrictive transfusion policies. Less than 50% of red cell units are now given to surgical patients. However, audits show that 15–50% of red cell transfusions in a range of surgical procedures are inappropriate and there is still significant variation in the use of blood for the same operations. The fourth edition of the handbook defined good blood management as ‘management of the patient at risk of transfusion to minimise the need for allogeneic transfusion, without detriment to the outcome’. Multidisciplinary, evidence-based and patient-centred programmes to achieve this, often called patient blood management (PBM), are being set up across the UK and in other countries, such as Australia (http://www.nba.gov.au/guidelines/review.html).