|Year : 2020 | Volume
| Issue : 2 | Page : 125-129
A retrospective study on the use of blood products in the emergency department
Ajay Christopher1, Darpanarayan Hazra1, Sandhana Inian1, Jaquiline C Jose1, Angelene Eliseba Philip1, Sherin Susan Thomas1, Gina Mariyann Chandy1, Joy Mammen2
1 Department of Emergency Medicine, CMC, Vellore, Tamil Nadu, India
2 Department of Clinical Pathology, CMC, Vellore, Tamil Nadu, India
|Date of Submission||08-Jan-2020|
|Date of Decision||26-Jan-2020|
|Date of Acceptance||10-Feb-2020|
|Date of Web Publication||17-Apr-2020|
Dr. Ajay Christopher
Department of Emergency Medicine, CMC, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Blood product transfusion occurs in a significant percentage of patients admitted in the emergency department. Adverse reactions occurring in the setting of transfusion are associated with increased morbidity and mortality and inadvertent use of blood can do more harm to the patient than good. Analyzing blood transfusion data will help in formulating policies for transfusion in the emergency medicine department (ED). Aim: To characterize transfusion requirements in the ED. Materials and Methods: This was a retrospective cohort study analyzing patients who required blood or blood product transfusion in the ED in January 2017. Results: The total number of patients requiring blood transfusions in January 2017 in the ED was 214, of which 56% were men with an average age of 44 years. The overall total number of blood products requested was 272, among them 78.7% of the blood products were ultimately transfused. Hematological diseases (30.4%) were the most common indication for blood product transfusion, followed by trauma (20.1%) and upper gastrointestinal bleed (18.7%). Among the blood products requested, 52.2% were packed red cells, 34.5% were platelet-rich concentrate, 8.1% were fresh frozen plasma, 3.7% were cryoprecipitate, and 1.5% were whole blood. The mean hemoglobin level for transfusion was 6.7 g/dL. Only 1.4% of patients developed adverse reaction during transfusion. Among the total study population, 58.4% of the patients were admitted, 34% of the patients were discharged stable, 6.5% of the patients took discharge against medical advice, and 1.1% of them died in the ED. Conclusion: There is large quantity of blood being transfused in the emergency department, for various indications. There is a discrepancy between the quantity cross-matched and that which is transfused. As we have characterized the same, we can further look at the policy-making for blood transfusions in the ED.
Keywords: Blood and blood products, blood product transfusion in the ED, blood transfusion, blood transfusion in emergency department, blood transfusion reaction
|How to cite this article:|
Christopher A, Hazra D, Inian S, Jose JC, Philip AE, Thomas SS, Chandy GM, Mammen J. A retrospective study on the use of blood products in the emergency department. Curr Med Issues 2020;18:125-9
|How to cite this URL:|
Christopher A, Hazra D, Inian S, Jose JC, Philip AE, Thomas SS, Chandy GM, Mammen J. A retrospective study on the use of blood products in the emergency department. Curr Med Issues [serial online] 2020 [cited 2020 Nov 24];18:125-9. Available from: https://www.cmijournal.org/text.asp?2020/18/2/125/282789
| Introduction|| |
The approach to blood product transfusion in emergent situations varies with the clinical scenario. Special advances in science and implementation of legal regulations have made blood product transfusion reasonably safe; however, these resources are scarce and therefore should be limited to specific indications., On the other hand, blood product transfusion is also associated with well-documented side effects that include acute respiratory distress syndrome, transfusion-related acute lung injury (TRALI), and transfusion-associated circulatory overload (TACO). Development of these complications is associated with an increase in morbidity and mortality.,, Various studies have demonstrated that hemodynamically stable patients with slow-to-moderate bleeding, chronic bleeding, or contained blood loss can be managed conservatively with crystalloid to maintain intravascular volume, when necessary. Guidelines have been made based on several randomized trials and observational studies regarding blood product transfusion in the ED.,,, The most evidence-based, and physiologically sound, indications for blood product transfusion in the ED are to improve early hemostasis in trauma cases, resulting in less overall transfusion requirements, or reverse early tissue hypoperfusion, resulting in less subsequent organ failure, in hematological malignancies or upper gastrointestinal (UGI) bleeding.,, Clinical assessment of the urgency for red blood cell (RBC) transfusion will determine whether the patient receives unmatched emergency Type O, Rh-negative RBCs, group-specific RBCs, or fully cross-matched RBCs. Understanding the way emergency blood is utilized may provide the first step toward implementing local guidelines and monitoring that will encourage safe and effective use of emergency blood.,, To the best of our knowledge, this is the first study done in an ED setup in South India.
| Materials and Methods|| |
This was a retrospective cohort study conducted in a large tertiary care center in South India.
The study was conducted in the ED of Christian Medical College Hospital, Vellore. Our ED is a 49-bedded department and tends to about 300 patients per day including trauma and nontrauma patients.
All patients who required blood or blood product transfusion in the emergency department in January 2017 were included in the study.
The charts were reviewed, and the relevant details of history, clinical findings, laboratory, and radiological investigations were documented in the study form.
The number of blood products requested for each patients with a clinical diagnosis and ultimately transfused were noted. Any transfusion related reactions in these patients were documented separately.
This was a retrospective study, and therefore, we could not control exposure or outcome assessment, and instead relied on others for accurate recordkeeping.
Based on a previous study done in the West, the prevalence of blood product transfusion in a month is approximately 14%. Using that prevalence with 5% precision and 95% confidence interval, the required sample for the study was calculated to be 192 patients.
The associated complaints and comorbidities of the patients were noted. All patients had routine investigations based on the initial clinical diagnosis.
All categorical variables were expressed as frequencies and percentages. The data were extracted from ED triage software and Clinical Workstation and entered into Statistical Package for the Social Sciences (SPSS Inc., Released 2018. SPSS for Windows, version 18.104.22.168, Chicago, IL, USA). The data were summarized using mean with standard deviation (SD) for continuous variables and frequencies with percentages.
This study was approved by the institutional review board before the commencement of the study (IRB Min No.: 10957, dated November 7, 2017). Patient confidentiality was maintained using unique identifiers and by password-protected data entry software with restricted users.
| Results|| |
A total of 4322 patients presented to the ED in January 2017. All these patients were triaged into priority I, II, or III, based on their hemodynamic stability. After primary examination and care, routine investigations were done based on which decision of blood product transfusion was made by the ED clinician. This study population included a total of 214 (4.96%) patients who were ultimately transfused in the ED [Figure 1]. Around 56% of patients were male, thus suggesting that there was no gender preponderance with an average age of 44 (SD 16.9) years. Common comorbidities included diabetes mellitus, hypertension, ischemic heart disease, chronic obstructive pulmonary disease, chronic kidney disease (CKD), chronic liver disease, and anemia. The baseline characteristics are given in [Table 1].
Majority of the patients who were transfused presented with a hematological condition/malignancy, UGI bleed, trauma, gynecological condition as in ectopic pregnancy rupture, preoperative transfusion for surgery, CKD, anemia in failure, or trauma. The overall numbers of blood products ordered were 272, among them 214 blood products were ultimately transfused. This is represented in [Figure 2] and [Figure 3]. Majority of the patients, i.e., 118 (55.1%), who were transfused in the ED before admission or discharge had a mean hemoglobin of <6 g/dL. Majority of the platelet-rich concentrate was transfused in patients with platelet count of <5000/mm. Patients with platelet count from 5000 to 10000/mm were 7 in number as depicted in [Table 2]. A total of five patients with abnormal INR (>1.5) were transfused with fresh frozen plasma.
The indications for transfusion and which blood products were requested and ultimately transfused are given in [Figure 2]. The most common indication was hematological malignancies, followed by trauma and UGI tract bleeding. [Figure 3] elaborates the quantity of different blood products requested and the percentage of the total that has been transfused ultimately. Among the patients included in the study group, only 3 (1.4%) patients developed adverse reaction during transfusion and were managed conservatively and later blood product transfusion was restarted once they were symptom free.
After initial ED resuscitation and management, most patients, i.e., 125 (58.4%), were admitted into the ward or intensive care units under different medical or surgical units. The rest were either discharged (73; 34.1%) stable or discharged against medical advice (14; 6.5%) after initial ED care. There were 2 (0.9%) mortalities in the ED; both succumbed to major polytrauma despite resuscitation.
| Discussion|| |
Transfusion of blood and blood products is a lifesaving intervention in the ED. In comparison to other departments, there has been an increase in the usage of blood products in the ED.,,
The objectives of this study were to determine the prevalence of use of blood products in the ED, indications for transfusion, amount of blood products not transfused for patients after being requested from the blood bank, and the incidence of transfusion reactions.
The World Health Organization data indicate that 87.5% of developing countries collect less than half of the blood needed to meet the transfusion requirements of their populations. Studies on developing countries in Africa reported that most of the limited blood supplies are used for complications of pregnancy and childbirth, trauma, and severe anemia in childhood which may not always be necessary.,,
In various studies, it has been noted that the incidence of inadequate indication for blood transfusions in the ED is higher due to quick decision-making to initiate lifesaving treatment. However, these transfusions are associated with additional reactions that include febrile nonhemolytic transfusion reaction, allergic reaction, acute hemolytic reaction, anaphylactic reaction, TACO, TRALI, iron overload, delayed hemolytic reaction, and transfusion-associated graft versus host disease. Therefore, the decision to transfuse should not be taken lightly, as the risk of infection occurring secondary to transfusion is quite common., However, in our study population, there was only 1.4% transfusion-related reaction that could be probably explained by the fact that ours being a tertiary care center, the blood bank has a strict blood product collection, processing, and issuing protocol, thereby ensuring minimal adverse effects. It could also be due to the fact that this study population included patients from the ED alone and only a few of them had multiple pints of transfusion in the ED. Multiple guidelines for transfusion exist and the most commonly followed is the American Association of Blood Banks (AABB). According to AABB, adherence to a restrictive transfusion, i.e., hemoglobin of 7–8 g/Dl threshold in stable hospitalized patients, is advised. In patients with previous cardiovascular disease, we are to consider transfusion only in symptomatic patients or when hemoglobin is <8 g/dL and no blood product transfusion is advised in stable acute coronary syndrome patients. They also recommend that the decision on transfusion should be influenced by symptoms as well as hemoglobin concentration.,,,
Our center being a tertiary care center is well equipped with a blood bank and dedicated team of technicians and clinicians. Packed red cell concentrates were the most used component in our study population. The most common indications were hematological malignancies, UGI bleed, and trauma. This is the product of choice for correction of an isolated defect in oxygen-carrying capacity by raising the hemoglobin concentration in patients. In our study, one-third required blood product transfusion due to hematological malignancies. These patients can develop anemia, which is associated with decreased functional capacity and quality of life and shorter survival; anemia in such cases usually develops most often in response to chemotherapy. In view of acute anemia, these patients present with worsening anemic symptoms, hence the need for blood product transfusion.
Blood products were used for forty patients with UGI bleed. Various trials were done to evaluate the requirement of transfusion in the ED in such cases. Villanueva et al. categorized patients with UGI tract bleeding into restrictive (7 g/dL) and liberal groups (9 g/dL). They demonstrated that patients in the restrictive group had lower mortality versus the liberal. The rate of bleeding was also lower in the restrictive group with fewer products transfused and hence they recommended a transfusion threshold of 7 g/dL. However, there are limited data to determine the transfusion trigger in Indian patients suffering from UGI bleed; hence, further studies are warranted to determine the threshold of hemoglobin in such patients before posting for procedures.
In a trauma scenario, most physicians would agree that transfusion is required in the setting of life-threatening trauma with massive hemorrhage. The PROPPR trial evaluated the ratio of blood products in massive transfusion. A ratio of 1:1:1 of platelet-to-plasma-to-RBC transfusion strategy was associated with decreased mortality and morbidity and hence transfusion of only packed RBCs in a patient with trauma and hemorrhagic shock should be avoided.,
More than half (58.4%) of the patients in this study population were admitted for further evaluation and were probably transfused further in their course of hospital stay. This has not been included in the study. However, in the ED, it was noted that there was a significant mismatch in blood products ordered and ultimately transfused. Our study showed that there was a discrepancy in blood products requested and transfused in ED, so definite protocols need to be made to optimize blood product use in ED. Majority of the study population were admitted into the ward or intensive care units under different medical or surgical units. There were few 2 (0.9%) mortalities in the ED; both succumbed to major polytrauma despite resuscitation.
| Conclusion|| |
Blood products are an important resource that should not be wasted. Wastage may also be a reason for shortage of blood and its products in the blood bank, with other reasons being increasing demand and shortage of donors. There is large quantity of blood being transfused in the ED, for various indications. Evidence-based protocols for transfusion among Indian population in the ED are warranted to optimize utilization of such a precious resource.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Research quality and ethics statement
The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is IRB Min No.: 10957, dated November 7, 2017. We also certify that we have not plagiarized the contents in this submission and have done a plagiarism check.
| References|| |
Vincent JL, Sakr Y, Sprung C, Harboe S, Damas P, Sepsis Occurrence in Acutely Ill Patients (SOAP) Investigators. Are blood transfusions associated with greater mortality rates? Results of the sepsis occurrence in acutely Ill patients study. Anesthesiology 2008;108:31-9.
Beckwith H, Manson L, McFarlane C, Matthew J. A review of blood product usage in a large emergency department over a one-year period. Emerg Med J 2010;27:439e442. doi:10.1136/emj.2008.068650.
Wells AW, Mounter PJ, Chapman CE, Stainsby D, Wallis JP. Where does blood go? Prospective observational study of red cell transfusion in North England. BMJ 2002;325:803.
Chapman J. The national blood stocks project. Br J Haematol 2001;113 Suppl 1:58.
Hennino A, Bérard F, Guillot I, Saad N, Rozières A, Nicolas JF. Pathophysiology of urticaria. Clin Rev Allergy Immunol 2006;30:3-11.
Wallace EL, Churchill WH, Surgenor DM, Cho GS, McGurk S. Collection and transfusion of blood and blood components in the United States, 1994. Transfusion 1998;38:625-36.
Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, et al
. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013;368:11-21.
Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, et al
. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs. a 1:1:2 ratio and mortality in patients with severe trauma: The PROPPR randomized clinical trial. JAMA 2015;313:471-82.
Abhilash KP, Jeevan JA, Mitra S, Paul N, Murugan TP, Rangaraj A, et al
. Acute undifferentiated febrile illness in patients presenting to a tertiary care hospital in South India: Clinical spectrum and outcome. J Glob Infect Dis 2016;8:147-54.
Fernandes JP, Hazra D, David SN, Abhilash KP. Acute undifferentiated febrile illness in elderly: A clinical profile. Curr Med Issues 2019;17:103-7. [Full text]
Kelly SL, Reed MJ, Innes CJ, Manson L. A review of blood component usage in a large UK emergency department after implementation of simple measures. Emerg Med J 2013;30:842-5.
Miraflor E, Yeung L, Strumwasser A, Liu TH, Victorino GP. Emergency uncrossmatched transfusion effect on blood type alloantibodies. J Trauma Acute Care Surg 2012;72:48-52.
Kuhne CA, Zettl RP, Fischbacher M, Lefering R, Ruchholtz S. Emergency Transfusion Score (ETS): A useful instrument for prediction of blood transfusion requirement in severely injured patients. World J Surg 2008;32:1183-8.
Perel P, Clayton T, Altman DG, Croft P, Douglas I, Hemingway H, et al
. Red blood cell transfusion and mortality in trauma patients: Risk-stratified analysis of an observational study. PLoS Med 2014;11:e1001664.
Washington CW, Schuerer DJ, Grubb RL Jr., Platelet transfusion: An unnecessary risk for mild traumatic brain injury patients on antiplatelet therapy. J Trauma 2011;71:358-63.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]