Blood Product Overtransfusion Is a Global Issue: Here Are 5 Reasons the Practice Must Change

Intravenous drip in operation room, blood transfusion during surgery, hospital

(Adobe Stock 295359885 by motortion)

Transfusion—sharing blood intravenously—can be a life-saving procedure, particularly in situations where a patient has lost an enormous amount of blood. However, in many cases, transfusions are not prescribed based on scientific evidence. An International Consensus Conference on Transfusion Outcomes reported that 59% of transfusions were deemed inappropriate, and the need for another 29% was questionable.1 Only 11% could be supported by internationally accepted standards.¹

Overtransfusion causes multiple adverse outcomes, including increased mortality, immune suppression, respiratory failure, kidney failure, extended hospital and ICU stays, and long-term autoimmune disease changes in transfusion recipients.^2,3 It also increases the risk of hospital-acquired infections like methicillin-resistant Staphylococcus aureus(MRSA). Increased infection rates are also associated with the transfusion of old (greater than 28 days) stored blood.⁴

Alternatives to avoid unnecessary transfusions make sense.^2,3 Most hospital physicians do not think of reducing transfusions to reduce infections. Treatments of health care-associated infections (HAIs) are costly, with side effects such as Clostridioides difficile infections in the colon or intestine or other secondary infections. According to the CDC, nationally 1 in 31 patients acquire a HAI during a hospital stay.⁵ It stands to reason that infection preventionists are chasing zero infections, and reducing unnecessary transfusions will support that goal.

Overtransfusion is a national issue,⁶ as the culture of transfusion is entrenched in medical circles.² Here are 5 reasons the practice must change:

1. Evidence suggests that overtransfused patients do not do better: Dozens of academic articles agree that patients transfused unnecessarily do worse and die at higher rates than those patients who receive the appropriate amount or no transfusions. Numerous randomized controlled studies compare outcomes with more transfusions versus less, but none definitively show an advantage of more transfusion.^7,8

Nearly all indicate that those patients who are transfused less do equally well or, in most cases, better. Notably, studies at centers that practice bloodless medicine in patients who decline allogeneic transfusion have shown good clinical outcomes with less frequent occurrence of hospital-acquired infection.^9,10

2. Risks—including those of banked blood—are undercommunicated: Medicine knew the hepatitis virus was present in 10% or more US-collected blood as early as 1947 and up to 40% of other countries' blood supplies.¹¹ Public relations campaigns and paid donors continued in the face of many ill patients. Hundreds of thousands of patients died of hepatitis or liver cancer or, more recently, underwent expensive, debilitating, and costly liver transplantation.

Another undercommunicated risk is the side effects of the banked blood. Blood oxidizes as it ages, creating a new chemistry and biology that affects the recipient. This can lead to increased mortality, longer hospital and ICU stays, prolonged ventilation, universal immunosuppression (HAIs), renal dysfunction/failure, heart attacks, and more.

3. The blood’s role in oxygen delivery is misunderstood. Physicians remain focused on long-standing teaching that transfusions are good for patients. Few genuinely understand the role blood plays in critical oxygen delivery or how the aging of stored blood reduces its capacity to release oxygen. A laboratory hemoglobin number, the most commonly invoked transfusion trigger, has been shown not to have a scientific-direct relationship to oxygen delivery.¹²

4. Patient blood management works: Patient Blood Management (PBM) is based on the principle that the best blood you will ever have is your own. Hence, the disciples of PBM espouse that there are multiple ways to treat anemia (a must before invasive procedures), reduce bleeding (including new technologies that diagnose risks and causes of coagulation dysfunction), salvage and return the patient's own blood, and learn the biology of oxygen transport and utilization.¹³

PBM has led to dramatically improved patient outcomes, shortened hospital stays, reduced pneumonia, perioperative infections and HAIs, renal dysfunction and failure, heart failure, cancer recurrence, heart attacks, and death. It saves lives, involves patients in their own care, empowers them to make decisions, and saves billions of health care dollars.^3,14 It is a triple win.

5. Blood is a precious resource: The American Red Cross declared a blood crisis at the beginning of 2024, and blood supplies are still dangerously low.15 Blood products cost about 1 to 2% of a hospital’s budget, and blood acquisition remains the most significant expense for hospital blood banks. It’s simple math: if less blood is transfused inappropriately, it will be available for those truly needing a transfusion for survival. Blood supplies are a homeland security issue,¹⁶ and the United States has at most 3 days’ supply.¹⁷ Wastage puts us all at risk.

To end the global problem of overtransfusion, physicians, policymakers, and stakeholders must work together to communicate the risks of overtransfusion and the potential for a better path forward.² Healthcare professionals must actively communicate the benefits of patient blood management to hospital staff and patients. This collaborative effort will ultimately safeguard patients, improve hospital efficiency, and save blood supplies for those needing transfusions.

References

1. Shander A, Fink A, Javidroozi M, et al. Appropriateness of allogeneic transfusion: The International Consensus Conference on Transfusion Outcomes. Transfus Med Rev. 2011;25:232-246.
2. World Health Organization. The urgent need to implement patient blood management: policy brief. World Health Organization; 2021.
3. Hofmann A, Shander A, Blumberg N, et al. Patient blood management: Improving outcomes for millions while saving billions. What is holding it up? Anesth Analg. 2022;135:511-523.
4. Purvis TE, Goodwin CR, Molina CA, Frank SM, Sciubba DM. Transfusion of red blood cells stored more than 28 days is associated with increased morbidity following spine surgery. Spine. 2018;34:947-953.
5. Healthcare-associated infections: Patient Safety. Centers for Disease Control and Prevention. Accessed September 4, 2024. https://www.cdc.gov/healthcare-associated-infections/php/data/.
6. Jadwin DF, Fenderson PG, Friedman MT, et al. Determination of unnecessary blood transfusion by comprehensive 15-hospital record review. Jt Comm J Qual Patient Saf. 2023;49(1):42-52.
7. Carson JL, Triulzi DJ, Ness PM. Indications for and adverse effects of red-cell transfusion. N Engl J Med. 2017;377:1261-1272.
8. Carson JL, Stanworth SJ, Dennis JA, et al. Transfusion thresholds for guiding red blood cell transfusion. Cochrane Database Syst Rev. 2021;12
9. Frank SM, Pippa A, Sherd I, et al. Methods of bloodless care, clinical outcomes, and costs for adult patients who decline allogeneic transfusions. Anesth Analg. 2022;135:576-585.
10. Gemelli M, Italiano EG, Veronica Geatti V, et al. Optimizing safety and success: The advantages of bloodless cardiac surgery. A systematic review and meta-analysis of outcomes in Jehovah's Witnesses. Curr Probl Cardiol. 2024;49:102078.
11. Starr D. Blood: An Epic History of Medicine and Commerce. New York, NY: Alfred Knopf Publishing; 2002.
12. Zimmerman RA, Tsai AG, Intaglietta M, Tartakovsky DM. A mechanistic analysis of possible blood transfusion failure to increase circulatory oxygen delivery in anemic patients. Ann Biomed Eng. 2019;47:1094-1105.
13. Shander A, Hardy JF, Ozawa SS, et al. A global definition of patient blood management. Anesth Analg. 2022;135:476-488.
14. Leahy MF, Hofmann A, Towler S, et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: A retrospective observational study in four major adult tertiary-care hospitals. Transfusion. 2017;57:1347-1358.
15. American Red Cross declares emergency blood shortage, calls for donations during National Blood Donor Month. American Red Cross. Accessed September 4, 2024. https://www.redcross.org/about-us/news-and-events/press-release/2024/red-cross-declares-emergency-blood-shortage-calls-for-donations-during-national-blood-donor-month.html.
16. U.S. Government Accountability Office. Blood Supply: Briefing for the Subcommittee on Oversight and Investigations, Committee on Energy and Commerce, House of Representatives. Accessed September 4, 2024. https://www.gao.gov/products/gao-02-1095t.
17. America's Blood Centers. America's blood supply. Accessed September 4, 2024. https://americasblood.org/for-donors/americas-blood-supply/.