Blood Product Transfusion in Emergency Departments: a Case-Control Study of Practice Patterns and Impact on Outcome by Alexander Beyer
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Presentation delivered at the second annual William G. Barsan Emergency Medicine Research Forum, Ann Arbor, April 12, 2017.
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Blood Product Transfusion in Emergency Departments: a Case-Control Study of Practice Patterns and Impact on Outcome by Alexander Beyer
- 1. Alexander Beyer, Ryan Rees, Christopher Palmer, Brian T Wessman, Brian M. Fuller
- 2. None
- 3. The effectiveness of transfusions has been studied in the ICU setting and has led to the development of evidence based guideline recommendations1. Based on this ICU evidence a restrictive stretegy of RBC transfusion for < 7 g/dL has been shown to be as effective as a liberal transfusion strategy of >10g/dL in ICU patients, except possibly in patients with myocardial ischemia.2 There is little evidence on the effect of transfusion practices on patient outcomes in the Emergency Department Setting. 1. Napolitano LM, Kurek S, Luchette FA, Anderson GL, Bard MR, Bromberg W, et al. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. J Trauma. 2009;67(6):1439-42. 2. Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340(6):409-17.
- 4. Retrospective Case Control Population: Adult Patients seen in a single urban teaching hospital who: Did not have multi-system trauma Were not discharged, did not die, and were not transferred Did not have a Hb < 7 Matching: 1 to 1 a priori matching strategy between ED transfusion vs Not Admission diagnosis Hemoglobin (+/- 1 g/ dL) Age (+/- 5 yrs) Gender Primary Outcome: Development of acute respiratory failure, need for ICU admission, development of ARDS within 3 days of presentation.
- 5. 204 patients matched ED Transfusion group had higher rates of : ICU admission, INR, Cirrhosis, Lactate, CVC Catheter use, IV Fluid administration ED Transfusion: 60.8% PRBC, 31.4% FFP, 26.5% Platelets During the first 24 hrs after admission, controls were transfused PRBC more often than cases. (43.1% vs 23.5%) Primary Outcome Occurred in 12.7% of controls and 13.7% of cases. No difference in mortality between the groups
- 8. There was a significant discordance between guideline indications for PRBC transfusion, and the observed practice. In regards to platelet transfusion, 24.1% of all patients were transfused due to neurologic injury with a mean platelet count of 197,000. There was NO significant difference between both groups in regards to the primary outcome, despite the cases being objectively sicker. Transfusion therapy could be clinically safer than previously described ED transfusion may mitigate further organ failure ED transfusion may limit overall transfusion requirements
- 9. Dr Brian Fuller Dr Brian Wessman, Dr Christopher Palmer, and Ryan Rees Dr Laura Hopson Twitter: @ratherbeclimbEM
Editor's Notes
- Not sure I would make “emergency departments” plural, since this was single center. Since this work was done at WashU, you should put a WashU logo somewhere on this title slide as well.
- Transfusions Have Consequences TACO TRALI Hemolytic reactions Fever Allergy Infection Embolism Maybe not pertinent to your talk, but I always tell our fellows and residents to keep in mind the inclusion and exclusion criteria of the TRICC trial. It excluded like 85% of the screened patients, so you have to know how this applies to your individual patient when deciding about transfusion.
- Reasoning for Hb< 7 as an exclusion criteria. Very little clinical equipoise on whether togive a transfusion or not. Was also practical ; ) Why Not Propensity Matching? Initially had limited data for matching, as I had to pull other data from charts, this limited matching as initially there was 2257 patients prior to exclusion and I ended up matching a total of 204 patients. Why Outcome?- account for potential complications associated with transfusion Why outcome at 3 days?? Because you need a temporal link to ED transfusion, and “delayed TRALI syndrome” has been described at 72 hours, so we went with that. That’s a citation in your manuscript.
- Cases were presumably sicker, however, did not have worse outcomes
- ED Transfusions may be beneficial if they result in early hemostasis resulting in less transfusion requirements, or if they reverse early tissue hypoperfusion, resulting in less organ failure ED Transfusions may be harmful if it promotes transfusion related complications In platelets, recent trial data does not support practice of giving patients in setting of anti platelet medications