Improving practice in blood management

The contribution that blood transfusion has made to modern medicine can not be overstated. The procedure has saved many lives since the early nineteenth century, when the enabling discovery of distinct blood types was first made. However, blood and blood products are not only expensive, but they are also associated with significant patient risk. Avoidance of blood transfusion of donor blood is now recommended, whenever possible, therefore. Worthing Hospital’s, consultant anaesthetist and chair of its transfusion committee with a longstanding interest in the field of blood management, Dr Howard Wakeling, pointed out that donor blood is also scarce. He explained that the national blood transfusion website shows that for the more popular varieties of blood only three days worth of supplies are held nationally. “It would not take much of a drop in the donor pool for this to fall considerably, putting our blood stocks in a very precarious situation. Many hospitals now have an O-/O+ policy based on gender and age and O+ blood is often given to males, or women well above child-bearing age, instead of O- because the stocks as so poor,” he commented, adding: “Recently, with the threat of a flu epidemic, we have had to take a close look at the way we manage blood at the Trust and have been developing an action plan.” He explained that the Trust’s strategy to minimise donor blood transfusion has also been driven by a commitment to reduce the risk of potential complications. “A transfusion reaction can occur due to an error anywhere in the chain – from the taking of the blood, through to the laboratory, to actually administering the blood. There is also a risk of transmitting infection, including vCJD, and we know that immune modulation occurs when patients receive donor blood,” Dr Wakeling continued. He added that donor blood transfusion also increases the risk of SSIs in patients having surgery. Furthermore, it is known that cancer survival is adversely affected, while patients who receive donor blood also experience longer hospital stays. There are a variety of approaches, that can be taken pre-operatively, which can help minimise the need for blood donor transfusion, including:

• Iron therapy, Erythropoietin.
• Pre-donation.
• Stop anticoagulants.
• Stop anti-platelet drugs.
• Stop non-selective COX-2 NSAIDs.

However, Dr Wakeling highlighted the fact that, for iron therapy, anaemic patients need to be identified early on for this to prove a viable strategy. In addition, there are logistical issues associated with getting patients in several weeks before surgery, to provide a supply of their own blood for pre-donation. Intra-operatively, some of the ways that donor blood transfusion can be avoided include: