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Choosing Wisely Lists American Association of Blood Banks

American Association of Blood Banks

Five Things Physicians and Patients Should Question

Released April 24, 2014

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1

Don’t transfuse more units of blood than absolutely necessary.

Each unit of blood carries risks. A restrictive threshold (7.0-8.0g/dL) should be used for the vast majority of hospitalized, stable patients without evidence of inadequate tissue oxygenation (evidence supports a threshold of 8.0g/dL in patients with pre-existing cardiovascular disease). Transfusion decisions should be influenced by symptoms and hemoglobin concentration. Single unit red cell transfusions should be the standard for non-bleeding, hospitalized patients. Additional units should only be prescribed after re-assessment of the patient and their hemoglobin value.

2

Don’t transfuse red blood cells for iron deficiency without hemodynamic instability.

Blood transfusion has become a routine medical response despite cheaper and safer alternatives in some settings. Pre-operative patients with iron deficiency and patients with chronic iron deficiency without hemodynamic instability (even with low hemoglobin levels) should be given oral and/or intravenous iron.

3

Don’t routinely use blood products to reverse warfarin.

Patients requiring reversal of warfarin can often be reversed with vitamin K alone. Prothromobin complex concentrates or plasma should only be used for patients with serious bleeding or requiring emergency surgery.

4

Don’t perform serial blood counts on clinically stable patients.

Transfusion of red blood cells or platelets should be based on the first laboratory value of the day unless the patient is bleeding or otherwise unstable. Multiple blood draws to recheck whether a patient’s parameter has fallen below the transfusion threshold (or unnecessary blood draws for other laboratory tests) can lead to excessive phlebotomy and unnecessary transfusions.

5

Don’t transfuse O negative blood except to O negative patients and in emergencies for women of child bearing potential with unknown blood group.

O negative blood units are in chronic short supply due in part to overutilization for patients who are not O negative. O negative red blood cells should be restricted to: (1) O negative patients; or (2) women of childbearing potential with unknown blood group who require emergency transfusion before blood group testing can be performed.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

AABB is a not-for-profit association representing individuals and institutions involved in the field of transfusion medicine and cellular therapies. The association is committed to improving health by delivering standards, accreditation and professional educational programs that focus on optimizing patient and donor care and safety. AABB membership consists of approximately 1,800 institutions and 8,000 professional individuals, including roughly 1,600 physicians.

To learn more about the AABB, visit www.aabb.org.

How this list was created: Recommendations were drafted by a work group led by AABB Director Jeannie Callum, MD. Ten draft statements were edited by the AABB Clinical Transfusion Medicine Committee, chaired by Aaron Tobian, MD. In order to identify the top five statements, a random sampling of AABB physician members working in the field of transfusion medicine in hospitals, as well as all members of AABB’s Clinical Transfusion Medicine Committee, were asked to rate the 10 draft statements. On a Likert scale, participants were asked to “indicate the importance of including each of the following transfusion-related statements in the Choosing Wisely campaign promoting the appropriate use of health care resources.” The final top five statements were approved by the AABB Board of Directors.

AABB’s disclosure and conflict of interest policy can be found at www.aabb.org.

Sources

1.

Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, Rao SV, Roback JD, Shander A, Tobian AA, Weinstein R, Swinton McLaughlin LG, Djulbegovic B; Clinical Transfusion Medicine Committee of the AABB. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2012 Jul 3;157(1):49–58.

2.

AABB. Guidelines for patient blood management and blood utilization. Bethesda (MD): AABB; 2011. 52 p.

Lin DM, Lin ES, Tran MH. Efficacy and safety of erythropoietin and intravenous iron in perioperative blood management: a systematic review.Transfus Med Rev. 2013 Oct;27(4):221–34.

Friedman AJ, Chen Z, Ford P, Johnson CA, Lopez AM, Shander A, Waters JH, van Wyck D. Iron deficiency anemia in women across the life span.J Womens Health (Larchmt). 2012 Dec;21(12):1282–9.

3.

Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ, Svensson PJ, Veenstra DL, Crowther M, Guyatt GH; American College of Chest Physicians. Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e152S–84S.

4.

Napolitano LM, Kurek S, Luchette FA, Corwin HL, Barie PS, Tisherman SA, Hebert PC, Anderson GL, Bard MR, Bromberg W, Chiu WC, Cipolle MD, Clancy KD, Diebel L, Hoff WS, Hughes KM, Munshi I, Nayduch D, Sandhu R, Yelon JA; American College of Critical Care Medicine of the Society of Critical Care Medicine; Eastern Association for the Surgery of Trauma Practice Management Workgroup. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. Crit Care Med. 2009 Dec;37(12):3124–57.

5.

The Chief Medical Officer’s National Blood Transfusion Committee (UK). The appropriate use of group O RhD negative red cells. Manchester (UK): National Health Service; 2008. 4 p.