posttransfusion testing

[etanous]

I have been requiring posttransfusion testing for PRBC's, platelets, and FFP for nearly twenty years. We are revising our blood bank policies and cannot find any standards for this in the Technical Manual or within the Standards booklet. Is this practice obsolete or am I looking in the wrong place? Thanks

[L106]

Can you please specify what "post-transfusion testing" you are doing? (Testing on the patient??? Or testing on the blood products???)

[etanous]

Testing on the patient. H/H post RBC transfusion, PT/PTT post FFP transfusion, Plt count post platelet transfusion.

[L106]

Basically, I do not believe this post-transfusion testing is "required". I might ask you, what do you do with that information? (If the answer is "collect it, but take no action", then it really is useless.) However, if you do 1- or 2-hour post-transfusion H&H's as part of your transfusion audits and report this info to the Transfusion Committee or some type of Quality Assurance Committee who reviews it and takes some type of action on "outliers", then that is a good practice to continue. (This is the type of thing that regulatory/accrediting agencies like.)

[LaraT23]

In my view, pretransfusion testing is the key thing. We want to make sure that the orders for products are within the criteria to transfuse. If you do post testing and say the patient is still bleeding or has gotten a lot of fluids and is dilutional, what will you do with that information? There are those patients who will not get a good correction of their coagulation testing with product transfusion, and that can be for a number of reasons. This information is really not of that much use if you ask me. Just my 2 cents.

[John C. Staley]

This is a new one on me. I have never heard of requiring routine post transfusion testing, but then just because I haven't heard of it........

[etanous]

Posttransfusion testing is a policy that has been set in stone in my hospital for nearly 20 years, probably driven by accrediting inspectors(JCAHO, CAP) who asked for evidence that a given transfusion helped/hurt the patient. It was handed off to me when I was made Medical Director, and I have staunchly defended it without asking why we did it..until now. We have pre-transfusion testing in place as well. All this data is collected and forwarded to our Quality committee. Frankly, little action has resulted over the years, so I'm not sure we'll continue with the posttransfusion testing.

I really appreciate the input from everyone.

[rravkin@aol.com]

Etanous,

Thank you for this interesting thread. You mention that "accrediting inspectors (JCAHO, CAP) who ask for evidence that a given transfusion helped/hurt the patient;" I would asy, what other means of evidence could your BB produce outside of post tranfusion testing. At my facility we give therapuetic transfusions to out patients regularly and do not perform any post transfusion testing. Does this mean that we are not addressing the inspectors need for evidence of a positive or negative impact of the transfused product on the patient's outcome? Is the mere fact that the patient was able to leave facility on thier own and go about thier day any indication of the impact on the patient? Is this evidence sought mainly for in-patients?

This is all very thought provoking and confusing because as I stated what other evedience can be acceptable to discern if the transfused product was beneficial or not. There are clear examples of when post transfusion testing is absolutely necessary but I'm sure that satisfying the acrediting agency inquest is not the priority in these cases; but as an off-shoot of the testing performed their question would be satisfyed.

Please let us know what you deside on and why if you can do so.

[AP44924]

One of the thing post transfusions are useful is ot see if the products ordered are really needed, or this is part of a routine practice. Doing a post platelet count is helpful in determining platelet refractoriness, H/H is useful to detrmine if transfusion is really helping patients. However, these are all let fo rthe attending to decide. We routinely as for post platelet count if platelt transfusions fail to "bump" the count up. H/H after evidence of an delayed immune reposne, but not routinely.

[heathervaught]

JAHCO was working on a system of evaluating 10 "Blood Management Performance Measures". One of them was "evaluation between multiple red cell transfusions". Yes, we all know that one unit should result in a 1 gram rise in a "normal" adult...but how many of your adult patienits are normal? (or how many of US are "normal"?!?!?!)

So the MD orders 2 units of RBCs for a patient with a hgb of 7. This should result in a hgb of 9, but what if the patient weighs 90 lbs and the donor of one of the units had a 58% hct? Maybe one unit would do the trick, so they recommend measuring patient hgb before the 2nd unit is given to evaluate if it is really needed.

I was visiting a hospital recently and their revised transfusion order form clearly stated that they would only issue one unit at a time...of course we are not talking about ER accident victims or bleeding surgical cases here, but the routine transfusions for the "diagnosis" of anemia.

[L106]

Within the last couple of years, we have done what heathervaught is describing. We put a big push on discouraging the common practice of automatically transfusing two units of donor red cells when a patient is anemic. Our pathologists, Lab Director, and hospital Administration recommend that an Hemoglobin be ordered after the transfusion of one unit and results evaluated before deciding whether a second donor unit needs to be transfused. (As Heather mentioned, ER trauma and surgery cases aren't under these guidelines.)

We have seen a decrease in the total number of transfusions, and this has resulted in somewhat of a cost-savings for the hospital.

[KKidd]

Does anyone have established criteria for obtaining PT/INR after transfusing a certain number of units of FFP? I have been thinking about talking to my Medical Director about checking the coags after 2 units unless the patient is a trauma.

:please::idea::plotting:

[John C. Staley]

It's amazing to watch the pendulum of practice swing. A while back (15 years give or take a few) the theory was that if the patient only needed one unit of blood then they really didn't need any and we were reviewing all single unit transfusions becasue they were "inappropriate". Now for the past few years the theory has changed to "if the patient only needs one unit then give them give them just one unit".

I wonder where we will go next.

:crazy:

[Malcolm Needs ☆]

It's amazing to watch the pendulum of practice swing. A while back (15 years give or take a few) the theory was that if the patient only needed one unit of blood then they really didn't need any and we were reviewing all single unit transfusions becasue they were "inappropriate". Now for the past few years the theory has changed to "if the patient only needs one unit then give them give them just one unit".

I wonder where we will go next.

:crazy:

I agree entirely with you John. I can also remember when giving one unit was frowned upon, so much so that it was regarded by same as an "in vivo experiment in antibody production."

I still wonder if a patient actually needs one unit of red cells, or whether they are basically trying to get the haemoglobin level up to the required level to get the patient out of hospital, and free up the bed (cardiac patients excepted).

As to what will happen next, there was talk (in the UK) of trying to work out the actual haemoglobin content of each individual unit of blood, and thus tailoring individual units to individual patients, depending on their body mass (amongst other parameters), but I think this idea has "died a death"; at least for the moment.

:eek:

[adiescast]

As to what will happen next, there was talk (in the UK) of trying to work out the actual haemoglobin content of each individual unit of blood, and thus tailoring individual units to individual patients, depending on their body mass (amongst other parameters), but I think this idea has "died a death"; at least for the moment.

:eek:

Wow, I think that may be taking this "personal medicine" idea a bit far. Can you imagine the work involved with that?

[Malcolm Needs ☆]

Wow, I think that may be taking this "personal medicine" idea a bit far. Can you imagine the work involved with that?

Yes, and I think that was why the idea has been abandoned (well that, and the fact that we have other thinks on our mind - vCJD????).

:D:D:D:D