News of two recent studies came across my desk during the past month that might have an impact on procedures in the blood bank—and, indirectly, on the economics of the industry.
A nationwide, multi-site study, published earlier this month in JAMA, compared two different methods of blood transfusion, and found that one approach gave trauma patients with significant bleeding a better chance of survival within the first 24 hours.
The study compared two transfusion techniques: One gave patients equal ratios of plasma, platelets, and red blood cells; the other gave patients a ratio that had equal numbers of plasma and platelets, but twice as many red blood cells. The results: subjects in the equal-ratio group were more likely to stop bleeding, and had a better chance of surviving, in the first 24 hours, compared to patients in the other group. The two groups had the same overall level of survival at 30 days.
Death from loss of blood within the first 24 hours significantly decreased in the equal-ratio group: 9.2 percent, compared with 14.6 percent in the unequal-ratio group. In addition, bleeding stopped in 86 percent of patients in the equal-ratio group, compared with 78 percent in the unequal-ratio group.
Some researchers have expressed concern that the equal-measure blood would cause increased inflammation, and might lead to problems such as organ failure, infection and blood clots. However, the study found no evidence that equal-ratio patients had more inflammation-related problems.
According to a press release that I received about this study, equal-ratio transfusion, first developed by the U.S. military to treat soldiers injured in Afghanistan and Iraq, is now used in most civilian hospitals in the U.S. Is it used by your institution?
A second study found that heart surgery patients underwent what the researchers considered a surprisingly high number of blood tests before and after surgery, and that, because of subsequent anemia, a higher number of tests correlated with a more frequent need for blood transfusions and with transfusion-associated complications.
The study of some 1,900 heart-surgery patients at the Cleveland Clinic in 2012 showed that they had more than 221,000 blood tests—an average of 116 tests per patient. The median amount taken from patients throughout the entire hospital stay was 454 milliliters of blood.
“We were astonished by the amount of blood taken from our patients for laboratory testing. Total phlebotomy volumes approached one to two units of red blood cells, which is roughly equivalent to one to two cans of soda,” study leader Dr. Colleen Koch of the Cleveland Clinic said. “Prior research shows that patients who receive blood transfusions during heart surgery have more infections after surgery, spend more time on the ventilator, and die more frequently—even after adjusting for how sick they were prior to surgery. Patients should inquire whether smaller-volume test tubes could be used for the tests that are deemed necessary.
Every attempt should be made to conserve the patient’s own blood.”
The studies are food for thought, as blood banks seek continually to improve blood product safety and to adjust to the falling number of transfusions in the United States—from about 15 million annually a decade ago to about 11 million in 2013, according to the American Red Cross. The decrease in revenue, and the subsequent need to reduce costs, while at the same time increasing efficiency and safety—that poses a significant challenge for most blood banks and the institutions affiliated with them. If the results of the Cleveland Clinic study, especially, lead to fewer blood tests for heart surgery patients, and fewer transfusions, that will put more pressure on blood banks.
In a sense, the blood bank industry is locked in a paradox: it is forever seeking ways to reduce the need for its product. Or am I over-simplifying a complex situation? Please give me your feedback, blood bankers, at [email protected].
