Kevin P Seitz1, Jonathan E Sevransky, Greg S Martin, John D Roback, David J Murphy. 1. 1Department of Medicine, University of Washington, Seattle, WA. 2Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Emory University, Atlanta, GA. 3Emory Critical Care Center, Emory University, Atlanta, GA. 4Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Emory University, Atlanta, GA.
Abstract
OBJECTIVE: Research supports the efficacy and safety of restrictive transfusion protocols to reduce avoidable RBC transfusions, but evidence of their effectiveness in practice is limited. This study assessed whether admission to an ICU with an restrictive transfusion protocol reduces the likelihood of transfusion for adult patients. DESIGN: Observational study using data from the multicenter, cohort Critical Illness Outcomes Study. Patient-level analyses were conducted with RBC transfusion on day of enrollment as the outcome and admission to an ICU with a restrictive transfusion protocol as the exposure of interest. Covariates included demographics, hospital course (e.g., lowest hematocrit, blood loss), severity of illness (e.g., Sequential Organ Failure Assessment score), interventions (e.g., sedation/analgesia), and ICU characteristics (e.g., size). Multivariable logistic regression modeling assessed the independent effects of restrictive transfusion protocols on transfusions. SETTING: Fifty-nine U.S. ICUs. PATIENTS: A total of 6,027 adult ICU patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 59 study ICUs, 24 had an restrictive transfusion protocol; 2,510 patients (41.6%) were in an ICU with an restrictive transfusion protocol. The frequency of RBC transfusion among patients with severe (hematocrit, < 21%), moderate (hematocrit, 21-30%), and mild (hematocrit, > 30%) anemia in restrictive transfusion protocol ICUs was 67%, 19%, and 4%, respectively, compared with 60%, 14%, and 2% for those in ICUs without an restrictive transfusion protocol. Only 27% of transfusions were associated with a hematocrit less than 21%. Adjusting for confounding factors, restrictive transfusion protocols independently reduced the odds of transfusion in moderate anemia with an odds ratio of 0.59 (95% CI, 0.36-0.96) while demonstrating no effect in mild (p = 0.93) or severe (p = 0.52) anemia. CONCLUSIONS: In this sample of ICU patients, transfusions often occurred outside evidence-based guidelines, but admission to an ICU with an restrictive transfusion protocol did reduce the risk of transfusion in moderately anemic patients controlling for patient and ICU factors. This study supports the effectiveness of restrictive transfusion protocols for influencing transfusions in clinical practice.
OBJECTIVE: Research supports the efficacy and safety of restrictive transfusion protocols to reduce avoidable RBC transfusions, but evidence of their effectiveness in practice is limited. This study assessed whether admission to an ICU with an restrictive transfusion protocol reduces the likelihood of transfusion for adult patients. DESIGN: Observational study using data from the multicenter, cohort Critical Illness Outcomes Study. Patient-level analyses were conducted with RBC transfusion on day of enrollment as the outcome and admission to an ICU with a restrictive transfusion protocol as the exposure of interest. Covariates included demographics, hospital course (e.g., lowest hematocrit, blood loss), severity of illness (e.g., Sequential Organ Failure Assessment score), interventions (e.g., sedation/analgesia), and ICU characteristics (e.g., size). Multivariable logistic regression modeling assessed the independent effects of restrictive transfusion protocols on transfusions. SETTING: Fifty-nine U.S. ICUs. PATIENTS: A total of 6,027 adult ICU patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 59 study ICUs, 24 had an restrictive transfusion protocol; 2,510 patients (41.6%) were in an ICU with an restrictive transfusion protocol. The frequency of RBC transfusion among patients with severe (hematocrit, < 21%), moderate (hematocrit, 21-30%), and mild (hematocrit, > 30%) anemia in restrictive transfusion protocol ICUs was 67%, 19%, and 4%, respectively, compared with 60%, 14%, and 2% for those in ICUs without an restrictive transfusion protocol. Only 27% of transfusions were associated with a hematocrit less than 21%. Adjusting for confounding factors, restrictive transfusion protocols independently reduced the odds of transfusion in moderate anemia with an odds ratio of 0.59 (95% CI, 0.36-0.96) while demonstrating no effect in mild (p = 0.93) or severe (p = 0.52) anemia. CONCLUSIONS: In this sample of ICU patients, transfusions often occurred outside evidence-based guidelines, but admission to an ICU with an restrictive transfusion protocol did reduce the risk of transfusion in moderately anemicpatients controlling for patient and ICU factors. This study supports the effectiveness of restrictive transfusion protocols for influencing transfusions in clinical practice.
Authors: Jeffrey L Carson; Michael L Terrin; Helaine Noveck; David W Sanders; Bernard R Chaitman; George G Rhoads; George Nemo; Karen Dragert; Lauren Beaupre; Kevin Hildebrand; William Macaulay; Courtland Lewis; Donald Richard Cook; Gwendolyn Dobbin; Khwaja J Zakriya; Fred S Apple; Rebecca A Horney; Jay Magaziner Journal: N Engl J Med Date: 2011-12-14 Impact factor: 91.245
Authors: Steven M Frank; Will J Savage; Jim A Rothschild; Richard J Rivers; Paul M Ness; Sharon L Paul; John A Ulatowski Journal: Anesthesiology Date: 2012-07 Impact factor: 7.892
Authors: Aryeh Shander; Axel Hofmann; Sherri Ozawa; Oliver M Theusinger; Hans Gombotz; Donat R Spahn Journal: Transfusion Date: 2009-12-09 Impact factor: 3.157
Authors: Victor A Ferraris; Jeremiah R Brown; George J Despotis; John W Hammon; T Brett Reece; Sibu P Saha; Howard K Song; Ellen R Clough; Linda J Shore-Lesserson; Lawrence T Goodnough; C David Mazer; Aryeh Shander; Mark Stafford-Smith; Jonathan Waters; Robert A Baker; Timothy A Dickinson; Daniel J FitzGerald; Donald S Likosky; Kenneth G Shann Journal: Ann Thorac Surg Date: 2011-03 Impact factor: 4.330
Authors: Nareg H Roubinian; Gabriel J Escobar; Vincent Liu; Bix E Swain; Marla N Gardner; Patricia Kipnis; Darrell J Triulzi; Jerome L Gottschall; Yan Wu; Jeffrey L Carson; Steven H Kleinman; Edward L Murphy Journal: Transfusion Date: 2014-08-18 Impact factor: 3.157
Authors: Jonathan E Sevransky; William Checkley; Phabiola Herrera; Brian W Pickering; Juliana Barr; Samuel M Brown; Steven Y Chang; David Chong; David Kaufman; Richard D Fremont; Timothy D Girard; Jeffrey Hoag; Steven B Johnson; Mehta P Kerlin; Janice Liebler; James O'Brien; Terence O'Keefe; Pauline K Park; Stephen M Pastores; Namrata Patil; Anthony P Pietropaoli; Maryann Putman; Todd W Rice; Leo Rotello; Jonathan Siner; Sahul Sajid; David J Murphy; Greg S Martin Journal: Crit Care Med Date: 2015-10 Impact factor: 7.598
Authors: Howard L Corwin; Andrew Gettinger; Ronald G Pearl; Mitchell P Fink; Mitchell M Levy; Edward Abraham; Neil R MacIntyre; M Michael Shabot; Mei-Sheng Duh; Marc J Shapiro Journal: Crit Care Med Date: 2004-01 Impact factor: 7.598
Authors: Tasnim Sinuff; John Muscedere; Neill K J Adhikari; Henry T Stelfox; Peter Dodek; Daren K Heyland; Gordon D Rubenfeld; Deborah J Cook; Ruxandra Pinto; Venika Manoharan; Jan Currie; Naomi Cahill; Jan O Friedrich; Andre Amaral; Dominique Piquette; Damon C Scales; Sonny Dhanani; Allan Garland Journal: Crit Care Med Date: 2013-11 Impact factor: 7.598
Authors: William Checkley; Greg S Martin; Samuel M Brown; Steven Y Chang; Ousama Dabbagh; Richard D Fremont; Timothy D Girard; Todd W Rice; Michael D Howell; Steven B Johnson; James O'Brien; Pauline K Park; Stephen M Pastores; Namrata T Patil; Anthony P Pietropaoli; Maryann Putman; Leo Rotello; Jonathan Siner; Sahul Sajid; David J Murphy; Jonathan E Sevransky Journal: Crit Care Med Date: 2014-02 Impact factor: 7.598
Authors: Ruqayyah J Almizraq; Philip J Norris; Heather Inglis; Somaang Menocha; Mathijs R Wirtz; Nicole Juffermans; Suchitra Pandey; Philip C Spinella; Jason P Acker; Jennifer A Muszynski Journal: Blood Adv Date: 2018-09-25