Transcript Transfusion Medicine Reviews April 2009 batch

Transfusion Medicine Reviews
April 2009 batch
Plus
“The difficult conversation”
“Transfusion medicine decisions
are easy, it is the ordering
physicians that are the most
difficult thing about transfusion
medicine.”
Conversation 1
• The technologist receives an order for 4 units
of FFP for an INR 1.29 for a patient with an
intracranial hemorrhage
• You call Dr. Brain to explain why the patient
will not benefit from the product
• He cuts you off after the first few words about
the clotting factors and the relationship with
the INR and why FFP will not help him
Conversation 1
• “I need it to be normal – she is coning”
• “The other neurosurgeons will think I am
crazy for not giving FFP”
• “She is going to die if we do not stop the
bleeding”
• “She is only 32 years old”
The worried MD
Conservation 2
• Resident on ortho orders 2 units of blood for
transfusion for an immediate post-op orthopedic case
(total knee replacement)
• The only hemoglobin is from 2 weeks ago in preadmission (167 g/L)
• The patient has a pacemaker set at 60 and he is at 80
bpm
• MD transfusing because the BP is 100/50 and the
patient has a ‘cardiac problem’
• Good urine output
• Regional anesthesia + gabapentin
• Refuses to do a pre-transfusion STAT hemoglobin
Conservation 2
• “Do you know who I am? – I am an
orthopedic surgeon”
• “You can not talk to me like this – I am
an orthopedic surgeon”
• “We can’t wait for a repeat hemoglobin
– he has a ‘cardiac’ problem and is
hypotensive
The god-complex MD
Conversation 3
• Patient with ITP is taken to the OR for
an ascending aorta repair
• Pre-op platelet count is 146 one week
before
• Call from the OR from anesthesia they
want 2 sets of platelets for management
of bleeding
• Patient is still ‘on-pump’
Conversation 3
• You ask them to do a platelet count preand post to see if this ITP patient
responds to platelets at all
• The anesthesiologist refuses – says he
is too busy to do this
• He hangs up on you
The irrational MD
Conversation 4
• 28 year old MVA with massive out of control
bleeding with thoracic and pelvic injuries
–
–
–
–
–
Hypothermic
Acidotic
Coagulopathic (INR 2.7)
Hypofibrinogenemic (0.8 g/L)
Anemic (57 g/L)
• They want r7a now! (although they have not
read any of the papers)
Conversation 4
• You try to explain that r7a is of
questionable value with good baseline
coagulation factors – probably
completely useless at this point with this
patient’s status
• “Should we just let the patient bleed to
death then??”
The hard-to-refuse &
no-time-to-talk MD
Fire-side chat
• The most difficult conversations are with MDs you
have never met face-to-face
• The first few years – your whole goal should be to
avoid difficult conflicts
– You will have decades to improve transfusion practice
– Inappropriate transfusions are common - half of plasma and
a quarter of RBCs – they have been going unnoticed for a
few decades – no rush
• The most likely consequence of a difficult
conversation = that MD will NEVER speak to you
again
Fire-side chat
• New staff MDs are the most difficult
– They come with baggage
– Often trained in the US – never questioned before
• Don’t take it personally
– Try to fall back asleep after – re-running the conversation
over and over in your head is not useful
• Give them an ‘easy out’ compromise to ‘save face’
– “Let’s try correcting the temperature, acidosis, coagulopathy
and platelet count first”
– “If that does not work, then I think you are right, let’s try r7a”
My approach
• Prevention
• Case related negotiation
• Re-grouping after a nasty encounter
– Email
– Coffee
– Medical literature
– Rounds
– Keep the lines of communication open
Prevention is the best medicine
• You need to do the rounds circuit for all the
subspecialties
– The more they see you the more they will trust
your judgment
– Don’t expect trust without hard work
• Academic detailing of any obliging MD
– Can we meet for coffee next week?
– I will look up some papers for you and bring them
• Ask for input when developing protocols
Prevention
• Send follow-up emails with key papers
– Very appreciated
– Prevents the next nasty conversation
• Send out key papers to subspecialties by email
spontaneously
– Very effective
• Get really good audit data for bigger problems –
come to them with data
– Then they may listen
• Try to be really helpful when they come to you with
problems or new initiatives
Prevention
• Send out yearly transfusion data
–
–
–
–
Reaction statistics
Utilization figures
Audit results
They will save your email and connect back to you
with any transfusion problems (you will get replies
to this email for years)
• Expedite consults from your high blood users
• Speak at retreats for your different
departments (including nursing conferences)
Really difficult residents
• Ask their supervisor for a week rotation
in blood bank for ‘extra help’
– Provide a binder of transfusion literature
– Intensive training x 5 days
– Don’t let them leave your hospital to go
and terrorize some other transfusion
medicine MD
Case based negotiation
• I haven’t perfected this encounter
– Not sure if you can
• Pick your battles carefully – it may take 10 years for
the MD to speak to you again if it goes badly
• Take the tactic “this patient seems to be causing
some problems – I just wanted to make sure we had
everything covered in the blood bank”
• Use first names – diffuses the situation and makes it
friendly
• Take them to the internet transfusion guidelines
– They will trust you more if they see it in writing
Really dangerous transfusion
decision that you can not avert
• Resident
– Easier – escalate to the staff MD
• Staff MD to department chief
– Not so easy
– If it is clear they will never back down…”we never refuse
blood even if it is outside the guidelines…we just put in a
comment in the blood bank information system that we
issued it outside of the guidelines and that you were aware.
I am going to call the blood bank now. They will call you
when the product is ready”
– 90% of the time they do NOT take the product
– ‘Easy out’ – they back down without you ‘knowing’
TMR April 2009
The three best articles from the
final quarter of 2008
The articles
• PLEX after infusion of
RBC ‘rich’ stem cells
• RCT of granulocyte
transfusions
• TT- Babesia 97-07
• Blood transfusion and
VTE
• DDAVP meta-analysis
• Freezed-dried plasma &
MVA pigs
• PINT – longterm followup
• G-6DP blood for
exchange transfusion
• ICU patients and CMV
infection
• Interruptions in the OR
during blood checks
• Strawberry lollipops for
DSMO-induced nausea
• Review article on PCCs
• Uncrossmatched RBCs
increase mortality
PINT study thresholds
Methods
• Patients were assessed using standard clinical tools
for measurement of neurological development
(measures of cerebral palsy, visual or hearing
impairment, and infant development)
• The primary outcome of the study was a composite
score of death or any single measure of neurocognitive deficit
• Those who assessed the children where blinded to
the original allocation
• The study was powered to detect a 13% absolute
difference in outcomes with 95% confidence
Baseline data
Primary outcome
Their take on their results
• “Our study provides some weak evidence of
benefit from a higher hemoglobin threshold
for transfusion primarily through a secondary
analysis of cognitive delay. Because this
finding combines a protocol-defined analysis
of borderline statistical significance with a
posthoc analysis of both clinical and statistical
significance, it is not conclusive in its own
right but is hard to dismiss as simply the play
of chance.”
Second paper suggests
liberal may better
• Pediatrics 2005; 115: 1685-91.
• N=100 (much smaller)
• Birth weights of 500 to 1300 g into a randomized
clinical trial comparing 2 levels of hematocrit threshold
• Infants in the restrictive-transfusion group were more
likely to have:
– intraparenchymal brain hemorrhage
– periventricular leukomalacia
– more frequent episodes of apnea ( mild and severe episodes)
What do you do at your hospital
while you await the next trial 10
years from now?
Hi Jeannie
I think our group is holding steady for now but I am
happy to explore that with the group in the coming
months.
I will tell you there are some preliminary discussions
taking place to try for another RCT that is powered
for 2 year outcome and be done internationally
(n=1200). I will have more details in the coming
weeks.
Liz
Error rates by location
Unit Transfusion
Location
Operating room
Emergency
Intensive care
Medical/surgical ward
Out patients
Rate
1 in 32
1 in 46
1 in 71
1 in 99
1 in 134
Denominator
18,203
6,829
30,546
36,546
669
Out patient procedures 1 in 341
Obstetrics
1 in 1,369
Denominator 123,766 of 187,297 (66%) products issued
32,690
1,369
Dr. Transfusalot in the
operating room with the blood
Who
Nurses/Anesthesiologists
Where
Operating room
What
Properly labeled blood to wrong patient
Why
Patient identification band not checked
When
During uncontrolled situation
ABO-Fatalities from SHOT
• 6 of 8 transfusion fatalities reported to
SHOT occurred in the operating room
– Janatpour, Kim A., et al. Clinical Outcomes of
ABO-Incompatible RBC Transfusions. American
Journal of Clinical Pathology 2008;129:276-281.
Interruptions and blood transfusion checks:
Lessons from the simulated operating room.
Liu D, Grundgeiger T, Sanderson PM, et al. Anesth Analg 2009; 108: 219-222.
• 12 anesthesiologists from the Royal Adelaide
Hospital and The University of Queensland
• Intentionally distracted at the time of arrival of
blood for a simulated ‘bleeding patient’
• They were given 180 seconds to detect a
transfusion error - blood hung by the nurse
without a pre-transfusion check
3 groups
•
•
•
•
Head mounted device – none
Head mounted device – near
Head mounted device – far
Plus the regular operating room
displays
Interruptions and blood transfusion checks:
Lessons from the simulated operating room.
Liu D, Grundgeiger T, Sanderson PM, et al. Anesth Analg 2009; 108: 219-222.
•
(1)
(2)
(3)
(4)
•
The authors classified the response of the anesthesiologist into
four behavioral options:
Engaging – they engaged with the distraction and organized
transfer;
Multitasking – discussed transfer while helping start the
transfusion;
Deferring – acknowledged the surgeon and then focused on
the transfusion;
Blocking – told the surgeon that the patient did not need a high
dependency unit and returned to the transfusion task
Two researchers coded the responses of the anesthesiologists
based on the video tapes.
Interruptions and blood transfusion checks:
Lessons from the simulated operating room.
Liu D, Grundgeiger T, Sanderson PM, et al. Anesth Analg 2009; 108: 219-222.
• 2 of 12 missed the omitted check in the 180
second grace period
– Both ‘engaged’ with the distraction
• One ‘multitasker’ just detected the error at
117 seconds
• The remaining 9 anesthesiologists detected
the omission within 30 seconds, 4 were
‘deferrers’ and 5 were ‘blockers’.
• Blood transfusion, thrombosis and
mortality in hospitalized patients with
cancer.
• AA Khorana, CW Francis, N Blumberg,
et al. Arch Intern Med 168:2377-2381,
2008
Methods
• The authors queried the University Health
System Consortium database which consists
of 60 academic medical centers
• Using ICD-9 codes, they identified adult
patients admitted with cancer from 1995-2003
– WE ALL HAVE PROBLEMS WITH CODING!
• They further used coding to determine
comorbidities, diagnosis of arterial or venous
thromboembolism (ATE, VTE) and whether
blood transfusions were administered
Blood transfusion happens to
sick patients
VTE happens to
sick patients
Patients
• Of the 504,208 patient studied,
approximately 15% of patients received
a blood transfusion
– 80% received only red cell transfusions
and 5% received only platelet transfusions
(rest both red cells and platelets)
• Average person in the database –
white, hypertensive, aged 65
Rates
• The rate of VTE 6.4 to 7.2%
• The rate of ATE 3.1 to 5.2%
• These rates were overall higher than
those for VTE and ATE in the nontransfused patients (3.7 and 3%).
Note:
ESAs
Missing!
Limitations
• Reliance on administrative coding
• The diagnostic criteria to identify VTE included superficial
thrombophlebitis
• Underreporting of transfusion
• ESAs data missing
• Data regarding compliance with appropriate thromboprophylaxis
unavailable
• Inability to determine the time of administration of transfusion in
relation to the development of VTE/ATE
• It is possible that anemia/transfusion is a surrogate for
aggressive tumor biology, more intense chemotherapy, or
“sicker” patients – can’t completely ‘control’ in multivariate
analysis
Rich’s bottom line
• This study is very limited in its ability to
determine whether transfusions directly
lead to unwanted clots in hospitalized
cancer patients
• Hypothesis generating only