ASA December 2002 Newsletter

Since approximately half of all allogeneic blood transfusions in the United States are administered in the operating room, anesthesiologists have a profound effect on the nation’s blood supply. In its 1998 Nationwide Blood Collection and Utilization Survey, the National Blood Data Resource Center noted an alarming trend of decreasing blood donations and increasing numbers of blood transfusions. Blood shortages can greatly impact surgical and critically ill patients. Recently there have been blood shortages reported in many areas of the United States, necessitating delay of elective surgical procedures in a number of hospitals.

The duties of the Committee on Transfusion Medicine are to promote the study and investigation of the use of blood and blood products, to recommend methods in the safe use and handling of blood and blood products and to act as a liaison representative with various other organizations concerned with blood and blood products. This year and throughout the past, the committee has performed many functions to fulfill these goals. For example, the committee conducted surveys of transfusion practices among ASA members in 1981 and again this year. The ASA Task Force on Blood Component Therapy, a subgroup of the committee, published practice guidelines for blood component therapy in 1996 <www.ASAhq.org/ publicationsAndServices/blood_component.html>.

Knowledge of current transfusion practice is essential if anesthesiologists are to improve the appropriate use of blood and blood products and to determine areas of knowledge that could be improved through education. This year’s survey assessed the most current transfusion practices of our members. In brief, a survey questionnaire examining transfusion practices was mailed to 2,500 randomly selected, active ASA members. The survey results, which will be submitted for publication, demonstrated that transfusion practices have changed considerably since 1981. It was found that the use of blood conservation techniques has increased. A large percentage of anesthesiologists determine hemoglobin intraoperatively prior to transfusing red blood cells. The majority of respondents were familiar with ASA transfusion publications and found them to be useful. The survey responses seemed to show that current transfusion practices were, in general, consistent with ASA guidelines, but there are areas for improvement. The committee is now developing plans to guide future educational efforts for ASA members.

Other activities of the Committee on Transfusion Medicine this past year included members acting as liaison representatives with various other organizations concerned with blood and blood products, especially to the American Association of Blood Banks (AABB) and the College of American Pathologists. The AABB Board of Directors has become concerned with the noninfectious serious hazards of transfusion (NISHOT), especially with mistransfusion and ABO/Rh-incompatible transfusion.¹ There has been a 10,000-fold reduction in the risk to patients of transfusion-transmitted infectious diseases over the last several decades. The risk of contracting hepatitis from blood has decreased from a rate of 1:10 in the 1960s to less than 1:100,000 in the year 2000. The risk of HIV infection has undergone a similar 10,000-fold reduction in risk during this same time period.¹

Unfortunately over the last four decades, there has been little if any change in the risk to patients from NISHOT.¹ The current passive reporting systems are widely believed to underestimate the magnitude of NISHOT. There have been multiple, prospective, active tracking studies that demonstrated higher rates of both minor and major reactions and mishaps than are reported by the current passive system.^2,3

The effective and safe transfusion of blood depends on a series of linked processes. Human errors in many areas of the series of linked processes can result in mistransfusion and ABO/Rh-incompatible transfusion. Patient safety has become a major concern of the general public and policy makers, particularly since the publication of the Institute of Medicine report To Err Is Human: Building a Safer Health System <www.nap.edu/books/0309068371/html>. Serious medical errors in the United States have been estimated to result in 100,000 deaths and 1 million serious injuries annually.⁴ Though transfusion errors are thought to make up only a small fraction of all medical errors in the United States, they stand in stark contrast to the current virologic safety of transfusion. NISHOT is now thought to represent the most common problem in blood transfusion. The Food and Drug Administration has reported that the transfusion-related death rate due to hemolytic transfusion reactions alone is more than two times higher than that due to all infectious hazards combined.⁵ Transfusion of incompatible blood or mistransfusion of blood has now become the most common cause of serious morbidity and mortality associated with transfusion of blood. ABO/Rh-incompatible transfusions may result from errors made anywhere along the series of linked processes for the proper transfusion of blood. The reported cause for mortality in as many as two dozen patients annually in this country is ABO/Rh-incompatibility due to the misidentification of type-and-crossmatch samples, laboratory errors or misidentification of recipients at the time of transfusion.⁶

Changes that may impact anesthesiologists are being considered by AABB in an attempt to reduce NISHOT,¹ including establishment of a nonpunitive, national transfusion-related error reporting system to help better understand and track the incidence of this problem. AABB may increase enforcement of existing standards, especially those related to transfusion administrations that occur outside of the transfusion services. New AABB standards also may require that facilities have in place a functioning peer-review program to monitor transfusion practices. AABB will formally request that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) place renewed focus on the effectiveness of the peer-review program in reducing transfusion errors and complications. AABB is interested in encouraging research and developing technologies such as bar coding to reduce errors and improve care.

Overall our committee has been active in improving the understanding and quality of current blood transfusion practices. We will continue to work within ASA and with other organizations to promote the study and investigation of the use of blood and blood products and recommend methods to improve the safe use and handling of blood and blood products.

References:

1. American Association of Blood Banks. Association Bulletin 01-4. Noninfectious serious hazards of transfusion. June 14, 2001. <www.aabb.org/Pressroom/Press_Releases/prab01-4.htm>.

2. Heddle NM, Kelton JG. Febrile nonhemolytic transfusion reactions. In: Popovsky MA, ed. Transfusion Reactions. 2nd ed. Bethesda, MD: AABB Press; 2001:47-85.

3. Baele PL, de Bruyere M, Deneys V, et al. Bedside transfusion errors. A prospective survey by the Belgium SAnGUIS Group. Vox Sang. 1994; 66:117-121.

4. Tye L. Hospitals struggling to root out care errors. Boston Globe, December 11, 2000; sect A:1.

5. Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York state: An analysis of 10 years’ experience. Transfusion. 2000; 40:1207-1213.

6. AuBuchon JP, Kruskall MS. Transfusion safety: Realigning efforts with risks. Transfusion. 1997; 37:1211-1216.

Gregory A. Nuttall, M.D., is Associate Professor of Anesthesiology, Mayo Clinic, Rochester, Minnesota.

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