Doctors warn of unnecessary blood transfusions in Australian hospitals as donations drop

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Doctors say unnecessary blood transfusions are being given in Australian hospitals and clinicians need to slow down and think when ordering a blood bag for certain patients.

The warning comes as donations on the east coast are hit due to COVID-19 and flooding in Queensland and northern New South Wales.

Research shows that blood transfusions, although widely used in the past, are not necessarily the best or safest treatment available for many patients today.

With few exceptions, doctors shouldn’t automatically order blood when treating conditions like anemia or low iron if a more patient-friendly treatment will do, said Anastazia Keegan, a hematologist. and transfusion medicine specialist from Perth.

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Although it is renewable – after all, it literally runs through our veins – Australia does not have an inexhaustible supply of blood.

“This is probably the biggest challenge our blood supply has had in the past two decades,” said Dr Keegan, who is also vice-president of the Australian and New Zealand Society of Blood Transfusion.

“Around half a million blood donors each year in Australia support the whole country, and we generally do a fairly good job of meeting supply and demand.

“But during COVID, we really saw a significant challenge with supply.

“Earlier this year, around January and February, we had 100,000 blood donors…affected by COVID.

“We still, in theory, have enough blood, but if we can help alleviate the demand at the clinical end, it can help balance the gap between supply and demand, especially during COVID and natural disasters. repeated.”

Why is blood used inappropriately?

Blood transfusions are perhaps familiar as something given to people brought to the emergency room in television series.

But many blood transfusions are for patients with medium- or long-term health conditions, with about a third of Australian Red Cross Lifeblood red blood cells going for the treatment of cancer and blood diseases.

They have also traditionally been used to boost low iron levels or treat anemia – a condition in which a person’s blood does not contain enough healthy red blood cells – and given regularly in surgery.

Research now shows that not all of these patients need a blood transfusion, says Simon Towler, intensive care specialist at Fiona Stanley Hospital.

“The evidence base regarding the adverse effects of transfusion has continued to grow over time.

An example of this is the treatment of low levels of hemoglobin – ie the molecule in our blood that contains iron.

A 1999 US study divided critically ill patients with low hemoglobin into two groups.

One group received a transfusion of red blood cells if their levels fell below a certain point.

The other group was transfused if its levels reached a threshold a few points lower than that of the first group.

It turned out that the second group was better off overall, with a lower mortality rate.

Now, if someone presents to the hospital with low iron, but their heart rate and blood pressure are normal, they should – with very rare exceptions – be treated with an iron supplement or intravenous iron, not a blood transfusion, says Dr. Keegan. .

But that doesn’t always happen.

Dr. Keegan cited a recent example where a woman presented to the emergency room with a heavy period.

His hemoglobin level had dropped by age 50. For most women, the hemoglobin level is between 120 and 150.

“She was a little dizzy, felt a little unwell, but…didn’t have a very high heart rate or very low blood pressure,” Dr Keegan said.

“Just because she [haemoglobin] number was low, they thought they should give him a red blood cell transfusion.

“So I think there’s still a bit of a knee jerk when it comes to giving a transfusion in that kind of setting.”

How do we know that blood is not always put to good use?

In that case, Dr. Keegan could step in and stop an unnecessary transfusion. But the exact amount of blood used inappropriately in Australia is not known.

The National Blood Authority maintains systems that track blood – and blood-based products – from suppliers such as Lifeblood to Australian healthcare providers.

These systems record whether units of blood are transfused to a patient or discarded.

Blood can be discarded if, for example, its expiry date has passed. A little of this type of waste is expected to ensure the availability of a sufficient quantity of blood products.

In other words, it is better to have too much and throw away a little than to run out.

Red blood cells are collected from approximately 1.6 million blood donations each year in Australia.(Provided: Red Cross Lifeblood)

Only 1.6% of blood is discarded in Australia – down from around 5% a few years ago, a National Blood Authority spokesperson said.

Whether transfused blood is being used appropriately, however, is harder to measure and not recorded in national blood systems, they added.

As medical and surgical practices have changed, the need for blood transfusions has also decreased.

Like Dr. Keegan, other physicians and specialists report that inappropriate transfusions still occur.

There are far fewer unnecessary transfusions these days compared to a few decades ago, but there is room for improvement, according to Erica Wood, a specialist in transfusion medicine and head of the Transfusion Research Unit at Monash University.

“If you can avoid even one transfusion of red blood cells that a patient [doesn’t need]so it’s a good investment,” said Professor Wood, who is also president of the International Society of Blood Transfusion.

Dr. Towler agreed.

He said there are systems overseas that could further reduce the number of unnecessary transfusions in Australia.

Software used in Maine, USA, for example, analyzes patient information when a clinician orders a blood transfusion.

“And if it wasn’t an emergency scenario, it would be up to the clinician ordering the blood if [was] coherent [or not] with current best practices and gave the clinician the opportunity to speak with a transfusion hematologist,” said Dr. Towler.

“We didn’t get that far.”

Focus on the patients, not the product

The National Blood Authority publishes patient blood management guidelines for Australia.

Dr Keegan was part of the Evolve initiative which today released a set of reminder recommendations to hospitals and clinicians ordering and using blood.

The shift from thinking about how best to manage the product – blood – to what is best for the patient has improved the way blood is used.

“It’s really about patient blood management – ​​optimal care for the patient,” Dr. Towler said.

About 28% of Lifeblood’s red blood cells go to surgeries, and surgery is where huge strides have been made in reducing blood transfusions.

“Before, there were policies that were to routinely donate two units of blood to anyone who had hip replacement surgery,” Dr. Towler said.

“In Western Australia, in the best programs here, less than 1% of patients are being transfused right now.

“Absolutely massive changes.”

Making sure people have enough red blood cells before they go under the knife is also important – and can be rectified without a blood transfusion if caught early enough, Dr Towler added.

“We’re just starting to see … more reliable assessments of patients in preparation for surgery, and simple things like managing anemia in advance.”

Involving patients in decisions about transfusions is also important, said Professor Wood.

“Patients are a very important part of planning and carrying out, not just receiving, transfusions.”


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