Overdoing Blood Transfusions? JAMA Special Issue Shines a Light

In conjunction with updated guidelines on red blood cell transfusion, JAMA has published a special issue on blood, bleeding, and transfusion.

In addition to the 2023 Association for the Advancement of Blood & Biotherapies (AABB) international guidelines, published as a “special communication,” the journal published two papers evaluating transfusion practices in the intensive care unit (ICU), as well as two investigations into new techniques for controlling hemorrhage in acute trauma patients, said Christopher Seymour, MD, MSc, associate editor of JAMA, who led the special issue.

The journal also published a host of viewpoints, notably one from the American Red Cross that reiterated the recently changed FDA guidance allowing men who have sex with men to donate blood, said Seymour, who is also an associate professor of critical care and emergency medicine at the University of Pittsburgh School of Medicine.

While there have been no substantial changes to the AABB guidance as to when blood is indicated for hospitalized patients, “we are feeling more certain about the thresholds that are being given,” Seymour said.

“Unfortunately,” he added, “the epidemiological work shows … that they’re not really being attended to, and that’s perhaps an area of focus that has been neglected.”

The series kicks off with an epidemiologic investigation by Alexander Vlaar, MD, PhD, MBA, of Amsterdam University Medical Centers in the Netherlands, and colleagues in the InPUT study group, looking at transfusion practices in 233 ICUs in 30 countries from 2019 to 2022. It showed “a lot of variability in how blood products are used, not surprisingly, depending on the type of patient and the indication,” Seymour said.

“A lot of the blood being transfused is above the recommended threshold,” he noted. “Perhaps it speaks to an opportunity for more data and more trials as to why.”

Seymour said that much of the blood being given to patients every day in the hospital or ICU relates to how much blood is taken for testing. The second investigation — the randomized STRATUS trial of 25 ICUs in Canada by Deborah Siegal, MD, MSc, of McMaster University in Hamilton, Ontario, and colleagues — found that using smaller tubes for blood collection may reduce blood cell transfusion without compromising testing quality.

“What’s probably not known to many of the clinicians ordering tests is that the majority of a blood sample sent down to the lab is not used for the clinical test,” Seymour said. “After a hold period, it’s discarded. So we’re perhaps taking a lot of unnecessary tests, wasting this blood, and then having to give it back.”

Seymour noted that there are system barriers around purchasing that may have limited the adoption of smaller tubes, “so it’s nice to elevate this evidence and show … there’s an opportunity here.”

The other two original investigations in the special issue are packaged around the very different clinical scenario of when a patient is bleeding from a traumatic injury. Since blood is something of a scarce resource in hospitals, clinicians have attempted to come up with other methods to try to reduce transfusion needs during hemorrhage control, Seymour said.

Unfortunately, both trials were negative, he added. The CRYOSTAT-2 trial showed that adding early, high-dose cryoprecipitate to standard major hemorrhage protocols as a fibrinogen replacement didn’t improve all-cause mortality at 28 days compared with standard care alone. The UK-REBOA trial showed that adding endovascular balloon occlusion of the aorta to standard hemorrhagic care in the emergency department didn’t reduce — and may increase — mortality at 90 days compared with standard care.

“We had interesting and surprising results from those trials,” Seymour said.

Among the issue’s three viewpoints is one from the American Red Cross, reiterating the recent change in FDA blood donation guidance that allows men who have sex with men to donate blood, and detailing the science that enabled the policy change.

The Red Cross has also raised alarms recently that blood continues to be in shortage, and that donations are needed. While Seymour said shortages stemming from the COVID pandemic due to people staying home have abated to some extent, need for blood and blood products remains for a host of reasons.

Responsible use of testing and transfusions in the hospital is one of those factors, he said: “Sensible approaches to testing go hand-in-hand with more sensible approaches to transfusion.”

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