When Is a Blood Transfusion Really Necessary?
“Blood transfusion has not been shown to reduce morbidity and mortality in surgical patients.” -National Anemia Action Council
What determines when a transfusion is given?
If you ask different surgeons the answer will vary as widely as the goal zones on a soccer field.
The official answer is that a 'transfusion trigger' determines when a blood transfusion is compulsory. It is defined by the Transfusion Medicine Bulletin as the “minimal hematocrit or hemoglobin level at which adult patients require transfusions.”
However, the facts clearly show that transfusions are given by different surgeons using different criteria. For example a National Institutes of Health panel investigating the use of post surgical blood transfusions discovered that 25% of transfused units of blood were unnecessary because they were using the transfusion trigger – which the NIH called ‘misinformed.’ -Fred J. McGlynn, M.D.
"There is too much confusion and controversy over blood transfusions today.
It is amazing to me that in 2007, we don't know how to appropriately prescribe transfusion.” -Science Digest - Dr. Sunil Rao, Cardiologist, Duke University
The transfusion trigger – the traditional decision maker
The transfusion trigger was established over 60 years ago when the science of blood transfusions was in its raw infancy stage. Was this trigger based on scientific research? “First proposed in 1942, the ‘10/30’ rule has become more a matter of faith than data.” The CRIT Study: Anemia and Blood Transfusion. Another expert states that the misunderstandings about when to transfuse blood go back even further. "For 100 years we've assumed blood transfusions are good for people, but most of these clinical practices grew before we had the research to support it." Neil Blumberg, M.D., professor of Pathology and Laboratory Medicine and director of Transfusion Medicine at the University of Rochester Medical Center.
These two quotations make this conclusion: every time a blood transfusion is given it is based on inaccurate assumptions made decades ago. The decision of when to transfuse is based on medical traditions and not on scientific facts. People were driving horse drawn buggies when blood transfusions were developed and there grandsons were still driving Model T’s when the 10/30 rule was suggested.
Dr. Charles B Huggins, a Nobel Prize Recipient said that "[Blood] is the most dangerous substance we use in medicine." But the answer to the question: ‘when should a blood transfusion be given?’ Based on the quotes from many unbiased experts listed on this page “considerable variation exists” as to when to give a blood transfusion because decisions are based on a “matter of faith”, is “unknown”, is actually “the subject of clinical investigation and controversy”, can be based on “personal views”, and can be decided by “by individual transfusion triggers rather than specific physiologic indications.”
Blood transfusion – the last line of attack
A growing number of doctors will answer never. In fact, if transfusion were such good medicine it would be given as a first line of attack in the medical setting. But it is not, blood transfusions are usually a last line of defense used when other methods have failed.
“Blood transfusions, because of their inconsistent effectiveness, are often the last line of defense used by doctors to help patients in life or death matters.” -Darren Swan – Medill Reports
Various studies of transfusion practices reveal a wide range of transfusion triggers from country to country and even from hospital to hospital. This is truly transfusion confusion.
The Sanguis Study
When is a blood transfusion necessary? The Sanguis Study was a study performed in Europe to help determine how doctors answered this question by examining de facto practices in real live settings. More than 7,100 patients in 43 hospitals in 10 countries were involved. The purpose of the Sanguis Study was to find out what current transfusion thresholds were being employed. What did the study reveal? “For each product [blood products and colloids] wide differences were found between hospitals, both in the proportion of patients transfused and the amount of product used for the same patient category.” There were “major differences among hospitals in patient red unit transfusion.” NIH goes on to comment on these astounding conclusions: “This suggests that consensus conferences and guidelines have so far had a limited impact on transfusion practice in many clinical units, even in teaching environments.” National Institutes of Health
The Canadian study
A similar study in Canada involving 5,298 patients admitted to six different intensive care units concluded that “There is significant institutional variation in critical care transfusion practice, many intensivists adhering to a 100g/l threshold, and opting to administer multiple units despite published guidelines to the contrary. There is a need for prospective studies to define optimal practice in the critically ill.” Critical Care
The ICCTO Study
When is a blood transfusion necessary? In April of 2009 a panel of experts convened at the International Consensus Conference on Transfusion and Outcomes (ICCTO) in Phoenix, Arizona to answer this question. The panel reviewed 555 separate studies on blood transfusions commissioned in the last 13 years. The experts concluded that the majority of transfusions administered had no beneficial effect on the patients who received them. Totally to the contrary the panel concluded that the 555 studies proved that the “vast majority of red blood cell transfusions” have a direct link between “higher rates of complications such as heart attack, stroke, lung injury, infection and kidney failure and death.”
The ICCTO panel was monitored by the Federal Drug Administration and other prestigious organizations. This was not a group convening in a basement and setting out to prove some preconceived agenda but rather was comprised of experts who reviewed the data without bias.
What was interesting about the five-hundred-plus studies that were reviewed is that the vast majority of the studies were commissioned to prove the effectiveness of blood transfusions – and yet the studies overwhelming proved the opposite. -Medical News Today
The Pennsylvania Hospital Study
In a 72 month period nearly 6,000 Bloodless Patients were treated at Pennsylvania Hospital in Philadelphia, Pennsylvania, USA with only 2 mortalities attributed to hematological complications. (link here) These figures highlight the safety of Bloodless Surgery. Figures may vary slightly from hospital to hospital depending on the types of surgeries, the age of the patients involved and other factors.
If Bloodless Surgery were unsafe it would not be allowed to be performed in over 160 hospitals in the United States. Over 70,000 surgeons in the United States would lose their licenses if Bloodless Surgery were risky.
Will it take another 100 years?
Perhaps now it can be appreciated more fully the statement that ““The administration of blood products is surrounded by emotions, misconceptions, and myths.” -Strategic Blood Management
After 100 years of transfusion practice there is a “significant variation” in this critical practice. And the “vast majority of red blood cell transfusions” have a direct link between “heart attack, stroke, lung injury, infection and kidney failure and death.”
If a drug proposed by a major pharmaceutical company had all the same credentials as blood would the FDA grant its approval?
Does the average patient want to risk his health to such a product?
National Anemia Action Council Advisory
"Transfusion has not been proven to improve postoperative outcomes.”
The importance of this advisory cannot be understated. Anemia is one of the most common reasons for blood transfusion. And yet the Anemia Action Council is stated that transfusions should not be given regardless of the level of preoperative anemia. What do they recommend? Bloodless Surgery. “Although alternative therapies have their own risks, these are typically minimal when compared to transfusion.” All of the ‘alternative therapies’ mentioned are cornerstones of Bloodless Surgery.
The viewpoint on the dangers of blood are not held by a few radical doctors with questionable degrees from some mysterious university with dubious credentials. Those questioning the validity of the supposed magical properties of blood are highly credentialed and elite doctors from every corner of the globe. They are still in the minority – but it is a minority that is growing larger and larger every year.
“[Bloodless surgery] has now grown into a serious practice being embraced by internationally respected clinicians and institutions.” -V. Martin et al, (Abstract)Transfusion and Apheresis Science 2002 Aug;27(1):29-43
There are over 3000 articles in the worldwide repository of medical literature that clearly explain the risks of blood transfusion. There are numerous studies that delineate the safety of Bloodless Medicine.
When is a blood transfusion necessary?
In fact, ‘many transfusions’ are “completely unjustified.” A ‘Bloodless Surgeon’ will likely say they are all unjustified given the current tools available and the current understanding of blood and its dangers. “It has been said that in cancer patients “transfusion decisions are greatly influenced by the personal views of the medical team.” -Abstract, American Journal of Clinical Oncology. 27(5):542-546, October 2004
Solid science is not based on personal views but on scientific fact. Blood transfusion triggers are not in reality constant or reliable. Patients are being given blood unnecessarily and without solid medical reasons. A patient must decide if he wants to be a Bloodless Patient and avoid the dangers and risks of a product that is handed out like Halloween candy – some get more some get less.
Bloodless Surgery and Medicine has the solution right now. It says that any surgery can be performed without blood transfusion – and it can be done safely and effectively.
The world isn't flat
There were those that thought the world was flat. Aristotle (330 BC) said it wasn't.
It would take about 2,000 years before his idea caught on. Scientists, academics and the best minds of every succesive generation fought such claims tooth and nail. The knew it was flat. No discussion. Then the truth was finally accepted. Imagine trying to prove the earth was a sphere in the 7th or 8th century. Imagine trying to prove that blood transfusions are dangerous in the 21st century. There's not much difference.
The Flat Earth Society is just a dusty memory in the tomes of university libraries. One day the Blood is Good Society will be a memory in yellow paged books sitting on the same shelves.
Listen to the experts
“The simplest approach is to avoid transfusion regardless of the level of preoperative anemia.” -National Anemia Action Council
“The sine qua non of success using this approach is meticulous surgery to eliminate or reduce operative blood loss. This strategy entails accepting a lowered transfusion threshold, or trigger, and has been proven to be safe by several surgical groups.25,32,33 The use of autologous blood either through preoperative donation or autotransfusion to return shed blood is also helpful.” -National Anemia Action Council
“In patients with intermediate hemoglobin levels, discretionary transfusion should be carefully considered, as the risks are marked, the benefits are unclear, and alternatives are available.” -Blood Transfusion: Risks And Alternatives, Pulmonary Reviews
“Mistransfusion occurs in 1:14,000–1:18,000 cases, with an approximate morbidity and mortality rate of 1:600,000. Approximately 50% of the errors occur at the clinical level and Your browser may not support display of this image. 30% in the laboratory.” -Oxford Journals
“Every pack of red blood cells (RBC) that you don’t transfuse decreases the risk to the patient.” -Tamara Doehner, ACP Member and a hospitalist at Methodist Hospital in Omaha, Neb., ACP
"Clearly, recombinant erythropoietin should be on everyone’s mind as the first drug of choice to treat anemia in patients who do not need to be transfused." Dr. Shander -Pulmonary Reviews
“The ability of red blood cell transfusions to increase oxygen consumption has not been clearly demonstrated.” -Hébert PC, Hu LQ, Biro GP. Review of physiologic mechanisms in response to anemia. CMAJ 1997;156:S27-40
“Autologous predonation can be very effective in reducing reliance on allogeneic blood, but it has been shown to increase overall exposure to [homologous] transfusion and to increase the chance of perioperative anemia.” -National Anemia Action Council
*This information appears on another page on MyBlood’s website and is included here as a convenince for the reader.