NoBlood

MY NOTE: The readers' commentaries are very insightful. Please see their comments after this article.
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BMJ 2005;330:558 (12 March), doi:10.1136/bmj.330.7491.558-b



Edinburgh Richard Smith





Evidence on the effectiveness of blood transfusion is severely lacking, and more research is needed. That was the main conclusion of a conference held last week at the Royal College of Physicians of Edinburgh.

The meeting was prompted by anxiety that too many resources may be being devoted to ensuring the safety of blood. The cost of supplying blood to the United Kingdom grew from £250m ($480m; €365m) in 1995 to £500m in 2004, and the increase is due mainly to new tests and processes to reduce the risk of transmitting infection.

Participants at the conference thought that some of the tests were undoubtedly needed but were concerned that the introduction of nucleic acid testing to supplement existing tests for hepatitis C cost between $5.8m and $8.4m for each quality adjusted life year (QALY) resulting from the avoidance of hepatitis C. (The National Institute of Clinical Excellence looks doubtfully at treatments that cost more than £30 000 for each QALY.)

Most of the extra cost was due to the need to reduce the risk of transmitting variant Creutzfeldt-Jakob disease. The introduction of prion reduction filtration could add £100m to the annual cost of the United Kingdom’s blood service, participants were told.

Yet although the costs were high, it could be argued that the spending was necessary because it meant that the public still trusted the blood supply, said Ian Franklin, national medical and scientific director of the Scottish National Blood Transfusion Service. Excessive expenditure on safety was understandable, said Steve Kleinman, a professor from Victoria, Canada, as a reaction to the situation in the early 1980s when many people were infected with HIV through blood transfusion.

The main adverse effects of transfusion were currently not infection but severe haemolytic reactions (usually caused by transfusion of the wrong blood) and volume overload, said Professor Kleinman. He said that severe reactions occur in about 43 in every 100 000 red cell transfusions (95% confidence interval 39 to 48 per 100 000).

The emphasis on safety had not, however, been matched by an equal emphasis on effectiveness. Transfusion clearly saved lives in cases of major haemorrhage, said Dr Tim Walsh, a consultant anaesthetist in Edinburgh. But not enough research had been conducted on the question of when transfusion should be given in other circumstances. For example, randomised controlled trials looking at the triggers for transfusion involved fewer than 2000 people. Half of these patients were in one trial, with intensive care patients, that showed no benefit from transfusion. In this study the liberal use of transfused blood was not associated with any benefit, and among younger and less severely ill patients mortality was higher in patients who were given more blood (New England Journal of Medicine 1999;340:409-17). The numbers needed to harm for cardiovascular complications were 13 for any complication, 45 for myocardial infarction, and 19 for pulmonary oedema, Dr Walsh said.

Blood transfusion was clearly needed for life threatening blood loss, but probably only about a fifth of blood was used in such circumstances, said Dr Walsh. The conference also considered what was actually life threatening. How many Jehovah’s Witnesses died because they were denied blood products? asked John Lilleyman, former president of the Royal College of Pathologists. Not many, he thought. "Much more research is needed on the effectiveness of blood transfusion," concluded Marcela Contreras, national director of diagnostics, development, and research at the National Blood Service. "Keeping the blood supply safe is clearly important, but we have lost the plot in putting so much emphasis on safety and neglecting research into effectiveness."


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Rapid Response Commentaries on this article:

Segundo R. Leon,
Professor of Immunohematology and Blood Bank
San Marcos National University, Lima 13, Peru
Certainly, the cost of blood products has increased over the last years with the inclusion of universal testing for HIV in the 80s, and now in northern Europe the other Blood Marker is Creutzfeld Jacob Disease, but instead of the increase of the cost of screening for blood borne infections, there is another reason that has increased the global cost of blood transfusions. We are talking about the excessive use of blood components to treat disease that could be traeted with other alternatives. There is no reason to transfuse in certain circumstances, where physicians could use other alternatives such as erythropoietin, gels and colloids, or simply blood recuperation in sterile surgical processes.


Mark A. Best,
Transfusion Medicine Specialist
Eastview, KY, USA


A significant number of transfusions are unnecessary, though some gains have been made to reduce this number over the past decade or two. However, in cases where there is a clear indication, the minimal effective dose should be transfused, and attention to the process should be of paramount importance to prevent human error, and to recognize adverse reactions such as transfusion – related acute lung injury (TRALI), that often goes undiagnosed. TRALI may be fatal in 5% or more of cases, and it is estimated to be the third most common cause of transfusion-related death. However, if recognized, TRALI typically responds well to treatment with ventilatory and pressor support, and resolves in 3 to 7 days.1 Hemolytic reactions are associated with the largest number of transfusion- related fatalities, and most of these are due to ABO-incompatible transfusions. Human error plays a major role in ABO-incompatible transfusions, and the incidence of fatal reactions in the US, from ABO- incompatible reactions has not decreased over the past three decades.2 In the transfusion chain of events, personnel in several departments (e.g. blood bank, phlebotomy, nursing) participate in parts of the process. Process hand-offs between departments, has been associated with an increased potential for errors.3 Cycles of continuous improvement in designing, measuring, assessing, and refining processes have resulted in improvements in health care.4 Training, education, and process improvement can result in reducing over-transfusion, identifying treatable adverse reactions (e.g. TRALI, volume overload), reduce transfusion errors, and overall reduce costs and improve safety of transfusions.

References 1. Zoon KC. Transfusion-related acute lung injury: Dear colleague letter (October 19, 2001) Rockville, MD: CBER Office of Communication, Training, and Manufacturers Assistance, 2001. 2. AuBuchon JP, Kruskall MS. Transfusion safety: Realigning efforts with risks. Transfusion 1997; 37:1211-6. 3. Slavin L, Best MA, Aron DC. Gone but not forgotten: The search for the lost surgical specimens: Application of Quality Improvement Techniques in Reducing Medical Error. Quality Management in Health Care, 2001; 10(1):45- 53. 4. Headrick LA, Neuhauser D. Quality healthcare. JAMA 1994; 271:1711-2.


Ruth A Melchers,
Senior Transfusion Nurse
Chair of SPOT, Specilaist Practitioners Of Transfusion.
I strongly agree with this article, here in the UK we now have over two hundred Hospital Transfusion Practitioners, most are focusing on approrate component use and training of all hospital staff involved in the transfusion process. Many Transfusion practitioners are struggling to implement alternatives to transfusion, with no budgets and even less good published practice evidence to support their work!