Blood transfusions were first used during World War II, when blood was first regarded as essential for patients undergoing surgery. There are, however, concerns that while blood transfusions have indeed saved lives, they may have also claimed them.
Recent studies suggest undergoing a blood transfusion during surgery subsequently increases the patient’s risk of death -particularly from heart attacks or strokes – and of serious illnesses, such as septicaemia, pneumonia and cancer of the lymph glands.
Experts fear National Health System (NHS) surgeons are unaware of the risks of using transfusions except where they are vital. The exact reason why being given a stranger’s blood may have such a devastating effect is a mystery. But it is not linked to contaminated blood infecting them with deadly viruses. Instead, scientists are investigating two possible causes. One is that donated blood, instead of boosting a sick person’s ability to ward off infection, might leave their immune system unable to resist attacks by bacteria and viruses.
Another concern is that transfusions may trigger inflammation in the blood vessels, increasing the risk of heart attacks and strokes following surgery. This is because, during its 30-day shelf-life, stored blood undergoes key changes that can make it toxic for some recipients.
It is thought that toxic enzymes that are released by red blood cells and flushed out of the body through waste products instead accumulate in stored blood and attack the immune system.
Factors to consider before administering blood products
Hannon (in Gauthier: 2014) stated that blood use in hospitals is a high-volume, high-risk, high-cost process that is often not appropriately utilised, therefore the management of blood products must be improved. In support of the above statement, four key points were identified:
The very high risk related to blood products usage
• Hannon argues that although the use of blood products is a very common practice, scientific evidence has consistently indicated over a period of 15 years that blood transfusions are less effective and substantially more harmful than previously assumed. Physicians and anaesthetists are increasingly aware of and concerned about the so-called non-infectious risks associated with transfusions, including lung injury, immune suppression, renal injury, and volume overload. Transfusion-related acute lung injury is the most common cause of major morbidity and death after transfusion. (Serious Hazards of Transfusion Annual Report.www.shot-uk.org (2004)
Blood transfusions are the single highest volume procedure in the US healthcare
• Volume: Blood transfusions are the single highest volume procedure in US healthcare. According to a survey that has been done for the past several years, blood transfusions are the most common procedures performed during hospitalisations. Somewhere between 10 to 20 percent of patients admitted to the hospital will get blood transfusions.
• A retrospective study of adult patients admitted to the ICU of a university-affiliated hospital, who were discharged or died between November 1, 2006, and June 30, 2012, indicated that nearly 40% of patients received at least one type of blood product while in the ICU.
• The most widely used blood product was red blood cells, administered to 32.6% of patients. A high percentage of admissions where transfusion was administered, subsequently ended in death and many of these transfusions happened on the day prior to death.
• These results should stimulate further evaluation of the benefit for transfusion at the end of life (Vincent; Baron; Reinhart; Gattinoni; Thijs & Webb, et al. Anemia and blood transfusion in critically ill patients. JAMA. 2002 Sep 25; 288(12):1499–507).
The cost factor
• Transfusions are very expensive. Transfusions are only about one to two percent of a hospital’s budget, but that only reflects the cost to buy blood from a blood centre or the Red Cross. If you include nursing time, laboratory time, supplies, and other factors involved with every transfusion, the costs rise to anywhere between three to five times the cost of buying blood to administer it.
• Transfusions can also lead to adverse events, including hospital-acquired infections, longer length of stay, etc. and those can substantially add to the costs, making it closer to eight times the cost to buy blood. But the fact that blood is expensive is not by itself a problem; the problem is giving blood that is unnecessary because that means wasting resources.
• According to Khoza the National Health Act and the World Health Organisation prohibits payment or compensation for organ and blood donation which is why donation is done voluntarily (Kgothatso Madisa: 2018) “That is why we are so grateful to each and every one of our selfless donors for their heroic act in donating, which allows us to help save the lives of countless South Africans,” said Khoza.
• He said South African National Blood Service (SANBS) is a non-governmental organisation that receives no subsidy from the government and selling blood to hospitals is the only way to recover costs.
Appropriate use of blood products
• Blood products are often poorly utilised. A variety of published studies show that easily 30 to 60 percent of transfusions given in the United States are not indicated, not warranted, and not appropriate according to evidence-based transfusion guidance and best practice.
• Visser; Geldenhuys; du Preez & van de Vyver stated that despite available guidelines on indications for fresh-frozen plasma (FFP) transfusion, inappropriate use is increasing worldwide. They evaluated FFP administration to patients admitted to the Steve Biko Academic Hospital over 4 months, including indications for use and completeness of requisition forms. Transfusions were considered inappropriate for 39.5% of units administered. Of request forms submitted, only 22% had sufficient information for the blood transfusion services of the indication for transfusion. Transfusion with FFP is a medical intervention that carries risks and should be undertaken with care. Although this study was conducted in one centre, it is evident that clinicians’ lack of knowledge of the indications for administration of FFP is widespread. Intervention is necessary to improve patient outcomes and reduce expenditure. (S A. Med J 2012;102(6):366-367)
Appropriate and inappropriate transfusions
• Although blood transfusions can be a life-saving intervention, however, like all other procedures it may result in acute or delayed complications and carries the risk of transfusion-transmissible infections, including HIV, hepatitis viruses, syphilis, malaria and Chagas disease (WHO: The Clinical Use of Blood Handbook on Blood transfusion Safety, Geneva. Undated).
The safety and effectiveness of transfusions are dependent on two key factors:
• A supply of blood and blood products that are safe, accessible at a reasonable cost and adequate to meet national needs
• The appropriate clinical use of blood and blood products
Transfusions are often unnecessary for the following reasons:
• The need for transfusion can often be avoided or minimised by prevention or early diagnosis and treatment of anaemia as well as the conditions that cause anaemia.
• Blood is often administered unnecessarily to increase a patient’s haemoglobin level before surgery or to make allowance for early discharge from the hospital. These are rarely valid reasons for a transfusion.
• Transfusions of whole blood, red cells, or plasma are often given when other treatments, such as the infusion of normal saline, or other intravenous replacement fluids would be safer, less expensive and equally effective for the treatment of acute blood loss.
• Transfusion requirements can often be minimised by good anaesthetic and surgical management.
• If blood is administered when it is not needed, the patient receives no benefit and is exposed to unnecessary risk.
• Blood is an expensive, scarce resource. Unnecessary transfusions may cause a shortage of blood products for patients in real need. (WHO: The Clinical Use of Blood Handbook on Blood transfusion Safety, Geneva. Undated)
In conclusion, the author wishes to re-emphasise the importance of considering the above information and that it is imperative to realise that appropriate use of blood and blood products means the transfusion of safe blood products.