Infections & Transfusions

We love our transfusions down in the Emergency Department.  We especially love them in our trauma patients – and, if anything, the move is to provide earlier, more aggressive volume replacement, and to use more FFP, cryoprecipitate, and platelet product to maintain optimal coagulation parameters.

The downside?  Besides cost, over-utilization of a limited resource, and the various adverse reactions that may occur – there’s a bit of an infection risk.

This JAMA meta-analysis pools together the results of 18 trials comparing “restrictive” vs. “liberal” transfusion strategies for PRBCs.  These trials ranged across medicine from cardiovascular settings, the critically ill, sickle cell disease, and other surgical settings.  In most trials, the restrictive transfusion setting ranged from a Hgb of 7 to 9 g/dL, while the liberal strategies were typically goals above 10 g/dL.  These authors simply looked at the pooled incidence of “serious infection”, which was typically reported as wound infection, bacteremia, pneumonia, or a broad definition of sepsis.

In the “restrictive” transfusion group, there was an overall pooled risk of infectious complication of 11.8% (95% CI, 7.0%-16.7%), compared with an infectious complication rate of 16.9% (95% CI, 8.9%-25.4%) in the “liberal” transfusion group.  The authors estimated a “number needed to harm” between 20 and 38, depending on the restrictive transfusion threshold.

This study does not, by itself, indicate transfusions ought to be withheld when indicated.  Rather, these authors primarily suggest, in order to fully describe the risks and benefits of any transfusion strategy, that infectious complications be included in data collection during trials.  This ought to be of even greater importance in the new surveillance of massive transfusion protocols – as PRBC products aren’t typically even the highest-risk for subsequent infectious complications.

“Health Care–Associated Infection After Red Blood Cell Transfusion”
http://www.ncbi.nlm.nih.gov/pubmed/24691607