European Journal of Cardiovascular Medicine

Transfusion of blood and its products is one of the important pillars in the treatment of patient in Emergency Department.1 Blood usage in the emergency department is a challenge to the treating doctor. Trauma cases are most commonly encountered in Emergency Department. About 85 million units of blood are transfused annually worldwide.13  Major trauma is a key global public health issue and an important financial burden for hospitals and society.2,3 Traumatic events are responsible for more than 7-8 million worldwide deaths annually representing 8% of all deaths.2,4 Evidence agrees with the idea that some deaths related to traumatic bleeding events are preventable if patients receive timely identification of bleeding sources and prompt blood support measures.2,5 The most commonly utilised blood product in Emergency Department is packed red blood cells and the most common indication is acute blood loss.1,6 The approach to blood product transfusion in Emergency Department varies with clinical scenario. The most evidence based indication for blood product transfusion in Emergency Department is to improve early hemostasis in trauma cases and to reverse early tissue hypoperfusion.7,8,9,10 Massive transfusion is also commonly done in the Emergency department in road traffic accidents.11 The present study aims at analyzing the blood requirement, utilization and wastage of blood and blood products in emergency department.

AIM

To prevent overuse of blood products for the patients and to reassess the rational use of blood and blood products in Emergency Department.

The study is a Cross Sectional study over a period of 12 months from March 2021 to February 2022. A total of 348  cases were assessed from the Emergency Department (Casualty) of SAIMS Hospital, Indore. The blood component required for the patient at the time of emergency and the indication for transfusion is recorded. Pre-transfusion hemoglobin was noted before transfusion at the of admission and then the patients is followed up next day for the post transfusion hemoglobin. Record of number of blood components transfused to each patient and the most commonly required blood group at emergency was also maintained. Statistical tool used for data analysis is SPSS software.

Ethical consideration: There is no breach of data privacy and patient consent in relation to this article data.

INCLUSION CRITERIA  

All acute cases receiving blood transfusion admitted under Emergency Department, Trauma Centre were included in the study.

EXCLUSION CRITERIA

Patients who were recently blood transfused before being admitted to Emergency Department were excluded from the study.

Total number of 348 patients who received blood transfusion in Emergency Department as included in the inclusion criteria over the study period.

Table no. 1- Gender wise distribution of cases-

Out of a total of 348 cases, males who received blood transfusion were 184 (53%) and females who received transfusion were 164 (47%).

Table no. 2 - Indications of transfusion -

The most common indication for transfusion were massive blood loss due to roadside accident in 167 (47.98%) patients , followed by heart disease patient on antiplatelet/ anticoagulant medication in 128 (36.78%) patients. Hemato-oncological disease patients who received transfusion were about 31 (8.9%). 22 patients (6.33% ) who were chronic anemic (based on lab reports) received transfusion.

Table no. 3 - Component transfused-

A total of 180 patients received RCC transfusion which was 51.72 % , 105 patients received PC/PRP transfusion which was 30.17 % and 63 patients received FFP transfusion which was 18.10 %.

Table no 4 -

The most common indication for RCC transfusion was Anaemia due to massive blood loss. The most common indication for PC transfusion was Thrombocytopenia due to Heart failure and Disseminated Intravascular Coagulation. Hypoproteinemia was the most common indication for FFP Transfusion.

Table no 5 - Pre-transfusion Hb distribution-

Transfusion was carried out in patients whose Hb was less than 7g/dl  even if they had no                 co-morbidities. Patients with co-morbidities were transfused if they had a Hb range between 7-10g/dl. 267 (76.72%) patients had a pre-transfusion Hb around 5- 7 g/dl, 73 (20.97 %) patients had pre-transfusion Hb between 8-10 g/dl and 8 (2.29%) patients had a Hb around 11-12 g/dl . Most of the patients Post Transfusion Hemoglobin were around 11-12 g/dl.

Table no. 6 – No. of PRBC units required according to Pre-transfusion Hb-

When the patients pre-transfusion Hb were around 5-7 g/dl , 3- 4 units of PRBC were transfused , when it was around 8 -10 g/dl , 2-3 units of PRBC were transfused . 1 unit of PRBC was transfused when Hb was above 11.

Table no. 7 – Blood group units required -

The most common Blood group which was required was B Rh (D)Positive in 126 patients which was around 36.4 % , followed by O positive in 121 patients which accounted for 34.8% , A positive in 66 patients which is about 19% , AB Positive in 24 patients around 7 % and other Negative Groups in 11 patients which accounted for 2.8 %.

The guidelines and clinical trials on Transfusion Requirements In Critical Care (TRICC) also recommend a value of 7g/dl as threshold for critically ill patient.12,14 One unit of packed red cells transfused will increase the hemoglobin by one gram per dl and Hematocrit by three percent.15 FFP is used in patients with bleeding disorders to replace lost coagulation factors. Fresh frozen plasma is  indicated in patients with liver failure, warfarin overdose, disseminated intravascular coagulation and thrombotic thrombocytopenic purpura.16,17 One unit of fresh frozen  plasma contains one unit of coagulation factor and one ml  of FFP contains two units of fibrinogen. Platelet transfusion is beneficial in cases of platelet deficiency or dysfunction. Cryoprecipitate is indicated in dysfibrinogenemia or fibrinogen deficiency.12 Clinical assessment of the urgency for red blood cell (RBC) transfusion will determine whether the patient receives unmatched emergency Type O, Rh‑negative RBCs, group‑specific RBCs, or fully cross‑matched RBCs.7

In present study , male patients received more transfusion which was similar to the study conducted by Linda papa wherein Male patients received more Red blood cells compared to female patients.21  In present study, the commonest indication for packed   red cell transfusion was Anaemia which accounted to 71 cases of the total 180 (38.8%). Yaddanapudi S et al conducted a study which also showed that the commonest   indication for blood transfusion for packed red cells was anaemia.16

In this study, RCC was the most common component transfused which was similar to the study conducted by Andrew J Doyle which RCC was the component mostly transfused.22 The most common indication for PC transfusion was Thrombocytopenia due to Heart failure in this study which is similar to the study conducted by Alexander Bayer which also showed similar results.23 In present study, the transfusion trigger was 7 grams/dl which is found to be similar to the other studies conducted by

Yaddanapudi S et al. In patients having co- morbid conditions blood transfusion was started at 7-9 grams/dl. Carson JL et al in their study also found out that the indication for blood transfusion in anaemia is 7 gram/dl in patients having no co-morbid conditions.18

Multiple guidelines for transfusion exist and the most commonly followed is the American Association of Blood Banks (AABB).19 According to AABB, adherence to a restrictive transfusion, i.e., hemoglobin of 7–8 g/Dl threshold in stable hospitalized patients, is advised. In patients with previous cardiovascular disease, we are to consider transfusion only in symptomatic patients or when hemoglobin is <8 g/dL and no blood product transfusion is advised in stable acute coronary syndrome patients. They also recommend that the decision on transfusion should be influenced by symptoms as well as hemoglobin concentration.20-23              

Villanueva et al. categorized patients with UGI tract bleeding into restrictive (7 g/dL) and liberal groups (9 g/dL).9 They demonstrated that patients in the restrictive group had lower mortality versus the liberal. The rate of bleeding was also lower in the restrictive group with fewer products transfused and hence they recommended a transfusion threshold of 7 g/dL. However, there are limited data to determine the transfusion trigger in Indian patients suffering from UGI bleed; hence, further studies are warranted to determine the threshold of hemoglobin in such patients before posting for procedures.

In a trauma scenario, most physicians would agree that transfusion is required in the setting of life‑threatening trauma with massive hemorrhage. The PROPPR trial evaluated the ratio of blood products in massive transfusion. A ratio of 1:1:1 of platelet‑to‑plasma‑to‑RBC transfusion strategy was associated with decreased mortality and morbidity and hence transfusion of only packed RBCs in a patient with trauma and hemorrhagic shock should be avoided.10

Limitation of study – The data of this study might not reflect to the centres where whole blood is also used as in emergency conditions.

Blood products are an important resource that should not be wasted. Wastage may also be a reason for shortage of blood and its products in the blood centre, with other reasons being increasing demand and shortage of donors. There is large quantity of blood being transfused in the ED, for various indications. For better utilisation and to reduce wastage of blood and blood products, a protocol has to be formulated.

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