We have the unique position to have a wealth of experience and critical care knowledge

concentrated in one room, at one time. We are also able to track and trend on a different scale
than the nurses at the bedside. We may be missing opportunities to share that information with
our counterparts. It is with this spirit in mind that this presentation was developed. Some may
know this information, some may not, but hopefully it will be information that can be shared as
needed with the bedside nurse who may not have our experienced resources, the ability to trend
data, nor the inclination as they are embroiled in on the ground care for two critically ill and
sometimes crashing patients.
Transfusion of red blood cells, or rather the over transfusion, has received worldwide recognition
for at least the last decade. Multiple studies, including recommendations from the TRICC study
and Surviving Sepsis Campaign, have recognized an over indulgence in blood product use that is
actually critically harmful to ICU patients. So, what changed the way of thinking? The end
story was that they realized you are affecting the patients now, at this moment, but the effects of
transfusion may be long lasting.
SLIDE 2:
It can be argued that these patients are critically ill and these increased lengths of stay and
complications are related to disease processes and not transfusions, but studies show a significant
increase in mortality for patients receiving transfusions versus those that did not. If you remove
all the confusing factors and comorbidities involved and compared simply patient x to patient y,
the critically ill, multiple, transfused patient will have a higher likelihood of mortality every
time.
SLIDE 3:

30-50% of needed transfused blood in an anemic patient can be accounted for in phlebotomy
practices during an ICU stay. Nursing practice can really help with this. Know the waste policy
for the line in use for blood draws. Return the waste when possible. Use pediatric tubes. Ask
the lab how much blood is needed for adult tubes for particular tests and use only that amount.
Coordinate arterial sticks with RT. Question the need for standing daily lab orders that are not
changing in trend. These are all educational points that we can pass on to the bedside nurse as
appropriate.
SLIDE 4:
1. RBCs are typically replaced every 120 days in response to lower oxygen levels detected by
the kidneys. This may take even longer in critically ill patients related to comorbid conditions
that cause hemolysis, decreased iron absorption, bone marrow suppression, or decreased
erythropoiesis.
2. A non-critically ill patient is capable of shifting oxygen off hemoglobin (shift to the right on
the oxyhemoglobin dissociation curve) to the tissue to compensate for anemia. Critical patients
cannot do this related to increased metabolic demands of their disease states.
3. As PRBCs are stored, they lose 2,3-DPG after 7 days. The hemoglobin-oxygen dissociation
curve then shifts to the left and less oxygen moves into the tissues. This is with blood older than
a week. Current standards allow blood to be preserved for between 35 to 42 days and the oldest
is to be used first, regardless of the patients comorbidities or critical nature. Critically ill
patients need the freshest blood, but policy usually dictates that the oldest blood be used first.
The storage solutions in the blood can also promote hemolysis and acidosis. So, now not only do
you have a shifting to the left patient to begin with, but you just added a treatment regimen that

may cause further shifting to the left, which means less off-loading of oxygen and tissue
perfusion, which is the exact opposite of what the prescribed treatment set out to do.
4. Studies have shown that the more RBCs that are transfused, the likelihood of their mortality
is also increased exponentially so the number of units considered, not just the transfusion itself
should also always be contemplated.
SLIDE 5:
These are the most common causes of transfusion related morbidity and mortality.
SLIDE 6:
Chagas affects heart and can be undetected for years. Parasitic disease caused by Trypanosoma
cruzi.
Human T-cell lymphotropic virus retrovirus that can lead to T-cell malignancies.
Viral transmission of diseases has been drastically reduced since the HIV epidemic of the 80s
identified a need for testing of the blood supply, although some patients do test postive. The
same could be accomplished for bacterial transmission, however, routine testing for Gram (+)
and Gram (-) organisms is not completed related to labor and cost concerns. The testing can only
be offered after suspected exposure and reaction are confirmed. The patient and blood would
have to then be cultured, tracked, and then the rest of the donated blood tested, tracked, all the
way back to the donor.
SLIDE 7:

Hemolytic transfusion reactions can be acute or delayed and are a destruction of red blood cells,
often occurring as a result of ABO incompatibility. This is generally a result of processing errors
or blood type ID errors.
SLIDE 14:
This goal of 7-9 is where the conservative ordering of blood can also play a role. As a general
rule, without acute blood loss, 1 unit of RBCs should raise a patients hemoglobin 1 g/dL.
Bearing that in mind, if the patient is not actively bleeding or hemodynamically compromised,
consider ordering only 1 unit as needed to reach goal rates and decrease transfusion risks.
Recognize signs and symptoms of organ hypoperfusion to adjust the need for RBC transfusion.
Track and trend the Hgb values, blood loss, urine output, mentation, HR, RR, BP, SaO2, and
CVP.