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American Journal of Critical Care. 2007;16: 206
Copyright © 2007 by the American Association of Critical-Care Nurses.
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LETTERS

Beware of Transfusion-Related Confounders in Studies on Packed Red Blood Cells

By Nishith K. Singh, MD. From All India Institute of Medical Sciences, New Delhi, India

Gould and colleagues1 provide an excellent review of the limitations of packed cell transfusion in the intensive care unit. I applaud their efforts to painstakingly summarize evidence on a topic of widespread occurrence that is easily overlooked.

Although new studies offer data on the judicious use of packed cells in different patient cohorts, one should be wary of potential residual confounders of transfusion-related consequences in these studies. These confounders may be hypothermia secondary to rapid infusion, fluid overload due to improper patient selection and technique, dilutional coagulopathies, infusion technique–associated hemolysis, route of administration, and guideline transfusion bedside compatibility check. Varieties of "lapse errors" exist and these errors vary with the urgency and repetition of situational parameters and potentially can be confounders with higher transfusions.2

In the developing world, based on my experience at various tertiary care hospitals in India, I have found that critical care units are understaffed and that health-care staff have poor understanding of the evidence regarding infusion rates, choice of blood product, patient selection, and so on. The need for prospective trials to account for potential confounders and the need for formulation and dissemination of effective transfusion guidelines cannot be overemphasized.

FINANCIAL DISCLOSURES
None reported.

REFERENCES

  1. Gould S, Cimino MJ, Gerber DR. Packed red blood cell transfusion in the intensive care unit: limitations and consequences. Am J Crit Care. 2007;16(1):39–49.[Abstract/Free Full Text]
  2. Dzik WH. Technology for enhanced transfusion safety. Hematology Am Soc Hematol Educ Program. 2005:476–482.
 

Response

By David R. Gerber, DO, Suzanne Gould, RN, MS, CCRN and Mary Jo Cimino, RN, CCRN.

We appreciate the comments and insights offered by Dr Singh. These issues and complications are clearly real, and their clinical impact merits independent evaluation. However, their impact on the results of packed red blood cell transfusion is presently undetermined in the literature; we feel they are likely of secondary importance.

The "dose-dependent" relationship that has been demonstrated between red cell transfusion and infection indicates that large volumes of transfused cells are not necessary to trigger adverse consequences, as is generally the case with dilutional coagulopathy, hypothermia, and fluid overload.

The situation in developing nations may be different, but system-related failures at the blood bank level or at the bedside that result in serious adverse consequences of transfusion are relatively uncommon in developed countries, even if the error rate clearly is not zero. Researchers estimate that the overall risk of error during transfusion of a blood component is 1 in 16500 and the risk of transfusion-related death due to administration of incompatible blood is roughly 1 in 500000 in the United Kingdom.1 Therefore, it is unlikely that such problems would have a significant confounding effect on the results we reviewed and summarized in our article.

Transfusion of packed red blood cells will undoubtedly remain a necessary therapeutic intervention for a long time, but further efforts to elucidate the reasons for adverse outcomes following such interventions, coupled with attempts to minimize those outcomes, remain welcome and important.

FINANCIAL DISCLOSURES
None reported.

REFERENCE

  1. Stainsbury D, Russell, J, Cohen H, Lilleyman J. Reducing adverse events in blood transfusion. Br J Haematol. 2005;131(1):8–12.[Medline]




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