Evaluation of RBC Transfusion Practice in Adult ICUs and the Effect of Restrictive Transfusion Protocols on Routine Care Open Access

Abstract

Research supports the efficacy and safety of Restrictive Transfusion Protocols (RTP) to reduce avoidable red blood cell (RBC) transfusions, but evidence of effectiveness in practice is limited. This study assessed whether admission to an intensive care unit (ICU) with an RTP reduces the likelihood of transfusion for adult patients. Observational study utilizing data from a multi-center, prospective cohort study for a patient-level analysis. RBC transfusion on day of enrollment was the outcome and admission to an ICU with an RTP was the exposure of interest. Covariates included demographics, hospital course (e.g. nadir hematocrit), severity of illness (e.g. SOFA score), interventions (e.g. sedation/analgesia), and ICU characteristics(e.g. size). Multivariable logistic regression modeling was used to assess the independent effect of RTPs on transfusions in moderate anemia. 6,027 adult ICU patients were included in this analysis, of whom 2,510 (41.6%) were in an ICU with an RTP. 771 (12.8%) patients were transfused, of whom 27.2% had nadir hematocrits (Hct) below 21%. In crude analyses, patients in ICUs with an RTP were transfused more often (14.8% vs 10.9%, p<0.0001) with less severe anemia (Hct 24.3% vs 23.4%, p=0.003). Adjusting for confounding factors, however, RTPs independently reduced the odds of transfusion in moderate anemia (Hct= 21-30%) with an odds ratio of 0.59 (95%CI: 0.36-0.96) with no effect in more (Hct<21%, p=0.93) or less (Hct>30%, p=0.52) anemic patients. In this multi-center sample of ICU patients, transfusions often occurred outside evidence-based guidelines, but admission to an ICU with an RTP did reduce the risk of transfusion in moderately anemic patients controlling for patient and ICU factors. This study supports the effectiveness of RTPs for influencing transfusions in clinical practice.

Table of Contents

SECTION

Introduction………………………………………………………………………………1

Background………………………………………………………………….……………3

Materials and Methods………………………………………………………………...6

Results…………………………………………………………………………………....10

Discussion…………………………………………………………………………..…...13

REFERENCES…………………………………………………………………………....18

TABLES

Table 1. Patient characteristics………………………………………………………22

Table 2. Logistic regression analysis………………………………………………..24

FIGURES

Figure 1. Study flow……………………………………………………………………..26

Figure 2. Histogram of anemia among transfused patients……………………27

Figure 3. Unadjusted frequency of tranfusion over hematocrit……………….28

Figure 4. Adjusted effect of protocol in final model……………………………..29

APPENDIX

Table A1. Power calculations………………………………………………………….30

Figure A1. Mixed-effects logistic regression and linear spline terms………..31

About this Master's Thesis

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School	Laney Graduate School
Department	Clinical Research Curriculum Program
Degree	MS
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Medicine and Surgery
Keyword	Intensive Care Unit Organization Erythrocyte Transfusion Clinical Protocols Evidence-Based Medicine
Committee Chair / Thesis Advisor	Roback, John D, Emory University Murphy, David J, Emory University
Committee Members	Bruce, Beau Benjamin, Emory University Manatunga, Amita, Emory University

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