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• Author response to 'Blood Transfusions: time for a change in practice?'
  Karen Neoh, Michael Bennett
  Published on: 3 December 2019

• Published on: 3 December 2019

  Author response to 'Blood Transfusions: time for a change in practice?'

  • Karen Neoh, Specialist Registrar in Palliative Medicine St Gemma's Hospice, Leeds, UK
  • Other Contributors:
    • Michael Bennett, Professor of Palliative Medicine

  We read and agreed with several points in the editorial [1] that accompanied our main research paper about UK clinicians' views on blood transfusion practice [2]. We have additional responses to the editorial.

  We recognise the lack of evidence about red cell transfusion within palliative care, which is why we undertook the largest audit of transfusion practice to date [3]. We analysed 465 transfusion episodes over 3 months from 121 UK hospices. Patients were not usually investigated for the anaemia. Of those that were, a significant proportion would have benefited from B12, folate or iron supplements, although rarely used. Despite being at higher risk of transfusion-associated circulatory overload (TACO), risk-mitigation practices like weighing patients or restricting transfusion to one unit (before review), were only undertaken in 15% of patients. In terms of patient benefit only 83 (18%) had improvement maintained at 30 days; 142 (31%) <14 days, and 50 (11%) had none. 150 patients (32%) were dead at 30 days, over double the predicted number.

  While documented death rates and major morbidity from red cell transfusion are low in the general population, there is growing evidence of under recognition and under reporting. A study across 157 UK hospitals showed that 4.3% of inpatients >60 years had increasing respiratory distress post-transfusion, but only one-third diagnosed with TACO by the hospital were reported to the SHOT Haemovigilance Group [...

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  We read and agreed with several points in the editorial [1] that accompanied our main research paper about UK clinicians' views on blood transfusion practice [2]. We have additional responses to the editorial.

  We recognise the lack of evidence about red cell transfusion within palliative care, which is why we undertook the largest audit of transfusion practice to date [3]. We analysed 465 transfusion episodes over 3 months from 121 UK hospices. Patients were not usually investigated for the anaemia. Of those that were, a significant proportion would have benefited from B12, folate or iron supplements, although rarely used. Despite being at higher risk of transfusion-associated circulatory overload (TACO), risk-mitigation practices like weighing patients or restricting transfusion to one unit (before review), were only undertaken in 15% of patients. In terms of patient benefit only 83 (18%) had improvement maintained at 30 days; 142 (31%) <14 days, and 50 (11%) had none. 150 patients (32%) were dead at 30 days, over double the predicted number.

  While documented death rates and major morbidity from red cell transfusion are low in the general population, there is growing evidence of under recognition and under reporting. A study across 157 UK hospitals showed that 4.3% of inpatients >60 years had increasing respiratory distress post-transfusion, but only one-third diagnosed with TACO by the hospital were reported to the SHOT Haemovigilance Group [4]. People treated in hospices commonly have several TACO risk factors (as outlined in the editorial). TACO symptoms are non-specific and include cyanosis, dyspnoea and tachycardia which can be mistaken for deterioration of underlying advanced disease.

  There is a misconception about how long it takes to correct abnormal haematinics; B12 and folate treatment can increase haemoglobin within 7–10 days and worth considering before transfusion if the cause of anaemia [5]. Intravenous iron to correct deficiency in palliative care is uncommon; however, it is offered by some services and increasingly seen as safer than red cell transfusion.

  We believe that our paper [2] suggests UK clinicians might be out of step with the evolving evidence base and clinical guidelines about red cell transfusions. This particularly applies to more rigorous anaemia investigation, increased use of alternative therapies and a more restrictive approach to red cell transfusions. Clinicians should discuss the limited benefit versus potentially higher risks in hospice patients to inform treatment decisions.

  References
  1) Brown E. Blood transfusions: time for a change in practice. BMJ Support Palliat Care, 2019
  2) Neoh K, Stanworth S, Bennett MI. How does blood transfusion practice by UK palliative medicine doctors compare with NICE guidance? BMJ Support Palliat Care 2019
  3) Neoh K , Gray R, Grant-Casey J, Estcourt L, Malia C, Boland JW, Bennett MI. National Comparative Audit of Red Blood Cell Transfusion Practice in Hospices: Recommendations for Palliative Care Practice. Palliative Medicine 2019, Vol. 33(1) 102–108 2019
  4) The TACO Audit Working Group, on behalf of the National Comparative Audit in Blood Transfusion (NCABT) Steering Group. The 2017 audit of Transfusion Associated Circulatory Overload (2018). NHSBT
  Accessed online https://hospital.blood.co.uk/audits/national-comparative-audit/medical-a...
  5) Devalia, V, Hamilton, MS, Molloy, AM. Guidelines for the diagnosis and treatment of cobalamin and folate disorders. Br J Haematol 2014; 166: 496–513.

  Conflict of Interest
  None declared

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  Conflict of Interest:
  None declared.

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