Abstract
Background:
An expert panel convened by the NHLBI in 2014 provided guidelines and indications for blood transfusions in patients with sickle cell disease (SCD). These recommendations were to help conserve the use of blood transfusions in SCD in order to reduce the complications of iron overload, transmission of blood-borne pathogens and development of alloantibodies. We retrospectively reviewed the charts of SCD patients who received blood during inpatient admissions and evaluated the indications for transfusions in this population.
Methods:
The hospital database was screened for admissions of patients with the diagnosis of SCD (HbSS, HbSβ0, HbSβ+, HbSC) who were billed for a blood transfusion between 8/1/2015 to 8/31/2016. All patients were >18 years of age. Each chart was reviewed individually to assess the clinical setting and reasons for transfusion. The following parameters were documented: age, sex, length of hospital stay (LOS), hemoglobin (Hgb) at time of transfusion, baseline Hgb, reticulocyte count, total bilirubin, number of units transfused, documented reason for transfusion, immediate reaction to transfusion, presence of alloantibodies and ferritin level. We defined the infusion of blood as a transfused event which included single or multiple units of blood. We excluded transfusions given for acute bleeding.
Results:
There were a total of 200 decisions to transfuse blood for 87 patients between 8/1/2015 to 8/31/2016. 72% of the patients had HbSS disease. HbSB0, HbSB+, HbSC, and unknown genotype constituted 14%, 19%, 6% and 7% of the cohort, respectively. Mean age was 30.6 years and 76% were female. A total of 434 units were transfused. The most common reasons for transfusion that deviated from guidelines were uncomplicated pain crises and a fall in Hgb (> 2g/dl, >1.5 g/dl) which accounted for 65.5% (n = 237 units) of the transfusion events (Pain 27%, Hgb drop > 2 gm 20.5% and Hgb drop > 1.5 gm 17.5%). The most common indicated guideline reasons for transfusion were symptomatic anemia and acute chest syndrome and only accounted for 12.5% and 10%, respectively of transfusions in this cohort. The mean Hgb at which patients were transfused was 6.6 g/dl, with a median value of 6.5 g/dl. The mean Hgb of those transfused for drop in hemoglobin and symptomatic anemia were 5.9 g/dl and 5.7 g/dl, respectively. The mean level of ferritin in this cohort was 2483. 15/87(17%) of patients had allo-antibodies. There was a 2% occurrence of immediate allergic blood transfusion reaction. The average LOS for all patients was 9.0 days. The average LOS for patient who received blood for uncomplicated pain or drop in Hgb was 8.9 days.
Conclusion:
In this group of patients with SCD, the majority of the inpatient transfusions were not indicated by national guidelines. Only 34.5% of transfusion events met expert panel recommendations. There was significant iron overload and development of allo-antibodies noted in our cohort. It is possible that there was a lack of documentation of symptoms due to anemia in those who received blood for a drop in hemoglobin. Regardless, there appears to be a significant number of unnecessary transfusions in SCD patients. We plan to develop and implement an educational program for care providers as to increase adherence to guidelines for transfusions in SCD.
No relevant conflicts of interest to declare.
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