When to use volume-reduced blood products for avoiding volume overload in patients at risk?

A blood banker is concerned about when to use volume-reduced blood products (partial units of RBCs, FFP aliquots, and volume reduced platelets) for avoiding volume overload in certain high-risk patients. For example, in 1985 it was reported (Transfusion 1985; 25: 469) that based on a 7-year retrospective study the incidence of circulatory overload was at least 1 in 3,168 patients transfused with RBCs, but this figure may have underestimated the true incidence. Another study (Audet AM, Popovsky MA, Andrzejewski C. Current transfusion practice in orthopedic surgery patients (abstract). Blood 1995; 86 (Suppl) 853) indicated that one percent of blood transfusion recipients developed circulatory overload, at times necessitating transfer to an intensive care unit and prolonged hospital length of stay. Extrapolating these 1995 data to a national level suggests that perhaps 30,000-40,000 patients annually might suffer volume overload from transfusion. In a 1999 prospective, multi-center, randomized trial (Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999; 340409-417) it was reported that patients admitted to critical care units were randomized to receive either a liberal or a conservative use of blood products. Patients randomly assigned to receive fewer blood transfusions did as well if not better (as a group) than the patients who had been randomly assigned to a more liberal transfusion strategy (and who received a greater number of blood transfusions). The more aggressively transfused patients had a higher incidence of cardiac and pulmonary morbidity. The authors concluded that a restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction and unstable angina. Could increased morbidity in more aggressively transfused critically ill patients be in some part related to volume overload?

Please share your data or experience with transfusion-induced volume overload, and your strategies to avoid this complication.

The following responses were submitted.

1. A transfusion medicine physician in Cleveland reports that she finds it especially frightening when reviewing cases at smaller outside hospitals to see how common it is for elderly nursing home patients, not bleeding, and mildly anemic for age to be sent to the hospital for usually 2 to 3 units of blood (there is a tendency to want to give them more at once so they don't have to be transported as often). She reports having personally seen morbidity and likely mortality from this practice, so, it is a very crucial concern. She believes that this discussion has hit on something that is a real problem, and one that is terribly underappreciated. The study by Wu WC et al (N Engl J Med 2001;345:1230-6) not only showed a survival advantage for anemic patients with an MI who are transfused but a survival disadvantage for this same patient group if these patients received blood when their starting Hct was greater than 36%. This all goes to emphasize the balancing act of transfusion therapy. Transfusion must be given appropriately since harm can result both from under and over transfusion.

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