|Year : 2020 | Volume
| Issue : 1 | Page : 23-32
Source of blood and its consumption at King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
AM Abdel Gader1, Abeer K Al Ghumlas2
1 Department of Physiology, College of Medicine, Al Faisal University; The Blood Bank, King Khalid University Hospital, Kind Saud University, Riyadh, Saudi Arabia
2 The Coagulation Research Laboratory, Department of Physiology, College and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||23-Jun-2019|
|Date of Acceptance||06-Sep-2019|
|Date of Web Publication||06-Jan-2020|
A M Abdel Gader
College of Medicine, Al Faisal University, P.O. Box 50927, Riyadh 11533
Source of Support: None, Conflict of Interest: None
The King Khalid University Hospital (KKUH) blood bank undertakes all the functions of blood transfusion service, from the recruitment of donors to the issue of blood products to patients. Currently, the blood bank depends on a mixture of replacement and voluntary donations. The blood bank had a previous experience of organizing a successful centralized King Saud University student donor drive which in the years 1885 to 1990 collected over 4000 blood units that almost covered KKUH blood needs. However, due to administrative difficulties, this drive did not continue. The main blood products consumed at the KKUH are packed red blood cell (PRBC), fresh frozen plasma (FFP), and platelet concentrate (PC). Long-term audits of their consumption showed that their consumption initially increased slowly with the total hospital admissions up to the year 1995 and then fell sharply to its lowest level in the year 2000: FFP dropped by 30.9%, PRBC by 27.8%, and PC by 48.6%. From 1995 onward, the total hospital patient admissions remained stable around 32,000 patients. The drop in consumption was taken to represent the magnitude of the inappropriate use of these products. This drop in consumption coincided with and was attributed to the widespread “HIV scare” that blood transfusion can transmit the infection, which made both patients and physicians reluctant to resort to blood therapy. There is a need to make sure that guidelines for the use of blood products are followed by all involved in the blood transfusion from blood collection to infusion into patients. These guidelines need to be supported by educational efforts targeting all those involved in hemotherapy, particularly physicians and nurses.
Keywords: Blood donation, blood products, blood transfusion, fresh frozen plasma, packed red blood cells, platelet concentrate
|How to cite this article:|
Abdel Gader A M, Al Ghumlas AK. Source of blood and its consumption at King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia. J Nat Sci Med 2020;3:23-32
|How to cite this URL:|
Abdel Gader A M, Al Ghumlas AK. Source of blood and its consumption at King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia. J Nat Sci Med [serial online] 2020 [cited 2020 Apr 2];3:23-32. Available from: http://www.jnsmonline.org/text.asp?2020/3/1/23/275170
| Introduction|| |
The transfusion of blood has historically been and remains a vital supporting service to clinical medicine, from life-saving therapy in emergencies characterized by massive blood loss to the use of immunoglobulins in the management of difficult-to-treat immune diseases and the current emergence of the new so-called regenerative medicine based on stem cell therapy. However, in the day-to-day practice of transfusion medicine, three blood products, namely packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelet concentrate (PC), are in continuous order and use in the management of patients, especially those going for surgery and hematology/oncology as well as trauma patients. Over the years, unaccountable developments have been achieved in all aspects of transfusion medicine practice which can be summarized in three distinct areas, namely, availability, efficacy, and safety of the transfused blood. In addition, as the transfusion practices have grown large and complicated, the need has arisen for the continuous and strict observation of these processes by the establishment of standard procedures, practices, and recognized guidelines within the transfusion chain, from the blood bank to the treating physician and patient. On the top of these steps and practices is the total quality management at local/institutional, regional, and international levels. Despite all these efforts, errors, although very rare, still occur in the transfusion of blood products. To review all these aspects of blood transfusion at the King Khalid University Hospital (KKUH) in one article is a nightmare and accordingly, this presentation deals only with the two important steps in the transfusion chain, namely source of the blood (blood donation) and the last step, the utilization of blood products at the KKUH. In both aspects, we will survey their long-term history according to the information available to us from the hospital's blood bank records.
| Blood Donations|| |
The KKUH was inaugurated in 1982, and services commenced by offering minimum admissions of cold, nonurgent pediatric and general medicine patients. Services in other hospital departments and divisions picked slowly as the recruitment of personnel and the establishment of a wide range of supporting services, including the blood bank, took time to run satisfactorily.
Earlier, around 1975, blood banks in Saudi Arabia, in the face of the shortage of blood supply, relied on two blood sources, namely paid blood donors (all foreigners who were paid 300 Saudi Riyals, $70/single whole blood donation), in addition to imported blood products from abroad (mainly, Switzerland and the USA). This is to be followed by the gradual adoption of replacement donations, from family members, friends, and workmates: “no donation no admission to hospital for patients who may need transfusion therapy.” Initially, there were few voluntary donors, mainly foreigners, who were already acquainted with voluntary blood donation. Some of the locals argued that while the government has approved payment for donors, why asking us to donate? This strong argument proved to be a major hurdle in convincing locals to donate their blood, even family donations, until eventually, in 1986, the government canceled its decision to pay donors.
Over the subsequent years, voluntary donations continued to grow due to the activity of outdoor blood collection teams who visited institutes of higher education, police and military colleges, and places of work such as governmental departments and commercial company headquarters and malls. In all these locations, the blood donors were predominantly males, with minimum contribution from females. For example, at our blood bank (KKUH Blood Bank), and other major hospital blood banks in Riyadh city, over the years and until today, females constitute <5% of the blood donors, while they constitute almost 50% of the Saudi population. A similar disparity in the contribution of females exists in neighboring countries. In contrast, females in Western societies give as high as 40%–50% of donated blood.,
When payment for donors was stopped in 1986 and the importation of blood from abroad was also phased out gradually by different hospitals, fortunately, this has coincided with the global “AIDS scare” that blood transfusion can transmit the disease, which was not known in the Kingdom of Saudi Arabia. There was then a general belief, propagated by the local press and other news media, that transfused blood, especially imported blood, was not safe and could transmit the disease. This helped the enforcement of the policy of “no blood donation no surgery” or admission to hospital. This notion took its extreme in patients going for open-heart surgery who will not be admitted for surgery until they provide at least 15 accepted donors. The benefit of this policy was twofold: first, it helped to safeguard the constant flow of donations to allow the blood bank to meet its obligations toward urgent cases requiring hemotherapy. It also facilitated the establishment of stock of blood products to meet the needs of supportive therapy for hematology/oncology patients as well as acute emergencies. Second, it proved to be a good initial step to create potential future “voluntary” blood donors, particularly first-time donors, who break the “fear barrier” and realize that blood donation, opposite to what they believed, after all is a safe procedure.
| King Saud University Students Donor Drive|| |
When the blood bank started functioning, the need for blood was minimal, and the main source of blood was paid donors. However, when surgical operations commenced, the dependence on paid donors was expanded, and this was supported by very scanty contribution from the patients' families, friends, and workmates. Four years later, the buildings of the adjacent King Saud University (KSU) campus were completed, and all the university colleges were shifted from the center of Riyadh City to their new modern premises at the north of the city. This was a great blessing to the blood bank, and the student donation activity became more organized and centralized in a large spacious donation center in the middle of the new campus. The organization of blood donor activity was put under the KKUH Blood Bank and Deanship of Student Affairs, KSU. The deanship looked after the donor center which was located adjacent to the Students' Health/Entertainment Centre and food halls. The center was easily accessible to students from all university colleges, and a good number of students and university employees will avail themselves each day at their leisure time and come and donate their blood. The KKUH blood bank and the Ministry of Health Central Blood Banks are permanent blood collectors. The annual total number of blood donations picked up gradually and reached a maximum of 4500 donors, 10 years later in the academic year 1986–1987 [Figure 1]. The university students were the predominant donors, and each day, the number of single blood units collected ranged from 20 to 50, and this varied according to the blood bank's inventory and the shortage of specific blood group type. The Deanship of Student Affairs which classifies the KSU blood donation as one of their social activities give out low-price gifts and incentives to donors (clocks, wristwatch, as well as Saudi headdress “Ghutra,” stamped by the university's emblem). At the end of the academic year, a “University Blood donation Trophy” was usually awarded to the university college that donated the maximum number of blood units. Each year, the university rector graced the donation project by giving the first donation, declaring the commencement of the annual activity, and his inauguration and all the activities of the donation center were given wide publicity within and outside the university.
|Figure 1: King Saud University students' annual blood donations (1997–2007)|
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The KSU donor drive uncovered the enormous voluntary potential upon which the KKUH blood bank can rely for its future needs of blood products to cover all the requirements of hemotherapy for hospitalized patients, without asking patients to provide donors or for outdoor blood donation teams to reach donors in their places of study or work. The number of donors was highest between 1986 and 1990. This was at the time the total number of full-time students enrolled at the KSU was approaching 30,000 students. The number has grown rapidly and in 2018, the number of enrolled students was over 120,000. If we add the number of employees, both academic and nonacademic, in addition to their families, the total potential donor population at the KSU could be well above 200,000. We need to draw the attention to the fact that almost all donors at the KSU donor center donate once/year. Accordingly, the annual total number of collected blood units could readily be doubled or tripled if the donors were bled twice or thrice/year. Thus, the enormous voluntary blood donor potential in this small selected sector of the KSU community was more than enough to supply all the present and future needs for blood products to cover the requirements of the KKUH.
The monumental success of the KSU Donor Drive did not survive for long basically due to the frequent changes in the administrations of both the student affairs and the KKUH blood bank, neither of the two realized the importance of maintaining the great success of the centralized KSU donor activity for the future blood requirements of the KKUH. A number of successive factors could be identified for the demise of the KSU Blood Donor Drive: first, when the annual total number of blood collected was at its maximum, the newly appointed administrator of Student Social Affairs decided to invite the four major hospital blood banks in Riyadh (largest and busiest hospitals) to bring over their blood collection teams to join and take their share from the KSU Donor Drive. As a result, the annual collection of blood units started to drop markedly; second, student affairs administrators preferred that the different hospital blood collection teams go to different university colleges in their premises to make it easier for students to donate, although such concern about the centralized donation has never been raised by the students. Different colleges do not have suitable space to the blood collection teams to replace the comforts of the well-equipped central facility. That step created great organizational difficulties in finding the suitable space, and very few students would have free time during the working day to come and donate within the assigned 2 weeks' visit of the blood collection team. Thus, collecting donations in different colleges proved to be an organizational nightmare and a catastrophe to the survival of the students' donor drive. The annual total number of blood units continued to drop rapidly so that by the year 2003, it reached 1755 and thereafter fluctuated between in 50 donors in 2004 and 2005 to 376 donors in 2009 and [Figure 1]. The successful KSU donor activity was put to rest as the KSU administration hammered the last nail on its coffin when a decision was taken to close the original student central donor center when it was noticed that the donor activity has dwindled and the space was re-assigned to become offices for other university research units. As a result, the KKUH blood bank started to rely once more on replacement donations as well as on outdoor donation campaigns. The latter was encouraged by the acquisition of a modern mobile blood collection vehicle.
Looking back, the King Saud Donor Drive remains strong evidence to the existence of a huge voluntary blood potential within the KSU community and could have covered all the future needs for blood products by the KKUH, a potential that has been tested and proven as described above. We hope that the newly formed KSU Medical City administration would intervene and with the help of the KSU administration bring life to the KSU student donor centralized drive and set a model for the rest of health institutes that continue to face frequent shortages in their blood supply.
While the supply of blood and its products has been successfully met by efforts of the staff of the donor division of the blood bank, now let us turn our attention to the pattern of consumption of the blood products by physicians in the management of patients who need hemotherapy.
| Consumption of Blood Products at the King Khalid University Hospital|| |
Blood was used as a replacement therapy (or hemotherapy), which started as early as the 17th century to save the lives of severely bleeding patients. The oldest blood replacement therapy in record was the transfusion of animal blood from either dog or sheep, directly to the patient who lost large volumes of blood. The outcome was catastrophic due to what was later recognized as severe and fatal anaphylaxis as a result of gross incompatibility between human and animal blood. Since then, significant discoveries and developments in this form of life-saving therapy have been achieved that made it safer and more crucial for the management of a wide range of diseases, other than the treatment of hemorrhagic patients. Developments in hemotherapy have never seized, with the most remarkable being the discovery of the ABO blood groups by the Austrian, Karl Landsteiner, in 1901, and the AB blood group in 1902 by Adriano Sturli and Alfred von Decastellom, who were working under Landsteiner, and lastly Karl Landsteiner and Alexander Wiener's description of the Rhesus blood group system in 1937.,, These blood group systems remain the most clinically important blood types upon which compatibility testing is based until this day.
Nowadays, whole blood is very rarely used for transfusion as technology backed by better understanding of the functions of various blood components facilitated the separation of a variety of derivatives of whole blood that made this therapy not only more effective but safer than ever. Currently, many components can be separated from one unit of whole blood to the benefit more than one patient. Besides, transfusing a single blood component can target specific patient needs than transfusing whole blood. Blood component therapy has also the added advantage of transfusing effective doses of a needed blood component in a small volume than would be the case if whole blood is transfused and, in this way, reducing the exposure of the patient to the un-needed components which may expose the patient to the risks of hemotherapy such as transmitting infection and other immune complications.,, Thus, blood component therapy is nowadays the standard practice of hemotherapy.
The blood components most routinely consumed each day by patients are PRBCs, FFP, and PC. PRBCs increase the blood oxygen-carrying capacity and deliver oxygen to tissues, especially in those patients who suffer significant blood loss or those with defective hemoglobin or erythrocyte production, whereas FFP and PCs are essential for the correction of hemostatic defects by preventing, reducing, or stopping bleeding.
At the KKUH blood bank, like other hospitals' blood banks in Saudi Arabia, there are guidelines for the transfusion of various blood components issued by the Hospital's Blood Transfusion Committee detailing the nature of the products, indications for their use and the expected benefits, the recommended doses, and the possible risks that may result from their infusion.
These guidelines are generally in line with international guidelines issued by the international regulatory bodies such as the American Association of Blood Banks in the USA,,, the British Society for Haematology Guidelines in the United Kingdom, and the American College of Pathologists. However, it must be emphasized that strong evidence to support these guidelines and the current practice of transfusion of blood products as well as the expected benefit and outcome is still lacking.,
Pavenski et al. published their recent 10-year systemic review (2005 to June 3, 2016), which is based on guidelines identified in 6174 citations, of which thirty guidelines met the inclusion criteria. Twenty-six guidelines had recommendations for red cells and 18 included recommendations for plasma use. Wide variations were found in recommendations for plasma use for bleeding patients and for the use of hemoglobin triggers for red cell transfusion in patients with acute coronary syndromes. There are also inconsistencies in recommendations for the same product. The conclusion of this review emphasizes the need for developing evidence-based guidelines that would enhance their implementation. This conclusion is by means new, as data published earlier reached similar conclusion that there is a need for additional randomized studies to establish more comprehensive and definitive guidelines for plasma transfusion.
Nonetheless, and despite the existence of guidelines, the final decision to transfuse blood components remains in the hands of the treating physician who orders the blood and who may reach his/her decision to transfuse depending on the patient's clinical condition and physiological needs, his/her age, existing comorbidities, and severity of illness in addition to the physician's previous experience with the management of similar clinical situations.,,,,,,
Other than reliable, high-quality, evidence-based guidelines for the transfusion of blood components that will encourage treating physicians to abide with these guidelines, concern has also been raised about the inappropriate use and wastage of transfused blood products. The inappropriate use of blood components has been attributed to many factors, such as the physician's previous experiences in the management of clinical situations requiring hemotherapy and/or his/her personal preferences to certain infusion protocols, variation within specific disease where strict guidelines cannot be applied,, clinical settings, and surgical procedures.
The decision to transfuse a blood product can also be influenced by the “transfusion trigger,” or threshold which is a lower limit in the measured circulating levels of blood constituents below which transfusion of a product is recommended. However, numeric triggers do not override the decision of the attending physician to transfuse blood products.,
It is also worthwhile bearing in mind that the transfusion of blood products unavoidably exposes recipients to both infectious and noninfectious risks. Recently, the infectious risks have dropped markedly mainly due to strict donor selection and the development of highly sensitive and specific blood screening laboratory tests, especially nucleic acid amplification tests. However, some patients may still be exposed to noninfectious risks, such as graft-versus-host disease and transfusion-related acute lung injury.,
In the face of these uncertainties, resort to strict blood management systems and less exposure of patients to transfusion is gaining a lot of popularity as it became the preferred way to guarantee the safety of hemotherapy and to economize in the transfusion of a limited resource in addition to saving costs.,,, In addition, the recent introduction of hemovigilance programs as an approach to assess most aspects of transfusion therapy allowed not only the checking on how transfusion therapy follows the institutional guidelines but also the evaluation of the scale of the risks associated with transfusion therapy.
Well before the introduction of hemovigilance in transfusion practice, auditing the consumption of blood products has been the subject of numerous publications.,,, The major lesson learned from these publications is the need and proven benefit of these audits as reliable tools for uncovering the extent of the inappropriate and unnecessary use of blood products, wastage, as well as the avoidable exposure of transfused patients to the potential risks of transfusion therapy. These audits have also been helpful in highlighting the extent of the compliance with the institutional guidelines for the use of these blood products.
Nowadays, all the above issues relating to blood component therapy have assumed marked significance in view of the fact that the quality of health offered to the general population and the community at large as well as the quality of the care offered to individual patients has become a major issue to health administration authorities.,
From its early days, the blood bank at the KKUH has based its practice and performance on the rules and well-established international guidelines. The recruitment of staff, both technical and medical from blood transfusion services in advanced countries, mainly the United Kingdom, proved to be a prime factor in the establishment of good transfusion practices in all aspects of the blood transfusion chain from the recruitment of blood donors to the issue of blood products, guided by written guidelines and manuals in each step. The blood bank records were well kept, initially on paper and later when computers became available, online records were adopted by the blood bank independently and later as part of the hospital's hospital information system. These records helped markedly in working out audits in all the blood bank activities. Some of these audits generated information and lessons not only for the blood bank but also for the clinical staff who order and/or consume blood, allowed the blood bank staff to expose their practice to experts in the field of blood transfusion in local, regional, and international specialized conferences,,,,,,, and were also the bases for a few publications.,,,,
| the Consumption of Fresh Frozen Plasma, Packed Red Blood Cells, and Platelet Concentrate|| |
In the following account, we will summarize our experience with long-term audits of the consumption of FFP, PRBC, and PC, as well as some of the lessons we learned from them.
FFP is one of the most consumed blood products and along with PC, it is ordered by treating physicians as part of the management of a wide range of hemostatic defects, both for treatment and prophylaxis purposes. In this function, FFP is transfused to correct deficiencies of clotting factors, for which a specific concentrate is not available. FFP contains about 70% of the original coagulant factors VIII and V and normal levels of the stable clotting factors and natural coagulation inhibitors, immunoglobulins, and albumin.
Our blood bank has guidelines for its use that states a shortlist of common clinical conditions where the infusion of FFP is indicated. These indications are by no means bind to the physicians, especially when managing minor bleeding disorders. In fact, up to date, there are no firm evidence-based indications for the use of FFP, and this unavoidably opens the door for its inappropriate use and the wastage of a costly blood product and, as expected, exposes the patient to the adverse effects of its transfusion.,
We have recently published a long-term, 22-year (1986–2007) audit of the FFP annual consumption of the KKUH [Figure 2]. The grand total number of units consumed during that interval was 68,480 units of FFP. Further analysis has shown that the annual consumption peaked at 4242 units of FFP/year in the year 1995 and then dropped sharply to its lowest level (2933/year) in 2000, representing a 30.9% drop. Thereafter, consumption continued to increase gradually up to the end of record keeping in 2008. Interestingly, the total hospital mortality in the same time interval [Figure 3] followed a similar fluctuation as FFP, i.e., there was a concomitant and overlapping drop in FFP consumption as well as the total hospital mortality/per patient admission, followed by a gradual increase up to 2008.
|Figure 2: The annual consumption of packed red blood cell, platelets concentrate, and fresh frozen plasma from 1986 to 2008 at the King Khalid University Hospital (1986–2008)|
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|Figure 3: Annual mortality per admission at the King Khalid University Hospital|
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We have reported a similar trend in the long-term survey of the consumption of PRBCs. The grand total consumption was 345,642 units over the period of the study. The consumption increased gradually and peaked in the year 1994, dropped to 27.8% 6 years later, and then increased gradually thereafter. Most of the PRBC consumption was by the Department of Medicine [Figure 4], most probably due to the care offered to the oncology/hematology patients.
|Figure 4: The annual consumption of packed red blood cells by hospital divisions at the King Khalid University Hospital|
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As for PC, the grand total consumption was 100,466 units, which was similar to the pattern of the long-term consumption of FFP and PRBC. There was a sharp drop in consumption that started in the year 1995 up to its lowest level around the year 2000, equivalent to 48.6% drop, and then the consumption increased slowly up to 2008.
The factor(s) responsible for the sharp drop in the consumption of blood products between 1995 and 2000 is open to speculation. We believe the main factor that may account for that sharp drop in the consumption of the three blood products to be the widespread general concern about the safety of allogeneic blood transfusion, and the general public's unease and worry about the transmission of HIV by blood transfusion. This HIV “scare” seemed to have been widespread among both patients and the treating physicians, since the early nineties, and that has impacted the practice of hemotherapy significantly.,,
Nowadays despite the maximum efforts to improve the safety of blood transfusion and reduce all its possible hazards to their minimum, that old standing heightened public concern about its safety still survives. A recent survey found that a significant proportion of patients and caregivers perceive transfusion of allogenic blood as a general health hazard.
According to Graw et al.'s findings, patients, in particular, still believe that the transmission of HIV and hepatitis C virus infections is the greatest health risk associated with blood transfusions, while caregivers found that ABO incompatibility poses more hazards than transmission of these infections. Similar concern about blood transfusion safety still exists in Saudi Arabia.
Our observation of the trend in all-cause annual hospital mortality coinciding closely with the trend in the consumption of the three blood products is of great interest. There was a slow increase in mortality to a maximum and then a sharp drop after 1995, followed by a slow increase after the year 2000 [Figure 3]. It is relevant to add here that the total number of patient admissions to the KKUH was just under 34,000 in 1996 and remained stable up to 2007. The sharp drop in mortality that coincided with a similar drop in the consumption of the three blood products confirms and extends earlier reports that less transfusion of blood products is associated with better patient outcome including morbidity and mortality.,, It is known that the benefit and efficacy of transfusing blood products in improving patient outcomes is not evidence based and has been mostly taken for granted and has opened the door to its abuse and wastage. In fact, excessive resort to hemotherapy, as has uncovered by numerous reports, as discussed above, is common in blood transfusion practice.,,,, The slow increase in the consumption of the three blood products which started after the year 2000 was attributed to the expansion of patient care in the departments of cardiac surgery, medicine (hematology/oncology service), and accident and emergency; the all-cause mortality increased slowly up to 2008.
Building on the notion that less blood transfusion improves the safety of blood transfusion, the recent adoption of blood management strategies, especially restrictive blood transfusion practices,,, is nowadays gaining a lot of popularity in many institutions. It is also a welcome message to developing countries which face continuous shortage of safe blood, as a result of both shortage of donors and poor laboratory facilities to test donated blood for the widespread infective agents such as HIV and HCV.,
Another revelation of our audits concerns the cross: match transfusion ratio (C:T ratio) in various clinical divisions at the KKUH as it allowed us to examine the extent to which the blood bank resources are utilized wisely. We found that the department of obstetrics and gynecology maintained the highest C:T ratio of 9:1, indicating that for each 10 units cross-matched, only one unit is transfused. This gross overuse of this laboratory test, instead of the Screen and Save procedure, not only reflected overordering of PRBCs that are not transfused, but also resulted in wastage of the limited blood bank resources. In addition, it shortens the shelf life of PRBC units that were cross-matched and kept waiting for 24 h for a specified patient and were not made available for use by other more needy patients. However, to solve this problem, the blood bank started to cross-match such booked PRBC units for more than one patient and enforced the implementation of the group and save policy. In contrast to the department of obstetrics and gynecology, the department of pediatrics where most consumption of PRBCs is in the day care unit that treats the transfusion-dependent sickle cell anemia and thalassemia patients, the C:T ratio is nearly 1, indicating that they consume almost all the PRBCs they order.
In the face of concern about the safety of blood transfusion and shortage of blood supply worldwide, a frequent question has been asked whether there are any alternatives to blood therapy. Nowadays, a lot of research is underway to find such alternatives. Although some progress has been achieved in finding a few promising oxygen carriers and deliverers which have hardly moved effectively beyond animal trials, real progress that found its place in patient therapy is recombinant erythropoietin as an alternative to red cell transfusion. Our audit of PRBCs has shown marked success of the use of erythropoietin in the renal dialysis unit where this recombinant therapy has almost replaced PRBC transfusion in the treatment of anemia of renal failure. These patients used to depend totally on regular transfusion of PRBCs to correct their anemia. The consumption of PRBCs was minimal after the introduction of erythropoietin therapy as replacement for the transfusion of PRBCs.,
| Conclusion|| |
The blood bank at the KKUH, like other hospital's blood bank in Saudi Arabia, undertakes all the functions of a blood transfusion service, from the recruitment of donors and the collection of donated blood to the preparation of blood products and their issue to needy patients. The donated blood is collected from a combination of involuntary replacement (family) donations and voluntary donations in organized outdoor donor campaigns. The blood bank had a unique experience depending on voluntary donations through the well-organized donation center at the KSU campus. Around the years 1985 to 1995, the number of collected whole blood units reached a maximum of 3500–4000 blood units per year, predominantly from university students. However, due to administrative difficulties, the activity of this center did not survive for long. Nonetheless, we hope that the blood bank will bring this centralized KSU donation activity to life to become its main source of donated blood and put an end to replacement donations. In the meantime, the combination of voluntary and involuntary donors allowed the blood bank to fulfill all the requirements of clinical medicine for blood products without failure.
As to the consumption of these products in this review, we concentrated on the most commonly consumed products by patients, namely FFP, PRBC, and PC. We presented a concise audit of their use over 22 to 23 years. The main lesson we learned from these audits is that the scale of inappropriate use of these products which at one point reached 40% of the consumption. The inappropriate use and wastage of these products and unnecessary exposure of the transfused patients to the risks of transfusion therapy were exposed during the years 1995–2000 when there was a widespread “HIV” scare among the general public, patients, and physicians that blood transfusion can transmit the infection. This was accompanied by a sharp drop in the consumption of the three blood products. This drop in consumption was accompanied by a simultaneous sharp decline in overall hospital mortality rates, confirming further the widespread notion that less transfusion is safer to patients. There is a need to make sure that guidelines for the use of blood products are followed by physicians and to support these guidelines by active educational efforts covering all aspects of blood product therapy and targeting all those involved in the different steps of hemotherapy mainly physicians and nurses. Deficiency in knowledge on blood transfusion among residents was exposed in a recent international study, which highlighted the need for such educational efforts in addition to the introduction of educational programs in both undergraduate and postgraduate levels.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Gader AG, Al Ghumlas AK, Al-Momen AK. Transfusion medicine in a developing country – Alloantibodies to red blood cells in multi-transfused patients in Saudi Arabia. Transfus Apher Sci 2008;39:199-204.
Javadzadeh Shahshahani H. Why don't women volunteer to give blood? A study of knowledge, attitude and practice of women about blood donation, Yazd, Iran, 2005. Transfus Med 2007;17:451-4.
Thomson RA, Bethel J, Lo AY, Ownby HE, Nass CC, Williams AE, et al.
Retention of “safe” blood donors. The retrovirus epidemiology donor study. Transfusion 1998;38:359-67.
Newman BH, Pichette S, Pichette D, Dzaka E. Adverse effects in blood donors after whole-blood donation: A study of 1000 blood donors interviewed 3 weeks after whole-blood donation. Transfusion 2003;43:598-603.
Newman BH. Management of young blood donors. Transfus Med Hemother 2014;41:284-95.
Boulton FE. Blood transfusion; additional historical aspects. Part 1. The birth of transfusion immunology. Transfus Med 2013;23:375-81.
Freedman J. Transfusion – Whence and why. Transfus Apher Sci 2014;50:5-9.
Avent ND, Reid ME. The Rh blood group system: A review. Blood 2000;95:375-87.
Goodnough LT, Levy JH, Murphy MF. Concepts of blood transfusion in adults. Lancet 2013;381:1845-54.
Yaddanapudi S, Yaddanapudi L. Indications for blood and blood product transfusion. Indian J Anaesth 2014;58:538-42.
] [Full text]
Gurevitz SA. Update and utilization of component therapy in blood transfusions. Lab Med 2011;
Carson JL, Guyatt G, Heddle NM, Grossman BJ, Cohn CS, Fung MK, et al
. Clinical practice guidelines from the AABB: Red blood cell transfusion thresholds and storage. JAMA 2016;316:2025-35.
Kaufman RM, Djulbegovic B, Gernsheimer T, Kleinman S, Tinmouth AT, Capocelli KE, et al
. Platelet transfusion: A clinical practice guideline from the AABB. Ann Intern Med 2015;162:205-13.
Roback JD, Caldwell S, Carson J, Davenport R, Drew MJ, Eder A, et al
. Evidence-based practice guidelines for plasma transfusion. Transfusion 2010;50:1227-39.
Robinson S, Harris A, Atkinson S, Atterbury C, Bolton-Maggs P, Elliott C, et al.
The administration of blood components: A British Society for Haematology guideline. Transfus Med 2018;28:3-21.
Lundberg GD. Practice parameter for the use of fresh frozen plasma, cryoprecipitate and platelets. JAMA 1994;271:777-81.
Pavenski K, Stanworth S, Fung M, Wood EM, Pink J, Murphy MF, et al
. Quality of evidence-based guidelines for transfusion of red blood cells and plasma: A systematic review. Transfus Med Rev 2018. pii: S0887-7963(18)30017-8.
Shah A, Stanworth SJ, McKechnie S. Evidence and triggers for the transfusion of blood and blood products. Anaesthesia 2015;70 Suppl 1:10-9, e3-5.
Gajic O, Dzik WH, Toy P. Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: Benefit or harm? Crit Care Med 2006;34:S170-3.
Murphy MF, Brunskill S, Estcourt L, Stanworth S, Dorée C. How to further develop the evidence base for transfusion medicine. Blood Transfus 2012;10:436-9.
Yawn BP, Buchanan GR, Afenyi-Annan AN, Ballas SK, Hassell KL, James AH, et al.
Management of sickle cell disease: Summary of the 2014 evidence-based report by expert panel members. JAMA 2014;312:1033-48.
Chu D. Use of restrictive transfusion in abdominal surgery: Should evidence-based medicine replace art of medicine? JAMA Surg 2015;150:631.
Chan AW, de Gara CJ. An evidence-based approach to red blood cell transfusions in asymptomatically anaemic patients. Ann R Coll Surg Engl 2015;97:556-62.
Hoeks MP, Kranenburg FJ, Middelburg RA, van Kraaij MG, Zwaginga JJ. Impact of red blood cell transfusion strategies in haemato-oncological patients: A systematic review and meta-analysis. Br J Haematol 2017;178:137-51.
Hasley PB, Lave JR, Hanusa BH, Arena VC, Ramsey G, Kapoor WN, et al.
Variation in the use of red blood cell transfusions. A study of four common medical and surgical conditions. Med Care 1995;33:1145-60.
Khanna MP, Hébert PC, Fergusson DA. Review of the clinical practice literature on patient characteristics associated with perioperative allogeneic red blood cell transfusion. Transfus Med Rev 2003;17:110-9.
Ejaz A, Frank SM, Spolverato G, Kim Y, Pawlik TM. Defining transfusion triggers and utilization of fresh frozen plasma and platelets among patients undergoing hepatopancreaticobiliary and colorectal surgery. Ann Surg 2015;262:1079-85.
Cho J, Choi SJ, Kim S, Alghamdi E, Kim HO. Frequency and pattern of noninfectious adverse transfusion reactions at a tertiary care hospital in Korea. Ann Lab Med 2016;36:36-41.
Kato H, Nakayama T, Uruma M, Okuyama Y, Handa M, Tomiyama Y, et al.
retrospective observational study to assess adverse transfusion reactions of patients with and without prior transfusion history. Vox Sang 2015;108:243-50.
Meybohm P, Herrmann E, Steinbicker AU, Wittmann M, Gruenewald M, Fischer D, et al.
Patient blood management is associated with a substantial reduction of red blood cell utilization and safe for patient's outcome: A prospective, multicenter cohort study with a noninferiority design. Ann Surg 2016;264:203-11.
Zacharowski K, Spahn DR. Patient blood management equals patient safety. Best Pract Res Clin Anaesthesiol 2016;30:159-69.
Franchini M, Muñoz M. Towards the implementation of patient blood management across Europe. Blood Transfus 2017;15:292-3.
Vasudev R, Sawhney V, Dogra M, Raina TR. Transfusion-related adverse reactions: From institutional hemovigilance effort to national hemovigilance program. Asian J Transfus Sci 2016;10:31-6.
] [Full text]
Hui CH, Williams I, Davis K. Clinical audit of the use of fresh-frozen plasma and platelets in a tertiary teaching hospital and the impact of a new transfusion request form. Intern Med J 2005;35:283-8.
Jackson GN, Snowden CA, Indrikovs AJ. A prospective audit program to determine blood component transfusion appropriateness at a large university hospital: A 5-year experience. Transfus Med Rev 2008;22:154-61.
Wade M, Sharma R, Manglani M. Rational use of blood components – An audit. Indian J Hematol Blood Transfus 2009;25:66-9.
Mirzamani N, Molana A, Poorani E. Evaluation of appropriate usage of fresh frozen plasma: Results of a regional audit in Iran. Transfus Apher Sci 2009;40:109-13.
Boulanger J, Keohane C, Yeats A. Role of patient safety organizations in improving patient safety. Obstet Gynecol Clin North Am 2019;46:257-67.
Salim SA, Elmaraezy A, Pamarthy A, Thongprayoon C, Cheungpasitporn W, Palabindala V, et al.
Impact of hospitalists on the efficiency of inpatient care and patient satisfaction: A systematic review and meta-analysis. J Community Hosp Intern Med Perspect 2019;9:121-34.
Al-Momen AK, Dahal A, Gader AM. Antibody Identification; a Comparison between the New ID-Gel and the Conventional LISS (Test Tube) Systems. Sao Paulo, Brazil: XXII Congress of the International Society of Blood Transfusion (ISBT); 1992.
Vancouver BC, Gader AM, Bayoumi NM, Al-Momen AK; 27th
Congress of the International Society of Blood Transfusion (ISBT). A 14 years audit on the use of blood components at King Khalid University hospital (KKUH), Riyadh. Vox Sanguinis 2002;83 Suppl 2:200.
Abdel Galil M, Gader A. Blood transfusion between races; is it really another Hazard of blood transfusion therapy? Applied Transfusion Medicine Symposium. Tabuk, KSA: North West Armed Forces Hospital; 2008.
Abdel Gader AM, Al-Qahtani F, Al Momen AK, Buyomi NM. A 23 years Audit of Blood Use in King Khalid University Hospital, Riyadh. Berlin: XXXI Congress of the International Society of Blood Transfusion; 2010.
Abdel Gader AG, Alqahtani FH, Abdul Malik A, Albanayan AA. An Audit of Fresh Frozen plasma usage in King Khalid University Hospital, Riyadh. Abuse, overuse? Inappropriate? Makkah: The 4th
Annual Symposium on Modern Trends in Transfusion Medicine; 2012.
The Third International Congress of the Saudi Transfusion Medicine Society. Presentation: Why Saudi Women do not Donate Blood? Jeddah: The Third International Congress of the Saudi Transfusion Medicine Society; 2016.
Saudi Society of Transfusion Medicine International Conference. Presentation: The Voluntary Donor Potential in Saudi Arabia. Al Khobar: The 4th
Saudi Society of Transfusion Medicine International Conference; 2018.
Al-Momen AK, Harakati M, Gader AM. Whole blood/packed red blood cell ordering practices in a university hospital: A call for better blood utilisation. Saudi Med J 1992;13:229-32.
Abdel Gader AG, AlGhumlas AK, Al Momen AK, Badri M. A 23 years audit of packed red blood cell consumption in a university hospital in a developing country. Transfus Apher Sci 2015;53:300-7.
Al-Johar AW, Al-Saud A, Abalkhail Y, Jawdat T, Al-Khamees S, Al Thanayan F, et al.
Why do-Saudi women refrain donating their blood? – A study on the attitude, belief and motivation of Saudi female University students towards blood donation. Clin Lab 2016;62:771-9.
Al-Ghumlas AK, Al Momen AK, Badri M, Abdel Gader AG. Long-term audit of platelet consumption in a university hospital. Transfus Clin Biol 2017;24:68-75.
Abdel Gader AG, Al-Ghumlas AK, Al Momen AK, Awadalla SB, Badri M. Long-term audit of the use of fresh frozen plasma in a university hospital. J Taibah Univ Med Sci 2017;12:437-44.
Lauzier F, Cook D, Griffith L, Upton J, Crowther M. Fresh frozen plasma transfusion in critically ill patients. Crit Care Med 2007;35:1655-9.
Motta M, Del Vecchio A, Chirico G. Fresh frozen plasma administration in the neonatal intensive care unit: Evidence-based guidelines. Clin Perinatol 2015;42:639-50.
Vetter TR, Adhami LF, Porterfield JR Jr., Marques MB. Perceptions about blood transfusion: A survey of surgical patients and their anesthesiologists and surgeons. Anesth Analg 2014;118:1301-8.
Ravry ME, Paz HL. The impact of HIV testing on blood utilization in the intensive care unit in patients with gastrointestinal bleeding. Intensive Care Med 1995;21:933-6.
Friedman MT, Bizargity P, Gilmore S, Friedman A. Patient inclusion in transfusion medicine: Current perspectives. Internet J Clin Transfus Med 2015;3:7-16.
Graw JA, Eymann K, Kork F, Zoremba M, Burchard R. Risk perception of blood transfusions – A comparison of patients and allied healthcare professionals. BMC Health Serv Res 2018;18:122.
Almutairi AF, Salam M, Abbas OA, Nasim M, Adlan AA. The public's risk perception of blood transfusion in Saudi Arabia. J Blood Med 2018;9:75-82.
Goodnough LT, Maggio P, Hadhazy E, Shieh L, Hernandez-Boussard T, Khari P, et al.
Restrictive blood transfusion practices are associated with improved patient outcomes. Transfusion 2014;54:2753-9.
Shander A, Goodnough LT. Can blood transfusion be not only ineffective, but also injurious? Ann Thorac Surg 2014;97:11-4.
Goodnough LT, Panigrahi AK. Blood transfusion therapy. Med Clin North Am 2017;101:431-47.
Roberts DJ, Field S, Delaney M, Bates I. Problems and approaches for blood transfusion in the developing countries. Hematol Oncol Clin North Am 2016;30:477-95.
Kralievits KE, Raykar NP, Greenberg SL, Meara JG. The global blood supply: A literature review. Lancet 2015;385 Suppl 2:S28.
Hall TC, Pattenden C, Hollobone C, Pollard C, Dennison AR. Blood transfusion policies in elective general surgery: How to optimise cross-match-to-transfusion ratios. Transfus Med Hemother 2013;40:27-31.
Spahn DR, Goodnough LT. Alternatives to blood transfusion. Lancet 2013;381:1855-65.
Haspel RL, Lin Y, Mallick R, Tinmouth A, Cid J, Eichler H, et al.
Internal medicine resident knowledge of transfusion medicine: Results from the BEST-TEST international education needs assessment. Transfusion 2015;55:1355-61.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]