CICM SAQ 2015.2 Q29

Discussion should cover:

• Involving patient If competent
• Ensure wife appropriate patient advocate
• Listening to and clarifying wife’s concerns including religious / cultural objections
• Patient’s wishes if known
• Pros and cons of transfusion in this situation
• Non-transfusion strategies

Pros:

• Transfusion at this low threshold is evidence based i.e. consistent with a restrictive approach as
  advocated by the National Guidelines. Transfusion is probably appropriate given the information
  available, but is not mandated.
• Administration of a single unit followed by reassessment is consistent with the National Guidelines.
• May improve oxygen delivery, enable cessation of noradrenaline, and potentially positively affect
  organ function and outcomes.
• Red cell transfusion is safe, with risks of viral transmission (HIV & HCV), CJD and fatal haemolytic
  reactions being less than 1 in 1 million.

Cons:

• There is insufficient evidence to suggest that transfusion in this situation will have a positive effect
  on mortality.
• This young man is relatively well compensated (although on noradrenaline), not actively bleeding
  and is unlikely to have significant ischaemic heart disease. Discussions with the family should weigh up the pros and cons of transfusion, and time devoted to hearing and clarifying their worries and concerns.
• There is some evidence that transfusion is associated with increased rates of VAP and other infections.
• Real risk of circulatory overload (up to 1 in 100 or Calman rating high), but probably less likely in this patient.
• Risk of TRALI (said to be 1 in 5000 to 1 in 190000, or low to minimal
• Anaphylaxis or non-fatal haemolytic reactions (very low)

In the event of a blood transfusion being administered, consent will be needed

It is also reasonable to wait

• Set a trigger for transfusion (absolute Hb, clinical parameters) with the family)
• A second opinion or even a substitute decision maker/legal opinion may need to be sought if
  clear harm or death is likely to result in the future without transfusion and consent is not likely to
  be forthcoming.
• Non-transfusion strategies should be employed
  • Maximising nutrition
  • Minimising haemodilution
  • Consideration of haematinics / EPO
  • Minimising blood volume for tests by using paediatric tubes etc. o Haematology input if necessary.

Calman scale of risk useful in this context:

• Negligible (less than 1 in a million or dying of lightning strike)
• Minimal, Very low, Low (1 in a thousand to 1 in 10000 or dying in a road accident)
• High (>1 in 1000)