You are the Intensivist looking after a 30-year-old male, with no significant past medical history, who has been in the Intensive Care Unit for eight days with severe community acquired pneumonia and septic shock.
Although there are no overt signs of bleeding, his haemoglobin has slowly dropped and is now 65 g/L. He has been recommenced on low dose noradrenaline and you have decided to transfuse one unit of packed cells.
His wife has concerns about the “safety” of this and refuses to consent until she speaks to you.
Outline the key points of your discussion with the patient’s wife, including the pros and cons of, and alternatives to blood transfusion in this context.
Answer and interpretation
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
- 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.
- There is insufficient evidence to suggest that transfusion in this situation will have a positive effect
- 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
- 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)
- Pass rate: 77%
- Highest mark: 8.0
Additional Examiners’ Comments:
- Candidates were not expected to give this much detail and were given credit for valid points not included in the answer template
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.