Transfusion guidelines: mind the gap

Do transfusion guidelines matter? Most hospital staff are familiar with transfusion because the use of blood is embedded within our everyday clinical practice. The provision of a readily available blood supply together with parallel developments in anaesthesia and intensive care during the 20 century has led to an explosion of surgical procedures. Blood has facilitated medical developments and is changing the face of regenerative medicine. However, the use of blood remains subject to the challenges of sufficiency and safety. Potential blood borne pathogens include Human Immunodeficiency Virus (HIV), hepatitis, bacteria, Creutzfeldt–Jakob disease (CJD) and more recently hepatitis-E virus. Globally, there have been concerns about Ebola and Zika. We are fortunate that the residual risk of infectious disease in the UK is minimal. In addition, many non-infectious risks such as transfusion-related acute lung injury (TRALI) and transfusion-associated graft versus host disease have been steadily reduced [1] through the introduction of universal leucodepletion, careful donor selection and clinical practice. However, history has taught us that there cannot be room for complacency. Constant haemovigilance and best practice is required. Guidance for the practitioner is therefore both essential and welcome. However, there has been a lot of it lately, with transfusion guidelines produced by the British Committee for Standards in Haematology (BCSH) [2] and the National Institute for Health and Care Excellent (NICE) [3, 4] in 2015. Transfusion also appears in other guidelines such as the recently published NICE guidelines for trauma [5]. Included in this edition of Anaesthesia are the new AAGBI guidelines for the use of blood components and their alternatives [6]. These are designed for the practicing anaesthetist with a focus on safety. These guidelines bring together three previous AAGBI guidelines: blood component therapy 2005; red cell transfusion 2008; and massive haemorrhage 2010. The aim is guidance on clinical indications, risks, blood conservation and the transfusion process. It is an ambitious remit, especially where there is an apparent potential tension between the cautious patient blood management (PBM) approach and the pre-emptive use of haemostatic components in the support of massive haemorrrhage. The document does well to balance what might appear as a dichotomous approach. Such success is due to the practical expertise of the Working Party members. The format of the guidelines is similar to the previous AAGBI ‘glossies’ in that they provide an easy-to-read overview of the subject with a set of recommendations. In addition, the online version permits use of the embedded hyperlinks to other guidelines. However, there are no supplementary tools. Examples may be found with the recent NICE guidelines for transfusion [7] which provide valuable guidance for patient information and practical tips on implementation. They also provide the level of evidence for each recommendation. Both guidelines cover the transfusion process. This is pertinent, as the biggest potential risk of transfusion is the transfusion of incompatible blood due to human error [1]. An error may occur anywhere in the process from the initial sample with a ‘Wrong Blood in Tube’ to the failure of the final bedside check. All staff should be trained and new guidance from the National Blood Transfusion Committee has been released. However, NICE reminds us that electronic systems make it easier for staff to do the right thing every time, and avoid errors. Electronic systems can also provide ‘decision support’ for doctors when ordering blood and promote the ‘appropriate’ use of blood [3]. This editorial accompanies the AAGBI guidelines by Klein et al., Anaesthesia 2016; 71: 829-42.