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Packed Red Blood Cell Transfusions and Health Care Associated Infections

Rohde J et al.  Health care-associated infection after red blood cell transfusion: A systematic review and meta-analysis. JAMA 2014; 311: 1317-1326

Transfusion of blood products is the most common procedure performed in U.S. hospitals with approximately 14 million units of blood products transfused in 2011.¹ Blood products today undergo rigorous testing to prevent disease transmission and the United States’ blood supply is safer than ever before. However, the testing of our blood supply does not prevent transfusion related immunomodulation (TRIM). TRIM represents an immune system suppression which may affect infection risk, although the pathophysiology has not been fully elucidated.

The recent meta-analysis by Rohde et al, JAMA, 2014, reviewed the link of health-care-associated infection (HCAI) and the relationship to restrictive vs. liberal transfusion practice. The researchers included 18 trials with 7593 patients. Trials were conducted in facilities in multiple countries. The meta-analysis included the well-known Transfusion Requirements in Critical Care (TRICC) trial, ³ the trial of symptomatic coronary artery disease by Carson et al.⁴ and the de Gast-Bakker and coauthors trial in pediatric cardiac patients.⁵ The study revealed an adult hemoglobin range of 6.4 g/dl to 9.7 g/dl in the restrictive groups and 9.0 g/dl to 11.3 g/dl in the liberal groups.

The meta-analysis showed an association with lower risk of serious infection in the restrictive groups even when leukoreduction was considered. The authors concluded that one patient could potentially avoid a HCAI for every 20 patients who were treated if using the restrictive strategy (target Hgb <7.0 g/dl). The authors also state that this review further supports the clinical practice guidelines set up by the AABB on restrictive use of blood and blood products.⁶

So what does this mean for those of us performing transfusion at the bedside, in our operating suites, and other clinical areas? What can we do to help prevent HCA transfusion infections in our patients?

We must remember that blood management is an evidence-based, multidisciplinary approach that includes transfusion safety. The first step in a patient-centered blood management program is to determine if the transfusion is medically necessary. Nurses and mid-level providers can have great influence, helping to reduce the number of transfusions and the total number of products transfused. The medical decision to transfuse should be considered by all members of the clinical team. The decision to transfuse a patient must include a clinical picture of the patient and is not made solely on the hemoglobin level.

The number of units of PRBCs transfused has an effect on increased patient morbidity and mortality.⁷ When transfusion is clearly indicated to improve the patient’s condition, it might not be necessary to transfuse multiple units. Single unit transfusion with reassessment of the clinical condition should be considered outside of the context of massive hemorrhage.

In conclusion, this recent review and meta-analysis by Rohde and colleagues once again highlights TRIM and the association of transfusion with HCAI. This amplifies the need for adherence to a restrictive transfusion practice for the majority of hospitalized patients.

It is vital that the health care professionals ordering or performing transfusions stay up–to-date with the latest evidence, become pro-active in preventing adverse reactions, and remain vigilant in recognizing and responding to possible transfusion-associate adverse events, including HCAIs. 


  1. Whitaker B and Hinkins S. The 2011 national blood collection and utilization survey.
  2. Hebert P et al. N Engl J Med. 1999; 340: 409-417
  3. Carson J et al. Am Heart J.  2013; 165: 964-971
  4. deGast-Bakker D et al. Intensive Care Med. 2013; 39: 2011-2019
  5. Carson J et al Ann Intern Med. 2012; 157: 49-58
  6. Bernard A et al.  J Am Coll Surg. 2009; 208: 931-939
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