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Critical Care Nurse. 2003;23: 34-41
Copyright © 2003 by the American Association of Critical-Care Nurses.
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Clinical Article

Blood Management Strategies for Critical Care Patients

Sharon Vernon, RN, AD
 Gail M. Pfeifer, RN, MA

Sharon Vernon is an internationally recognized speaker on bloodless care. She is president and founder of the Bloodless Medicine and Surgery Institute, Mentor, Ohio, president of the Nurses Association for Bloodless Medicine and Surgery, and director of education at Hemo Concepts, Eatontown, NJ.

Gail Molnar Pfeifer is a freelance writer and editor with clinical experience in medical-surgical, emergency department, and intensive care nursing. She has previous experience teaching nursing at the baccalaureate and associate degree levels and is the executive editor of 2 medical journals.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.

Medical professionals historically regarded blood transfusion as an integral component of major surgery or critical illness. A growing appreciation for the risks involved in transfusing donated blood, as well as the refusal of some patients to accept transfusion because of personal or religious beliefs, encouraged researchers and clinicians to develop techniques and strategies that allow transfusion-free surgery and medical care, that is, bloodless treatment. These developments also led to the emergence of a new specialty that minimizes transfusion for all patients.1 The number of formal bloodless management centers or programs in the United States increased from only a few in 19902 to approximately 130 today,3 indicating the growing need for alternatives to transfusion.

Reducing or eliminating blood transfusion in critically ill patients, however, has its own risks, making outstanding nursing care more important than ever before. Blood conservation requires careful planning, proactive strategies to prevent or rapidly address complications, and vigilant monitoring of patients, all of which hinge upon the knowledge and skills of the critical care team. To this end, critical care nurses must know the rationale behind blood management in the intensive care unit (ICU), the issues associated with blood transfusion, and the principles of blood conservation. They must also have a thorough knowledge of the pathophysiology of anemia (which is often the cause of transfusion), including strategies for preventing this abnormality.


   Issues Associated With Blood Transfusion
Top
 Issues Associated With Blood...
Principles of Blood Conservation
 Maximizing Oxygen Delivery and...
 Stimulating Production of Red...
 Conclusion
 References
 
High Use of Transfusions
The increasing interest in bloodless medicine and surgery in recent years was fueled in large part by the high use of transfusions in the United States and growing concerns about their necessity, safety, effectiveness, and cost. In 1995, Corwin et al4 reviewed the occurrence of transfusion in a critical care setting and found that of the 23% of ICU patients who required long-term care (>1 week), 85% received blood transfusions, with a mean of 9.5 units per patient. No clear indication could be determined for nearly a third of these transfusions.

Initially, the National Blood Data Resource Center predicted that approximately 14.5 million units of blood would be collected in the United States in 2001.5 After the events of September 11, 2001, the center modified that prediction to 15 million units. (Approximately 26% of the 2001 total blood supply was collected in the 10-week period after September 11, but the number of donations has decreased since then, and shortages are again predicted.)

Risks of Transfusion
Viral Infection
The large number of persons who receive and donate blood is of particular concern because of the risks associated with transfusion. Although extensive testing procedures have been established to safeguard the blood supply against hepatitis B and C viruses, human immunodeficiency viruses 1 and 2, and human T-lymphotropic viruses I and II,5 transfusion is still associated with a limited risk of infection by these viruses as well as by other pathogens.6 In addition, some viral tests may be unreliable when blood is donated by persons who are undergoing seroconversion.7 Newer, more sensitive tests that shorten the window of uncertainly about the presence of infection reduce the risk of transfusing contaminated blood; however, these newer assays cannot entirely replace current tests.7 Newer tests are expensive, and false-positives and false-negatives are more likely when the recent, less costly practice of testing pooled samples of blood is used.8

Bacterial Infection
Risks associated with transfusion are not limited to viral infections. Bacterial infection and sepsis are far more frequent complications than is residual viral infection.6,9 Bacteria are most often found in platelets, which are kept at room temperature. Some bacteria implicated in sepsis, including Yersinia enterocolitica and Pseudomonas fluorescens, also grow at the blood-storage temperature of 4°C.6,9,10 In a retrospective cohort study11 of 9598 patients who had hip repair, patients who received transfusions had an increased risk of 35% for serious bacterial infection and an increased risk of 52% for pneumonia. Hospitalization costs were $14000 higher for those with these serious complications, and nearly 29% of patients with serious bacterial infections died during their hospital stay.

Immune System Responses
In addition to the threat of introducing infectious agents, allogeneic blood transfusions (blood donated from a person other than the patient) can also trigger changes in the recipient’s immune system. Hemolytic transfusion reactions can result from accidental ABO blood type incompatibility or, more rarely, from transfusion-related anaphylaxis and graft-versus-host disease, which are often fatal.6 Long-term immunologic effects of transfusion include an increase in humoral immunity and downregulation of cell-mediated immunity.12 These changes have been associated with cancer recurrence, activation of latent viruses, accelerated progression of infection with human immunodeficiency virus, and sensitivity to postoperative infection.6

Stored Blood
Blood transfusion can pose additional problems for critically ill patients, particularly those in need of rapidly improved oxygen delivery. Transfusion of stored blood not only does not improve oxygen transport but may contribute to the development of tissue ischemia in patients with sepsis, because of the microcirculatory occlusion of some organs.13 Compared with blood donated by nonsmokers, blood donated by heavy tobacco smokers has less oxygen-carrying capacity and the carbon monoxide saturation of the transfused hemoglobin is greater.14

Concerns about blood use may also stem from religious beliefs. Jehovah’s Witnesses, for example, generally refuse transfusion15 (see Sidebar).



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Transfusion Availability and Costs
Conservation is another important issue.16 Although donors give their blood free of charge, the mean costs of recruiting donors and processing, storing, and shipping donated blood may be as high as $495 per unit.17 A recent report18 to Congress indicated that hospital costs for blood and blood products during the past 15 years increased more rapidly than did overall operating costs. Fewer than 5% of potential donors give blood each year, and seasonal swings in donations and demand often occur in which demand is at its highest when donations are at their lowest.5 An annual shortfall in donor blood of 4 million units by the year 2030 has been projected.19 In response to an impending shortage in the New York metropolitan area, health officials are pressuring the Food and Drug Administration to loosen restrictions on donor residency requirements.20 This approach could increase the risk of acquiring the agent that causes new variant Creutzfeldt-Jakob disease, West Nile virus, or the sources of other as yet unknown diseases through blood transfusions.


   Principles of Blood Conservation
Top
 Issues Associated With Blood...
 Principles of Blood Conservation
Maximizing Oxygen Delivery and...
 Stimulating Production of Red...
 Conclusion
 References
 
A strong knowledge of the general therapeutic principles of non-blood management allows nurses to anticipate and prepare for potential problems and to intervene before complications occur. A multidisciplinary team that can anticipate problems and is prepared to address potential risks delivers the best bloodless care. A comprehensive plan for avoiding allogeneic blood transfusion should incorporate a proactive rather than a watch-and-wait approach.

Table 1Go summarizes the broad nursing considerations for blood conservation. Clinical judgment should be used to modify routine practice. Nurses need to know when to consult with senior specialists, such as coordinators of bloodless programs, who are experienced in bloodless treatment if complications do occur. Intervention may include transferring patients to a major center that specializes in bloodless management. The primary nursing principles for managing care include minimizing blood loss, maximizing oxygen delivery, and improving the red blood cell count to prevent and treat anemia in critically ill patients. These strategies are detailed in the following sections.


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  		Table 1 A summary of nursing interventions for blood conservation in the intensive care unit

 
Minimizing Blood Loss
Anemia severe enough to warrant blood transfusion can develop in critically ill patients for many reasons. Although blood loss is a major factor in the development of this abnormality, studies indicate that much of the loss is due to chronic blood loss throughout a patient’s ICU stay rather than to acute bleeding episodes. Long-term ICU patients may require 2 to 3 units of blood per week.4,21 Acute anemia normally triggers an exponential increase in circulating erythropoietin, although the response to erythropoietin is decreased.21

An optimal transfusion practice for different types of critically ill anemic patients has not been clearly defined.22 A hemoglobin level of 100 g/L and a hematocrit of 0.30 have been considered the minimums acceptable. Surgical patients who do not receive a blood transfusion, however, can tolerate hemoglobin levels as low as 70 to 80 g/L.4

Using strategies that minimize initial blood loss and maximize oxygen status can reduce the need for transfusion. Vigilant monitoring and proactive blood management strategies can be used to prevent or treat anemia in critical care patients.

Preventing Diagnostic Blood Loss
Critically ill patients lose clinically significant amounts of blood during routine phlebotomy for diagnostic tests. A retrospective review4 of 142 patients admitted to an ICU during 1990 (stays >1 week) revealed that patients who had transfusions lost a mean of 61 to 70 mL/day via phlebotomy, a volume that accounts for about 30% of total blood loss and is comparable to that indicated in other studies. The volume of routine blood samples for standard tests can equal as much as 45 times the volume required for analysis,23 and ICU patients with arterial catheters have more blood samples obtained than do those without.24 In a more recent study,21 lower volumes of blood loss due to phlebotomy in ICU patients were reported. Reductions were attributed to the use of smaller test tubes; individualized blood test orders for each patient; and point-of-care microanalyzers for blood gas, electrolyte, and hemoglobin analyses.

Reducing blood loss due to phlebotomy depends on having critical care nurses implement conservation protocols and monitor levels of blood loss.25 Practice recommendations include periodically reviewing orders with patients’ physicians to assess the frequency and types of routine diagnostic tests needed, questioning physicians about potentially repetitive or unnecessary tests, and suggesting noninvasive monitoring techniques when appropriate. Diagnostic tests can often be scheduled simultaneously so the same blood sample can be used for all of them. Documenting blood loss due to phlebotomy as part of daily intake and output records can assist nurses in detecting patients who are experiencing excessive losses.26 Recording blood loss due to phlebotomy on ICU flow sheets can decrease the amount of blood patients lose, presumably by heightening awareness among care providers and leading to discussion between nurses and other members of the critical care team about other blood conservation measures.25

Nurses can also consult with the hospital laboratory about using smaller-volume collection tubes, that is, tubes used for infants and children, which often supply enough blood for diagnostic tests for adults.25,26 Total blood losses due to phlebotomy during ICU stays were consistently reduced by 33% to 47% when smaller-sized tubes were used.25,27,28 Techniques for eliminating discarded blood when obtaining samples from arterial catheters may be beneficial, because discarded volumes account for 24% to 30% of the total daily blood loss in ICU patients.25

Point-of-care testing at the bedside with microanalyzers, which require 1 mL or less of blood, can also reduce blood loss due to phlebotomy. Standard assays for electrolytes, hemoglobin, hematocrit, and arterial blood gases, which are performed frequently for ICU patients, can be accomplished with only 1 or 2 drops of capillary blood when point-of-care testing is used, whereas 9 mL of blood is required for tests in the laboratory.

Noninvasive monitoring, such as pulse oximetry and capnography, can also reduce the number of samples required for blood gas analysis during weaning of postoperative patients from short-term mechanical ventilation.26,29

Minimizing Hemorrhagic Blood Loss
In addition to diagnostic blood loss, critically ill patients are also at risk for episodes of acute bleeding, not only as a result of surgery but also in association with advanced liver disease or acute gastrointestinal bleeding.4,21 Critical care patients can also experience nonacute blood loss while undergoing minor procedures, such as the insertion of arterial or central venous catheters, or as a result of occult gastrointestinal bleeding or renal failure.21 All potential risks for blood loss should be minimized when instituting bloodless care or attempting to limit the use of blood transfusion.

Surgeons have several blood conservation techniques (Table 2Go) available for patients undergoing bloodless surgery, including intraoperative autotransfusion, plateletpheresis, and veno-veno or cardiopulmonary bypass.30 During the immediate postoperative period, hemodynamic monitoring and fluid management are clinical priorities for ICU nurses.30 Nurses should be aware of the estimated surgical blood loss recorded in the operative notes. If intravascular volume becomes depleted because of bleeding, dehydration, or fluid shifts, patients should be given crystalloids, such as isotonic sodium chloride solution. Care should be taken with volume expanders, such as dextran or hetastarch, because they may decrease the concentration of coagulation factors and exacerbate hypertension.30


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  		Table 2 Blood conservation techniques for surgery and anesthesia

 
Controlling blood pressure is essential, because a sudden postoperative increase in blood pressure increases the risk of bleeding from surgical wounds, anastomosis sites, or cerebral hemorrhage.30,31 Patients with preexisting primary hypertension are at particular risk for this complication, although increased blood pressure can be triggered in any patient by factors such as perioperative pain, anxiety, shivering, hypothermia, hypoxia, bladder distention, or volume overload. If nursing interventions to relieve these triggers do not adequately lower blood pressure, patients may require antihypertensive therapy.31

Patients who request bloodless care in the ICU must be monitored closely for postoperative or other acute bleeding, because rapid diagnosis is essential. Obvious signs of hemorrhage, such as formation of a hematoma or saturation of surgical dressings, may not be present. Early, more subtle signs and symptoms of hemorrhage include hypotension, tachycardia, pain, decreased urine output, reduced cardiac output, lower mixed venous oxygen saturation, and a decreased level of consciousness.32 If postoperative hemorrhage is suspected, critical care nurses must work with the ICU team to rapidly stabilize the patient’s condition by beginning resuscitation measures, securing an airway, and supporting respiration. A central venous catheter can be inserted for additional intravenous access, and crystalloid solutions or other volume expanders may be needed. Physicians also need rapid access to information on preoperative and postoperative hematocrit and hemoglobin levels and coagulation studies; exact sites of bleeding, including quantity and quality of dressing drainage and fluid in drains; condition of the surgical site and surrounding areas; fluid and oxygenation status; and a current set of vital signs.

In addition to stabilizing a patient’s condition and controlling the bleeding, nurses may need to rapidly prepare the patient for surgery.32 Patients with rapid blood loss may require perioperative autotransfusion of blood salvaged from tubes or drains in sterile closed-collection systems. This practice may be acceptable to some of Jehovah’s Witnesses (Hospital Information Services, World Headquarters for Jehovah’s Witnesses, oral communication, September 2003).

In addition to postoperative bleeding, critically ill patients are at high risk for gastrointestinal bleeding.

Signs of gastrointestinal bleeding include hypovolemic shock, bright red or brown emesis, and bright red or black tarry stools.33 If acute bleeding occurs, nursing priorities include notifying a physician, administering volume replacement fluids, attempting to control the bleeding, and monitoring for further complications.33 Upper gastrointestinal bleeding often develops in critically ill patients because of stress-related mucosal damage caused by the ischemia associated with decreased gastric blood flow. Consequently, prophylactic drug treatment to reduce this risk may be warranted. Drugs used include antacids; intravenous H2-receptor antagonists, such as cimetidine, ranitidine, and famotidine; oral or intravenous proton-pump inhibitors, such as omeprazole; and mucosal defense agents, such as sucralfate.34

The risk of blood loss can also be reduced by using hemostatic agents to promote clotting abilities (Table 3Go). The prophylactic use of desmopressin, a synthetic analog of vasopressin that increases levels of clotting factors, can decrease the need for blood transfusion in surgical patients with normal hemostasis.32 In cardiac surgical patients, prophylactic administration of aprotinin, a serine protease inhibitor with antifibrinolytic and platelet-preserving activities, can reduce blood loss by 40% to 50% and decreases the percentage of patients needing transfusion by 30% to 40%.35 The prophylactic administration of phytonadione, which increases levels of several clotting factors, can reduce the risk of bleeding for patients who have vitamin K deficiency or who take medications, such as aspirin or anticoagulants, that interfere with the activity of this vitamin.36 {varepsilon}-Aminocaproic acid, which inhibits plasminogen activation, may enhance hemostasis when fibrinolysis contributes to bleeding as a complication of cardiac surgery.37


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  		Table 3 Hemostatic agents for the treatment of bleeding or coagulation problems

 
Many critical care patients may be taking medications that inhibit the clotting cascade, a situation that can increase the risk of hemorrhage. Such medications include aspirin; nonsteroidal anti-inflammatory drugs, such as ibuprofen and ketorolac; anticoagulants, such as warfarin and heparin; thrombolytic agents for the treatment of coronary thrombosis or acute stroke, such as streptokinase and recombinant tissue plasminogen activator; and fibrinolytics, such as glycoprotein IIb/IIIa inhibitors.38–41 Careful monitoring to detect bleeding is crucial for patients taking these medications.


   Maximizing Oxygen Delivery and Consumption
Top
 Issues Associated With Blood...
 Principles of Blood Conservation
 Maximizing Oxygen Delivery and...
Stimulating Production of Red...
 Conclusion
 References
 
A common problem for critically ill patients is tissue hypoxia, an inadequate supply of oxygen that can lead to organ dysfunction and failure if not promptly addressed.42 The stress of acute illness, blood loss, surgery, infection, pain, and anxiety can lead to greater than normal oxygen demand.42,43 Critically ill patients, particularly those undergoing transfusion-free care, need greater than normal oxygen delivery. Critical care nurses should carefully monitor measurements that reflect patients’ oxygen status to prevent or quickly recognize and treat indications of tissue hypoxia.42,43 These measures include cardiac output, hemoglobin and arterial oxygen saturation, oxygen delivery, oxygen consumption, oxygen extraction ratios, and indicators of oxygen debt, such as lactate, pH, and mixed venous oxygen saturation.44 Because simply maintaining oxygen delivery within the normal range for healthy adults is not sufficient for critically ill patients, the following target values are recommended: oxygen delivery, greater than 800 mL/min per square meter; oxygen consumption, 170 mL/min per square meter or more (30% greater than normal); cardiac index, greater than 4.5 (50% greater than normal; index calculated as cardiac output in liters per minute divided by body surface area in square meters); and oxygen extraction ratio, less than 0.31.42

Nursing interventions that improve oxygen delivery include the administration of fluids to increase preload; positive inotropic agents to improve cardiac contractility; or vasodilating agents, such as nitro-prusside or nitroglycerin, to decrease afterload and peripheral resistance. With the collaboration of physicians and respiratory therapists, critical care nurses can also improve patients’ arterial oxygenation by adjusting the settings of mechanical ventilators or by assisting patients who are not receiving mechanical ventilation with coughing and deep breathing exercises.42,44

Nurses play a key role in reducing oxygen demand by managing patients’ pain and anxiety and by preventing hyperthermia, which contributes to increased oxygen demand.44 Routine nursing procedures, such as bathing, repositioning, chest physiotherapy, and endotra-cheal suctioning, can increase oxygen demand by increasing skeletal muscle activity and by causing pain and anxiety.43 Monitoring mixed venous oxygen saturation before, during, and after these procedures will help manage these activities to decrease oxygen demand. Shivering, agitation, coughing, or pain can be relieved before a procedure likely to increase oxygen demand is started; analgesics may help reduce agitation if given before critically ill patients are repositioned.43,44


   Stimulating Production of Red Blood Cells
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 Issues Associated With Blood...
 Principles of Blood Conservation
 Maximizing Oxygen Delivery and...
 Stimulating Production of Red...
Conclusion
 References
 
Insufficient erythropoiesis may contribute to anemia in critically ill patients.45 Giving pharmacological doses of erythropoietin to stimulate production of red blood cells could help alleviate the need for blood transfusions. Human recombinant erythropoietin (r-HuEPO, epoetin alfa) reduces the need for transfusions in patients with anemia due to chronic renal failure, treatment for infection with human immunodeficiency virus, chemotherapy, and major surgery.46 In a prospective, randomized, double-blind, placebo-controlled multicenter trial45 involving 160 long-term ICU patients, compared with patients given a placebo, patients given epoetin alfa had a significant reduction in the number of units of red cells transfused and an increase in final hematocrit. In a study47 of patients undergoing open heart surgery, treatment with epoetin beta improved oxygen uptake and decreased the rate and severity of postoperative lactic acidosis. Such changes in oxygen status may also benefit critically ill ICU patients.45

The optimal dose of epoetin alfa has not been determined.45 Because erythroid progenitors take several days to mature and to be released into the circulation, a clinically significant increase in hematocrit usually requires 2 to 6 weeks.46 Thus, early initiation of therapy would be expected to improve efficacy. Long-term ICU patients may benefit the most from epoetin alfa, but this group is difficult to identify prospectively.

Absolute or functional iron deficiency can develop during treatment with epoetin alfa.46 Functional iron deficiency may be the result of mobilization of iron stores that is inadequate for the increased erythropoiesis. Patients’ iron status, serum transferrin saturation (serum iron concentration divided by total iron-binding capacity), and serum ferritin levels should be monitored before and during epoetin alfa therapy. Transferrin saturation should be 20%, and the ferritin level should be 100 µg/L.46 All patients treated with epoetin alfa will eventually require supplemental iron to maintain sufficient transferrin saturation.46

Providing enough iron for the enhanced erythropoiesis that occurs with epoetin alfa therapy will maximize patients’ responses to this drug.48 Iron therapy is particularly important when large doses of epoetin alfa are used. In critical care patients, intravenous administration of iron may be required to rapidly increase iron availability. Patients’ sensitivity to iron dextran, including anaphylaxis, has been an obstacle to intravenous administration of iron, but new intravenous iron preparations, iron sucrose and iron gluconate, have been used safely and effectively.49–51 The total cumulative dosage (approximately 1 g) of iron sucrose and iron gluconate is given over several days to achieve a favorable hemoglobin or hematocrit response.52,53 Intravenous test doses are not needed with either iron gluconate or iron sucrose.52,53

Whether epoetin alfa causes hypertension is unclear. In early studies, reports of hypertension in patients treated with the agent were investigated.54,55 This complication was thought to be due to an overly rapid increase in hematocrit and the consequences of that increase, which include increases in hemoglobin level, blood viscosity, and red cell mass and normalization of the cardiac index of anemia. In recent studies,56,57 no sustained increases in blood pressure occurred with the use of epoetin alfa. Until this issue is clarified, nurses should carefully monitor blood pressure in patients undergoing epoetin alfa therapy.


   Conclusion
Top
 Issues Associated With Blood...
 Principles of Blood Conservation
 Maximizing Oxygen Delivery and...
 Stimulating Production of Red...
 Conclusion
References
 
Critical care nurses play a crucial role in reducing the need for blood transfusions in ICU patients undergoing bloodless treatment. Vigilant monitoring can improve the hemodynamic and oxygen status of these patients. Nurses can actively use techniques that reduce sources of chronic blood loss, increase oxygen delivery, and decrease oxygen consumption. Careful observation and assessment of ICU patients who request bloodless care can reap rewards for both patients and staff nurses. An integrated program delivered by a knowledgeable interdisciplinary team addresses the patients’ physical, psychological, and spiritual needs.


   References
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 Issues Associated With Blood...
 Principles of Blood Conservation
 Maximizing Oxygen Delivery and...
 Stimulating Production of Red...
 Conclusion
 References
 

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