One is better than two when it comes to blood transfusions

November 16, 2017

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One is better than two when it comes to blood transfusions

One doctor is commending RQHR staff for the decrease in blood transfusion volumes by adopting the motto— Why use two when one will do? In 2016, Saskatchewan transfusion volumes of packed red blood cells decreased by 1,783 units, which represents a direct cost savings of $754,209 and an indirect savings of $2,496,200 in lab and facility costs associated with transfusions. Of that RQHR decreased 689 units for a direct cost savings of $291,447 and associated costs of $964,000.

A bag of donated red blood cells. Photo: Sask Blood

Dr. Ryan Lett, physician lead for the Blood Transfusion and Stewardship Program, says the Why use two, when one will do? campaign has been a good tool to reduce the unnecessary transfusions.

“When blood transfusions are being ordered, the majority of clinicians are choosing wisely and ordering single unit transfusions,” said Lett. It is better to give a single unit of blood than two units of blood; but even better than that is no transfusion at all.”

Best practice is to replenish nutritional stores of iron, B12, and protein to produce your own red blood cells. Clinicians are beginning to favour using intravenous iron in stable, non-bleeding patients rather than doing blood transfusions. This is also less risky for the patient.

“Intravenous iron has a ten-fold lower risk of all comparable complications and no biological risks such as alloimunizatiton, immunomodulation, or human to human transmission of pathogens,” he said.

Anemia and iron deficiency

The disease that red blood cell transfusions treat is anemia. Up to 20 per cent of the overall population is anemic, and in those with chronic diseases that number increases to 40 to 60 per cent. Of all causes of anemia, iron deficiency remains the most common, particularly amongst children, women, and the elderly.

The vast majority of anemia cases are due to iron deficiency and in many cases intravenous iron is more helpful to these patients than blood transfusion.

“The nursing staff and residents have been instrumental in taking this information to their respective units and instituting change. Nurses and other health care workers are seeing the benefits of intravenous iron and the risks of transfusion. Rather than saying, ‘This patient’s hemoglobin level is low, should we transfuse?’ they are asking, ‘This patient’s hemoglobin level is low, should we treat the underlying cause?’”

The correct treatment for iron deficiency and asymptomatic anemia is nearly always iron. Between 40 to 70 per cent of patients will be intolerant of oral iron. Patients who are admitted to hospital, have upcoming surgery, or are near term delivery of infants do not have time to absorb and convert iron to hemoglobin.

Those who receive an iron infusion have a persistent rise in hemoglobin, unlike the short term increase that a red blood cell transfusion provides.

Pregnancy and iron deficiency

There is a growing amount of evidence that iron deficiency in pregnancy is associated with poor fetal outcomes. Iron is an important element for early brain development; some studies have demonstrated decreased memory and learning ability even up to age 10 if the infant was born to an iron deficient mother. Intravenous iron takes about seven to 21 days to increase the mother’s hemoglobin level, but the baby is able to absorb the iron almost immediately. If iron deficiency is diagnosed prior to conception or in the first or second trimester, oral iron may be adequate. By the third trimester the mother’s oral intake is unable to keep up with the increased demands of the fetus and intravenous iron may become necessary.

Province doing well

“Congratulations, bragging rights are in order. There is still work to be done on our management of outpatient anemia, but we have a considerable head start in the province of Saskatchewan and all members of the health care team are to be commended.”
For more information on this topic, visit

Ryan Lett
Physician lead for the Blood Transfusion and Stewardship Program

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