You might want to check out Rana et al. Critical Care Medicine 2006; 34(7):1892-7.

The key element of this approach is to ask the ordering provider to justify the use of red blood cells in any patient, whose hemoglobin level is >7g%.

Why not?

Make another three possible and simple questions:

one) who can justify the "unversal" transfusion of the "two units pack" of red cell concentrates?

two) who can justify that a patients admitted at the surgical waiting list during months could come anemic to the operation room?

three) who can justify to do not use autologous blood? why do not recover intra or post surgical bleeding and reinfuse after wash it?

Please, do not ask if we follow, ask youself why you do not follow the blood management guidelines?

Rolf

Thanks for the paper you mentioned. would you explain the protocol you currently use. Do you use absolute number of Hb or look at Hb changes in circumstances such as cardiac patients after cardiopulmonary bypass?

José

Thanks for your comments. You pointed out important common mistakes. And there are many other questions. We don't follow guidelines simply because we have not agreed on a protocol and/or available guideline. Bad decision may be worse than doing nothing. Our colleagues' experiences would be helpful.

The approach I have outlined excludes patients with acute hemodynamically significant blood loss and patients with unstable angina/MI. To my reading of the literature there is rarely a good reason to transfuse a patient with a hemoglobin level >7.0g%   

As to trends in Hb I would only say that I will take them into account if a fall in hemoglobin below 7.0 is imminent. Forcing people to justify their transfusion decision is  the way to tackle all too liberal transfusion practices.

Dear Mahdi

Your first step has been walked: Ask yourself why or how to do it?

Second steps must be:

- a) identify who can participate and who will be an obstacule or a wall: You a need a team with some leaders (captain, trainer, goalkeeper, etc) and avoid "black sheep"

- b) identify which measures (drugs, devices, protocols, guides, etc) are avaible in your hospital. You must begin with the closer, easier or well knew. But never any measure isolated will work. Always this new actions, drugs, device use, etc must be included in protocols where "restricted" transfusion criteria (normovolemic anemia tolerance) and anemia treatment must be the stonecorner.

- c) identify wich patientos or population need first or will be most benefit 

- d) and the most important: be patient! this is like the fine rain: drop by drop, without sounds neither strong winds...but at the end all will be wet and green!

My Surgical ICU is working on the research on transfusion guideline, my junior colleague is still recruiting her patients. Agree that there must be a team working together, as of today I would love to apply hypotensive anaesthesia for my patient, but the surgical team refused it, so it was ended with nearly 3 litres of blood wasted, and need to give my patients 2 units of blood, despite he had 41% haematocrit preoperatively.

Our ICU is mainly a post-surgical ICU. We usually follow blood conservation guidelines which implies patients have much better HB before surgery. Secondly like one some of the previous speakers we also follow a restrictive policy and will not transfuse if the Hb is >8.0g% and if the patients have no clinical signs.  Dont forget that malaria is prevalent in our sub-region and therefore has to be in our minds at all times

Recently a conference was held in our hospital and experts from different disciplines discussed on challenging aspects of coagulation control and transfusion. We had a panel on prerequisites of an appropriate protocol for our hospital. We came to agreement on some topics:

1. To determine time interval from discontinuing anticoagulants and surgery

2. To rely more on TEG results for bleeding control

3. To agree on fibrinogen indications and dosage

4. To measure heparin level (Anti X) in bleeding patients

5. To agree on the indications, route of use and dosage of vitamin K in patients on warfarin who are candidates for emergent surgery

To agree on the critical Hb level for transfusion in different situations.

However, to be honest there is a deep valley between knowledge and practice.