Transfusion-associated circulatory overload prevention: a retrospective observational study of diuretic use.

BACKGROUND AND OBJECTIVES: Approaches to preventing transfusion-associated circulatory overload (TACO) include the use of diuretics. The purpose of this study was to determine how commonly diuretics are prescribed in patients receiving a red-blood-cell (RBC) transfusion. MATERIALS AND METHODS: This was a retrospective study of 200 adult inpatient RBC transfusion orders, 50 consecutive at each of four academic institutions. Only the first transfusion order for each patient was included. Only 1 or 2 unit orders were included. The primary outcome was the percentage of patients receiving furosemide peri-transfusion. Secondary objectives included the dose, route, and timing of furosemide and the association of clinical factors with ordering furosemide. RESULTS: The median age was 62·5 years (IQR 53, 73), and 52% were female. Peri-transfusion furosemide was ordered in 16% (95% CI 11-21%). The most common dose was 20 mg (55%), the route intravenous (90%) and timing post-transfusion (74%). At least one risk factor for TACO was present in 55% of patients: renal dysfunction (33%), older than 70 years (28%), history of congestive heart failure (18%), ejection fraction <60% (16%) and diastolic dysfunction (5%). Low haemoglobin as an indication for transfusion (OR 4·2; 95% CI 1·4-12·8) and diuretics on admission (OR 3·5; 95% CI 1·5-8·0) were associated with ordering furosemide peri-transfusion. CONCLUSIONS: Furosemide is not routinely ordered for RBC transfusion, even in patients with risk factors for TACO. Studies assessing the safety, efficacy, optimal dose, and timing of furosemide in preventing TACO are justified.

Audit of appropriate use of platelet transfusions: validation of adjudication criteria.

BACKGROUND AND OBJECTIVES: Platelet (PLT) transfusions must be used appropriately, as they are in chronic short supply, costly and risky to patients. The goals of this audit were to: (1) validate preset adjudication criteria through an audit of appropriateness at four large academic hospitals; (2) identify variability in appropriateness across medical services, physician specialties or hospital locations; and (3) inform logistical or educational interventions that may reduce inappropriate use. MATERIALS AND METHODS: A chart review of two hundred patients receiving PLT transfusions was performed. Fifty consecutive transfusion episodes per site were audited in detail. Each transfusion episode was independently adjudicated as appropriate or inappropriate by two transfusion specialists based on predetermined criteria. RESULTS: The adjudication criteria performed well with simple agreement of 95% (kappa statistic 0·83) between reviewers. Overall, 78% (95% CI: 72-84%) of PLT transfusions were adjudicated as appropriate, with results varying significantly by hospital site (range 62-94%). Prophylactic transfusions for non-bleeding patients had the highest proportion of appropriateness (85%, n = 80), and therapeutic transfusions for bleeding patients had the lowest (73%, n = 99). The lowest levels of appropriate platelet transfusions were observed in the operating rooms (60%) and when ordered by the general surgery service (55%). CONCLUSIONS: One in five platelet transfusions may be unnecessary, suggesting that interventions to improve PLT transfusion practice are warranted.

Audit of provincial IVIG Request Forms and efficacy documentation in four Ontario tertiary care centres.

OBJECTIVE: Retrospective audit of IVIG Request Forms in four Ontario tertiary care centres: to determine the case mix of new IVIG requests, to authenticate information provided, and to determine documentation of clinical efficacy. AIMS: To understand contributors to increases in IVIG utilisation and to determine whether IVIG is being used and monitored appropriately. INTRODUCTION: Intravenous immunoglobulin (IVIG) use in Canada is high compared with other developed countries. We performed a retrospective audit of new IVIG Request Forms across four tertiary care centres in Ontario, one with an active surveillance programme, to determine the case mix, authenticate information provided and assess documentation of efficacy. METHODS: Consecutive adult patients with a first-time IVIG request in 2014 were included. The ordering physician specialty, form completeness, documentation of diagnostic criteria for the medical condition and indication for IVIG use and documentation of efficacy were assessed by form and chart review. RESULTS: Of 178 patients, the most common indications for IVIG were immune thrombocytopenia (24.2%) and secondary immune deficiency (20.2%). The most frequent prescribers were haematologists (37.6%) and neurologists (10.7%). Other conditions not listed on the form represented 24.2% of cases, with most not indicated in current guidelines. A total of 32.6% of cases overall lacked verification of diagnostic criteria and 51.7% lacked verification for IVIG utilisation criteria, with the number of cases meeting criteria based on documentation being higher at the active surveillance site (P = 0.005). A total of 19.1% of cases had a discrepancy between the indication written on the form and the documented clinical diagnosis. A total of 18.7% of clinic notes following IVIG had no mention of efficacy. CONCLUSION: Our audit demonstrates a lack of compliance with IVIG Request Form requirements, a lack of documentation of diagnostic criteria and efficacy, and suggests inappropriate use of IVIG. Current implementation of the form may not be sufficient as a strategy for improving appropriate IVIG use.