Sunday, December 18, 2011

Modern Day Bloodletting: The Good Samaritan, the Red Cross, and the Jehovah's Witness

How many studies do you suppose that we need before doctors realize that their tendency to want to transfuse blood in every manner of patient admitted to the hospital is nothing more than an exercise in stupidity futility based on the normalization heuristic?  It's a compelling logic and an irresistible practice, I know.  The hemoglobin level is low, that can't be good for the heart, circulation, perfusion, oxygen delivery, you name it.  If we just give a transfusion or two, everything will be all better.  I can hear family members on their mobile phones reassuring other loved ones that the doctors are acting with great prudence and diligence taking care of Mr. Jones, having perspicaciously measured his hemoglobin (as by routine, for a hospital charge of ~$300/day - the leviathan bill and the confused, incredulous faces come months later - "why does it cost so much?"), discovered that perilous anemia, and ordered two units of life-saving blood to be transfused.  It's so simple but so miraculous!  Thank God for the Red Cross!

Not so fast.  The TRICC trial published in 1999 demonstrated that at least in critically ill patients, using a lower as compared to a higher transfusion threshold led to a statistically insignificant trend towards improved outcomes in the lower threshold group.  That is, less blood is better.  For every reason you can think of that transfusion can improve physiological parameters or outcomes, there is a counterargument about how transfusions can wreak havoc on homeostasis and the immune system (see :Marik_2008_CCM, and others.)

Not to mention the cost.  My time honored estimate of the cost of one unit of PRBCs was about $400.  It may indeed be three times higher.  That's right, $1200 per unit transfused, and for reasons of parity or some other nonsense, in clinical practice they're usually transfused in "twos".  Yep, $2400 a pair.  (Even though Samaritans donate for free, the cost of processing, testing, storage, transportation, etc. drive up the price.)  What value do we get for this expense?