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2/14/2015 1 Show Me the Evidence: Is the Routine Use of Premedication for Transfusion Really Necessary? The newly created EBP committee looked for their first


  1. 2/14/2015 1 Show Me the Evidence: Is the Routine Use of Premedication for Transfusion Really Necessary? �������������������������� The newly created EBP committee looked for their first project � ������������������������ � ��������������������������������� � ������������� �!� � ������������������������ 3 1

  2. 2/14/2015 The newly created EBP committee found their first project � ������������������������" ������������� ��#���#����$��� � ��������������������������������� 4 Practice Issues Identified • Current premedication standard • Acetaminophen 650mg PO • Diphenhydramine 25050mg PO • 30 minutes prior to starting transfusion. • Toxicities associated with the premeds • Are we exposing the patient to potential side effects unnecessarily? • Is there any alternative from the “same old, same old”? • Are premedications even necessary? Side Effects of Pre0medication ����������������� ���������������� %���� *�����(�,����' &�'������ &��#������������� (���'������ - �������� )�����'���������� - �'��,�� ��#����������������� �������� &������� ���������*�#���'������ +�,���'� 2

  3. 2/14/2015 Is there an alternative? • Claritin as a second generation antihistamine • Decreased risk for sedation, tachycardia, hypotension, and urinary retention. • Little evidence that utilizes direct comparison of Claritin vs. Benadryl as premedication and prevention of reaction to blood products in hematology/oncology patients Transfusion Reactions • Transfusion reactions can range from – Mild (itching, hives) to – Anaphylaxis (bronchospasm, hypotension, and shock) • How often and how severe? Reactions are common: Fact or fiction? • There have been many improvements in transfusion medicine, blood typing, and donor screening in the modern world. • Leuko0reduced (the reaction is in the WBC exposure mostly) • Irradiated reduces GVHD and reactivation • Human leukocyte antigen0matched platelets (HLA) • Antigen0negative platelets • Antigen0negative PRBCs • Has the technology of transfusion medicine advanced to the point that quite possibly we do not need to pre0medicate patients anymore prior to blood product transfusions? 3

  4. 2/14/2015 A project was Born! 10 PICO Question • P=Population • In the adult oncology patient • I=Intervention • does the prophylactic use of acetaminophen and diphenhydramine • C=Comparator/Control • versus no premedication • O=Outcome • affect the incidence of blood transfusion reactions? Search Strategy � PubMed (MEDLINE), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Medline, Elton B. Stephens Company (EBSCO), Ovid, and Scopus to gather established information for the literature search. � Keywords used were0 Blood Products, Transfusions, Reactions, Tylenol, Benadryl, Steroids, Platelets, Packed Red Blood Cells, Transfusion Medicine 4

  5. 2/14/2015 Integration and Synthesis of the Evidence Study 1 Author/Year0 Wang (2002) Type0 Prospective/Randomized/Double0blind/Placebo0controlled Purpose0 Evaluate the use and effectiveness of Acetaminophen and Diphenhydramine vs. placebo when used as premedication for transfusions in Oncology Patients Limitations0 Studied platelet transfusions only, Low number of transfusions Results0 No statistical difference in reactions between the two groups. Significance0 The study reflected no difference in the premedication vs. placebo groups but it also showed something significant that the researchers were not looking for. The study demonstrated that patients with a history of reactions will be more likely to have reactions with or without pre0medication. 13 Integration and Synthesis of the Evidence Study 2 Author/Year0 Sanders (2005) Type0 Retrospective0examined 7,900 transfusions Purpose0 Evaluate the effectiveness of premedication with acetaminophen and/or diphenhydramine in febrile non0hemolytic transfusion reactions and allergic transfusion reactions. Limitations0 Retrospective, Pediatric Population, No doses specified Results0 No difference noted between the types of reactions Significance0 This data clearly demonstrates that pre0medicating patients prior to transfusions show no marked benefit. Utilized only Single donor apheresis for platelets and leukocytereduced and irradiated PRBCs0consistent with our current practices Integration and Synthesis of the Evidence Study 3 Author/Year0 Patterson (2000) Type0 Prospective with 3 large hospitals Purpose0 Examine the rates of reactions that patients experienced when given premedication prior to transfusion and comparing it with the rate of reactions exhibited after premed guidelines initiated0 note a drop in use of premeds by 50% with little change in reactions. Limitations0 Observational, No standard dose of premedication Results0 Platelet reactions had little significant change from baseline when pre0medications were administered Significance0 These prospective studies document a high rate of plt transfusion rxn in onc pts and indicate that the reduction in routine use of premed doesn't increase occurrences of transfusion related reactions. The study also validates the use of leukoreduced and/or plasma reduction of platelet products reduces the incidence but does not completely eliminate reactions. Reaction rate reduction of 10% when leuko and/or plasma reduced platelets were given 5

  6. 2/14/2015 We have a Case for Change! • &������������������������������������������ ������������������������������������������������� �������������������'������������������. • ���������������#�������������������������� ��������������������������������������� �����������������'����"�������.���'�������� ��'������/�����#�'��������#��������������� ���������������. • (������������������#��������������������� �������������������������������������� ���0�����'������������'������������������ ��������������.� • (���������������������������������������#���� ������������������������������������������� �������������������������������������������������� ��������"���������������.� Comparing Apples to Oranges? • We felt the need to establish a baseline • Linking the research to our current practice and supplying actual numbers to substantiate a change in practice. • Let’s see if it changes if we changeM Plan For Change: Establishing a baseline • Collected Data from 137 patients transfused pts at Siteman Cancer Center outpatient oncology/BMT/Heme infusion center from – January 1, 2014 through April 1, 2014. Data collection included0 • Patient Initials • Disease • Service (Med Oncology/BMT/Hematology) • Type of Blood product given (Packed Red Blood Cells (PRBC), Single Donor Platlets (SDP,PLT) • Type of Premedication used0 Tylenol, Benadryl, Claritin, Solu0Cortef) • Did reaction occur? (Yes/No) • Was a transfusion Reaction form filled out? • When did it occur? (during/after) • Did we proceed with remaining once symptoms resolved? • Description of reaction 6

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