Transcript Transfusion therapy in critical care

Red cells and the critically ill patient
“Conservatives” or “Liberals”
Dr A. Surekha Devi
Consultant, Transfusion Medicine
Hyderabad
Introduction
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Blood transfusion is an essential part of modern health
care.Transfusions are an index of severity of illness
Critical care physician should decide to transfuse based on the
risks, benefits and alternatives of treatment
Suboptimal patient care due to over-use & under-use of blood
products
Evidence-based transfusion triggers
90% of RBC transfusions in ICU are for treatment of anemia
Total blood management aimed
-to improve management of anemia
-to reduce or eliminate allogenic transfusions
Guidelines for red cell transfusions
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There is no single value of hemoglobin concentration
that justifies or requires transfusion
RBCs are administered when Hgb<7 g/dl, those with
acute coronary syndrome when Hgb<8 g/dl and
unnecessary when Hgb>10 g/dl
When Hgb is 7-10 g/dl, red cell transfusion is based
on the following factors:
- organ ischemia
- ongoing bleeding(rate and magnitude)
- Patient’s intravascular volume status
- Patient’s risk factors for complications of inadequate oxygenation
(low cardiopulmonary reserve and high oxygen consumption)
- Physiological triggers such as O2 ER >50%, SVO2 <50%
*Anesthesiology 2006;105:198-208.
Indications for red cell transfusion
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Hemorrhagic shock
Acute hemorrhage(35%) with hemodynamic instability
inadequate oxygen delivery(25%)
Anemia due to
- sepsis
- hemolysis
- decreased production of endogenous erythropoietin
- immune associated functional iron deficiency
- blunted reticulocyte response
- overt or covert blood loss
Crit Care Med 2009;37:3124-57.
“Conservatives”
TRICC trial
Canadian Critical Care Trials Group - 838 patients, over
3 yrs from 25 centers – Paul C.Hehert et al
Restricted strategy(n=418)
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Transfusion trigger of 7 g/dl &
maintenance of 7-9 g/dl
Average 2.6 units given
Received 54% less blood
1/3 rd patients did not require
transfusions
Decreased 30-day all cause
mortality, lower MOF, fewer
cardiac complications
Recommended restrictive
transfusion strategy as the
clinical outcome was better
Crit Care Med 2009 Vol. 37, No. 12.
Liberal strategy(n=420)
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Transfusion trigger of 10 g/dl
& maintenance of 10-12 g/dl
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Average 5.6 units given
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All patients required
transfusions
Septic patients should have
liberal transfusion practice
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CRIT study: Data on red cell transfusion and outcome was
collected on 4892 patients from 284 ICUs in 213 US hospitals.
Mean Hgb was 11 g/dl. 90% of transfusions were for anemia.
Blood transfusions were associated with increased mortality
ABC study: Cohort of 3534 patients admitted to 146 western
European ICUs. Mean Hgb at admission was 11.3 g/dl.
Documented longer ICU stay and increased mortality
Transfusion triggers in SICU: Robertie & Gravlee
Well compensated patients with no heart disease: 6 g/dl
Stable cardiac disease & blood loss of 300ml: 8 g/dl
Older patients and those with post-op complications: 10 g/dl
Crit Care Med 2009;37:3124-57.
Johns Hopkins study
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Steven M.Frank et al. have done study on 48,000 surgical
patients from February 2010 to August 2011 at Johns Hopkins
hospital
2,981(6.2%) patients received blood transfusions during surgery
There was wide variation among surgeons and anesthesiologists
in ordering blood transfusion
Patients undergoing surgery for pancreatic cancer, orthopedic
problems, aortic aneurysms received blood at higher trigger
points >10 g/dl
It was decided to transfuse at a trigger of <7-8 g/dl as blood is
in short supply, pricey and associated with risks like infections,
immunomodulation and triggers complex immune reactions
Johns Hopkins Medicine News and Publications. 04/24/2012
“Liberals”
Sepsis occurrence in acutely ill patients
study (SOAP Study)
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Prospective, multicenter, observational study, to evaluate
epidemiology of sepsis of ICU patients in European countries,
initiated by European Society of Intensive Care
Transfused patients had a better survival, than those who were
not transfused
Changes in blood processing so that blood transfusions are safer
today in terms of viral transmission that they were a decade ago
Leukodepletion
of
red
cells
removes
negative
immunosuppressive effects of transfusion, TRIM, TRALI and
also transmission of leukotropic viruses
76% of centers were routinely using leukodepleted blood
This study suggests that blood transfusions may not be
associated with increased mortality and may be associated with
improved survival
Anaesthesiology 2008; 108:31-9.
Sepsis
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Although transfusion increases oxygen delivery, tissue utilization
of oxygen does not increase in patients with sepsis
There is increased splanchnic ischemia following transfusion with
old blood in patients with sepsis. This paradoxically decreases
microcirculatory oxygen delivery and contribute to tissue hypoxia
Marik & Sibbald et al
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Sepsis is an indication of transfusion need in anaemic patient
because of increased tissue oxygen debt and resetting of DO2 /
VO2 interactions; Shoemaker et al
Patients with ARDS have hidden oxygen debt unrelated to Hb
level; Bihari et al
Should have liberal transfusion strategy
Crit Care Med 2009;37:3124-57.
Liberal transfusion strategy
Red cells:
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Hb <7-9 g/dl (in absence of significant coronary artery disease,
acute hemorrhage or lactic acidosis)
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Hb <10 g/dl in patients with low central venous oxygen
saturation during first 6 hrs of resuscitation of septic shock
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Erythropoietin is not recommended in severe sepsis
Liberal transfusion strategy is also followed in
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ARDS
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MOF
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Traumatic brain injury
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Cerebrovascular disease
Crit care Med 2004; 32: 858-873.
Red cell transfusion risks
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Transfusions cause immunosuppression by decreasing cell
mediated immunity, altering of T-cell ratios
Associated with increased nosocomial infections
- wound infection
- pneumonia
- sepsis
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- Cystitis
- bacteremia
- line infections
It is independent risk factor for MOF and SIRS
Associated with longer ICU and hospital stay
Increased morbidity and mortality
There is a relationship between transfusion and ALI & ARDS
Possible development of immunomodulation and autoimmune
diseases later
Febrile & allergic reactions, TRALI, TACO, TRIM, hemolytic
reactions and human errors
Crit Care Med 2009;37:3124-57.
Crit Care Med 2002 Vol.30, No.10
Indian J Crit Care Med October-December 2007 Vol 11 Issue 4.
Leucoreduction of red cells
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Pre-storage leucoreduction of RBCs is recommended for
critically ill patients
Lowers transfusion associated immunosuppression
lowers incidence of post-operative infections
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Red cells should be <15 days old
- as older blood decreases microcirculatory oxygen delivery
- decreases red cell 2,3 DPG concentration in old blood
- increased splanchnic ischemia occurs with old blood
Neonatal intensive care(NICU)
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Red cells should be compatible with the ABO group and Rh type
as well as unexpected red cell antibodies in the maternal serum
Red cells of <7days old, preserved in CPDA1 (avoidance of
preservative solution), HbS negative, CMV reduced risk and
irradiated
Transfusion volumes on the basis of ml/kg body weight
Minimal donor exposure; one unit is designated and aliquoted
for a given neonate
3 kg neonate has total plasma volume of 150 ml; hence group
identical RDPs and cryo should be transfused
Venous Hb of <13 g/dl in the first 24 hrs of life indicates
anaemia; healthy FT neonate <10 g/dl; PT neonate <7-9 g/dl
Use of rhEPO with efforts to reduce blood loss from phlebotomy
for lab tests can reduce / avoid transfusions
Pediatric transfusion 2nd ed. AABB 2006.
Pediatric intensive care(PICU)
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Red cells: 10-15 ml/kg = 2-3 gm/dL
Platelets: 5-10 ml/kg = 50,000-1,00,000/μL
FFP: 10-15 ml/kg = factor activity 15-20%
Cryo: 1-2 units/10 kg = 60-100 mg/dL(infant)
5-10 mg/dL (older children)
CPDA1 red cells should be given in infants less than 4 months
old, red cells with preservative are not recommended
Decision to transfuse critically ill pediatric patients should be
individualised and restricted to patients with Hb levels <9 g/d L
Pediatric transfusion 2nd ed. AABB 2006.
Blood conservation
Outcomes can be improved, risk reduced and costs
saved
 To reduce acute blood loss
- Antifibrinolytic agents: Aprotinin, TA, EACA
- Recombinant activated factor VII
- Artificial O2 carriers: HBOCs, Perflurocarbons
- Postoperative blood recovery: cell salvage
To prevent subacute anemia
- Erythropoietin(rHuEpo)
- Restrictive red cell transfusion trigger
- Reduction in diagnostic laboratory testing
- Use of low-volume adult/pediatric blood sampling tubes
CMAJ Jan 2008; 178:49-57.
Study at University of Pittsburgh Medical Center
Transfusion 2012;52:1643.
On-screen warning
Transfusion 2012;52:1640-45.
Comparison of monthly no.of RBC alerts
Transfusion 2012;52:1642.
Summary
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Implementing a hospital-based blood management strategy
Restrictive transfusion strategy is superior to liberal transfusion
strategy as clinical outcomes are better
Critically ill patients can tolerate anemia to an Hgb level of 7 g/dl
There is no single value of Hgb concentration that justifies
transfusion, patient’s clinical situation should also be evaluated
Pre-storage leucoreduced RBCs minimizes adverse effects of
transfusion
RBC transfusions are associated with increased infections, longer
ICU stay, immunomodulation, increased morbidity and mortality
Adopting blood conservation techniques–meticulous hemostasis,
use of desmopressin, IV iron, rHuEpo, rFVIIa, use of cell
salvage, reduction of transfusion triggers and minimizing blood
loss for diagnostic purposes
“The best transfusion is the
transfusion not given……”
Thank you for your attention