Transcript Transfusion Therapy: Optimal Use of Blood Products

Transfusion Therapy:
Optimal Use of Blood Products
Jennifer Jou M.D.
September 2, 2011
Objectives
Review risks/benefits of RBC, platelet,
and FFP transfusion
Re-examine our strategies to optimize
transfusion for each of these
components relative to patient
population
Case
 49 y.o., 5'4", 95kg female presents for Posterior Fusion of C5C7. Her past medical history is significant for HTN and smoking
(1/4ppd x 30 yrs). Her medications are Metoprolol, Percocet prn,
and occasional Advil prn. Her vital signs are normal.
 The patient is intubated and positioned uneventfully. During
dissection, the Orthopedic surgeon states that the patient is oozy
and bleeding and asks to have blood and platelets hung. What
do you do?
Lab Values
H/H= 11/33
 Plts= 101k
 INR= 1.2
 Chemistry: Cr = 1.3 o/w WNL
 EKG: NSR with flipped T's in lateral leads
 CXR: hyperinflation
State of Blood Utilization in the
U.S.
 American Association of Blood Bankers 2009 Nationwide Blood
collection and Utilization Survey Report
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Total number of transfusions unchanged
Decreased autologous blood collection and transfusion
Increased allogeneic transfusion
Increased use of leukocyte reduced blood by 20%
Increase in cost of each unit of leukocyte reduced blood
(approx 5.5%, $223)
 mean age of RBC at time of transfusion 18.2 days
Variation in Transfusion Practice
 Despite availability of guidelines, variation
persists
 Not explained by patient or surgical
variables, rather by differences in provider
and institutional preferences.
 A “best practice” is yet to be identified
Surgenor et al. Determinants of red cell, platelet, plasma and cryoprecipitate transfusions during coronary
artery bypass graft surgery: the Collaborative Hospital Transfusion Study. Transfusion 1996;36:521-32.
Guidelines Overview
 National Institute of Health, American College of Physicians, Blood
Management Practice Guidelines Conference, American Society of
Anesthesiologists, Society of Cardiovascular Anesthesiologists...etc.
 Old “10/30,” Adams and Lundy, 1942
 Strict guidelines relatively ineffective in reducing unwarranted
transfusions
 One prescribed trigger is not appropriate for all patients and clinical
scenarios (ie: there is no consistent physiologic deterioration seen in all
patients at a specific H/H level)
 An overall understanding of benefits and risks of transfusion specific to
the patient should be used to guide decision making.
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Adams RC, Lundy JS. Anesthesia in cases of poor risk. Some suggestions for decreasing
risk. Surg Gynecol Obstet 1942;74:1011-101
RBC Transfusions
1.Risks of Anemia
2.Benefits of RBC Transfusion
3.Risks of RBC Transfusion
Risks of Anemia
 Mortality is related more to blood loss than low
preoperative hematocrit.
 Acute Normovolemic Hemodilutional Anemia in
Healthy Patients has historically been well tolerated.
 Hemodilutional Anemia during CPB is less tolerated
Carson JL et al. Severity of anemia and operative mortality and morbidity.
Lancet 1988;1:727-729
Benefits of Transfusion
1. Critically Ill without active bleeding
(with and without cardiovascular
disease)
2. Patients with Acute Coronary
Syndromes (AMI and unstable angina)
3. Patients with sepsis or septic shock
Benefits of Transfusion
 TRICC Trial: Transfusion in critically ill patients without active
bleeding11
 Restrictive strategy (Hgb 7-9g/dL) vs Liberal strategy (10-12g/dL)
 Population: Euvolemic patients not actively bleeding
 Exclusion: Chronic anemia following cardiac surgery, significant
CAD
 Endpoint: 30 day survival
 Result: Restrictive strategy at least as effective and possible
superior to liberal strategy. Improved 30 day survival in patients
younger than 55 yrs old or those with APACHE II scores less than
20 managed with restrictive strategy.
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Hebert PC et al. A multicenter, randomized, controlled clinical trial of transfusion
requirements in critical care. N Engl J Med 1999;340:409-417
Benefits of Transfusion
 TRICC subgroup: Patients with
Cardiovascular Disease
 357 pts with cardiovascular disease
 no difference in mortality rates comparing
restrictive vs. liberal strategy
 Decreased Survival in restrictive group in setting of
ACS (AMI or unstable angina)
Studies specifically looking at ACS/AMI patients
 Wu et al. Improved survival in patients with AMI and HCT<30 who
received transfusion
 Yang et al. Increased risk of death or reinfarction in ACS patients who
received transfusion
 Rao et al. Association of increased 30 day mortality and transfusion in
patients with ACS (significant for nadir Hct as low as 25%)
 All 3 studies were retrospective in nature. Need for prospective
analysis.
Wu et al. Blood Transfusion in elderly patients with acute myocardial infarction. NEJM 2001; 345:
1230-6
Yang X et al. The implication of blood transfusions for patients with non-ST elevation acute
coronary syndromes. JACC 2005; 46: 1490-5.
Rao SV et al. Relationship of Blood Transfusion and clinical Outcomes in Patients with Acute
coronary Syndromes. JAMA 2004; 292:1555-62
Transfusion during Sepsis or
Septic Shock
 Rivers et al.
 randomized, standard resuscitation vs goal-directed protocol.
 RBC transfusions performed in goal-directed protocol to
maintain Central Venous Oxygen >70%.
 Improved mortality with goal directed therapy in hospital, at
day 28 and day 60.
 **Multiple other interventions were used as part of the goal
directed therapy so not possible to discern the true effect of
transfusion on survival benefit.
Rivers et al. Early goal-directed therapy in the treatment of severe sepsis and
septic shock. NEJM 2001; 345:1368-77
Risks of RBC Transfusion
Transmission of Infectious Disease
Negative effects on immune system
TRALI/ARDS
Risk of Transmission
Viral:
 Well known: HBV, HCV, HIV, HTLV
 Emerging: Chagas, West Nile, Malaria,
Creutzfeldt-Jakob disease
 Screening tests contribute to rising cost of
transfusion
Immune System Effects
 Postoperative Infection
 Taylor et al: 10% increase in nosocomial infection
with each unit of transfused RBC19
 Chemeler et al: similar results of increased
nosocomial infection in patients undergoing CABG.
Taylor RW et al. Red blood cell transfusions and nosocomial infections in critically ill
patients. Crit Care Med 2006; 34:2302-08
Chemeler SB et al. Association of bacterial infection and RBC transfusion after
coronary bypass surgery. Ann Thor Surg 2002; 73: 138-42.
Immune System Effects
 Immunomodulation
 Moore et al: dose response relationship between early transfusion
and development of multi organ failure in trauma patients
 Fransen et al: Increased concentrations of inflammatory mediators
after intra-op allogeneic blood transfusion
 Prospective Study
 LBP*, BPI*, IL-6
Moore FA et al. Blood transfusion: An independent risk factor for post-injury multiple
organ failure. Arch Surg 1997; 132:620-25
Fransen E et al. Impact of blood transfusions on Inflammatory Mediator Release in
patients undergoing cardiac surgery. Chest 1999;116:1233-1239.
Immune System Effects
 Mechanism?
 Possible mediation by allogeneic white blood cells
(donor leukocytes) directly impacting recipient’s
immune function or causing release of mediators
of immunomodulation into the stored RBC unit)
Vamvakas EC. White blood cell containing allogeneic blood transfusion and
postoperative infection or mortality: an updated meta-analysis. Vox Sang
2007; 92:224-32
ARDS/TRALI
 ARDS: Defined clinically as dyspnea, bilateral
pulmonary infiltrates, hypoxemia, non-cardiogenic
edema
 TRALI: Non-specific constellation of dyspnea,
hypotension, non-cardiogenic edema, and fever.
 **Importance of differentiation: Low mortality in TRALI
in contrast to ARDS
 Donor anti-leukocyte antibodies react with WBCs of
recipient
Curtis BR et al. Mechanisms of transfusion related acute lung injury; anti leukocyte
antibodies. Crit Care Med 2006;34: s118-23.
Other Factors Influencing
Risk/Benefit
 Leukocyte Reduction
 Hypothesized to be capable of reducing the
aforementioned morbidity/mortality
 Both randomized controlled and meta-analyses
have failed to justify a universal adoption of
leukocyte reduced transfusion except perhaps for
the cardiac surgery population.
 Costly: $223 per unit
Gong MN et al. Clinical predictors of and mortality in acute respiratory distress
syndrome; the potential role of red blood cell transfusion. Crit Care Med
2005; 33: 1191-8.
Other Factors Influencing
Risk/Benefit
Storage Lesion
 predictable changes to RBCs during
storage
 loss of biconcave shape renders the cells
less deformable and more adherent to
endothelium
 depletion of ATP and 2,3-DPG
Platelet Transfusions
 collection methods
 Transmission of Bacterial Infection
 TRALI
 Febrile Reactions
 Circulatory Overload
 Platelet use in CABG Surgery Patients
 Limited Data (majority relevant to
chemotherapy induced thrombocytopenia)
Platelet Transfusion
Collection
 Room Temp and Constant Motion =
Shorter Shelf Life (typically 5 days)
 Semi Permeable Plastic
Platelet Transfusion
Bacterial Contamination
 1:2,000 to 1:3,000
 donor bacteremia, collection bag
contamination, contamination during
processing, room temperature storage
Schrezenneier et al. Bacterial contamination of platelet concentrates: results of
a prospective multicenter study comparing pooled whole blood-derived
platelets and apheresis platelets. Transfusion 2007;47:644-52
Platelet Transfusion
Other Risks
 TRALI
 Febrile Reactions
 Transfusion Associated Circulatory
Overload (dyspnea, orthopnea, peripheral
edema, rapid increase in blood pressure)
Platelet Transfusion
 CABG Patients (adjusted for patient and
disease characteristics)
 Increased risk of
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stroke
inotrope requirement
pulmonary dysfunction
death
Spiess BD et al. Platelet transfusion during coronary artery bypass
surgery are associated with serious adverse outcomes. Transfusion
2004; 44: 1143-8.
Platelet Transfusion
Looking at the data...
 Majority derived from management of noncritically ill heme-onc patients
 thrombocytopenia 2/2 chemotherapy
 difficulty extrapolating this data to the OR
and ICU
Ongjen G et al. Fresh frozen plasma and platelet transfusion for non-bleeding
patients in the intensive care unit. Crit Care Med 2006; 34 [suppl]: 170-3.
FFP and Cryoprecitpitate
 FFP: factors plus fibrinogen
 Cryo: made from FFP, higher conc. of fibrinogen, vWF, Factor
VIII
 Administered to patients with elevated Prothrombin (PT) or
Activated Partial Thromboplastin Time (PTT)
 Risks of use: infection, allergic reactions, hemolysis, circulatory
volume overload, ABO incompatibility, TRALI
Serious hazards of transfusion steering committee. Serious hazards of
transfusion: annual report 2004.
FFP and Cryoprecipitate
Appropriate:
 abnormal coagulation studies prior to procedures associated with
bleeding risks
 during an episode of active hemorrhage
Inappropriate:
 Volume expansion
 Prevention of spontaneous bleeding
Chin-Lee I et al. Transfusion of red blood cells under shock conditions in the rat
microvasculature. Blood 2004; 104:2713A
Gajic O. et al. Fresh frozen plasma and platelet transfusion for nonbleeding patients in the
intensive car unit: benefit or harm? Crit care Med 2006; 34: S170-3.
Key Points
 Pre-op Risk Factor Identification
 organ ischemia (cardiorespiratory disease)
 coagulopathy (inherent or iatrogenic)
 Intra and Post-op
 close monitoring for blood loss and inadequate perfusion
 generally, transfuse Hb<6, don’t transfuse Hb>10
 6-10...JUSTIFY
 Plt transfusion rarely indicated >100 x 109/L, Usually indicated <50 x
109/L in presence of excessive bleeding
 FFP if bleeding and PT >1.5 x nl or INR >2, PTT > 2 x nl
 Cryo if fibrinogen < 80-100mg/dl with bleeding
A look back at the case...
What changes, if any would you make to
your initial transfusion strategy?
THANKS!