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RBC transfusions in critically ill patients

RBC transfusions in critically ill patients. TMR Journal Club March 1, 2007 Maggie Constantine. RBC transfusions in critically ill patients Background. RBC transfusion relationship to mortality morbidity infection.

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RBC transfusions in critically ill patients

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  1. RBC transfusions in critically ill patients TMR Journal Club March 1, 2007 Maggie Constantine

  2. RBC transfusions in critically ill patientsBackground • RBC transfusion relationship to • mortality • morbidity • infection

  3. RBC transfusions in critically ill patientsBackground – RCTs Liberal vs Restrictive RBC Strategies

  4. RBC transfusions in critically ill patientsBackground - TRICC P=0.10 NEJM 1999; 340(6)

  5. RBC transfusions in critically ill patientsBackground – TRICC – CVD Subgroup Analysis Crit Care Med 2001

  6. P Value <.01 RBC transfusions in critically ill patientsBackground - ABC Difference in Mortality by Number of Units Transfused JAMA 2002; 288 (12)

  7. RBC transfusions in critically ill patientsBackground - CRIT Crit Care Med 2004;32(1)

  8. RBC transfusions in critically ill patientsBackground - CRIT P<0.001 Crit Care Med 2004;32(1)

  9. RBC transfusions in critically ill patientsBackground – Nosocomial infections • Recent literature • Link between RBC transfusion and development of nosocomial infections in a variety of ICU patients • ABC Newsletter Feb 16, 2007 – Gould et al., Am J Crit Care 2007;16:3948. • “According to the available data, transfusion of packed red blood cells should be reserved only for situations in which clear physiological indicators of transfusions are present.”

  10. RBC transfusions in critically ill patientsArticle review • Crit Care Med 2006;34(9): 2303-2308. • Prior retrospective study – Project Impact (PI) • ? Association between nosocomial infections, mortality and length of stay with RBC transfusions

  11. RBC transfusions in critically ill patientsArticle review • Are the results of study valid? • Prospective observational cohort • >/18 years – 50% random sample of all ICU patients • N=428 transfused vs 1657 nontransfused • Decision to transfuse made by treating physician • Single center med/surgical ICU • August 2001 to June 2003 • Primary objectives • Development of infections • Compare rates of infectious complications between cohorts • Secondary objective • “whether patients in the transfused group remained at higher risk of NI when stratified by the patients’ probability of survival.” - ? Post hoc

  12. RBC transfusions in critically ill patientsArticle review • Cohorts similar? NO • Significantly, transfused cohort was • Older • Had lower MPM-0 scores • Different admitting diagnoses • Exposures and outcomes measured in the same way for both cohorts? POSSIBLY • Exposure opportunity not equal amongst cohorts • Unclear if “senior critical care nurses” blinded to transfusion • Standard definition of NI

  13. RBC transfusions in critically ill patientsArticle review • Was follow-up sufficient? YES • “throughout the patients’ ICU stay.” • Temporal relationship correct? UNCLEAR • NI included if occurring during ICU stay AND absent on admission • But unclear if infection occurred AFTER RBC transfusion • Dose-response gradient? YES • “for every unit increase in RBCs transfused, the risk of NI increased 9.7%”

  14. RBC transfusions in critically ill patientsArticle review • Dose-response gradient? YES • Rate of NI 14.3% “post-transfusion” vs. 5.8% in non-transfused (p<0.0001) • “for every unit increase in RBCs transfused, the risk of NI increased 9.7%”

  15. RBC transfusions in critically ill patientsArticle review • Relative risk of NI with transfusion = 2.74 • Related to illness severity at baseline? • Adjusted for POS • NI rate still significantly higher in transfused group (p<.0001) • Patients with better prognosis – higher risk of NI if transfused • 95% CI taken from Odds ratio • Very close to 1

  16. RBC transfusions in critically ill patientsArticle review • Secondary analysis • Transfused patients (NI vs. No NI) • No significant difference in age of RBC (NI vs. No NI) • No effect of RBC age on rate of NI (NI vs. No NI) • No significant difference in LR status of RBC (NI vs. No NI) • Significantly higher mortality rate patients (21.8% vs. 10.2%, p<.0001) • Significantly longer IUC stay (p<.0001)

  17. RBC transfusions in critically ill patientsArticle review • Implications for my practice? • Medical / surgical ICU • Adult • No suspected or actual infection on admission • Magnitude of risk? • RR = 2.7 • AR increase = 8.5% • For every 12 patients transfused – one will develop NI • Should I attempt to stop exposure? • YES, BUT PERHAPS FOR OTHER REASONS • Prospective cohort – hypothesis generating – possible RCT • Strength of RBC transfusion to NI is clearly established

  18. RBC transfusions in critically ill patients TMR Journal Club March 1, 2007 Maggie Constantine Comments? Questions?

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