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Transfusion practice in the critically ill

Transfusion practice in the critically ill. Howard L. Corwin, MD; Stephen D. Surgenor, MD; Andrew Gettinger, MD Critical Care medicine 2003 Vol, No. 12. Anemia of critical illlness. 95% patients are anemic by day 3 after ICU admission

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Transfusion practice in the critically ill

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  1. Transfusion practice in the critically ill Howard L. Corwin, MD; Stephen D. Surgenor, MD; Andrew Gettinger, MD Critical Care medicine 2003 Vol, No. 12

  2. Anemia of critical illlness • 95% patients are anemic by day 3 after ICU admission • There are two main mechanisms that commonly contribute to anemia in the critically ill. • Phlebotomy • Inappropriately low production of red blood cells.

  3. Phlebotomy in ICU Patients • A significant source of blood loss in the ICU. • > ½ p’t receives blood transfusion that were phlebotomized more than one unit of blood. • Phlebotomized average 65ml per day Phlebotomy for diagnostic laboratory tests in adults: Pattern of use and effect on transfusion requirements. Smoller BR, Kruskall MS: NEJM 1986; 314:1233-1235

  4. Phlebotomy in ICU Patients • Averaged 41 mL/day in western Europe • Frequency of blood drawn were twice to three times in ICU compared with patients on the wards. • Patients who are phlebotomized less in the ICU receive fewer RBC transfusion. • Are we “Medical Vampires” ?

  5. Inappropriately low production of red blood cells • Decreased levels of RBC production • Underproduction anemia consistent with what is commonly referred to as the anemia of chronic inflammatory disease. Anemia of the critically ill: “Acute” anemia of chronic disease Crowin HL, Krants SB Crit Care Med. 2000; 28:3098-3099

  6. Inappropriately low production of red blood cells • >90% of ICU patients have low serum iron and TIBC • Iron/ TIBC ratio normal • Elevated Ferritin levels • EPO mildly elevated and little reticulocyte. • The same condition in patients of multiple organ dysfunction.

  7. Compare EPO levels in critically ill patients with those in patients with IDA • EPO levels were somewhat elevated compared with adults without anemia • EPO significantly lower compared with patients with IDA with the same levels of anemia Erythropoietin response is blunted in critically ill patients Rogiers P, Zhang H, Leeman, M, et al Intensive care medicine 1997: 23:159-162

  8. Inappropriately low production of red blood cells • Blunted EPO response results from the inhibition of the EPO gene by inflammatory mediators • IL-1 in RA are proportional to the degree of anemia • IL-1 activates T-lymphocytes which increase the production of Interferon  that in turn directly inhibits RBC production in vitro. • TNF-α inhibits the action of EPO on bone marrow and the production of EPO by the kidney.

  9. Transfusion Practice • In 2000-2001, observation of 4892 patients , 50% of all patients admitted to ICU are transfused during ICU admission Anemia and blood transfusion in the critically ill: Current clinical practice in the US. Crowin HL. Abraham E. Fink MP. Et al: Crit Care Med 2001;29 A3 • 85% receive a transfusion (longer stay than 1 wk)

  10. Transfusion Practice • The “pretransfusion trigger” was 8.61.7 g/dL • The RBC transfusion were not restricted to the ICU. 13% accepted 3units of RBC transfusion following ICU discharge.

  11. Transfusion Practice Anemia and blood transfusions in the critically ill: An epidermological, observation study. Vincent JL, Baron JF, Gattinoni L, et al JAMA 2002;288:1499-1507 • 3534 patients admitted to ICU during 2 wks • 37% were transfused with mean 4.8 RBC units in ICU • 12.7 were transfused post-ICU period • 42% were transfused during 28 day study period • Pretransfusion Hgb was 8.4 g/dL

  12. Transfusion Practice • Maintain Hgb > 7g/dL range is at least equivalent A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Hebert PC, Wells G, Blajchman MA, et al NEJM 1999;340 409-417 • Automatic transfusion thresholds be abandoned in favor of a practice of RBC transfusion only for defined physiologic need.

  13. Transfusion Practice • Maintain Hgb >10g/dL to most patients with cardiovascular disease • Active ischemic cardiac disease may require a higher hemoglobin level. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Hebert PC, Yetisir E, Martin C, et al Crit Care Med 2001; 29:227-234

  14. Transfusion Practice • CABG: 10%-20% RBC consumption • Transfusion rate for elective primary CABG operation at 23 academic centers varied widely 16%-90% • The number of RBC transfusion varied from 0.4 to 6.3 units • 15% blood transfusion is inappropriate

  15. Transfusion Practice Determinants of red cell, platelet, plasma and cryoprecipitate transfusions during coronary artery bypass graft surgery: The collaborative Hospital Transfusion Study. (CHTS) Surgenor DM, Churchill EL, Wallance WH, et al Transfusion 1996; 36:521-532 • 33%-90% transfusion rate • Highest utilization rate, a high proportion of cases were transfused on the operative day. • The variation in transfusion practice did not differ significantly among surgeons within one hospital.

  16. Transfusion Practice • Non-ICU patients 35% of RBC transfusion were judged • The inappropriate transfusion ranged from 4% -57% • What determines whether a patient receives a blood transfusion?

  17. What determines whether a patient receives a blood transfusion? • Physicians’ confidence in their knowledge was negatively associated with actual knowledge. • Senior physicians tended to have lower knowledge scores but were more confident and they tended to influence the transfusion practice of the junior physicians. Influence of clinical knowledge, organizational context, and practice style on transfusion decision making Salem-Schatz SR, Avorn J, Soumerai SB: JAMA 1990:264:476-483

  18. What determines whether a patient receives a blood transfusion? CRIT study • Transfusion decision tend to be driven by “transfusion trigger” rather than by specific physiological indications. • There was little evidence that either age or co-morbidities significantly influenced transfusion practice.

  19. Benefits of RBC Transfusion • Immediately improve oxygen delivery and prevent cellular injury • RBC transfusion can not increase blood pressure like fluid resuscitation. Risk of blood transfusion: • Allergy • HIV infection

  20. Benefits of RBC Transfusion • In a study of patients with GI bleeding, patients who received only colloid solution had lower mortality and morbidity than patients who were transfused with RBCs. • Other studies also document a lack of improvement in tissue oxygenation after RBC transfusion, despite increase oxygen delivery.

  21. Benefits of RBC Transfusion Stored RBC • Decreased 2.3-diphosphoglycerate levels interfering with the ability of RBCs to unload oxygen, and decreases RBC deformability. • Stored >15 days developed more evidence of splanchnic ischemia compared with <15 days. • Fresh RBCs acutely increased systemic oxygen uptake

  22. Pretransfusion Trigger Liberal transfusion strategy (Hb 10-12g/dL, with a transfusion trigger of 10g/dL) Vs Restrictive transfusion strategy (Hb 7-9g/dL, with a transfusion trigger of 7g/dL) Result: • Overall in-hospital mortality was significantly lower in the restrictive strategy group

  23. Pretransfusion Trigger 2. The 30-day mortality rates was not significantly different. 3. Less ill( APACHE<20) or younger(<55yrs of age) the 30-day mortality rates were significantly lower for the patients in the restrictive transfusion group.

  24. Pretransfusion Trigger • No significant difference in mortality between the two transfusion strategies in this subgroup was noted. • However, in the patients with severe ischemic heart disease, a tend toward decreased survical was observed in the group managed with therestrictive strategy. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Hebert PC, Yetisir E, Martin C, et al Crit Care Med 2001; 29:227-234

  25. Conclusion • There is little evidence that “routine” transfusion of stored allogenic RBCs is beneficial to critically ill patients. • For critically ill patients who are not actively bleeding and without cardiovascular disease, a Hb level of 7.0 g/dL is well tolerated. • With active ischemic cardiac disease in whom the higher transfusion trigger would be appropriate.

  26. Conclusion • To minimize the blood loss and to increase the production of blood may also be important to management of all critically ill patients.

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