Red Blood Cell Transfusion in Intensive Care

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Red Blood Cell Transfusion in Intensive Care
A teaching hospital of Harvard Medical School

• BIDMC Transfusion
• Steering Committee
• 30 January 2006

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Anemia in the ICU

• Anemia is common among patients in the ICU for
  several reasons
• Acute blood loss (trauma, GI bleeding)
• Bone marrow suppression
• Iron depletion
• Phlebotomy
• Erythropoietin deficiency and / or insensitivity

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Overview of RBC transfusion

• Benefits
• - RBC transfusion allows rapid volume expansion
  and increased oxygen carrying capacity
• - RBC transfusion is a life-saving intervention
  in the setting of acute hemorrhage
• Challenges
• - Transfusion is also associated with a small
  risk of potentially severe adverse reactions
• - Red blood cells are a scarce resource, and
  their appropriate use requires balancing the
  positive and negative effects of transfusion

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Risks of RBC Transfusion

• Risk Incidence
• Febrile transfusion reactions lt1 in 100
• Allergic reaction 2-3 in 100
• Anaphylaxis 2 in 100,000
• Transfusion related lung injury
• (TRALI) 2 in 10,000
• Transfusion related circulatory overload
• (TACO) 1 in 100
• Viral Infection (Hepatitis B, HIV, CMV)
• HIV 1 in 2,000,000
• Hepatitis B 1 in 150,000

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Recently Appreciated Risks

• RBC transfusion is immunosuppressive and has been
  associated with an increased risk of bloodstream
  infection
• RBC transfusion is pro-inflammatory and may
  result in an increased incidence of acute
  respiratory distress syndrome (ARDS) and multiple
  organ system failure

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RBC transfusion in the ICU

• The indication for RBC transfusion can be divided
  into four clinical categories
• - Maintenance transfusion
• - Hemodynamically unstable bleeding patients
• - Other hemodynamically unstable patients
• - Patients with acute cardiac ischemia
• Suggested guidelines for RBC transfusion in each
  of these groups will be considered separately

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Maintenance transfusion in stable patients

• Transfuse only when HCT is lt 21 percent
• Minimize phlebotomy via judicious use of blood
  testing
• Consider the use of iron supplementation

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Hemodynamically unstable bleeding patients

• Transfuse blood to maintain a cushion above the
  relevant threshold (21 percent in the
  uncomplicated patient)
• The size of the cushion will depend on the rate
  of bleeding
• Transfuse blood if other fluids do not improve
  hemodynamics, unless the patient is known to have
  a normal hematocrit

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Other hemodynamically unstable patients

• Demonstrate evidence of inadequate tissue
  oxygenation (usually by measuring a central or
  mixed venous oxygen saturation lt70 percent or
  increased blood lactate levels)
• Consider other ways to improve oxygen delivery
  (including volume expansion with crystalloid or
  colloid solutions, inotropes and/or vasopressors)
• If transfusion is administered, look for evidence
  of improved tissue oxygenation

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Patients with acute cardiac ischemia (acute
coronary syndromes)

• Transfuse to maintain a hematocrit around 30
  percent
• Consider a more restrictive strategy in the
  stable patient
• Minimize phlebotomy via the judicious use of
  blood testing
• Consider iron supplementation

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New POE Interface
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Summary

• For hemodynamically stable patients without acute
  blood loss or acute cardiac ischemia, restrictive
  RBC transfusion targeting a hematocrit of 21
  percent is safe and associated improved clinical
  outcomes.
• For hemodynamically unstable bleeding patients,
  RBC transfusion should be used to allow a cushion
  above the goal hematocrit of 21 percent.
  Determine the size of the cushion based on the
  rate of blood loss.
• For hemodynamically unstable patients without
  ongoing blood loss and with evidence of impaired
  tissue oxygenation, RBC transfusion should be
  considered.
• For patients with acute cardiac ischemia (acute
  coronary syndromes), maintain a target hematocrit
  of 30 percent.
• For patients with iron deficiency and for
  patients on erythropoietin, provide supplemental
  iron.
• For all patients, minimize blood draws order
  blood testing judiciously.

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Selected References

• Arslan, E, Sierko, E, Waters, JH, et al.
  Microcirculatory hemodynamics after acute blood
  loss followed by fresh and banked blood
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• Bordin, JO, Heddle, NM, Blajchman, MA. Biologic
  effects of leukocytes present in transfused
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• Fransen, E, Maessen, J, Dentener, M, et al.
  Impact of blood transfusions on inflammatory
  mediator release in patients undergoing cardiac
  surgery. Chest 1999 1161233.
• Gong, MN, Thompson, BT, Williams, P, et al.
  Clinical predictors of and mortality in acute
  respiratory distress syndrome Potential role of
  red cell transfusion. Crit Care Med 2005
  331191.
• Hébert, PC, Wells, G, et al. A Multicenter,
  Randomized, Controlled Clinical Trial Of
  Transfusion Requirements In Critical Care N Engl
  J Med 1999 340409.
• Malone, DL, Dunne, J, Tracy, JK, et al. Blood
  transfusion, independent of shock severity, is
  associated with worse outcome in trauma. J Trauma
  2003 54898.
• Rao, SV, Jollis, JG, et al. Relationship of blood
  transfusion and clinical outcomes in patients
  with acute coronary syndromes JAMA 2004
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• Robinson, WP, Ahn, J, Stiffler, A, et al. Blood
  transfusion is an independent predictor of
  increased mortality in nonoperatively managed
  blunt hepatic and splenic injuries. J Trauma
  2005 58437.
• Shorr, AF, Jackson, WL, Kelly, KM, et al.
  Transfusion practice and blood stream infections
  in critically ill patients. Chest 2005 1271722.
• Wu, WC, Rathore, SS, Wang, Y, et al. Blood
  transfusion in elderly patients with acute
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