blood transfusion icu
TRANSCRIPT
-
8/19/2019 Blood transfusion ICU
1/64
BLOOD TRANSFUSION IN IC
By
Dr.Sherif Badrawy
Critical Care Registrar
-
8/19/2019 Blood transfusion ICU
2/64
HISTORY OF TRANSFUSION
• Important dates:• 1665: frst recorded transusion; between dog• In 166! blood transusron rom s"eep to male• 1#5 frst "uman$to$"uman transusion
• 1#%1& description o blood groups• 'orld 'ar 1: de(elopment o blood ban)s• 1#6%s$1#%s: met"ods to separate w"ole bloopre(entantibody ormation! and detect inections
-
8/19/2019 Blood transfusion ICU
3/64
EVOLUTION OF TRANSFUSION
-
8/19/2019 Blood transfusion ICU
4/64
SOME FACTS ABOUT BLOOD TRANSFUSION
• *nly absolute indication is to increase oxygen
to +issues in anaemic patients$ to increase o,yg
carrying capacity&
• It is a tissue transplantation procedure
• Blood s"ould not be used or in!raasc"lar o
ex$ansion
-
8/19/2019 Blood transfusion ICU
5/64
-
8/19/2019 Blood transfusion ICU
6/64
BLOOD TRANSFUSION
-
8/19/2019 Blood transfusion ICU
7/64
FACTORS THAT MAY RESULT IN A PATIENT POTENTIALLY CLOSER TO THE CRITICAL P
THAN NORMAL
•Red"ced oxygen deliery&• %a& Decreased cardiac o"!$"!'
-i. /re$morbid disease e&g&!I0! (al(ular "eart disease&
-ii. 0ypo(olaemia e&g&! increased capillary lea)&
-iii. 2rr"yt"mias e&g&! atrial fbrillation&
-i(. /ulmonary embolism&
-(. 3pecifc "eart muscle disease e&g&! systemic in4ammato
response syndrome -3IR3. related cardiomyopat"y&
• %(& )y$oxae#ia secondary !o ac"!eres$ira!ory fail"re.*%ALI&+ %ARDS&.
-
8/19/2019 Blood transfusion ICU
8/64
FACTORS THAT MAY RESULT IN A PATIENT BPOTENTIALLY CLOSER TO THE CRITICAL P
THAN NORMAL
,ain- s!ress- anxie!y.
Shiering.
Feer.
Seere infec!ion.Se$sis+%SIRS&.
Tra"#a
S"rgery.
B"rns.
Adrenergic dr"g inf"sions.
or/ of (rea!hing e.g.- d"ring weaning.
Con"lsions.
Increased oxygen cons"#$!ion
-
8/19/2019 Blood transfusion ICU
9/64
Ane#ia 0S (lood !ransf"sioin ICU
-
8/19/2019 Blood transfusion ICU
10/64
1 Anemia Frequency
>60% of ICU patients upon admission
90% of ICU patients by day 3 in ICU
97% of ICU patients by day 8
Thomas J, Jensen L, ahi!nia" #, $ibney T& 'nemia and b(ood t!ansfusion p
the )!iti)a((y i((* a p!ospe)ti+e )oho!t !e+ie& -ea!t Lun.& /0013923*/74//5
-
8/19/2019 Blood transfusion ICU
11/64
1 Anemia morbidity and mortality
'sso)iated ith in)!eased 904day mo!ta(ity in patients ith )h!oni) obst!u)ti+e pu(mona!y disease
'sso)iated ith ad+e!se out)omes in patients ith
)on.esti+e hea!t fai(u!e, a)ute myo)a!dia( infa!)tion,
and )h!oni) "idney disease
asmussen L, Ch!istensen #, Len(e!4ete!sen , Johnsen #&'nemia and
in C patients !eui!in. in+asi+e me)hani)a( +enti(ation& C(in :pidem
-
8/19/2019 Blood transfusion ICU
12/64
1 Anemia Cost
'sso)iated ith >ti)e inpatient )osts in patients i
)h!oni) )onditions 'sso)iated ith in)!eased (en.th of stay in patients
ith hea!t fai(u!e
issenson ', ;ade #, $oodnou.h T,
-
8/19/2019 Blood transfusion ICU
13/64
2 Blood transfusion Frequency
/0% to 6/% of ICU patients !e)ei+e o! mo!e uof b(ood
Tay(o! ;, ?@!ien J, T!ottie! #J, et a(& ed b(ood )e(( t!ansfusion
infe)tions in )!iti)a((y i(( patients& C!it Ca!e =ed& /0061329*/30
-
8/19/2019 Blood transfusion ICU
14/64
2 Blood transfusion morbidity and mortality
'sso)iated ith as mu)h as a 0% in)!ease in 304day
mo!bidity 'sso)iated ith as mu)h as a 38% in)!ease in
mo!ta(ity
@e!na!d 'C, a+enpo!t L, Chan.
-
8/19/2019 Blood transfusion ICU
15/64
2 Blood transfusion Cost
'sso)iated ith a!ound / day in)!ease in (en.th ot!ansfusion
-i(( #, Ca!(ess ', -en!y ', et a(& T!ansfusion th!esho(ds and othe! st!ate.ies fo
!ed b(ood )e(( t!ansfusion& Co)h!ane atabase #yst e+& /00/2/*C00/0/&
-
8/19/2019 Blood transfusion ICU
16/64
DOES OLD BLOOD IMPROVEOXYGEN CONTENT?
-
8/19/2019 Blood transfusion ICU
17/64
STORAGE DEFECTS AND MICROVASCULAPERFUSION
ecreased !$/7! 2/!8*Build$up ocyto)ines! 9ree0b! ! debris/oor deormability
'ill t"ey impro(e
o,ygen content adeli(ery <
Immunesuppression
InectionsClinical and animal studies report contradictory fndings about t"eo,ygenation capacity o
stored RBCs
-
8/19/2019 Blood transfusion ICU
18/64
TRANSFUSION TRIGGER
2cceptable "emoglobin concentration2cceptable "emoglobin concentration
Ris/ of (lood !ransf"sion Ris/ of low he#oglo(i
-
8/19/2019 Blood transfusion ICU
19/64
TRANSFUSION “TRIGGER” CONTROVERSY
Transfusion tri3he#oglo(in ohe#a!ocri! le(elow which a !ransf"sion wagien. 4os! !rico#$ared o"!cin $a!ien!s!ransf"sed a! )!hresholds (e!5 and 67 g+dL9
=>?<
5+:6;
67+
-
8/19/2019 Blood transfusion ICU
20/64
TRANSFUSION LITERATURE
• The c"rren! $aradig# of !he !ransf"sion !rigger o
g+dL co#es fro# !he TRICC !rial=
• I! challenged !he solid (elief !ha! high he#oglo(i
al"es are safe- e>ec!ie- and necessary in !he cr
ill.• I! !riggered a #ore foc"sed loo/ a! !he $hysiology
oxygen !rans$or! in !he con!ex! of hae#oglo(in
aaila(ili!y
• I! raised !he ?"es!ion of whe!her !ransf"sion has
$ro(le#s in i!s own righ!
-
8/19/2019 Blood transfusion ICU
21/64
TRANSFUSION TRIGGERS IN NON-BLEEPATIENTS
-
8/19/2019 Blood transfusion ICU
22/64
STUDY DESIGN
• The $a!ien!s incl"ded were @6 years old- cri!ically
nor#oolae#ic- non*(leeding- )( 7 wi!hin 5: h o
ad#ission
• 4C RCT inoling : cen!ers oer < years wi!h n E
• The co#$arison gro"$s had di>eren! )( !arge! rang
were res!ric!ie %57*7g+L& s li(eral gro"$s %677*6:
!he lower al"e as !he !ransf"sion !hreshold
-
8/19/2019 Blood transfusion ICU
23/64
FINDINGS
• no di@erence in t"e t"e primary endpoint o mortality A
• increased complications in liberal strategy group
• signifcant reduction in blood e,posure in t"e more restr
group
• signifcantly lower in$"ospital mortality in t"e less sic) -2
% *R 33: =& percent in t"e• restricti(e$strategy group and 16&1 percent in t"e libera
group! p D %&%. and t"ose aged E55y
• in t"e restricti(e transusion strategy group
-
8/19/2019 Blood transfusion ICU
24/64
• The #or!ali!y ra!e d"ring hos$i!aliHa!ion was sign
lower in !he res!ric!ie*s!ra!egy gro"$ %::.: $erce
:.6 $ercen!- $ E 7.7&.
• !rend !o decreased s"rial wi!h a res!ric!ie s!ra
$a!ien!s wi!h cardioasc"lar disease
• no di>erences in d"ra!ion of 40 or en!ila!or free
-
8/19/2019 Blood transfusion ICU
25/64
QUESTIONS UNANSWERED IN TRICC TRIAL
; hy li(eral s!ra!egy gro"$ failed !o i#$roe #or!
ra!es of organ fail"re in cri!ically ill ;;
,ossi(le ex$lana!ions '
a& grea!er no. of allogenic RBC "ni!s de$ressed
hos! i##"ne res$onses.
K0ermans F et al circulation 1##=
(& al!ered #icrocirc"la!ory Mow as conse?"ence
of $rolonged s!orage !i#es.
-
8/19/2019 Blood transfusion ICU
26/64
A CANADIAN PAEDIATRIC STUDY
MIRRORED THE FINDINGS OF TRICC, B WITH MODS AS THE PRIMARY OUTCOM
-
8/19/2019 Blood transfusion ICU
27/64
-
8/19/2019 Blood transfusion ICU
28/64
-
8/19/2019 Blood transfusion ICU
29/64
CURRENT GUIDELINES ON TRANSFUSISEPSIS
G 4ain!ain a hae#a!ocri! of @
-
8/19/2019 Blood transfusion ICU
30/64
TRANSFUSION REQUIREMENTS IN SEPSHOCK ( TRISS) TRIAL
• trial to e(aluate t"e e@ects on mortality o leu)o
reduced blood transusion at a lower (ersus a "i
"emoglobin t"res"old among patients wit" septi
s"oc) w"o are in t"e -ICH.&
• multicenter! parallel$group trial
• w"en t"e "emoglobin le(el was g >dl or less -lo
t"res"old. or w"en t"e le(el was # g >dl or less -
t"res"old. during t"e ICH stay& /t recei(es 1 u
leu)o reduced red cells
-
8/19/2019 Blood transfusion ICU
31/64
TRANSFUSION REQUIREMENTS IN SESHOCK ( TRISS) TRIAL
/rimary outcome$ eat" at #% days post randomis
A signican! di>erence in #or!ali!y wafo"nd
?J in t"e lower t"res"old group
?5J in t"e "ig"er t"res"old group
• +"ere were no di@erences in isc"emic e(ents! du
o (asopressor or mec"anical (entilation! and len
stay
-
8/19/2019 Blood transfusion ICU
32/64
TRANSFUSION REQUIREMENTS IN SESHOCK ( TRISS) TRIAL
• CONCLUSIONS' 2mong patients wit" septic s"mortality at #% days and rates o isc"emic e(en
use o lie support were similar among t"ose ass
to blood transusion at a "ig"er "emoglobin t"re
and t"ose assigned to blood transusion at a lowt"res"old; t"e latter group recei(ed ewer trans
-
8/19/2019 Blood transfusion ICU
33/64
• Six*#on!h #or!ali!y ra!es were higher in $a!ien!s
receiing !ransf"sion %:.6 s 66.5&
• $ro!ec!ie e>ec! of !ransf"sion in $a!ien!s wi!h na
he#oglo(in or E g+dL
• !ransf"sion was associa!ed wi!h increased #or!al
$a!ien!s wi!h nadir he#oglo(in @ g+dL
-
8/19/2019 Blood transfusion ICU
34/64
• RC+ wit" n D 5%
• 0C+ %J (s 0C+ K ?J
• no di@erence in mortality and se(ere morbidity
• number o RBCLs transused was an independentactor or clinical complications
-
8/19/2019 Blood transfusion ICU
35/64
TRANSFUSION TRIGGERS IN BLEEDPATIENTS
-
8/19/2019 Blood transfusion ICU
36/64
OUTCOMES
• primary outcome was mortality at ?5 days: 5J (in a(our o restricti(e approac"
• ot"er secondary outcomes: urt"er bleeding ass
wit" "emodynamic instability or 0gb drop M
• wit"in 6 "ours! number o RBCs transused! card
complications! transusion reactions and mean
-
8/19/2019 Blood transfusion ICU
37/64
COMMENTARY AND CRITICISMS
• /atients wit" maFor "aemorr"age or low rebleeding ris) e,cluded
• /atients "ad emergency upper 7I endoscopy wit"in a m
"ours o admission N unrealistic in most clinical setting
•3ubgroup analysis suggested beneft e,tends beyond t"portal "ypertension
• t"e liberal arm may "a(e benefted rom "emostatic
resuscitation rat"er t"an simply RBC transusion w"ic"
cause dilutional coagulopat"y
HARMFROMBLOODTRANSFUSIO
-
8/19/2019 Blood transfusion ICU
38/64
HARM FROM BLOOD TRANSFUSIO
O Concl"sion
• Blood !ransf"sion is an inde$enden! ris/ fac!or for
• #or(idi!y and #or!ali!y
• ICU ad#ission
• )os$i!al LOS
•
Increased cos!
-
8/19/2019 Blood transfusion ICU
39/64
• Se$sis Occ"rrence in Ac"!ely Ill ,a!ien!s s!
was a #"l!icen!er- o(sera!ional s!"dy follo
"$ !o 7 days
• Transf"sed $a!ien!s were sic/er and did wo("! (lood !ransf"sion was no! signican!ly
associa!ed wi!h dea!h in #"l!iaria!e analy
fac! !he o$$osi!e was fo"nd.
-
8/19/2019 Blood transfusion ICU
40/64
Massive Transfusion
-
8/19/2019 Blood transfusion ICU
41/64
MASSIVE TRANSFUSION
• 3ettings
• +rauma
• *bstetric
• 3urgical
-
8/19/2019 Blood transfusion ICU
42/64
MASSIVE TRANSFUSION
Deni!ions• Replacement o one blood (olume in a ? "our
• +ransusion o K1% units RCC in ? "ours
• +ransusion o ? or more RCC wit"in 1 "our w"eongoing need is oreseeable
• Replacement o K5%J o t"e total blood (olume "ours
-
8/19/2019 Blood transfusion ICU
43/64
“BLOODY VICIOUS CYCLE”
-
8/19/2019 Blood transfusion ICU
44/64
MASSIVE TRANSFUSION
• 8ow recognised IC is a signifcant contributio localisation micro(ascular damage
• depletion o coagulation actors
• In t"e massi(ely transused patient! platele
impaired platelet unction are t"e most consis
signifcant "aematological abnormalities& 9ac
defciency is initially confned to actors P and
-
8/19/2019 Blood transfusion ICU
45/64
SOME HELP….
• Con!ac! Pey ,ersonnel
• surgeon> obstetrician
• Blood Ban)
• 0aematologist
• Shoc/+hy$o$erf"sion is !he /ey "nderlying $ro(le#
i!• Con!rol (leeding'
• arly s"rgery %s $re*o$ s!a(ilisa!ion&
-
8/19/2019 Blood transfusion ICU
46/64
BLOOD TRANSFUSION RISKS EARLY
• TACO %!ransf"sion associa!ed circ"la!ory oerload
• TRALI %!ransf"sion rela!ed ac"!e l"ng in"ry&
• hae#oly!ic reac!ions %inco#$a!i(ili!y G ABO- Rh&
• feer
• allergy %#ild *@ ana$hylaxis&
• infec!ion' (ac!erial con!a#ina!ion
• air e#(olis#
• hy$o!her#ia
-
8/19/2019 Blood transfusion ICU
47/64
BLOOD TRANSFUSION RISKS LATE
• iral infec!ion' he$a!i!is B %V6 in 57-777&- )I0 %6 in a #illio
• (ac!erial infec!ion' Tre$one#a $allid"#- Sal#onella- Wersinia
,se"do#onas- S!a$hylococc"s s$$
• $arasi!ic infec!ion' #alaria %6 in a #illion&- !oxo$las#osis- $
• X0)D %graf! ers"s hos! disease&
• i##"ne sensi!isa!ion
• TRI4 %!ransf"sion*rela!ed i##"no#od"la!ion&Y leading !o inc
infec!ion- !"#o"r
• rec"rrence- ac!ia!ion of la!en! iral infec!ions- rec"rren! #i
TRALI
-
8/19/2019 Blood transfusion ICU
48/64
TRALI
TRALI
-
8/19/2019 Blood transfusion ICU
49/64
TRALI
• hy$oxia and (ila!eral $"l#onary ede#a occ"rring d"ring or w
a !ransf"sion in !he a(sence of o!her ca"ses s"ch as cardiac f
in!raasc"lar ol"#e oerload• incidence is 6 in -777 U of $las#a con!aining $rod"c!s %FF,- $
or whole (lood&
• Theories
• %6& donor an!i*gran"locy!ic an!i(odies called le"/oaggl"!inins
!arge! reci$ien! le"cocy!e an!igens on ne"!ro$hils se?"es!erel"ngs- res"l!ing in an i##"ne reac!ion
• %:& 3(iological res$onse #odiers9 %BR4s& s"ch as cy!o/ines a
(iologically ac!ie li$ids %e.g. in aged cell"lar co#$onen!s& ca"
#edia!ed res$onse
-
8/19/2019 Blood transfusion ICU
50/64
Z MANAGEMENT OF TRALI
• stop transusion• respiratory support -may reQuire 8IP or intubation.
• lung protecti(e (entilation i intubated
• "aemodynamic support i needed e&g& noradrenaline
• supporti(e care and monitoring
• no e(idence or steroids
• inorm blood ban) and "aematology
-
8/19/2019 Blood transfusion ICU
51/64
Z PROGNOSIS OF TRALI
• most reco(er wit"in ?=$#6 "ours• radiological c"anges oten last days
• mortality 5J
/RP8+I*8 o +R2I
• limit transusion o blood products
• a(oid donations -especially 99/. rom multiparous wome
TRANSFUSION OF OTHER BLOOD
-
8/19/2019 Blood transfusion ICU
52/64
S USO O O OOPRODUCTS
•Transf"sion of $la!ele!s
[ ,ro$hylaxis'
S E 1% wit"out associated ris) or E % wit" additional ris) actors
S eep K 5% in patients undergoing surgery or in(asi(e procedures
S E 5% in massi(e "aemorr"age and E 1%% in di@use micro(ascular
T No! a$$ro$ria!e if'S +"rombocytopenia is due to immune mediated destruction
S In ++/ and 0H3 e,cept i continuous bleeding
S In uncomplicated cardiac bypass surgery
-
8/19/2019 Blood transfusion ICU
53/64
TRANSFUSION OF OTHER BLOODPRODUCTS
• Transf"sion of Fresh froHen $las#a
• 99/ "as an I8R o U1&6 $K cannot lower below I8R 1&
• 99/ must be ABO co#$a!i(le
• 1%$% cc>)g -?$6 units in adults. will increase actors by U%J
• 99/ contains all coagulation actors in normal concentrations&
• R" actor need not be considered
• t"ere are no (iable leu)ocytes so plasma does not carry a ris) o C
transmission or 7P0
TRANSFUSION OF OTHER BLOOD PROD
-
8/19/2019 Blood transfusion ICU
54/64
• Indica!ions of Fresh froHen $las#a
• doc"#en!ed coag"la!ion fac!or deciencies and ac!ie (lee
who are a(o"! !o "ndergo an inasie $roced"re.
• Deciencies #ay (e congeni!al or ac?"ired secondary !o li
disease- warfarin an!icoag"la!ion-DIC.
• Reco#(inan! or Fac!or 0III concen!ra!es sho"ld (e "sed !o r
Fac!or 0III.
• Reersal of warfarin an!icoag"la!ion wi!h $las#a is indica!e
signican! (leeding or ris/ is $resen!.
• Ra$id reersal for life !hrea!ening (leeding #ay (e achiee
reco#(inan! Fac!or 0IIa %Noo5\&
FACTORVIIA
-
8/19/2019 Blood transfusion ICU
55/64
FACTOR VIIA
• reco#(inan! $ro!ein• 4C)ANIS4 OF ACTION Q !iss"e fac!or ] 0IIa ]
$la!ele!s *@ $la!ele! aggrega!ion
• Q $rod"c!ion of $la!ele!*(rin #a!rix Q hae#os
• "sed in #assie !ransf"sion senario^s !o a!!e#$! con!rol in!rac!a(le hae#orrhage
• ex$ensie
• need $la!ele!s for rF0IIa !o (e e>ec!ie
EVIDENCEOFFACTORVIIA
-
8/19/2019 Blood transfusion ICU
56/64
EVIDENCE OF FACTOR VIIA
• initially de(eloped or "aemop"ilia• encouraging case reports rom use in trauma
• may a(oid problems wit" ongoing transusion W disease
transmission! acute lung inFury! +R2I! "ypot"ermia! aci
disturbance! (olume o(erload
• probable publication bias $K tendency to publis" cases
"as produced successul results
• massi(e transusion and trauma $K o@ licence use
-
8/19/2019 Blood transfusion ICU
57/64
•
4"l!icen!re RCT• n E
-
8/19/2019 Blood transfusion ICU
58/64
TYPES OF RBC PRODUCTS
'0* B** : RBCplateletsplasma proteins
$ indicated in "emorr"age X anemia
$ autologous donation prior to surgery
/2C RBCL3 : %%ml o RBCL3 preser(ati(es
$ eac" bag "as 0ct o 6%J X appro,
%% mg elemental iron&
72VV2 IRR2I2+ : destruction o donor +$lym&
or 7P0 pre(ention in immunocom&!
stem cell recepient&
- CVP antibody neg : used in transplant X pregnancy-"
-
8/19/2019 Blood transfusion ICU
59/64
CVP complications.
- eu)ocyte depleted : in ebrile reactions!to a(oid leucimmuniYation in "ema tological malignancy&
- 'as"ed RBCL3 : was"ed wit" 83 to remo(e donor ser
$used in Ig2 de X t"ose at "ig" ris)anap"yla,is!
$ in /80 pt - to deplete complemen
-
8/19/2019 Blood transfusion ICU
60/64
GRANULOCYTES
-Used in $rofo"nd J $rolonged ne"!ro$enia secon#arrow s"$$ression.
- Collec!ed (y ' 6& l!ra!ion le"/a$heresis
- :& con!in"o"s Mow cen!rif"ga!io
- Usef"lness is do"(!ed d+! '
6& ina(ili!y !o collec! s"cien! cells
:& early deelo$#en! of allo*i##"niH.
-
8/19/2019 Blood transfusion ICU
61/64
CRYOPRECIPITATE
contains fbrinogen!($'actor!PIII!ZIII!fbronectin!
- conc& o fbrinogen in cryo K 1% times o 99/Indications : 1. IC! along wit" 99/
. isolated"ypofbrinogenemia-E1%%$
mg>dl.
. platelet dysunction notresponding
to 2P/>dialysis&
ose : U one bag > 1% )g body weig"t
28+I$+0R*VBI8 C*8C8+R2+3 :
-
8/19/2019 Blood transfusion ICU
62/64
$ used in anti$t"rombin defciency
t"rombop"ilia
72VV2$7*BHI83 :
$ in "ypogammaglobulinemia!
$ in "ig" doses in autoimmune diseases
- 3/CI9IC IVVH8*7*BHI83 :
$ or prop"yla,is in r"esus!tetanus!Yoster
0ep B&
CRASH-2 TRIAL : EFFECT OF TRANEXAMIC AC
-
8/19/2019 Blood transfusion ICU
63/64
DEATH,VASC. OCCLUSIVE EVENTS & BLOO TRANSFUSION IN TRAUMA PATIENTS.
- arly administration o trane,amic acid!an antifbrinolytic agent!to
patients!wit" or at ris) o signifcant bleeding reduces t"e ris) o de
"emorr"age wit" no apparent increase in atal or non$atal (ascula
e(ents&-wit" no stastically signifcant di@erence in transusion reQ
- DOSAX : 1gm loading dose in 1% mins >b inusion o 1gm o(er =
Klance!* :767
-
8/19/2019 Blood transfusion ICU
64/64