Anemia and blood transfusion in a surgical intensive care unit

Department of Anesthesiology and Intensive Care, Friedrich Schiller University Hospital, Erlanger Allee 103, Jena 07743, Germany.
Critical care (London, England) (Impact Factor: 4.48). 05/2010; 14(3):R92. DOI: 10.1186/cc9026
Source: PubMed


Studies in intensive care unit (ICU) patients have suggested that anemia and blood transfusions can influence outcomes, but these effects have not been widely investigated specifically in surgical ICU patients.
We retrospectively analyzed the prospectively collected data from all adult patients (>18 years old) admitted to a 50-bed surgical ICU between 1st March 2004 and 30th July 2006.
Of the 5925 patients admitted during the study period, 1833 (30.9%) received a blood transfusion in the ICU. Hemoglobin concentrations were < 9 g/dl on at least one occasion in 57.6% of patients. Lower hemoglobin concentrations were associated with a higher Simplified Acute Physiology Score II and Sequential Organ Failure Assessment score, greater mortality rates, and longer ICU and hospital lengths of stay. Transfused patients had higher ICU (12.5 vs. 3.2%) and hospital (18.3 vs. 6.5%) mortality rates (both p < 0.001) than non-transfused patients. However, ICU and in-hospital mortality rates were similar among transfused and non-transfused matched pairs according to a propensity score (n = 1184 pairs), and after adjustment for possible confounders in a multivariable analysis, higher hemoglobin concentrations (RR 0.97[0.95-0.98], per 1 g/dl, p < 0.001) and blood transfusions (RR 0.96[0.92-0.99], p = 0.031) were independently associated with a lower risk of in-hospital death, especially in patients aged from 66 to 80 years, in patients admitted to the ICU after non-cardiovascular surgery, in patients with higher severity scores, and in patients with severe sepsis.
In this group of surgical ICU patients, anemia was common and was associated with higher morbidity and mortality. Higher hemoglobin concentrations and receipt of a blood transfusion were independently associated with a lower risk of in-hospital death. Randomized control studies are warranted to confirm the potential benefit of blood transfusions in these subpopulations.

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Available from: Utz Settmacher, Oct 13, 2015
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    • "during pregnancy (Hungary) [129] 24.4% in 11 maternity units (UK) [130] 39.6% from 14 cities (China) [131] 43.7% and 89.8% in registries from the 1970s and 2000s, respectively (Kola, Russia) [132] Hb b10 and b8 g/dL seen in 22% and 3% of deliveries between 1993 and 2008 in an obstetrics department (Germany) [133] Increasing prevalence from first to third trimesters [131] CKD 32.3% in stage 3-5 CKD (anemia defined as Hb b11 g/dL or documented treatment of ESAs) [135] Increased risk of kidney disease progression, hospitalization, and death [135] [136] [137] 41.3% in stage 3-5 CKD (defined as Hb 11-13.5 g/dL in men and Hb 11-12 g/dL in women) [136] 45% in predialysis cases (defined as Hb ≤11 g/dL) [137] 56.9% of nursing home residents with CKD [138] Respiratory disease Increased risk of hospitalization, readmission, and death [85] [87] [140] [142] [143] 7.5%-34% in COPD [139] 9.8%-33% in cases of acute exacerbation of COPD [85] [87] [140] 11.5% in restrictive disease [141] 13.3% in chronic respiratory failure [141] 14.7% in obstructive disease [141] 18% in first-time admissions to ICU requiring mechanical ventilation [140] 33.9% at admission and 62.1% during stay for community-acquired pneumonia [142] Cerebrovascular disease 6.4%-19% [144] [145] [146] Increased risk of short-and long-term mortality and poor functional outcomes [145] [146] [148] IDA in 6.4%, iron deficiency without anemia in 2.1%, and anemia of other etiologies in 6.4% in patients aged N65 years old admitted with TIA or first ischemic stroke [147] Ischemic heart disease 9.1%-38% overall [149] [150] [151] [152] [153] [154] [155] [156] [157] Increased risk of cardiac events (including heart failure and recurrent ischemia); complications; poor health status; and in-hospital, short-and longterm death [149-157,159-164] 18.2% of patients aged N80 y admitted for acute MI [158] 20%-27.4% at admission [159-161] 34.7% at discharge and 19.5% persistent during follow-up [162] 40% at seventh week after admission [159] 46.8% new-onset during admission [161] Hospital-acquired anemia seen at discharge in 45.4% of patients who were admitted with MI and normal Hb [163] Heart failure (hospitalized) 10% in chronic heart failure at age ≥70 y [165] Poor outcome, hospitalization, readmission, and mortality (cardiovascular as well as all cause) [165-177] 29%-57% [166-170] Cardiac surgery 28%-54.4% [178-180] Increased risk of receiving blood transfusions [179,180], major morbidity, acute kidney injury, mortality, prolonged hospital stay [178] [179] [180] [181] [183], and cardiovascular events [182] 41.9% of 80-to 90-year-old patients undergoing CPB [181] 44% had sustained postoperative anemia for N50 d [182] Organ transplant 42% [5] and 53.7% [184] during posttransplant follow-up. Poor graft outcome and death [101] [184] 89.4% at time of transplantation, 49.2% at 1 y, and 44.3% at 2 years after transplantation [185] Critically ill 18.7% had Hb b7 g/dL and 29.5% had Hb levels of 7-9 g/dL [186] Increased risk of allogeneic blood transfusion and in-hospital death [186] Incidence of 46.6% and prevalence of 68% in cancer patients admitted to ICU [187] 98/100 consecutive patients admitted to ICU [188] Cancer 18% of women with stage 0-II breast cancer at diagnosis and 21% during radiotherapy [189] Worse prognosis in 2 reports [192] [193], but not in another study [189] 34.8% with solid tumors at diagnosis and 38.9% during radiotherapy [190] 55.7% of adult patients during systemic chemotherapy or radiotherapy [6] 78.3% of cases undergoing gastrectomy for gastric cancer [191] Orthopedics 16.3% of total hip and knee arthroplasty [194] Increased risk of allogeneic blood transfusion [195], discharge to nursing home and readmission [196], but not increased mortality [196] [197] or diminished quality of life [194] [198] 24%-44% in preoperative and 51%-87% in postoperative period [195] 42.5% in hip fracture surgeries [196] Abbreviations: CPB, cardiopulmonary bypass; ENSANUT, Encuesta Nacional de Salud y Nutricion (Mexican National Health and Nutrition Survey); ICU, intensive care unit; KNHANES, Korean National Health & Nutrition Examination Survey; MI, myocardial infarction; TIA, transient ischemic attack. "
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    ABSTRACT: Despite its high prevalence, anemia often does not receive proper clinical attention and its detection, evaluation, and management of iron deficiency anemia and iron-restricted erythropoiesis can possibly be an unmet medical need. A multidisciplinary panel of clinicians with expertise in anemia management convened and reviewed recent published data on prevalence, etiology, and health implications of anemia as well as current therapeutic options and available guidelines on management of anemia across various patient populations, and made recommendations on the detection, diagnostic approach and management of anemia. The available evidence confirms that the prevalence of anemia is high across all populations, especially in hospitalized patients. Anemia is associated with worse clinical outcomes including longer length of hospital stay, diminished quality of life and increased risk of morbidity and mortality, and it is a modifiable risk factor of allogeneic blood transfusion with its own inherent risks. Iron deficiency is usually present in anemic patients. An algorithm for detection and management of anemia was discussed which incorporated iron study (with primary emphasis on transferrin saturation), serum creatinine and GFR and vitamin B12 and folic acid measurements. Management strategies included iron therapy (oral or intravenous), erythropoiesis stimulating agents and referral as needed.
    Transfusion medicine reviews 07/2014; 28(3). DOI:10.1016/j.tmrv.2014.05.001 · 2.92 Impact Factor
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    • "Moreover when patients were matched by propensity scoring in the SOAP cohort, RBC transfusion was associated with improved outcome [14]. These results are supported by data from a single, surgical ICU [15] and a cohort of patients with community-acquired severe sepsis from multiple ICUs [10]. It may be questioned if any of the statistical models used are valid to adjust for the obvious differences between transfused and non-transfused in cohorts of ICU patients. "
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    ABSTRACT: Treating anaemia with red blood cell (RBC) transfusion is frequent, but controversial, in patients with septic shock. Therefore we assessed characteristics and outcome associated with RBC transfusion in this group of high risk patients. We did a prospective cohort study at 7 general intensive care units (ICUs) including all adult patients with septic shock in a 5-month period. Ninety-five of the 213 included patients (45%) received median 3 (interquartile range 2-5) RBC units during shock. The median pre-transfusion haemoglobin level was 8.1 (7.4-8.9) g/dl and independent of shock day and bleeding. Patients with cardiovascular disease were transfused at higher haemoglobin levels. Transfused patients had higher Simplified Acute Physiology Score (SAPS) II (56 (45-69) vs. 48 (37-61), p = 0.0005), more bleeding episodes, lower haemoglobin levels days 1 to 5, higher Sepsis-related Organ Failure Assessment (SOFA) scores (days 1 and 5), more days in shock (5 (3-10) vs. 2 (2-4), p = 0.0001), more days in ICU (10 (4-19) vs. 4 (2-8), p = 0.0001) and higher 90-day mortality (66 vs. 43%, p = 0.001). The latter association was lost after adjustment for admission category and SAPS II and SOFA-score on day 1. The decision to transfuse patients with septic shock was likely affected by disease severity and bleeding, but haemoglobin level was the only measure that consistently differed between transfused and non-transfused patients.
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    • "Dr Sakr and colleagues [1] report a single centre cohort study evaluating the relationship between anaemia, blood transfusions and mortality in patients admitted to a surgical ICU. The authors report some findings that are not new or surprising, namely that anaemia is associated with adverse patient outcomes. "
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    ABSTRACT: Current evidence suggests that critically ill patients tolerate anaemia well and that blood transfusions may increase the risk of adverse outcomes. Dr Sakr and colleagues present a contradictory analysis of a surgical ICU cohort, finding an association between blood transfusions and lower hospital mortality after adjustment for a range of potential confounders. Analyses of this kind are interesting and provocative, but are limited by residual confounding and bias by indication. The data emphasise the need for additional high quality trials of transfusion practice in critical care.
    Critical care (London, England) 06/2010; 14(3):170. DOI:10.1186/cc9043 · 4.48 Impact Factor
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