Red blood cell transfusions and the risk of acute respiratory distress syndrome among the critically ill: a cohort study

School of Public Health and Health Sciences, University of Massachusetts, Amherst, P,O, Box 303, Goshen, MA 01032, USA.
Critical care (London, England) 06/2007; 11(3):R63. DOI: 10.1186/cc5934
Source: PubMed

ABSTRACT Recent data indicate that transfusion of packed red blood cells (pRBCs) may increase the risk for the development of acute respiratory distress syndrome (ARDS) in critically ill patients. Uncertainty remains regarding the strength of this relationship.
To quantify the association between transfusions and intensive care unit (ICU)-onset ARDS, we performed a cohort study within Crit, a multicenter, prospective, observational study of transfusion practice in the ICU which enrolled 4,892 critically ill patients in 284 ICUs in the United States. Diagnostic criteria for ARDS were prospectively defined, and we focused on subjects without ARDS at admission. The development of ARDS in the ICU served as the primary endpoint.
Among the 4,730 patients without ARDS at admission, 246 (5.2%) developed ARDS in the ICU. At baseline, ARDS cases were younger, more likely to be in a surgical ICU, and more likely to be admitted with pneumonia or sepsis than controls without ARDS. Cases also were more likely to have a serum creatinine of greater than 2.0 mg/dl (23% versus 18%) and a serum albumin of less than or equal to 2.3 g/dl (54% versus 30%) and were more severely ill upon ICU admission as measured by either the APACHE II (Acute Physiology and Chronic Health Evaluation II) or SOFA (Sequential Organ Failure Assessment) score (p < 0.05 for all). Sixty-seven percent and 42% of cases and controls, respectively, had exposure to pRBC transfusions (p < 0.05), and the unadjusted odds ratio (OR) of developing ARDS in transfused patients was 2.74 (95% confidence interval [CI], 2.09 to 3.59; p < 0.0001) compared to those never transfused. After age, baseline severity of illness, admitting diagnosis, and process-of-care factors were adjusted for, the independent relationship between pRBC transfusions and ICU-onset ARDS remained significant (adjusted OR, 2.80; 95% CI, 1.90 to 4.12; p < 0.0001).
Development of ARDS after ICU admission is common, occurring in approximately 5% of critically ill patients. Transfusion of pRBCs is independently associated with the development of ARDS in the ICU.

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    • "Thirdly, recent studies have strengthened the association between transfusions and adverse events. These include an independent association with the development of the acute respiratory distress syndrome [5], an increase in the incidence of nosocomial infections [6], as well as increased length of ICU stay and mortality [7] [8]. Finally, RBCs are a limited and expensive resource. "
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    ABSTRACT: The aim of the study was to document transfusion practices in a cross section of general intensive care units (ICUs) in Israel and to determine whether current guidelines are being applied. This prospective study was performed in 5 general ICUs in Israel over a 3-month period. Red cell transfusion data collected on consecutive patients included the trigger, units transfused per transfusion event, and indications, categorized either to treat a specified condition for which transfusions may be beneficial (acute hemorrhage, acute myocardial ischemia, or severe sepsis) or to treat a low hemoglobin concentration. Of the 238 patients studied, 50% received at least one red blood cell transfusion. The main indication for transfusion (43.7%, or 162/368 U transfused) was to treat a low hemoglobin concentration, in the absence of one of the specified conditions. Total red cell use was 3.0 ± 2.9 U per admission, and patients received a mean of 1.2 ± 0.4 U per transfusion event. The transfusion trigger for the whole group was 7.9 ± 1.1 g/dL. This did not differ significantly between the indications apart from a significantly higher trigger for patients with acute myocardial ischemia (8.8 ± 0.9 g/dL). In addition, patients with a history of heart disease had a higher trigger irrespective of the primary indication for transfusion and received significantly more units per transfusion event. Patients receiving a transfusion had significantly longer ICU stay and hospital mortality. Our study showed that evidence-practice gaps continue to exist, and it appears that physician behavior is mainly driven by the absolute level of hemoglobin. Educational interventions focused on these factors are required to limit the widespread and often unnecessary use of this scarce and potentially harmful resource.
    Journal of critical care 04/2010; 26(1):106.e1-6. DOI:10.1016/j.jcrc.2010.03.010 · 2.19 Impact Factor
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    • "The incidence of TRALI in critically ill patients is estimated to be 8%, the transfusion incidence approaches 40%, and thus approximately 3% of all ICU admissions will develop TRALI, indicating that critically ill patients are the most vulnerable patient population (Gajic et al, 2007a). Because ALI is so common in ICUs it is rarely recognized as TRALI despite multiple studies showing an independent, dose-dependent increase in ALI with transfused blood products when controlling for severity of illness and other known ALI risk factors (Gajic et al, 2004; Croce et al, 2005; Gong et al, 2005; Silverboard et al, 2005; Khan et al, 2007; Zilberberg et al, 2007; Chaiwat et al, 2009). In light of these studies and in response to the limitations of the consensus conference definition regarding timing of ALI in our critically ill patients, a 2008 review suggested expanding the definition of TRALI (Marik & Corwin, 2008). "
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    ABSTRACT: HINTERGRUND: An unserem Klinikum wurde im Rahmen eines Chefarztwechsels am 1. Januar 2003 das perioperative Flüssigkeitsmanagement umgestellt. Eine intraoperative Hypotension sollte im Zeitraum 2003 statt mit einem Vasopressor primär mit der Infusion eines Flüssigkeitsbolus behandelt werden. ZIELSETZUNG: Die Folgen einer großzügigeren intraoperativen Flüssigkeitszufuhr sollten erfasst und statistisch ausgewertet werden. METHODE: In einer retrospektiven Studie wurden die Häufigkeit postoperativer Komplikationen bei insgesamt 477 Patienten verglichen, die sich in den Jahren 2002 und 2003 einer größeren Resektion im Gastrointestinaltrakt unterziehen mussten und die postoperativ intensivmedizinisch betreut wurden. ERGEBNISSE: Die mittlere intraoperative Infusionsmenge war 2003 für kristalloide Lösungen im Mittel um ca. 1200 ml, für kolloidale Lösungen im Mittel um ca. 180 ml höher als 2002. Der Anteil der Patienten, die einen Vasopressor erhielten war 2003 niedriger (22% vs. 32%). Bei gleicher chirurgischer Technik der Anastomosennaht war 2003 die Rate an Anastomoseninsuffizienzen niedriger als 2002 (2,2% vs. 6,3%). Für die Häufigkeit einer Anastomoseninsuffizienz bestehen statistische Zusammenhänge mit dem Behandlungszeitraum als Surrogat für das Flüssigkeitsmanagement, dem intraoperativen Blutverlust und einem hohen ASA-Score. Die Rate an kardialen Komplikationen, Pneumonien, zerebrovaskulären Ereignissen und Wundheilungsstörungen änderte sich nicht. Risikofaktoren für kardiale Komplikationen waren der ASA-Score und ein Diabetes mellitus, Risikofaktoren für eine postoperative Pneumonie ein hoher ASA-Score, eine lange OP-Dauer und eine Leberzirrhose. Risikofaktoren für eine postoperative Beatmung waren eine lange OP-Dauer und der ASA-Score des Patienten. Das Risiko für den Patienten postoperativ hämodialysiert zu werden hing allein davon ab, ob eine chronische Niereninsuffizienz vorbestand. FAZIT: Die Umsetzung des großzügigen perioperativen Flüssigkeitsregimes war mit einer Reduktion von Anastomoseninsuffizienzen assoziiert. Für alle weiteren schwerwiegenden Komplikationen wurden keine Unterschiede entdeckt.
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