Clinical consequences of anemia and red cell transfusion in the critically ill.
ABSTRACT Despite the frequent use of red cell transfusions, only one large randomized trial has examined red cell administration perioperative and in the critical care setting. However, the TRICC Trial does not provide sufficient evidence to determine optimal transfusion practice in postoperative care, in critically ill children, or in patients with a myocardial infarction or acute coronary syndromes. In addition, most transfusion practice guidelines published before the completion of the TRICC Trial are now dated and need to have expert opinion informed by solid evidence in diverse clinical settings. In the next several years,several randomized trials will provide additional evidence in support of bedside decision-making. For example, two transfusion studies will be evaluating transfusion triggers, including one in premature infants and the other in critically ill children. At this juncture, high-quality clinical evidence is not yet available for many decisions related to red cell transfusions. We anticipate that risks and benefits of red cells and alternatives will be elucidated in the coming years.
- SourceAvailable from: Beata Marie Redublo Quinto[Show abstract] [Hide abstract]
ABSTRACT: To investigate the relation between the need for red blood cell transfusion and serum levels of soluble-Fas, erythropoietin and inflammatory cytokines in critically ill patients with and without acute kidney injury. We studied critically ill patients with acute kidney injury (n=30) and without acute kidney injury (n=13), end-stage renal disease patients on hemodialysis (n=25) and healthy subjects (n=21). Serum levels of soluble-Fas, erythropoietin, interleukin 6, interleukin 10, iron status, hemoglobin and hematocrit concentration were analyzed in all groups. The association between these variables in critically ill patients was investigated. Critically ill patients (acute kidney injury and non-acute kidney injury patients) had higher serum levels of erythropoietin than the other groups. Hemoglobin concentration was lower in the acute kidney injury patients than in other groups. Serum soluble-Fas levels were higher in acute kidney injury and end-stage renal disease patients. Critically ill patients requiring red blood cell transfusions had higher serum levels of soluble-Fas (5,906±2,047 and 1,920±1,060; p<0.001), interleukin 6 (518±537 and 255+502; p=0.02) and interleukin 10 (35.8±30.7 and 18.5±10.9; p=0.02), better iron status and higher mortality rates in the first 28 days in intensive care unit. Serum soluble-Fas levels were independently associated with the number of red blood cell units transfused (p=0.02). Serum soluble-Fas behaved as an independent predictor of the need for red blood cell transfusion in critically ill patients (p=0.01). Serum soluble-Fas level is an independent predictor of the need for red blood cell transfusion in critically ill patients with or without acute kidney injury. Further studies are warranted to reconfirm this finding.Einstein (Sao Paulo, Brazil). 12/2013; 11(4):472-478.
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ABSTRACT: There is accumulating evidence that restricting blood transfusions improves outcomes, with newer trials showing greater benefit from more restrictive strategies. We systematically evaluated the impact of various transfusion triggers on clinical outcomes. The Medline database was searched from 1966 to April 2013 to find randomized trials evaluating a restrictive hemoglobin transfusion trigger of <7 g/dL, compared with a more liberal trigger. Two investigators independently extracted data from the trials. Outcomes evaluated included mortality, acute coronary syndrome, pulmonary edema, infections, rebleeding, number of patients transfused, and units of blood transfused per patient. Extracted data also included information on study setting, design, participant characteristics, and risk for bias of the included trials. A secondary analysis evaluated trials using less restrictive transfusion triggers, and a systematic review of observational studies evaluated more restrictive triggers. In the primary analysis, pooled results from 3 trials with 2364 participants showed that a restrictive hemoglobin transfusion trigger of <7 g/dL resulted in reduced in-hospital mortality (risk ratio [RR], 0.74; confidence interval [CI], 0.60-0.92), total mortality (RR, 0.80; CI, 0.65-0.98), rebleeding (RR, 0.64; CI, 0.45-0.90), acute coronary syndrome (RR, 0.44; CI, 0.22-0.89), pulmonary edema (RR, 0.48; CI, 0.33-0.72), and bacterial infections (RR, 0.86; CI, 0.73-1.00), compared with a more liberal strategy. The number needed to treat with a restrictive strategy to prevent 1 death was 33. Pooled data from randomized trials with less restrictive transfusion strategies showed no significant effect on outcomes. In patients with critical illness or bleed, restricting blood transfusions by using a hemoglobin trigger of <7 g/dL significantly reduces cardiac events, rebleeding, bacterial infections, and total mortality. A less restrictive transfusion strategy was not effective.The American journal of medicine 10/2013; · 5.30 Impact Factor
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ABSTRACT: Background Evidence-based medicine incorporates critical appraisal of the literature, individual clinical expertise, patient values, clinical circumstances and societies’ expectations into medical decision-making. This approach is increasingly utilized to formulate individual transfusion decisions and to set national transfusion policies.Aims To describe the process of evidence-based decision-making and its application to transfusion medicine through the analysis of a test case.Methods Critical appraisal of the literature and evidence-based medicine techniques are described and applied to the issue of the duration of red cell storage and the incidence of complications after transfusion, as raised by the report of Koch et al. (N Engl J Med 358:12, 1229–39). This report compared the outcomes of patients transfused with blood after ≤ 14 or > 14 days of storage during and after cardiac surgery.Results The methods and logic of literature appraisal and evidence-based medicine are reviewed, and applied to the paper by Koch et al (N Engl J Med 358:12, 1229–39). This report describes a case-controlled, retrospective observational study with Level 3-4 evidence to support the use of younger blood (≤14 days old) in cardiac surgery patients. Issues are raised concerning the equivalence of the prestudy prognosis of the test and control groups and the use of non-risk adjusted statistics in comparing data. After risk adjustment, the association of an older blood transfusion with a poorly defined composite index of adverse outcomes has only marginal significance (OR: 1·16, 95% CI: 1·01–1·33). Reports of systematic review of the literature reveals 19 publications: 14 studies are retrospective observational studies and many suggest an association of older blood with various adverse outcomes. Five prospective studies fail to show an adverse relationship, however, these are small and underpowered. Society values emphasize the availability of blood products, which at this time requires inventory management practices that prevent the transfusion of blood < 14 days storage on a routine basis for all patients.Conclusions Evidence-based decision-making provides a formal process to evaluate the information supporting individual clinical and national policy decisions in transfusion medicine. Application to the specific problem of whether to limit the use of older blood suggests that the level of available evidence does not yet justify changing clinical practice. Adequately powered randomized controlled trials are necessary to determine the relative safety of older blood compared with younger blood in transfusion practice.ISBT Science Series 11/2009; 4(n2).