blood transfusion icu

8/19/2019 Blood transfusion ICU

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BLOOD TRANSFUSION IN IC

By

Dr.Sherif Badrawy

Critical Care Registrar


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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


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EVOLUTION OF TRANSFUSION


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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


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BLOOD TRANSFUSION


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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&.


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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


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Ane#ia 0S (lood !ransf"sioin ICU


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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


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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


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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,


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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


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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.


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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/&


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DOES OLD BLOOD IMPROVEOXYGEN CONTENT?


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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


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TRANSFUSION TRIGGER

2cceptable "emoglobin concentration2cceptable "emoglobin concentration

Ris/ of (lood !ransf"sion Ris/ of low he#oglo(i


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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+


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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!


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TRANSFUSION TRIGGERS IN NON-BLEEPATIENTS


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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


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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


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• 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


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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.


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A CANADIAN PAEDIATRIC STUDY

MIRRORED THE FINDINGS OF TRICC, B WITH MODS AS THE PRIMARY OUTCOM


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CURRENT GUIDELINES ON TRANSFUSISEPSIS

G 4ain!ain a hae#a!ocri! of @


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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


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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


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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


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• 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


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• 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


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TRANSFUSION TRIGGERS IN BLEEDPATIENTS


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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


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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


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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!


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• 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.


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Massive Transfusion


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MASSIVE TRANSFUSION

• 3ettings

• +rauma

• *bstetric

• 3urgical


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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


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“BLOODY VICIOUS CYCLE”


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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


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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&


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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


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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


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TRALI

TRALI


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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


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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


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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


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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


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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


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• 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


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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


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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


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•

4"l!icen!re RCT• n E


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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-"


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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


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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.


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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 :


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$ 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


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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


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blood transfusion icu

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