Critical Care Focus 8: Blood and Blood Transfusion


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RBCs were administered to Overall, patients who received blood products were older and had longer lengths of stay as compared to patients who did not receive blood products. A higher proportion of patients who did not receive blood products had lower Charlson comorbidity scores indicating low burden of disease , compared to patients who received blood products Table 1. Of patients who received RBCs, plasma or platelets, The overall ICU mortality rate was The in-hospital mortality rate ranged from a low of In comparison, of all blood products administered to patients hospitalized under any service during the study period, Of all blood products administered in the ICU, Figs 2 to 4 illustrate the percentage of patients in the ICU who received RBCs, plasma and platelets, the mean number of units received, and the percentage of the total volume of each blood product administered in the ICU on each of the 7 days leading up to discharge or death.

The vertical bars in each figure represent the observed values, and the lines represent the predicted values based on the regression models. In patients who died, the proportion transfused RBCs or plasma significantly increased in the days leading up to death RBCs: 1. There was no significant change in the proportion of patients transfused platelets in the days leading up to death platelets: 1.

Of the patients who received RBCs within 24 hours of death, 37 8. These patients received a mean SD of No patient who received RBCs within 24 hours of being discharged alive underwent a massive transfusion. There was a significant decrease in the mean number of plasma units transfused leading up to discharge plasma: 0.

In patients who died, the mean number of blood product units transfused per patient significantly increased leading up to death, with the largest increase observed for RBCs RBCs: 1.

Blood transfusion

In patients who died, the percentage of blood product used in the ICU prior to death significantly increased leading up to the day of death RBCs: 1. We also observed a significant reduction over time in the proportion transfused plasma in patients who died and in those who were discharged alive died in hospital: 0. There was no significant change over time in platelet use died in hospital: 1.

In this study, we described patterns of transfusion in patients admitted to the ICU, and further explored transfusion patterns in patients who died in hospital. Of all blood products used in the ICU over the study period In patients who died, the intensity of transfusion increased in the days preceding death. Of all of the blood products, red blood cells were administered to the largest number of patients. Our finding that a large proportion of patients who receive blood products subsequently die in hospital was somewhat expected given the higher burden of illness in patients who receive transfusions [ 19 ].

In addition the intensity of transfusion in the days preceding death identifies a proportion of critical care patients with a higher mortality rate. This was consistent with our observation of higher Charlson scores in patients requiring transfusion. The high proportion of blood products administered immediately preceding death is similar to the increased use of other resources such as critical care services that occur at the end of life [ 5 , 9 ].

However, this has not been previously described for blood products. While our analysis does not imply that transfusions near the end of life caused death, increased resource utilization near the end-of-life, in other settings, has not been shown to be associated with improved care and may result in a worse quality of death [ 20 ]. Could transfusion be also associated with a poor quality of death? There are a few limitations to this study.

Generalizability may be limited as this is a single center study in a health system where blood products are provided free of charge to hospitals. However, the large sample size of this study, and the inclusion of two hospital sites supports the validity of the results. This high acuity is supported by the advanced age median 64, IQR 51—75 , high proportion of mechanically ventilated patients In addition, using administrative data does not lend to an understanding of the necessity or indication for transfusion.

As it has been shown that diagnoses coded in the ICU have limited validity [ 22 ], we were cautious to not rely on diagnosis codes to identify indications for transfusion. However, given the fact that the Charlson score, in addition to selected administrative data have been previously shown to be as good as SAPS II, SAPS III and Apache II to predict mortality in the ICU population [ 15 ], we believe that the data reported provides clinically relevant information that could be used to estimate the mortality risk of our population.

Finally, the marked increase in the number of patients who received blood products prior to death is unlikely to be indicative of hemorrhage as massive hemorrhage occurs in a small proportion of the population [ 23 ], and only a small proportion of admissions to the critical service are secondary to hemorrhage. The most widely used blood product was red blood cells, administered to A high percentage of admissions where transfusion was administered subsequently ended in death, and many of these transfusions happened on the day prior to death.

These results should stimulate further evaluation of the benefit for transfusion in the last hours of life. Conceived and designed the experiments: NS KW. Analyzed the data: NL. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract While it is known that the use of health care resources increases at the end of life in patients admitted to the Intensive Care Unit ICU , the allocation of blood products at the end of life has not been described. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited Data Availability: The data used in this study are from a patient-level hospital database that is governed by privacy legislation in Ontario.

Introduction A considerable proportion of patients in critical care units are transfused. Indian J Anaesth ; Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion. Transfusion ; Cardiopulmonary exercise testing before and after blood transfusion: A prospective clinical study. Br J Anaesth ; Practice guidelines for perioperative blood transfusion and adjuvant therapies: An updated report by the American society of anesthesiologists task force on perioperative blood transfusion and adjuvant therapies.

Anesthesiology ; Appropriateness of perioperative blood transfusion in patients undergoing cancer surgery: A prospective single-centre study. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Inflammatory response, immunosuppression, and cancer recurrence after perioperative blood transfusions. What is really dangerous: Anaemia or transfusion?

Br J Anaesth ; Suppl 1:i First, in order to explore the early phase of septic shock, a restrictive strategy could be assessed with a RCT. Then, because of the limits of RCTs in the case of adverse events such as ischemic events, we believed that observational studies with newer statistical causal models would be less biased and could lead to more definitive conclusions about the deleterious effect of transfusion in different subgroups and for different outcomes.

Other transfusion triggers than hemoglobin should be explored. Anemia and blood transfusion in critically ill patients. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. Effects of the combination of blood transfusion and postoperative infectious complications on prognosis after surgery for colorectal cancer. Br J Surg. Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev.

Inflammatory response, immunosuppression, and cancer recurrence after perioperative blood transfusions. Br J Anaesth. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Ann Intern Med. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. Lower versus higher hemoglobin threshold for transfusion in septic shock.

Transfusion of Blood and Blood Products – Clinical Procedures for Safer Patient Care

Red blood cell transfusion during septic shock in the ICU. Acta Anaesthesiol Scand. Red blood cell transfusion in septic shock—clinical characteristics and outcome of unselected patients in a prospective, multicentre cohort. Red blood cell transfusion and outcomes in patients with acute lung injury, sepsis and shock. Crit Care. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. Meta-analysis of observational studies in epidemiology: a proposal for reporting.

When can odds ratios mislead? Higgins J. Cochrane handbook for systematic reviews of interventions version 5. Cochrane Collaboration; Wells G. Restrictive versus liberal transfusion strategies for older mechanically ventilated critically ill patients: a randomized pilot trial. Blood transfusion practice in critically ill patients: a single institutional experience. Predictors of hospital mortality for patients with severe sepsis treated with drotrecogin alfa activated. Are blood transfusions associated with greater mortality rates?


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Anemia and blood transfusion in a surgical intensive care unit. Recurrent catheter-related bloodstream infections: risk factors and outcome. Int J Infect Dis. Risk factors for the development of acute lung injury in patients with septic shock: an observational cohort study. Predictors of acute kidney injury in septic shock patients: an observational cohort study.

A randomized trial of protocol-based care for early septic shock. Goal-directed resuscitation for patients with early septic shock. Intensive Care Med. In-hospital mortality following treatment with red blood cell transfusion or inotropic therapy during early goal-directed therapy for septic shock: a retrospective propensity-adjusted analysis.

Crit Care Lond Engl. STROBE-compliant article: blood transfusions within the first 24 hours of hospitalization did not impact mortality among patients with severe sepsis. Liberal or restrictive transfusion after cardiac surgery. Transfusion requirements in surgical oncology patients: a prospective, randomized controlled trial. Anesthesiology [Internet].

Red cell distribution width and all-cause mortality in critically ill patients. Red blood cell transfusions—are we narrowing the evidence-practice gap? An observational study in 5 Israeli intensive care units. J Crit Care.

Background

Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease. Am Heart J. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. Blood transfusion in elderly patients with acute myocardial infarction. Association of blood transfusion with increased mortality in myocardial infarction: a meta-analysis and diversity-adjusted study sequential analysis. The effect of fluid loading, blood transfusion, and catecholamine infusion on oxygen delivery and consumption in patients with sepsis.

Am Rev Respir Dis. Does red blood cell transfusion result in a variate microvascular response in sepsis? Reply Crit Care Med. Variables with time-varying effects and the Cox model: some statistical concepts illustrated with a prognostic factor study in breast cancer. Competing risk regression models for epidemiologic data. Am J Epidemiol. Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. Transfusion immunomodulation—the case for leukoreduced and perhaps washed transfusions.

Blood Cells Mol Dis. Clinical outcomes following institution of the Canadian universal leukoreduction program for red blood cell transfusions. Engoren M. Does erythrocyte blood transfusion prevent acute kidney injury?

Introduction

Propensity-matched case control analysis. Association between systemic hemodynamics and septic acute kidney injury in critically ill patients: a retrospective observational study. The impact of packed red blood cell transfusion on clinical outcomes in patients with septic shock treated with early goal directed therapy. Transfusion of red blood cells is associated with improved central venous oxygen saturation but not mortality in septic shock patients. J Clin Med Res. Implementation of early goal-directed therapy and the surviving sepsis campaign resuscitation bundle in Asia. Download references.

CD and JT conceived and designed the study, contributed to the analysis and interpretation of data as well as drafting the manuscript, and gave their final approval of the version to be published. All authors read and approved the final manuscript. Reprints and Permissions.

Search all SpringerOpen articles Search. Abstract Red blood cell transfusion RBCT threshold in patients with sepsis remains a matter of controversy. Background Anemia is frequent in intensive care medicine and is associated with increased morbidity and worsened outcome [ 1 ]. Methodology Data sources and searches This review was systematic and comprised two subcategories: 1 RCTs dealing with the comparison of two transfusion thresholds; and 2 observational studies on the impact of transfusion on the outcome among ICU patients with sepsis.

Study selection Study selection was conducted through independent review. Meta-analysis Effects estimates were primarily presented as adjusted odds ratios ORs.

Critical Care Focus 8: Blood and Blood Transfusion Critical Care Focus 8: Blood and Blood Transfusion
Critical Care Focus 8: Blood and Blood Transfusion Critical Care Focus 8: Blood and Blood Transfusion
Critical Care Focus 8: Blood and Blood Transfusion Critical Care Focus 8: Blood and Blood Transfusion
Critical Care Focus 8: Blood and Blood Transfusion Critical Care Focus 8: Blood and Blood Transfusion
Critical Care Focus 8: Blood and Blood Transfusion Critical Care Focus 8: Blood and Blood Transfusion
Critical Care Focus 8: Blood and Blood Transfusion Critical Care Focus 8: Blood and Blood Transfusion
Critical Care Focus 8: Blood and Blood Transfusion Critical Care Focus 8: Blood and Blood Transfusion
Critical Care Focus 8: Blood and Blood Transfusion Critical Care Focus 8: Blood and Blood Transfusion
Critical Care Focus 8: Blood and Blood Transfusion

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