Impact of national transfusion indicators on appropriate blood usage in critically ill patients.

BACKGROUND: The objective was to investigate the impact of three national blood transfusion indicators (NBTIs) specifically designed for critical care regarding the appropriate blood transfusion indications. STUDY DESIGN AND METHODS: This was a prospective, single-center study, carried out at a university hospital. A total of 1808 patients admitted to the intensive care unit (ICU) in 1 year were included. RESULTS: The study consisted of four 90-day periods (P). P1 was a control period with no intervention. P2 followed the inclusion of NBTIs into the ICU database, aimed at reinforcing NBTI knowledge. After presenting and discussing the results of P1 and P2, the early (P3) and late (P4) impacts of NBTI knowledge were evaluated. All patients who were transfused with at least 1 unit of any blood component (33.3%) were included. Thirteen percent of red blood cell transfusions (RBCTs) were given outside of NBTI protocols (13% deviation of NBTIs for RBCTs) without a significant change throughout the duration of the study. Most RBCTs (95%) were prescribed for a hemoglobin threshold of less than 90 g/L. There was a steady and significant improvement in the adherence to NBTI guidelines for platelet concentrate transfusions (PCTs) from 36% (P1) to 52% (P4; p < 0.01). In contrast, the lack of adherence to NBTI guidelines for fresh-frozen plasma transfusions (FFPTs) remained high (74%) and stable throughout the study period. The most frequent reason for inappropriate use of FFPTs or PCTs was absence of severe bleeding. CONCLUSION: The introduction of NBTI guidelines demonstrated a variable impact on the appropriateness of blood component transfusions in critically ill patients.

¿Eritropoyetina humana recombinante, ¿Una alternativa válida para el tratamiento de la anemia del paciente crítico? / Is there still a role for recombinant erythropoietin in the management of anaemia of critical illness?

La anemia es muy frecuente en los pacientes médicos y quirúrgicos que ingresan en las unidades de cuidados intensivos y puede tener un efecto negativo sobre la evolución de éstos. El tratamiento habitual de la anemia del paciente crítico es la transfusión de sangre alogénica (TSA), pero ésta se asocia a un mayor riesgo de morbimortalidad. Dado que se ha observado una disminución de la secreción y de la acción de la eritropoyetina en la mayoría de estos sujetos, se considera que la administración de eritropoyetina humana recombinante (rHuEPO) puede ser una alternativa de la TSA. Desafortunadamente, los resultados de estudios recientes demuestran que el tratamiento con rHuEPO sólo produce una discreta reducción de los requerimientos transfusionales cuando se aplica junto con criterios de transfusión «restrictivos», pero no disminuye la mortalidad, excepto en 2 estudios con pacientes traumatológicos; en otros, se observó un aumento dependiente de la dosis de complicaciones trombóticas en sujetos sin profilaxis antitrombótica. En conjunto, los datos clínicos evidencian que la rHuEPO puede ser útil para el tratamiento de la anemia de los pacientes traumatológicos, especialmente aquéllos con traumatismo craneoencefálico, mientras que para el resto de los pacientes críticos, sin una indicación aprobada, la administración de rHuEPO es una opción cara, que no parece mejorar el pronóstico y puede tener efectos adversos graves. Por consiguiente, se requieren más estudios básicos y clínicos para determinar qué sujetos pueden beneficiarse con la administración de rHuEPO, así como para definir las dosis y las pautas de administración óptimas, junto con la administración de hierro (AU)

There is a high prevalence of anaemia among patients admitted to the intensive care unit (ICU), and it may have a negative effect on patient's outcome. The most common treatment for anaemia in the ICU patient is allogeneic blood transfusion (ABT), yet it has been found to be a risk factor associated with an increased risk of morbidity and mortality in critical care patients. As a reduction of erythropoietin secretion and action is observed in most ICU patients, the administration of (rHuEPO) has emerged as a therapeutic option. Unfortunately, the results from different studies show that rHuEPO treatment results in a small reduction of ABT requirements when “restrictive” transfusion criteria are applied, which has only been supported by three of the studies. Yet this did not result in a decreased mortality rate, except for patients with a diagnosis on admission of trauma in two studies, even though one study reported a dose-dependent increase of thrombotic vascular events among patients without thromboprophylaxis. Altogether, clinical data suggest a role for rHuEPO in the treatment of anaemia in trauma patients, especially in those sustaining neurotrauma, whereas for non-trauma patients without an approved indication, rHuEPO administration is an expensive approach, does not seem to improve outcome, and might result in serious adverse effects. Consequently, more basic and clinical studies are required to ascertain which patients are more likely to benefit from these treatments, as well as to identify the optimal doses and administration schedules, and iron administration (AU)

[Results of a national survey on transfusion practice in Intensive Care Units]. / Resultados de una encuesta nacional sobre hábito transfusional en unidades de cuidados intensivos.

INTRODUCTION: Blood derivatives are clinical products that are currently used, for which their lack of availability, clinical relevance and presence of associated side effect that make it necessary to known and evaluate their utility rigorously are characteristic. OBJECTIVE: To analyze knowledge of attitudes, knowledge and behavior on transfusional policy in the different Spanish Intensive Care Units (ICU). DESIGN: A mail-based survey (electronic and conventional) in the ICUs. DURATION: The study was planned in 2005 and conducted during the year 2006. SETTING: Spanish ICUs. PATIENTS AND METHOD: A 27-question questionnaire. RESULTS: Most are middle-sized ICUs (10-20 beds), with predominantly medical activities. The staff member, alone or with the resident, generally decides the transfusion based on his/her experience, although with a tendency to follow the scientific guidelines. Generally, there is no transfusional committee. When red blood packs are transfused, generally between 2 to 4 units are used. The hemoglobin value is orientative, although the decision is clear if < 7 g/dl (10 g/dl if there is heart disease). Drug alternatives to transfusion are not generally used due to lack of evidence and price. In 50% of cases, the association between transfusion and increase in mortality is considered to be certain. CONCLUSIONS: Strong consideration must be made about transfusion and its over use should be avoided. For this purpose, educational guidelines and consensus meetings are necessary to establish recommendations on the use of blood products and their pharmacological alternatives.

Impact of age of transfused blood on cerebral oxygenation in male patients with severe traumatic brain injury.

OBJECTIVE: Prolonged erythrocyte storage time might reduce the efficacy of transfusion. In this study, the effects of transfusion of erythrocytes with four different storage periods (<10 days, n = 18; 10-14 days, n = 15; 15-19 days, n = 17; and >19 days, n = 16 patients) on brain tissue oxygen tension (PtiO2) in stable male patients with severe traumatic brain injury were investigated during a 24-hr follow-up period. DESIGN: Prospective, observational study. SETTING: Neurotrauma critical care unit of a university hospital. PATIENTS: Sixty-six male, nonbleeding, hemodynamically stable anemic patients (hemoglobin <95 g/L) with Glasgow Coma Scale score <9. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: PtiO2, cerebral perfusion pressure, mean arterial pressure, intracranial pressure, peripheral oxygen saturation, CO2 pressure at the end of expiration, and intracerebral temperature were recorded in all patients at baseline, immediately after the completion of transfusion, and 1, 2, 3, 4, 5, 6, 12, and 24 hrs posttransfusion. All four groups were homogeneous with respect to multiple baseline variables, except for storage time of transfused erythrocytes (p < .0001). There was a significant short-lasting (3-4 hrs) increase in PtiO2 values after transfusion of erythrocytes stored for <10 days, 10-14 days, or 15-19 days, compared with those at baseline. In contrast, no significant changes in PtiO2 were observed after transfusion of erythrocytes stored >19 days. CONCLUSIONS: Transfusion of erythrocytes increased cerebral oxygenation in patients with severe traumatic brain injury, except in those transfused with erythrocytes stored >19 days.

Transfusion of erythrocyte concentrates produces a variable increment on cerebral oxygenation in patients with severe traumatic brain injury: a preliminary study.

OBJECTIVE: To investigate the long-term influence of erythrocyte transfusion on cerebral oxygenation in patients with severe traumatic brain injury. DESIGN: Prospective and observational study. SETTING: Neurotrauma intensive care unit of trauma center level I. PATIENTS: Sixty consecutive, hemodynamically stable patients with severe traumatic brain injury, pretransfusion hemoglobin<100g/l, non-bleeding and monitored through intracranial pressure and brain tissue partial pressure of oxygen (PtiO(2)) catheters were included. INTERVENTIONS: Transfusion of 1-2 units of red blood cells. MEASUREMENTS AND RESULTS: Ten sets of variables (pretransfusion, end of transfusion, and 1, 2, 3, 4, 5, 6, 12 and 24h after transfusion) were recorded, including: PtiO(2), cerebral perfusion pressure (CPP), end-tidal CO(2), peripheral saturation of oxygen, temperature, hemoglobin, lactate and PaO(2)/FiO(2) ratio. Transfusion was associated with an increase in PtiO(2) during a 6-h period, with a peak at 3h (26.2%; p=0.0001) in 78.3% of the patients. No relationship was observed between PtiO(2), CPP and hemoglobin increments. The relative increment in PtiO(2) at hour 3 was only correlated with baseline PtiO(2) (r(2) 0.166; p=0.001). All of the patients with basal PtiO(2)<15mmHg showed an increment in PtiO(2) versus 74.5% of patients with basal PtiO(2)>or=15mmHg (p<0.01, hour 3). CONCLUSIONS: Erythrocyte transfusion is associated with a variable and prolonged increment of cerebral tissue oxygenation in anemic patients with severe traumatic brain injury. Low baseline PtiO(2) levels (<15mmHg) could define those patients who benefit the most from erythrocyte transfusion.

Transfusión sanguínea perioperatoria en el paciente neoplásico (II). Alternativas para la reducción de los riesgos transfusionales / Perioperative blood transfusion in neoplastic patient 2. Alternatives for the reduction of transfusion risks

La administración perioperatoria de hemoderivados alogénicos (TSA), junto con los efectos de la anestesia y del traumatismo quirúrgico, originan un estado de inmunodepresión (inmunomodulación inducida por transfusiones alogénicas [IMITA]) que puede dar lugar a un aumento de las infecciones postoperatorias y de la recurrencia del tumor, aumentando por tanto la morbimortalidad de estos pacientes. Para evitar o minimizar los efectos adversos de las TSA en el paciente neoplásico es necesaria una óptima preparación preoperatoria a la que deben sumarse estrategias farmacológicas o anestesicoquirúrgicas encaminadas a conseguir: a) un aumento de la masa sanguínea circulante, mediante la estimulación de la eritropoyesis con eritropoyetina, lo que eleva los valores preoperatorios de hemoglobina y/o acelera su recuperación postoperataria, y que permite, además, aumentar el predepósito de sangre autóloga en cirugía programada; b) una reducción del sangrado perioperatorio mediante desmopresina, antifibrinolíticos sintéticos (tranexámico y -aminocaproico) o aprotinina; c) un aumento de la capacidad de oxigenación, mediante el uso de transportadores artificiales de oxígeno basados en la hemoglobina o en los perfluorocarbonos, y aumentando la concentración de oxígeno en el aire inspirado, y d) una recuperación y reinfusión de la sangre autóloga que se pierde durante o después del acto quirúgico. Para que estas medidas sean plenamente efectivas es necesaria la creación de equipos multidisciplinarios así como la implantación de una política transfusional restrictiviva. Además, cuando sea necesario transfundir, deben utilizarse hemocomponentes frescos y desleucocitados, administrándolos de uno en uno y revaluando al paciente después de cada transfusión. Cabe plantearse, además, el uso de fármacos inmunomoduladores o inmunorrestauradores que neutralicen o disminuyan los efectos inmunodepresores de la cirugía y la TSA. (AU)

Transfusión sanguínea perioperatoria en el paciente neoplásico. I. Alteraciones inmunológicas y consecuencias clínicas / Perioperative blood transfusion inthe neoplastic patient. I. Immunological alterations and clinical consequences

La administración perioperatoria de hemoderivados alogénicos (TSA) es relativamente frecuente en los pacientes oncológicos sometidos a cirugía y, aunque nunca antes habían sido tan seguros como en la actualidad, sobre todo con respecto a la transmisión de enfermedades infecciosas, sabemos que esta práctica no está exenta de efectos adversos. Uno de ellos es la inmunomodulación inducida por transfusiones alogénicas (IMITA), que mediante mecanismos no completamente esclarecidos induce un predominio de la respuesta Th2, caracterizada por la liberación de interleucina-4 (IL-4), IL-5, IL-6, IL-10 e IL13 que inducen un predominio de la inmunidad humoral y una disminución o anulación de la inmunidad celular, creando un estado de susceptibilidad a la enfermedad. Tampoco se conocen con exactitud los componentes de la TSA que participan en la inducción de IMITA, aunque diversos estudios han implicado a los leucocitos del donante o los productos liberados por los mismos durante la conservación. En el paciente neoplásico sometido a cirugía, el grado de IMITA parece depender del volumen transfundido y va a potenciar otras alteraciones del sistema inmunitario producidas por la enfermedad de base, el estado nutricional e inflamatorio del paciente, el tipo de anestesia que se emplee, la magnitud del trauma quirúrgico y la medicación perioperatoria. Este estado de inmunodepresión, junto con las alteraciones de la microcirculación y la hipoxia tisular regional provocadas por la lesión de almacenamiento de los eritrocitos, puede llevar a un aumento de las infecciones postoperatorias y de la recurrencia del tumor, aumentando por tanto la morbimortalidad de estos pacientes. Por ello, es necesario el desarrollo de programas multidisciplinarios para optimizar el manejo transfusional del paciente oncológico y reducir el número de TSA al mínimo indispensable, disminuyendo los riesgos inherentes a las mismas (AU)