Dr Tushar Mahambrey. Consu ltant Critical Care Med icine & Anaesthetics St Helens and Knowsley N H S teaching hospitals Liverpool

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1 Dr Tushar Mahambrey Consu ltant Critical Care Med icine & Anaesthetics St Helens and Knowsley N H S teaching hospitals Liverpool

2 History Why do we give blood Why does anaemia occur in critical care patients Problem s associated w ith blood transfu sion Transfusion trigger & evidence Conclusions

3 RBC transfusions have been standard of care to treat anaemia for over 100 years with little evidence of im p roving clinical ou tcom es. (Blu nd ell 2002) Questions started being asked only since 1980s and 1990s when first RCTs w ere perform ed (Blair 1986) Practice is so ingrained that we can now only look at triggers rather than transfu sions for clinical benefit. To maintain Hb >10 and give 2 units at a time.. trad ition rather than science (Marshall 2004)

4 DO2= CO x CaO2 DO2= (1.39x [Hb] x SaO2 + PaO2 x 0.003) Anaemia is the commonest encountered abnormal laboratory finding in critical care (Vincent et al CCM 2006)

5 Reduction in red cell production Increased red cell destruction Blood loss (acute or chronic) Dim inished erythrop oietin response Im p aired p roliferation and d ifferentiation of erythroid progenitors in the bone marrow Phlebotomy

6 Transplantation of allogenic cells- risks modest but not negligible H aem olytic and N on-haem olytic febrile reactions TACO, TRALI, TRIM Citrate toxicity Hyperkalemia Hypothermia Infection- Hepatitis, HIV, Bacterial, Parasites, CJD Graft vs Host disease

7 Transfusion related mortality and major morbidity in the UK was 3.1 and 46.7 per million blood components issued respectively Errors in the process of correct blood being transfused and acute haemolytic reactions are the commonest p athological reactions follow ed by TACO

8 Approximately 85 million units are transfused worldwide annually Approximately 2 million units of red cells were issued across UK in 2011 with surgical patients requiring almost 40% 80% of critically ill p atients get transfu sed for nonbleeding reasons IT IS A SCARCE RESOURCE

9 Restrictive is giving less blood, at a lower Hb, lower target Hb level, 7-8 g/dl Liberal is giving more blood at a higher Hb level, 9-10 g/dl

10 TRICC - Restrictive strategy is as safe as liberal in stable non-bleeding critically ill patients. 30 day mortality was reduced in younger (age <55) P-0.03 and less sick patients (APACHE<20) P-0.02 with reverse trend in IHD patients. 2 big observational studies- ABC in Western Europe (146 units/ 3534 patients) and CRIT in USA (284 units/ 4892 patients), increase mortality, ITU and hospital LOS.

11 TRACS trial (JAMA 2010)- Single centre study in elective CABG patients showed increase in 30 day mortality and risk of serious infection by 20% after every unit of RBC (P=0.007). Marik et al 2008 (adult trauma and surgical) and Villanueva 2013 (GI bleed) showed increase mortality in subgroups of critically ill patients with liberal strategy.

12 Holst et al 2014, TRISS trial, in septic shock patients, found that restrictive group showed no difference in mortality at 90 days, ischaemic events and use of life support as compared to liberal group. Also no difference in sub-grou p s of old er p atients, chronic CVS d isease and sicker p atients.

13 Adult and Paediatric critical care

14 Cochrane review (2012) 19 RCTs, 6264 patients across various clinical settings, restrictive transfusion trigger is associated with fewer transfusions without adverse association with mortality, cardiac morbidity, functional recovery or hospital LOS. (Rohde 2014) 18 RCTs, 7593 patients concluded that restrictive transfusion strategy was associated with fewer health care associated infections

15 31 RCTs, over 9000 patients RBCs transfused (mean difference 1.43, 95% confidence interval 2.01 to 0.86)

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18 Over 2000 patients Non-emergency cardiac surgery-cabg & valve surgery Composite primary outcome were infection or ischaemic events 35.1% to 33% with OR 1.11, CI to 1.34,P= day mortality- 4.2% v 2.6% HR 1.64 (CI ,P=0.045), small number, hence inconclusive 30 day mortality, morbidity & healthcare costs were similar. Restrictive not superior to liberal in elective cardiac surgery

19 MINT trial, 110 patients with stable angina and ACS undergoing cardiac catheterisation. SOAP investigators, observed im p roved su rvival in critically ill septic patients with liberal strategy after extended cox hazard analysis. (P-0.004) Propensity matched analysis of CAP with septic shock, RBC transfusion was associated with lower risk of 7 day (P<0.001), 28 day (P=0.007) and in hospital mortality (P= 0.044).

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21 BCSH & Survival of Sepsis Campaign 2012, recommends blood transfusion in critical care for Hb < 70 g/l unless actively bleeding, ACS, acute sepsis, severe hypoxaemia or neurological injury

22 Prof Walsh evidence supports limiting RBC transfusions in most clinical situations but uncertainty remains in patients with acute CVS disease and brain injuries. Trials are needed to measure QOL & health care costs. (Eye of evid ence N ICE 2015) J Marshall quotes that the decision to transfuse should be based on individual physiological benefit than on any nu m eric transfu sion trigger (Marshall 2004)

23 Blood is a scarce resource Optimal stewardship and Hospital wide blood management programs in guiding transfusion practices are important Use of restrictive transfusion trigger in critical care for select population is recommended Ind ivid u al physiological benefit in other clinical situations Giving one unit at a time for clinically stable critically ill non-bleeding patients when Hb < 7g/ d l is acceptable

24 Leuco-depleted blood and short storage blood transfusion need more studies but will have huge implications!! There is study overlap in most systematic reviews and swaying of the results by big studies Studies with QOL are also needed..

25 In your practice regarding blood transfusion on critical care in non-bleeding, non-acute coronary syndrome and non acute sepsis patients do you use Option 1 - transfusion trigger... OR Option 2 - Blood transfusion for individual patient physiological benefit...