Goal Directed Therapy : Liberal vs Restrictive Transfusion.. Syafri Kamsul Arif

Transcription

1 Goal Directed Therapy : Liberal vs Restrictive Transfusion. Syafri Kamsul Arif

2 Sepsis Perioperative EGDT PGDT

3 PGDT Protocol Stroke volume optimization with fluid protocol SVV or PPV based GDT Protocol

4 Why a protocol? To maintain adequate circulations To ensuring adequate tissue oxygenation To ensure proper waste removal. requires Adequate Adequate Oxygenation Delivery Adequate Content requires

5 Adequate Delivery DO 2 = CO x CaO 2 DO 2 = CO x (1.39 x Hb x SaO 2 + PaO 2 x 0.003) Fall in Hb reduced arterial oxygen content Fall in DO 2 (Unless compensated)

6 Risks of RBC Transfusion Early Late Haemolytic reactions immediate or delayed Non-haemolytic febrile reactions Transfusion-associated circulatory overload Transfusion-associated acute lung injury Citrate toxicity Electrolyte disturbances hyperkalaemia Hypothermia Post-transfusion purpura Infection Viral hepatitis A, B, C, E, HIV Bacterial Parasites Graft vs host disease Transfusion-related iron overload Immunomodulation

7 Allogeneic blood transfusion (ABT) related mortality Acute Lung Injury (TRALI) ABO and non-abo hemolytic transfusion reactions (HTRs) Transfusion-associated sepsis (TAS)

8 French, transfusion-related deaths 18 deaths due to TAS 6 deaths due to ABO HTRs

9 SHOTS - UK transfusion related deaths in UK Lowest mortality rate in death definitely attributable to ABT 1 death was probably attributed to TRALI

10 Liberal Transfusion Strategy Restrictive Transfusion Strategy

11

12 RCT of RBC transfusion consistently support the restrictive approach in most settings Degree which the optimal Hb or transfusion trigger should be modified for patients with additional specific risk factors (e.g. ischaemic heart disease) is less clear. It is sensible to modify the decision to transfuse in the presence of symptoms such as chest pain, heart failure, or tachycardia unresponsive to fluid resuscitation

13 Increasing arterial oxygen content by increasing Hb does not necessarily increase tissue oxygen delivery or uptake Altered rheological properties of transfused cells and increasing Hct increases viscosity Reduce blood flow through the microcirculation.

14 2016 patients aged > 50 years old who had either a history or risk factors for cardiovascular disease and whose hemoglobin was <10g/dL following surgery for hip fracture

15 Carsons et al - FOCUS Trial Random assignment to a liberal transfusion strategy or a restrictive transfusion strategy Findings Transfusions were 3x higher in the liberal group Similar rates of primary outcome Similar rates of in-hospital cardiac event or death Similar rates of death at 60 day follow up similar No benefit of using liberal transfusion strategy in elderly patients at high cardiovascular risk

16 TBI may require liberal transfusion strategies to prevent secondary cerebral ischaemic Injured brain may not compensate for decreased oxygen delivery associated with anaemia RCT using a factorial design compared the effects of erythropoietin and two different haemoglobin thresholds for red blood cell transfusion (7 versus 10 g/dl) in 200 patients with a closed head injury Showed no difference in neurological outcome at six months

17 Evidence in Cardiac Surgery Johnson et al.(1993) Bracey et al.(1999) Hajjar et al.(2010) RCTs in patients undergoing elective coronary artery bypass, valve replacements or a mixture of both. All three trials used different transfusion thresholds with the lowest being Hct < 25% although this was a small study The TRACS trial showed that a restrictive strategy (Hct < 24%, mean Hb 91 gr/l) appears to be as safe as liberal strategy (Hct < 30%, mean Hb 10.5 gr/l).

18 Evidence in Vascular Surgery Bush et al.(1997) RCT in patients undergoing elective aortic or infrainguinal arterial reconstruction Liberal group had Hb maintained at 100 gr/l, n = 49 Restrictive group were transfused only if Hb < 90 gr/l, n = 50 There were no significant differences in mortality, cardiac morbidity and hospital LOS between both groups. However, the liberal group had a postoperative Hb 110±12 gr/l and the restrictive group had a postoperative Hb 98±13 gr/l

19 Evidence in Orthopedic Surgery Carson et al.(1998) Grover et al.(2005) Foss et al.(2009) Carson et al.(2011) Parker(2013) So-Osman et al.(2013) All these RCTs focused on major lower limb surgery elective hip/knee arthroplasty or hip fracture repair. There was heterogeneity between the studies with regard to the transfusion triggers used. The lowest restrictive transfusion trigger was 80 g/l The FOCUS trial showed that a restrictive transfusion strategy (symptoms of anaemia or at physician discretion for an Hb < 80 gr/l) was safe even in patients with history/risk factors for cardiovascular disease. Overall, a restrictive transfusion strategy appears to be safe for majority of patients undergoing orthopaedic lower limb surgery. However in patients presenting with acute cardiac disease or any other organ dysfunction (e.g. heart failure, sepsis), it may be sensible to adopt a less restrictive strategy aiming for an Hb between 90 and 100 gr/l.

20 Evidence in Plastic Surgery Rossmiller et al.(2010) There was no significant increase in the rate of complications, including flap loss, in the restrictive group. However, there are no RCTs yet in this subgroup of patients

21 Summary Restricted transfusion strategy is to transfuse patient when hgb < 7 gr/dl and maintain between 7-9 gr/dl Higher limit will not bring better outcome due to altered rheology properties of transfused cells MABL computation is no longer an ideal transfusion trigger, it serves as high alert, triggers should be presence of symptoms

22 Overwhelming ample evidence supporting restricted transfusion strategy Will YOU still transfuse unnecessarily???

23