JOURNAL CLUB INDICATIONS FOR AND ADVERSE EFFECTS OF RED CELL TRANSFUSION. Maggie Woods PGY-3

Transcription

1 JOURNAL CLUB INDICATIONS FOR AND ADVERSE EFFECTS OF RED CELL TRANSFUSION Maggie Woods PGY-3

2 BACKGROUND Objective: To describe evidence for current guidelines, review trends, examine the risks of transfusion and discuss ongoing research. 11 million units of red cells transfused annually in the U.S. 1 A total of 31 trials examined in a meta-analysis including more than 12,000 patients. Higher hemoglobin concentration threshold ( liberal transfusion ) versus lower hemoglobin concentration threshold ( restrictive transfusion ). 30 day mortality, pneumonia, MI, CHF and long term mortality (mean of 3.1 years for follow-up).

3 TRENDS

4 SUBGROUPS Cardiovascular disease Some evidence exists to support evidence of liberal transfusion 2007 study 2 : 30d outcome unchanged, but 90d mortality increased in restrictive-transfusion group. Many trials are currently underway to further investigate this group. GI Bleeding This group is benefitted by a restrictive transfusion threshold (lower mortality, lower rebleeding rate) as demonstrated by three large trials in the meta-analysis. Children No difference in restrictive versus liberal transfusion (Hgb 9.5*) in 637 ICU patients. 3

5 RECOMMENDATIONS Authors recommend following American Association of Blood Banks guidelines: Safe to use restrictive transfusion threshold for most patients including those in the ICU. May consider using the liberal threshold for patients with preexisting cardiovascular disease and those undergoing cardiac or orthopedic surgery. Limited data on how to manage those with acute coronary syndromes, chronic hematologic disorders, cancer, acute neurologic disorders, etc.

6 RECOMMENDATIONS

7 RECOMMENDATIONS

8 TRENDS Rate of red-cell transfusions has fallen from 2008 to Attributed to use of patient-focused blood management programs Predications that rate of red-cell use could increase as U.S. population ages (cancer, cardiac disease, etc). 1 U.S. rates of red cell transfusion among the highest in developed countries. 1 Likely related to aggressive trauma and transplantation programs. 1

9 TRENDS

10 TRENDS

11 SAFET Y Risk of contracting HIV and HCV from red cell transfusion is less than 1 in 1 million in developed countries. 4 Volunteer donations screened for HBV, HIV, HTLC, HCV, West Nile, Chagas, and Zika (new addition). 1 Many illnesses are eliminated by travel exclusions (e.g. malaria) Babesia infection is a recent concern (15-20% mortality rate). 1 Pathogen reduction 1 : Already available for platelets and plasma in the U.S. Potential red cell techniques including riboflavin and UV light or alkylating agents and glutathione Would eliminate need for irradiation (inactivates white cells). Safety improvements must be weighted against potential red cell damage.

12 SAFET Y TACO: Transfusion Associated Circulatory Overload 1 to 5% of transfusions Cardiogenic pulmonary edema leads to acute respiratory distress An especially important consideration in heart disease and renal failure Diagnosis: Respiratory distress within 6-12 hr, evidence of fluid overload (elevated BNP pulm edema enlarged cardiac silhouette) Prevention/treatment includes minimum amounts, slower transfusion (4 hours per component), administering diuretics TRALI: Transfusion Related Acute Lung Injury Non-cardiogenic pulmonary edema (bilateral pulmonary infiltrates) Occurs within the first 6 hours Pathogenesis: Leukoagglutinating antibodies in donor plasma

13 SAFET Y Hemolytic transfusion reactions Immediate-ABO incompatibility Leads to acute renal failure, mortality 8-44%. 5 Delayed (non-abo antibodies) Less severe, spleen plays a protective role. Graft-versus host disease Viable donor T cells, leads to pancytopenia. Prevented by irradiation Iron overload-related to chronic transfusions Accumulates in heart, liver, and endocrine organs Chelation therapy required MBT risks: Hypothermia, hyperkalemia, dilutional coagulopathy, metabolic alkalosis. 6 Citrate toxicity (especially with liver dysfunction)-binds divalent cations resulting in hypocalcemia and hypomagnesemia. 6

14 SAFET Y

15 FUTURE RESEARCH Methods to measure levels of tissue oxygenation (lactate, base deficit, etc) over oxygen carrying capacity (Hgb). 1 Alternatives to red cells for oxygen carriers. 1 In vitro production of red cells from hematopoietic stem cells. 1

16 CONCLUSIONS Transfusion safety is an important healthcare consideration. Extensive evidence exists supporting a restrictive transfusion threshold in most cases. American Association of Blood Banks is an excellent resource. Be prepared for a possible uptrend of transfusion needs in the U.S. Many risks still exist, and patients should be appropriately counseled to such. More research is needed to continue to improve patient outcomes.

17 REFERENCES 1) Carson JL, Triulzi DJ, Ness PM, et al. Adverse Effects of Red- Cell Transfusion. N Engl J Med 2017; 379: ) Murphy GJ, Pike K, Rogers CA, et al. Liveral or restrictive transfusion after cardiac surgery. N Engl J Med 2015; 372: ) Lacroix J, Hebert PC, Hutchinson JS, et.al. Tranfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007; 356: ) Zou S, Dorsey KA, Notari EP, et al. Prevalence, incidence, and residual risk of HIV and HCV among US blood donors since the introduction of nucleic acid testing. Transfusion 2010; 50: ) Davenport RD, Bluth MH. Hemolytic transfusion reactions In: Rossi s principles of transfusion medicine 5 th ed. West Sussex, United Kindgdom: Wiley-Blackwell, 2016: ) Elmer J, Wilcox SR, Raja AS. Massive transfusion in traumatic shock J Emerg Med 2013; 44:829-38