Red blood cell transfusions worsen the outcomes even in critically ill patients undergoing a restrictive transfusion strategy
Keywords:
Anemia, Blood transfusion, Intensive care, Hospital mortality, MorbidityAbstract
CONTEXT AND OBJECTIVE: Anemia and blood transfusions are common in intensive care. This study aimed to evaluate epidemiology and outcomes among critically ill patients under a restrictive transfusion strategy. DESIGN AND SETTING: Prospective observational cohort study in an intensive care unit (ICU) at a tertiary hospital. METHODS: All adults admitted to the ICU over a one-year period who remained there for more than 72 hours were included, except those with acute coronary syndrome, ischemic stroke, acute hemorrhage, prior transfusion, pregnant women and Jehovah’s Witnesses. The restrictive strategy consisted of transfusion indicated when hemoglobin levels were less than or equal to 7.0 g/dl. RESULTS: The study enrolled 167 patients; the acute physiology and chronic health evaluation II (APACHE II) score was 28.9 ± 6.5. The baseline hemoglobin level was 10.6 ± 2.2 g/dl and on day 28, it was 8.2 ± 1.3 g/dl (P < 0.001). Transfusions were administered to 35% of the patients. In the transfusion group, 61.1% did not survive, versus 48.6% in the non-transfusion group (P = 0.03). Transfusion was an independent risk factor for mortality (P = 0.011; odds ratio, OR = 2.67; 95% confidence interval, CI = 1.25 to 5.69). ICU stay and hospital stay were longer in the transfusion group: 20.0 (3.0-83.0) versus 8.0 (3.0-63.0) days (P < 0,001); and 24.0 (3.0-140.0) versus 14.0 (3.0-80.0) days (P = 0.002), respectively. CONCLUSIONS: In critically ill patients, there was a reduction in hemoglobin with increasing length of ICU stay. Moreover, transfusion was associated with worse prognoses.
Downloads
References
Corwin HL, Gettinger A, Pearl RG, et al. The CRIT Study: Anemia and blood transfusion in the critically ill--current clinical practice in the United States. Crit Care Med. 2004;32(1):39-52.
Rodriguez RM, Corwin HL, Gettinger A, et al. Nutritional deficiencies and blunted erythropoietin response as causes of the anemia of critical illness. J Crit Care. 2001;16(1):36-41.
Levy PS, Chavez RP, Crystal GJ, et al. Oxygen extraction ratio: a valid indicator of transfusion need in limited coronary vascular reserve? J Trauma. 1992;32(6):769-73; discussion 773-4.
Russell JA, Phang PT. The oxygen delivery/consumption controversy. Approaches to management of the critically ill. Am J Respir Crit Care Med. 1994;149(2 Pt 1):533-7.
Corwin HL, Parsonnet KC, Gettinger A. RBC transfusion in the ICU. Is there a reason? Chest. 1995;108(3):767-71.
Taylor RW, Manganaro L, O’Brien J, et al. Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient. Crit Care Med. 2002;30(10):2249-54.
Carson JL, Duff A, Poses RM, et al. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet. 1996;348(9034):1055-60.
Hébert PC, Wells G, Tweeddale M, et al. Does transfusion practice affect mortality in critically ill patients? Transfusion Requirements in Critical Care (TRICC) Investigators and the Canadian Critical Care Trials Group. Am J Respir Crit Care Med. 1997;155(5):1618-23.
Weiskopf RB, Viele MK, Feiner J, et al. Human cardiovascular and metabolic response to acute, severe isovolemic anemia. JAMA. 1998;279(3):217-21.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818-29.
Vincent JL, de Mendonca A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26(11):1793-800.
Marshall JC, Cook DJ, Christou NV, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 1995;23(10):1638-52.
Nelson AH, Fleisher LA, Rosenbaum SH. Relationship between postoperative anemia and cardiac morbidity in high-risk vascular patients in the intensive care unit. Crit Care Med. 1993;21(6):860-6.
Hebert PC, Schweitzer I, Calder L, Blajchman M, Giulivi A. Review of the clinical practice literature on allogeneic red blood cell transfusion. CMAJ. 1997;156(11):S9-S26.
Vincent JL, Baron JF, Reinhart K, et al. Anemia and blood transfusion in critically ill patients. JAMA. 2002;288(12):1499-507.
Silva JM Jr, Cezario TA, Toledo DO, et al. Complications and prognosis of intraoperative blood transfusion. Rev Bras Anestesiol. 2008;58(5):454- 61, 447-54.
Looney MR, Gropper MA, Matthay MA. Transfusion-related acute lung injury: a review. Chest. 2004;126(1):249-58.
Silliman CC, Ambruso DR, Boshkov LK. Transfusion-related acute lung injury. Blood. 2005;105(6):2266-73.
Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010;304(14):1559-67.
Park KW, Chandhok D. Transfusion-associated complications. Int Anesthesiol Clin. 2004;42(3):11-26.
Robinson WP 3rd, Ahn J, Stiffler A, et al. Blood transfusion is an independent predictor of increased mortality in nonoperatively managed blunt hepatic and splenic injuries. J Trauma. 2005;58(3):437- 44; discussion 444-5.
Vincent JL, Sakr Y, Sprung C, et al. Are blood transfusions associated with greater mortality rates? Results of the Sepsis Occurrence in Acutely III Patients study. Anesthesiology. 2008;108(1):31-9.
Napolitano LM, Corwin HL. Efficacy of red blood cell transfusion in the critically ill. Crit Care Clin. 2004;20(2):255-68.
Silliman CC, Moore EE, Johnson JL, Gonzalez RJ, Biffl WL. Transfusion of the injured patient: proceed with caution. Shock. 2004;21(4):291-9.
Spinella PC, Perkins JP, Grathwohl KG, et al. Risks associated with fresh whole blood and red blood cell transfusions in a combat support hospital. Crit Care Med. 2007;35(11):2576-81.
Hébert PC, Tinmouth A, Corwin H. Anemia and red cell transfusion in critically ill patients. Crit Care Med. 2003;31(12 Suppl):S672-7.
Klein HG, Spahn DR, Carson JL. Red blood cell transfusion in clinical practice. Lancet. 2007;370(9585):415-26.
Howell PJ, Bamber PA. Severe acute anaemia in a Jehovah’s Witness. Survival without blood transfusion. Anaesthesia. 1987;42(1):44-8.
Sakr Y, Lobo S, Knuepfer S, et al. Anemia and blood transfusion in a surgical intensive care unit. Crit Care. 2010;14(3):R92.
Silva JM Jr, Toledo DO, Magalhães DD, et al. Influence of tissue perfusion on the outcome of surgical patients who need blood transfusion. J Crit Care. 2009;24(3):426-34.
Purdy FR, Tweeddale MG, Merrick PM. Association of mortality with age of blood transfused in septic ICU patients. Can J Anaesth. 1997;44(12):1256-61.
Carson JL, Armas-Loughran B. Blood transfusion: less is more? Crit Care Med. 2003;31(9):2409-10.
Walker RH. Mathematical calculations in transfusion medicine. Clin Lab Med. 1996;16(4):895-906.
Strumia MM, Dugan A, Taylor L, Strumia PV, Bassert D. Splenectomy in leukemia and myelofibrosis. Changes in the erythrocyte values. Am J Clin Pathol. 1962;37:491-8.
Walsh TS, McArdle F, McLellan SA, et al. Does the storage time of transfused red blood cells influence regional or global indexes of tissue oxygenation in anemic critically ill patients? Crit Care Med. 2004;32(2):364-71.
Weiskopf RB, Feiner J, Hopf H, et al. Fresh blood and aged stored blood are equally efficacious in immediately reversing anemia- induced brain oxygenation deficits in humans. Anesthesiology. 2006;104(5):911-20.
Fergusson D, Khanna MP, Tinmouth A, Hébert PC. Transfusion of leukoreduced red blood cells may decrease postoperative infections: two meta-analyses of randomized controlled trials. Can J Anaesth. 2004;51(5):417-24.
Vamvakas EC. Meta-analysis of randomized controlled trials investigating the risk of postoperative infection in association with white blood cell-containing allogeneic blood transfusion: the effects of the type of transfused red blood cell product and surgical setting. Transfus Med Rev. 2002;16(4):304-14.
