Evidence for Parsimonius RBC Transfusion

7/31/2019 Evidence for Parsimonius RBC Transfusion

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Parsimonious RBC

Transfusion: State of the Art

Moises Auron, MD, FAAP, FACPAssistant Professor of Medicine and

Pediatrics


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Disclosure of Financial Relationships

Dr. Auron has no relationships with entities

producing, marketing, re-selling, or

distributing health care goods or services

consumed by, or used on, patients.


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Outline

Anemia Physiology

Current evidence for transfusion medicine

Adverse effects of blood utilization


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It is right to say

The safest transfusion is the one that isavoided

The best transfusion is the one that isavoided

What is the evidence? What is the comparison?


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Physiology

Pre-load

After-load Stroke volume (SV)

Contractility

SV x Heart rate = Cardiac output (CO)

CaO2= SaO2 x 1.34 x Hb + [PaO2 x 0.003]

DO2= CO x CaO2

O2ER = VO2/DO2 (~20-30%)

DO2crit= < 7.3 ml O2/kg/min

Madjdpour C, et al. Crit Care Med 2006; 34[Suppl.]:S102S108.


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Physiology

Acute response to Anemia

Central CO

Regional Redistribution

Microcirculationcapillary recruitment

http://www.frca.co.uk/article.aspx?articleid=100345

Shander A, et al. Brit J Anaesth 2011;107 (S1): i41i59.
http://www.frca.co.uk/article.aspx?articleid=100345http://www.frca.co.uk/article.aspx?articleid=100345


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Outline

Anemia Physiology




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Anemia tolerance: what is theideal hemoglobin level?

Cardiovascular effect

- Coronary artery disease

- Valvular disease

- Elderly patient

CNS effects

Effects on splachnic and renalperfusion


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Preoperatory Anemia andCardiovascular Disease

Carson JL. Lancet 1996; 348: 105560.

Retrospective (N = 1958)

Jehovah's witnesses > 18a

Mortality 1.3% (Hb > 12)

Mortality 33.3% (Hb < 6)


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Circulation. 2007;116: 471-479.http://www.euroscore.org

N = 5065

4804 were not transfusedbefore surgery

Hb < 11 increase in post-op adverse effects (renal,

CNS (P=0.001))

Specially in patients withEUROSCORE > 4


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Journal of Cardiac Failure. 2004:10(6)467-72.

N = 1,136,201

1996-1997


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N = 227 425 patients (69 229 preoperatory anemia)

Postoperative mortality (30 days) (OR 1.42, 95% CI 1.31-1.54)- Mild Anemia (OR 1.41, 1.30-1.53)

- Moderate-severe Anemia (OR 1.44, 1.29-1.60)

Postoperative morbidity (30 days) (OR 1.35, 1.30-1.40)

- Mild Anemia (OR 1.31, 1.26-1.36)

- Moderate-severe Anemia (1.56, 1.47-1.66)

Lancet 2011; 378: 1396407.


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What is my cut-off Hemoglobinvalue to transfuse?

10/30?

- Based in experience

- Not supported by evidence Indiscriminate use of blood

- USA: 15 million pRBC/year

- Global: 85 million pRBC/year

Carson JL, et al. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB. Ann Int Med 2012.


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Anesth Analg 1996;82:687-94.

Hb 12.60.2 to 9.9 0.2 g/dl

N = 90 (60 hemodilution)


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Crit Care Med. 2005 Mar;33(3):591-7.

- Hemoglobin 131.3 to 9.31 g/dl

- No left ventricle dysfunction or hemodynamic

instability.


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Anaesthesia, 2004;59:11701177.

Hb 9.1 g/dL Increase C.I, C.O, and pre-load indexes

- Less viscosity increases venous return, pre-load increase stroke voume

- Consider in patients with preserved LV function


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Anaesthesia, 1998;53:20-24.

Increase in C.I and O2 extraction (VO2/DO2)- Independent of baseline rhythm


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Anesthesiology. 2000;92:1646-52.

Immediate memory

Delayed memory

Horizontal addition

Numeric substitution

There is no difference between time ofreaction (speed and precision ofprocessing information) or in immediateand delayed memory between

Hemoglobin of 7 g/dL vs. 14 g/dL.


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Anesthesiology 2002; 96:8717.

N = 31 healthy volunteers (28 y/o +/- 4)Tests: verbal and standard memory; computerized neuropsychologicalBasal hemoglobin 12.7 g/dL hemodilution to 5.7 g/dL

There is no difference in reaction time inpatients with Hemoglobin of 5.7 g/dL whoused supplemental O2 (PaO2 > 350 mm Hgequals to increase Hb ~ 2-3 g/dL reverseeffects of acute anemia


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Renal and splachnic perfusion

Studies in animals (dogs)

Normovolemic hemodilution

- Hct 30- Hb 7 g/dL

Preserve adequate renal perfusion and

blood distribution

Habler O, et al. Eur J Med Res1997;2:419424.

Meier J, et al. Clin Physiol Funct Imaging2005; 25: 158-65.


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18% vs. 23%

NEJM 1999;340(6):409-17.

TRICC StudyN = 838Hb < 9.0 g/dL

Euvolemic

Restrictive Hb < 7 g/dL(N = 418)

Liberal Hb < 10 g/dL

(N = 420)

8.7% vs. 16.1%

5.7% vs. 13%


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TRIPICU Study (non-inferiority)

N = 637 hemodinamically stable children

320 Transfused for Hb < 7.0 g/dL

317 Transfused for Hb < 9.5 g/dL

No significant difference in prognostic markers(death, infections, inpatient stay in ICU).

N Engl J Med 2007;356:1609-19.


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N Engl J Med 2011;365:2453-62.

Patients > 50 y/o

10 g/dL 8 g/dL


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Liberal Hct 30.6%Conservative Hct 27.9%

Am J Cardiol 2011;108:11081111.


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Rao SV, et al. JAMA 2004. 292(13):1555-62.

N = 24112

Acute coronary syndromes

Studies: GUSTOIIb,

PURSUIT, PARAGON B

HR 3.94; (95% CI, 3.26-4.75)


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J Surg Research. 2002; 102:237

244.


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ComplicationBlood

> 14 d (%)

Blood

< 14 d (%)

P

Inpatient

mortality2.8% 1.7% 0.004

Mortality at 1

year11% 7% 0.001

Prolonged

intubation

(>72h)

9.7% 5.6% 0.001

Renal failure 2.7% 1.6% 0.003

Sepsis 4.0% 2.8% 0.01

N Engl J Med 2008;358:1229-39.


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Changes in aging blood

RBC age rapidly in refrigeration 75%viable at 24hs

Decreased ATP and 2,3 DPG

Loss of membrane phospholipids

Progressive structural rigidityechinocytes at 14-21 days

Poor tissuedelivery of O2

Holme S. Transfus Apher Sci 2005;33:5561.

Hovav T, et al. Transfusion 1999; 39(3):277-81.


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Crit Care Med 2006; 34[Suppl.]:S102S108

Physiologic factors that indicate blood transfusion

Hypotension and tachycardia refractory to euvolemia

New ST depression > 0.1 mVNew ST elevation > 0.2 mV

New LV free wall motion abnormality (Echocardiogram)

PVO2 < 25 mmHg

O2ER > 50%

SVO2 < 50%

Decrease VO2 > 10%


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Crit Care Med 2006; 34[Suppl.]:S102S108

Hemoglobin levels that indicate blood transfusion

All patients 7Patients > 80 y/o 7-8

CAD/CHF 8

SaO2 < 90% 8

Catabolic state 7-8


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Transfusion limits: Guidelines

Society Year Hb Limit (g/dL)

ASA 1996 6

BCSH (British Committee of

Hematology Standards) 2001 7

Australian and NZ Society of

Blood Transfusion 2001 7

ESC (European Society of

Cardiology) 2007 8

SCCM/ACCM 2009 7

AABB (American Assoc of

Blood Banking) 2012 7

Anesthesiology. 1996;84:732-47. Murphy MF, et al. Br J Haematol. 2001;113:24-31.

http://www.nhmrc.gov.au/guidelines/publications/cp78 (2001) Bassand JP, et al. Eur Heart J. 2007;28:1598-660.

Napolitano LM, et al. J Trauma. 2009;67:1439-42. Carson JL, et al. Ann Int Med 2012 (online first).


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Transfusion restriction andmortality

Carson JL, et al. Transfus Med Rev. 2002;16(3):187-99.


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Transfusion restrictive strategy

Critical patients consider transfusion if Hb< 7 g/dL

Post-op surgical patients - consider

transfusion if Hb < 8 g/dL or if symptomatic(angina; orthostatic hypotension; tachycardia

refractory to IVF resuscitation, CHF)



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Outline

Anemia Physiology




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Blood transfusion: Risks



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Infections: HCV, HBV, HIV, HTLV, XMRV Immunologic reactions:

- Non-hemolytic febrile reaction

- Early and delayed hemolytic reactions

- Anaphylaxis

- Urticaria

TRALI

TACO

TRIM ( infections)

XMRV Chronic fatigue syndrome?

Meiers J. Transfus Med Hemother 2012;39:98103http://www.frca.co.uk/article.aspx?articleid=100902

Blood transfusion: Risks


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Documents

Evidence for Parsimonius RBC Transfusion