Page 1237 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

844 PART 7: Hematologic and Oncologic Disorders

have documented an association between prolonged storage times and
adverse clinical outcomes including mortality, pneumonia, serious KEY REFERENCES
infections, and length of stay in many patient populations including • Corwin HL, Gettinger A, Fabian TC, et al. Efficacy and safety of
multiple trauma victims, critically ill patients, and patients undergoing epoetin alfa in critically ill patients. N Engl J Med. September 6,
cardiac surgical procedures. In summary, there is laboratory evidence 2007;357(10):965-976.
suggesting that prolonged RBC storage may be deleterious as well as • Corwin HL, Gettinger A, Pearl RG, et al. The CRIT Study: anemia
observational studies demonstrating associations between prolonged and blood transfusion in the critically ill—current clinical prac-
storage and adverse clinical outcomes such as mortality and organ tice in the United States. Crit Care Med. January 2004;32(1):39-52.
failure. However, there is still no definitive study regarding the clinical • Hebert PC, Carson JC. Transfusion threshold of 7 g per
consequences of prolonged RBC storage. Given the importance of the deciliter—the new normal. N Engl J Med, 2014; 371:1459-1461.
question, a definitive clinical trial is necessary to answer this question. If
https://kat.cr/user/tahir99/
age of transfused RBCs does in fact have clinical consequences, it would • Hebert PC, Fergusson D, Blajchman MA, et al. Clinical outcomes
have major ramifications on the already limited blood supply. following institution of the Canadian universal leukoreduc-
tion program for red blood cell transfusions. JAMA. April 16,
2003;289(15):1941-1949.
ERYTHROPOIETIN IN THE CRITICALLY ILL
• Hebert PC, Wells G, Blajchman MA, et al. A multicenter, random-
As noted above, the anemia associated with critical illness is fundamentally ized, controlled clinical trial of transfusion requirements in critical
similar to the anemia of chronic inflammatory disease. A major feature of care. Transfusion Requirements in Critical Care Investigators,
the anemia of critical illness is a failure of circulating erythropoietin con- Canadian Critical Care Trials Group. N Engl J Med. February 11,
centrations to increase appropriately in response to the reduction in Hb. 1999;340(6):409-417.
These observations have suggested that treatment with pharmacological • Holst LB, Haase N, Wetterslev J., et al. Lower versus higher hemo-
doses of EPO might decrease exposure to allogeneic blood and raise the Hb globin threshold for transfusion in septic shock. N Engl J Med.
level in critically ill patients. The rationale for EPO therapy is that increased 2014; 371:1381-1391.
erythropoiesis will result in higher Hb levels and thus a reduced need for • Marik PE, Sibbald WJ. Effect of stored-blood transfusion on oxy-
RBC transfusions. The extension of this is that by avoiding the negative gen delivery in patients with sepsis. JAMA. June 16, 1993;269(23):
effects of transfused RBCs clinical outcomes would improve. 3024-3029.
The above rationale led to a series of studies assessing the role of • Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice
EPO therapy in the critically ill. 31-33 Taken together, the studies, which guideline: red blood cell transfusion in adult trauma and critical
enrolled close to 3000 critically ill patients overall including 1500 trauma care. J Trauma. December 2009;67(6):1439-1442.
patients, suggest there is little benefit for RBC transfusion reduction
with EPO therapy if transfusion practice is conservative (lower trans- • Rao SV, Jollis JG, Harrington RA, et al. Relationship of blood
transfusion and clinical outcomes in patients with acute coronary
fusion threshold). However, the studies do provide some evidence
suggesting a mortality benefit for EPO in trauma patients. The absence syndromes. JAMA. October 6, 2004;292(13):1555-1562.
of significant RBC transfusion reduction suggests that the mortal- • Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy
ity benefit observed is a result of nonhematopoietic actions of EPO. in the treatment of severe sepsis and septic shock. N Engl J Med.
Mortality was not significantly decreased in medicine and surgery November 8, 2001;345(19):1368-1377.
nontrauma patients receiving EPO therapy. There was an increase in • Rohde JM, Dimcheff DE, Blumberg N, et al. Health care- associated
thrombotic complications observed with EPO therapy. Whether EPO infection after red blood cell transfusion: a systematic review and
should or should not be considered for trauma patients will require meta-analysis. JAMA. 2014;311:1317-1326.
additional confirmatory trials. On the other hand, the data available • Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for
do not support the use of EPO for medicine or surgery nontrauma acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11-21.
patients admitted to the ICU, unless they have an approved indication • Vincent JL, Baron JF, Reinhart K, et al. Anemia and blood transfusion
for EPO. Treating these latter patients would expose them to potential in critically ill patients. JAMA. September 25, 2002;288(12):1499-1507.
risk (thrombotic complications) with no identifiable benefit in either • Weiskopf RB, Viele MK, Feiner J, et al. Human cardiovascular and
transfusion reduction (assuming conservative practice) or mortality. metabolic response to acute, severe isovolemic anemia. JAMA.
Given the increase in thrombotic complications with EPO therapy, January 21, 1998;279(3):217-221.
prophylactic heparin should also be considered if EPO is given. Future
studies should focus on understanding how the nonhematopoietic
actions of EPO are beneficial in the critically ill. REFERENCES
Complete references available online at www.mhprofessional.com/hall
SUMMARY OF RECOMMENDATIONS
Based on the data available recent guidelines have been proposed for
trauma and critically ill patients. 34 CHAPTER Bleeding Disorders
• Transfusions are indicated for patients with evidence of hemorrhagic 90 Karl Thomas
shock.
• Consider transfusion of one unit of RBCs if the Hb is less than or
equal to 7 g/dL in stable critically ill patients.
• Consider transfusion of one unit of RBCs if Hb is less than 10 g/dL
in the first 6 hours of resuscitation of severe sepsis or septic shock if KEY POINTS
has not reached 65% with resuscitation to target CVP.
Scv O 2 • Bleeding disorders and hemorrhagic complications are common
• Consider transfusion of one unit of RBCs for patients with active in ICU patients.
acute coronary syndromes with Hb less than 8 g/dL. • Bleeding disorders may be divided into thrombocytopenias,
• In the absence of bleeding, RBC transfusions should be given as soluble coagulation factor deficiencies, and combined disorders.
single units.

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