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The Price of Transfusion: Can the Patient Afford It?

The Price of Transfusion: Can the Patient Afford It?. Babak Sarani, MD, FACS, FCCM Associate Professor of Surgery Chief, Trauma and Acute Care Surgery George Washington University. Objectives. Background Anemia Incidence of transfusion Is Transfusion Good? Is Transfusion Bad?

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The Price of Transfusion: Can the Patient Afford It?

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  1. The Price of Transfusion: Can the Patient Afford It? Babak Sarani, MD, FACS, FCCM Associate Professor of Surgery Chief, Trauma and Acute Care Surgery George Washington University

  2. Objectives • Background • Anemia • Incidence of transfusion • Is Transfusion Good? • Is Transfusion Bad? • Balancing Risk/Benefit of Transfusion • Past and present guidelines for transfusion

  3. Background • 4 million people per year in the US • 8-12 million units of blood per year • 80% are surgical or critically ill patients • $500 / unit

  4. Frequency of Transfusion in the ICU Napolitano et al. CCM 2009; 37 (12): 3124

  5. Anemia in the ICU • Blood loss • Phlebotomy – 40cc/day in ABC trial • Surgery • GI Bleed • Decrease Production • Epo resistance and secretion • RBC Destruction • Increase plasma volume after resuscitation

  6. ICU Patient T.R. * 50 yo Female * Pancreatitis * Acute MI Respiratory Failure ICU LOS 105 days

  7. ICU Patient T.R. * No Documented GI Bleed * Never Anticoagulated * No Renal Failure

  8. Medical Vampire TOTAL BLOOD WITHDRAWN 3,502 CC

  9. ICU Patient T.R. * Transfused 20 units of pRBCs over ICU Stay * No Major Surgery * No Documented GI Bleed * Never More than Two Units in a Day

  10. ICU Patient T.R. * CBCs $4332.00 * PT/PTTs $4796.00 * CHEM-7 $4075.50 * Ca/Mg/PO4 $7956.00 * ABGs $18150.00 $39, 309.50

  11. So What? Just Refill the Tank.

  12. Why Transfuse - Benefits • Blood is good • 1958 pts, mortality 1.3% if Hg > 12 v 33% if Hg < 6 pre-op* • 2083 pts, OR post-op death 2.5 for each gram Hg < 8* • Volume resuscitation *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 Carson JL, Noveck H, Berlin JA, Gould SA. Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion. Transfusion 2002;42(7):812-8.

  13. Why Transfuse - Benefits • Hg 5 v 7 g/dL in healthy volunteers • No change in aerobic metabolism • Impaired cognition, memory, reaction time Weiskopf et al. Clin Neurophysiol 2005; 116:1028 Weiskopf et al. Anesth 2000; 92:1646

  14. Why Transfuse • O2 delivery = cardiac output x O2 content O2 content = 1.34 x hg x SaO2 + 0.003 x PaO2 • Volume expansion [Colloid]

  15. Indications for Transfusion • Hg 10, Hct 30% • Rheologic value described in 1975 • Indicated for active MI/Angina • Recommended for those at risk of bleeding (cushion) • NOT a useful endpoint in active hemorrhage

  16. The Downside of Transfusion • Blood borne pathogens • Volume overload • Immune dysfunction • Lung Injury • Net Result • TRICC, ABC, CRIT • What about CAD??

  17. RBC Blood Borne Infection

  18. Studies to Know • TRICC – Hebert 1999 • ABC – Vincent 2002 • CRIT – Corwin 2004

  19. Transfusion Requirements in Critical Care (TRICC) • Design: Prospective, randomized, Hg 7 v 10 • Setting: 22 Canadian ICU’s • Patients: 838 patients • End Points: Mortality, Organ Failure • A priori: subgroup analysis for APACHE, age, CAD Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999;340(6):409-17.

  20. TRICC Trial No benefit from transfusion

  21. TRICC Trial Detrimental effect in low acuity

  22. TRICC Trial Detrimental effect in young

  23. Anemia and Blood Transfusion in Critically Ill Patients (ABC) • Design: Prospective, observational • Setting: 146 ICU, multi-national • Patients: 3534 pts, MICU/SICU • Phlebotomy 41cc/day • Adjusted mortality 23% v 17% • Adjusted OR of death 1.37/unit transfused Vincent JL, Baron JF, Reinhart K, et al. Anemia and blood transfusion in critically ill patients. Jama 2002;288(12):1499-507

  24. The CRIT Study: Anemia and Blood Transfusion in the Critically Ill -- Current Clinical Practice in the United States Design: Prospective, observational Setting: A total of 284 ICUs in 213 hospitals Patients: 4,892 patients Combined MICU/SICU Excluded: Peds, CTICU, CCU, NICU, Burn, Dialysis Endpoints: Incidence of transfusion, mortality 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

  25. CRIT Study NOTE: Results adjusted for severity of illness

  26. Transfusion in CAD • Excluded from most trials • Post-Hoc analysis of GUSTO IIb, PARAGON, PURSUIT • 24,112 pts; 2401 transfused RBC • Increase mortality if hct > 25% • Hazard ratio 3.94 after transfusion (adjusted) Rao SV, Jollis JG, Harrington RA, et al. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. Jama 2004;292(13):1555-62.

  27. Transfusion in CAD (TRICC) Hebert CCM 2001 29:227

  28. Transfusion for MI or ACS

  29. Out-of-ICU Periop RBC Transfusion • N=8787, 20 hospitals, 1983-1993 • Age >60, hip ORIF Carson. JAMA 1998; 279:199

  30. TRICC Trial - CAD • “We believe that a restrictive strategy can be implemented in patients with CAD but should be considered with caution in patients with acute MI or unstable angina” • Hebert

  31. CCM 2005; 33: 1104

  32. Anemia and TBI JACS 2008; 207 : 398

  33. Transfusion in TBI JACS 2008; 207 : 398

  34. N=15,000 2003; 54:898

  35. J Trauma 2003; 54:898

  36. PRBC and Mortality Crit Care Med 2008; 36 (9)

  37. Napolitano et al. CCM 2009; 37 (12): 3124

  38. Mechanisms to Explain Detrimental Effects of Transfusion • Sludging and Age of RBC • Transfusion Associated Volume Overload (TACO) • Transfusion Related Acute Lung Injury (TRALI) • Transfusion Related Immunomodulation (TRIM)

  39. Biological Impact of RBC Storage Crit Care Med 2007; 35 : 2576

  40. Sludging • Change in cytoskeleton • ATP depletion • Oxidative Stress • Depletion of NO • RBC is 7 microns, cap is 3 microns

  41. Sludging

  42. Sludging Marik, JAMA 1993; 269:3024

  43. Age of RBC and Mortality in Massive Transfusion J Trauma 2008; 65 : 279

  44. Age of Blood Adjusted for age, sex, ISS, MV Weinberg. J Trauma. 2008; 65:794

  45. TRALI • Non-cardiogenic pulm edema within 4 hours of transfusion • Incidence 1:5,000 – 1:100,000 • Confounded in setting of pre-existing lung injury/ARDS/Contusion • Inflammatory reaction to transfused protein/antigen – highest risk with FFP

  46. PRBC and ARDS Crit Care Med 2008; 36 (9)

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