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Risks and Indications for RBCs Transfusions. David Stroncek, MD Chief, Laboratory Services Section Department of Transfusion Medicine, Clinical Center, NIH, Bethesda, Maryland. Adverse Effects of RBC Transfusions. Viral Infections Hepatitis B Hepatitis C HIV

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risks and indications for rbcs transfusions

Risks and Indications for RBCs Transfusions

David Stroncek, MD Chief, Laboratory Services Section Department of Transfusion Medicine, Clinical Center, NIH, Bethesda, Maryland

adverse effects of rbc transfusions
Adverse Effects of RBC Transfusions

Viral Infections

  • Hepatitis B
  • Hepatitis C
  • HIV
  • HTLV I and II
  • West Nile Virus
  • CMV
risk of transfusion transmitted infections
Risk of Transfusion-Transmitted Infections

1. Dodd RY et al. Transfusion. 2002;42:975-9

2. O\'Brien SF et al.Transfusion. 2007;47:316-25

adverse effects of rbc transfusions1
Adverse Effects of RBC Transfusions

Other pathogens

  • Bacteria
  • Malaria
  • Chagas
  • Babesia
adverse effects of rbc transfusions2
Adverse Effects of RBC Transfusions

Hemolytic Transfusion Reactions

  • ABO (wrong unit of blood)
  • Antibodies to other RBC antigens (delayed hemolytic transfusion reactions)

Leukocyte antibody mediated problems

  • Alloimmunization (refractory to platelet transfusions)
  • Febrile reactions (antibody in transfusion recipient)
  • Transfusion related acute lung injury (TRALI) (antibody in blood donor)
adverse effects of rbc transfusions3
Adverse Effects of RBC Transfusions

Other

  • Fluid overload
  • Anaphylaxis
  • Urticaria
  • GVHD
  • Immune modulation
function of rbcs
Function of RBCs

Oxygen Transport

  • Delivery of oxygen from lungs to tissues

Oxygen transport is dependent on

  • Hematocrit
  • Cardiac output
  • Oxygen extraction
normovolemic amenia
Normovolemic Amenia

As hematocrit falls

  • Blood viscosity decreases
  • Cardiac output increases (Stroke volume,  pulse)
  • Delivery of O2 
  • O2 extraction 
  • Consumption of O2 remains constant
limits of compensation
Limits of Compensation

At very low hemoglobin levels (approximately 4 g/dL)

  • O2 delivery does not meet demand
  • Anerobic metabolism  lactic acidosis  cardiac arrest
indications for rbc transfusions
Indications for RBC transfusions

1940s

  • Recommended that surgery patients have a hemoglobin of 8 to 10 g/dL
  • Led to a general rule of hemoglobin > 10 g/dL of surgery patients

1980s

  • Development of invasive monitoring techniques lead to a better understanding of oxygen delivery and consumption
  • Lower hemoglobin levels could be tolerated
hemoglobin and hematocrit levels in healthy adults
Hemoglobin and Hematocrit Levels in Healthy Adults

Hematology: Basic Principles and Practice. Elsevier 2005

transfusion trigger multicenter randomized control study of icu patients
Transfusion Trigger:Multicenter, Randomized Control Study of ICU Patients

Herbert PC et al. N Engl J Med. 1999;340: 409-417

transfusion trigger multicenter randomized control study of icu patients1
Transfusion Trigger:Multicenter, Randomized Control Study of ICU Patients

Herbert PC et al. N Engl J Med. 1999;340: 409-417

restrictive vs liberal transfusion in other conditions
Restrictive vs Liberal Transfusion in Other Conditions

No difference

Pediatric ICU patients

  • 7.0 g/dL vs 9.5 g/dL
  • Lacroix J, et al. N Engl J Med. 2007:356;1609-1619

Moderate to severe head injury

  • 7.0 g/dL vs 10.0 g/dL
  • McIntyre LA et al. Neutrocrit Care 2006;5:4-9

Possible difference

Cardiovascular disease

  • 7.0 g/dL vs 10.0 g/dL
  • Liberal transfusions may be better in patients with acute myocardial infarction and unstable angina
  • Hebert PC et al. Crit Care Med. 2001;29:227-234.
optimal hematocrit
Optimal Hematocrit?

Laboratory and mathematical model

  • Maximize delivery of oxygen
  • O2 delivery is proportional to hematocrit and blood flow rate.
  • As hematocrit increases viscosity increases and flow rate decrease
  • Optimal hematocrit is approximately 35%
  • Crowell JW and Smith EE. J Appl Physiol 1967;22:501-504

Clinical

  • Risks associated with increasing the hemoglobin/hematocrit justify the clinical benefits
conclusions
Conclusions
  • Although RBCs are much safer than 20 years ago, transfusion practices have become more restrictive
  • The transfusion threshold at most institutions is a hemoglobin of 7 to 8 g/dL for most patients
  • Higher thresholds are used for specific patients
disclaimer
Disclaimer

The views expressed are those of the presenter and do not necessarily represent the position of the National Institutes of Health or the Department of Health and Human Services.

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