Risks and indications for rbcs transfusions
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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

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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


Transfusion fatalities reported to the fda fy 2004 to 2006

Transfusion Fatalities Reported to the FDA (FY 2004 to 2006)


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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