1 / 46

Update on Transfusion Practice Where’s the Evidence?

Update on Transfusion Practice Where’s the Evidence?. Connie Lorette Calvin, PhD, CRNA, APRN Northeastern University. Richard Lower (1631-1691) Performed the first transfusion (animal to animal) in 1665 Lamb to human 1667. History. 1667 Jean Baptist Denis Lambs blood Calves blood.

naif
Download Presentation

Update on Transfusion Practice Where’s the Evidence?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Update on Transfusion PracticeWhere’s the Evidence? Connie Lorette Calvin, PhD, CRNA, APRN Northeastern University

  2. Richard Lower (1631-1691) Performed the first transfusion (animal to animal) in 1665 Lamb to human 1667 History

  3. 1667 Jean Baptist Denis • Lambs blood • Calves blood

  4. 1774 – Lavoisier - Role of oxygen in respiration Priestley – RBC as oxygen carriers 1818 - first human to human transfusion James Blundell

  5. 1900 – Landsteiner A-B-O 1902– Sturli & DeCastello AB 1940-Landsteiner Rh typing Karl Landsteiner1930 Nobel Prize Laureate

  6. Lewisohn’s Method of Transfusion1913Blood is collected in a citrated flask….…...and immediately transfused.

  7. Enculturation of Transfusion • Blood is a “life giving force” • 1-800-save a life

  8. 1971 - 1987 • Red cell transfusion more than doubled • Platelet transfusion grew 50 fold • Risk of hepatitis transmission was approximately 1/100 U transfused • HIV / AIDS • Is transfusion beneficial

  9. Transfusion Trigger • Hemoglobin 10gm/dl • Hematocrit 30% • Blood loss of 15% of circulating blood volume • Clinical presentation • Risk:Benefits

  10. “Safest Blood” • Voluntary blood donation – self exclusion • Surrogate tests • NAT • Does transfusion of banked blood improve outcome for patients?

  11. Infectious Risk of Transfusion

  12. Infectious Risk of Transfusion

  13. Troublesome Events! • Alloimmunization (platelets – Leukocytes - RBC) • HLA – antigens • Granulocyte – platelet – RBC specific • Allergic reactions • Febrile reactions • ABT – related mortality • TRALI – TAS – HTRs – TTI • What are the costs of these?

  14. Mean annual # of ABT related deaths from 3 leading causes Eleftherios et al., 2010

  15. TRALI -Transfusion Related Acute Lung Injury • All plasma containing blood products • Non-cardiogenic pulmonary edema • 1-2 hours post-transfusion • Dyspnea -cough - fever • Misdiagnosed - TACO • Volume overload • Cardiogenic pulmonary edema • Multiparous donors • HLA sensitization

  16. Hemolytic Transfusion Reactions • ABO • ABO antigens and/or antibodies to other RBC antigens. • Acute = 24 hours • Delayed > 24 hours • Non-ABO • RBC antibodies • Jkb, Jka, Kell, Fya, Fyb, E, Jsa, I

  17. Percent of HTR deaths ABO versus Non-ABO Eleftherios et al., 2010

  18. Transfusion Associated Sepsis • Bacterial contamination • Platelets – highest • Decreased with single-donor • Organisms • Staphylococcus epidermidis • E-coli • Staphylococcus aureus • Bacillus cereus

  19. Transfusion Related Immunomodulation - TRIM • APCs and plasma • Non-specific immunosuppression • Antigen-specific immunosuppression • Impaired T-cell mediated immunity • Decreased macrophage • Altered cytokine • Renal allografts – better outcomes • Tumor recurrence • Reduction in survival • WBCs – HLA – CD4 – Helper T-cell

  20. Leukocyte Reduction • Non-hemolytic transfusion reactions • CMV transmission • HLA alloimmunization • Capraro et al. • Infection rate • 90-day mortality • Length of ICU stay

  21. Benefits???

  22. Oxygen Transports • Blood flow - CO • Arterial O2 content • DO2 = CO X CaO2 • Transportation • Hemoglobin • Plasma • DO2 = CO X (%Sat X 1.39 X [Hb])

  23. Impact of Anemia • CRIT • NNE • Lowest hct on bypass = increased mortality and incidence of heart failure • However blood transfusions = increased need for mechanical and inotropic support • Nadir hgb following MI predicts mortality • Aronson et al. 2007

  24. Adaption to Anemia • Shift in oxyhemoglobin dissociation curve • Right -  synthesis 2,3-DPG • Hemodynamic alterations • CO • Microcirculatory alterations • Vascular tone • Renin-angiotensin-aldosterone system

  25. Impact of Preop Anemia on Postop Adverse Events • Cardiac surgical patients n=5065 • Low preop hgb = Comorbidities = adverse cardiac events • Anemia = adverse postop neurologic and renal outcomes • Kulier et al. 2007 • Preoperative anemia and intraoperative blood transfusion were both independent risk factors for adverse outcomes. • Incidence increased significantly as a function of numbers of units of RBCs transfused

  26. Efficacy of RBC transfusion • DO2 and utilization = improved outcomes • Delivery - Stored RBC • Low p50 – shift oxygen dissociation curve – left • Depletion 2,3, DPG • Depletion ATP • Oxygen utilization • Organ level • Hemodynamics and oxygen transport parameters

  27. Anemia and Transfusion • Anemia predicts adverse outcomes • Current transfusion practice provides no benefit or is harmful • Ischemic complications were not decreased with blood transfusion • Murphy et al. 2007 • Patients who received blood that was stored for more than 2 weeks prior to transfusion had a statistically significant increase in in-hospital mortality, prolonged intubation, renal failure and sepsis or septicemia • Koch 2007

  28. Storage LesionsBiochemical Changes • Lactate  = 1.6 - 30.1 mmol/L • pH  = 7.2 - 6.6 • 2,3-DPG  • ATP • GSH  • K+ = 3.9 - 78 mEq/L • SNO-Hb  • Ionized Calcium and magnesium = 0 • Free Hemoglobin 

  29. Regulation of microvascular perfusion mediated by Hemoglobin + NO Low pO2 Low pH • Release • ATP 

  30. Storage LesionsBiomechanical • Hemolysis • Membrane area  • Osmotic fragility • RBC adhesion • Deformability 

  31. Storage LesionsOxidative • Hemoglobin oxidation • Hemoglobin denaturation • Lipid peroxidation • Bioactive Substance • Cytokines • Histamines • Lipids • Soluble HLA

  32. Storage • Morphologic • Biochemical • Storage duration • Increased mortality • Increased length of stay in ICU/Hospital • Multiple organ failure • TRALI • Increased infections • Impaired tissue oxygen utilization

  33. Benefits • Hemorrhagic shock • Critically ill do not tolerate anemia • Goal • Increase DO2 • Increase VO2

  34. Efficacy of RBC Transfusion in the Critically Ill • RBC transfusion did not improve VO2 • RBC transfusion was not associated with improvements in clinical outcomes • RBC transfusion was associated with worse outcomes • Factors to identify patients who may benefit • Lack of efficacy related to • Adherence of stored RBCs • Nitric Oxide binding • Donor leukocytes • Inflammatory response • Decreased red cell deformability

  35. Large Randomized Controlled Trials • Restrictive strategies vs. liberal strategies • Carson et al. 1996 • No data demonstrating that allogeneic RBCs increase oxygen carrying capacity • Hebert et al. 1997 • Mortality rate was doubled for patients receiving perioperative transfusion • Engoren et al. 2002 • The number of RBC units transfused is an independent predictor of worse clinical outcome • Corwin et al. 2004 • Corwin et al. 2007

  36. Transfusion (1-2 U) Does Not Increase Oxygen Delivery!! • The influence of allogeneic RBC transfusion compared with 100% oxygen ventilation on systemic oxygen transport and skeletal muscle oxygen tension after cardiac surgery • O2 - not the blood transfusion increased tissue oxygen levels Suttner et al. (2004) anesth analg 99: 2-11

  37. Rejuvenation • Post-storage metabolic manipulations • Mixture of pyruvate – inosine – phosphate – adenine • Rejuvesol (Cytosol Laboratory Inc) • 37°C incubation followed by cell washing [24] • Restored ATP • Elevated 2,3-DPG

  38. Goals • Reduce hemolysis • Reduce dead-on-arrival RBC • Iron toxicity • Vasoconstriction via NO scavenging • Maintain deformability / prevent aggregation • Prevent capillary blockage • Maintenance of high ATP – 2,3, DPG – SNO-hb • Minimize oxidative damage • Prevent release, and/or remove bio-active substances • Prevention of TRALI • Leukoreduction, irradiation, pathogen-reduction, etc.

  39. Hemoglobin Solutions • Limited duration of action • Half life 10 - 30 minutes • High colloidal osmotic pressure • 7 g/dL • Vasoactive properties • Oxygen affinity • Dissociation into dimers

  40. Acute Normovolemic Hemodilution • Conserved RBC Mass • Improved Oxygenation • Preservation of Hemostasis

  41. Other Autologous Transfusions • Intraoperative blood collection • Cell saver – shed blood • Postoperative blood collection • Shed blood

  42. Recombinant Factor VIIa • Approved for hemophilia patients • Enhances thrombin generation on activated platelets • Cost – exorbitant $15,000.00 • Thrombotic complications

  43. DDAVP • Dose: 0.3 mcg/kg over ½ hour • Release of factor VIII and vWF • Enhances platelet adhesion to the vessel wall • Shortens the prolonged aPTT and bleeding time

  44. Conclusion • Benefits of transfusion are theoretical • Risks of transfusion are fact • Transfusion of allogeneic blood represents a major risk for immunosuppression and adverse outcome • Transfusion must be considered carefully • Accept lower transfusion thresholds • Alternatives to RBC transfusion

  45. References Spiess BD. Blood transfusion: The silent epidemic. Ann Thorac Surg 2001;72:S1832-7. Gombotz H, Rehak PH, Shander A, Hofman A. Blood use in elective surgery: The Austrian benchmark study. Transfusion 2007;47:1468-80. Corwin HL, Carson JL. Blood transfusion-When is more really less? N Engl J Med 2007;356:1667-9.Shander A. Emerging risks and outcomes of blood transfusion in surgery. Semin Hematol. 2004:41(suppl):117-24. Brecher ME, Goodnough LT. The rise and fall of preoperative autologous blood donation. Transfusion 2001;41(12):1459-62. Sugai Y, Sugai K, Fuse A. Current status of bacterial contamination of autologous blood for transfusion. Transfus Apheresis Sci. 2001;24(3):255-9. Carson Jl, Duff A, Poses RM, et al. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet 1996;348:1055-60. Hébert PC, Wells G, Tweeddale M, et al. Does transfusion practice affect mortality in critically ill patients? Am J Respir Crit Care Med 1997:155:1618-23. Vincent JL, Baron JF, Reinhart K, et al. Anemia and blood transfusion in critically ill patients. JAMA 2002;288(12):1499-1507. Hébert PC, Wells G, Blajchman MA, et al. A Multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Eng J Med 1999;340(6);409-17. Ho J, Sibbald WJ, Chin-Yee IH. Effects of strorage on efficacy of red cell transfusion: When is it not safe? Crit Care Med 2003:31[suppl.]:S687-97. Opelz G, Sengar DPS, Mickey MR, et al. Effect of blood transfusions on subsequent kidney transplants. Transplan Proc. 1993;5:253-9. Blumberg N, Heal JM, Murphy P, et al. Association between transfusion of whole blood and recurrence of cancer. Br Med J. 1986;293:530-3. Blumberg N, Heal JM, Chuang C, et al. Further evidence supporting a cause and effect relationship between blood transfusion and cancer recurrence. Annm Surg. 1988;207:410-5. Blumberg N, Chuang-Stein C, Heal JM. The relationship of blood transfusion, tumor staging, and cancer recurrence. Transfusion. 1990;30:291-4.

  46. Vamvakas EC. Possible mechanisms of allogeneic blood transfusion-associated postoperative infection. Trans Med Rev. 2002;16(2):144-60. Blumberg N, Heal SM. Universal leukocyte reduction of blood transfusion. Clin Inf Dis. 2007;45:1014-15. Vamvakas EC, Blajchman MA. Universal WBC reduction: The case for and against. Transfusion 2001;41:691-712. Capraro L, Kuitunen A, Vento AE, et al. Universal leukocyte reduction of transfused red cells does not provide benefit to patients undergoing cardiac surgery. J Cardiothor Vas Anes. 2007;21(2):232-6. Silliman CC, Boshkov LK, Mehdizadehkashi Z, et al. Transfusion related acute lung injury: epidemiology and a prospective analysis of etiologic factors. Blood 2003;101:454-62. Looney MR, Gropper MA, Matthay MA. Transfusion-related acute lung injury. Chest 2004;126:249-58. Kopko PM, Marshall CS, MacKenzie MR, et al. Transfusion-related acute lung injury: report of a clinical look-back investigation. JAMA 2002;287:1968-71. Vamvakas EC, Taswell HF. Long-term survival after blood transfusion. Transfusion 1994;34:471-7. Purdy FR, Tweeddale MG, Merrick PM. Association of mortality with age of blood transfused in septic ICU patients. Can J Anaesth 1997;44:1256-61. Moore FA, Moore EE, Sauaia A. Blood transfusion: An independent risk factor for postinjury multiple organ failure. Arch Surg 1997;132:620-5. Napolitano LM, Corwin HL. Efficacy of red blood cell transfusion in the critically ill. Crit Care Clin 2004;20:255-68. Engoren MC, Habib RH, Zacharias A, et al. Effect of blood transfusion on long-term survival after cardiac operation. Ann Thorac Surg. 2002;74:1180-6. Corwin HL, Gettinger A, Pearl RG, et al. The CRIT study: Anemia and blood transfusion in the criticallhy ill – current clinical practice in the United States. Crit Care Med 2004;32(1):39-52. Suttner S, Piper SN, Kumle B, et al. The influence of allogeneic red blood cell transfusion compared with 100% oxygen ventilation on systemic oxygen transport and skeletal muscle oxygen tension after cardiac surgery. Anesth Analg 2004;99:2-11.

More Related