Blood and Blood products in ICU - Indications and Complications

Yasser Alwabli

Introduction

• Anemia in ICU

• No of transfusions

Indications - RBCs

• Acute hemorrhage with hemodynamic instability (ie, hemorrhagic shock).

Clinical practice guidelines Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice guideline: red blood cell transfusion in

adult trauma and critical care. Crit Care Med 2009; 37:3124

Indications - RBCs

• Hb < 7 g\dL

TRICC TrialHébert 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; 340:409.

• 838 critically ill patients• 418 - restrictive transfusion (Hb<7.0 g\dL → 7.0 – 9.0)• 420 - liberal strategy (Hb<10.0 g\dL → 10.0 – 12.0 g\dL)• 30-day mortality was similar in the two groups (18.7%

vs.23.3%, P= 0.11)• Less acutely ill (APACHE II < 20) - 8.7% and 16.1% in the;

P=0.03• Age < 55 - 5.7% and 13.0%; P=0.02• Clinically significant cardiac disease (20.5% and 22.9%

P=0.69)• The mortality rate during hospitalization was significantly

lower

Upper GI bleedVillanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal

bleeding. N Engl J Med . 2013 Jan;368(1):11-21

• 921 patients with severe acute upper gastrointestinal bleeding

• 461 to a restrictive strategy and 460 to a liberal strategy

• The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02).

• Conclusions: compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. 

Indications - Plasma

• Controversial

• Generally indicated whenever hemostasis is inadequate and the benefit of correcting the insufficient hemostasis (ie, reduced bleeding) is believed to outweigh the risks of the plasma transfusion.

Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized

controlled trials. Yang L, Stanworth S, Hopewell S, et al. Transfusion 2012; 52:1673.

• Trials involving transfusion of FP up to July 2011• Covered prophylactic and therapeutic FP use in liver, in

cardiac surgery, for warfarin anticoagulation reversal, for TTP treatment, for plasmapheresis, and in other settings, including burns, shock, and head injury.

• CONCLUSION: – Combined with the 2004 review, 80 RCTs have

investigated FP with no consistent evidence of significant benefit for prophylactic and therapeutic use across a range of indications evaluated.

Indications - Plasma

• Examples:– Active bleeding in the setting of known or strongly

suspected coagulation abnormalities.– Massive transfusion of packed red bloods cell– Prior to invasive and surgical procedures for which

there is a HIGH risk of bleeding complications if the patient has ANY potentially significant abnormality of their coagulation tests

– Prior to invasive procedures for which there is a LOW risk of bleeding complications if the patient has a SEVERE abnormality of their coagulation tests 

Indications - Platelets

• Patients with a platelet count <10 X 103 platelets/mL. – The purpose is to prevent spontaneous hemorrhage.

• Patients with a platelet count <50 X 103 

platelets/mL who are actively bleeding, are scheduled to undergo an invasive procedure, or have a qualitative intrinsic platelet disorder.

Indications - Platelets

• Patients with a platelet count <100 X 103 platelets/mL who have a central nervous system injury, have multisystem trauma, are undergoing neurosurgery, or require an intrathecal catheter for anesthesia.

• Patients with a normal platelet count who have ongoing active bleeding and a reason for platelet dysfunction, such as a congenital platelet disorder, chronic aspirin therapy, or uremia.

Complications

• Acute hemolytic reactions: Incidence: 0.016 of transfusions Causes: ABO incompatibility, clerical errors Symptoms: pain, fever, chills, retrosternal pain,

back pain, dyspnea, hypotension Investigations: free Hb, Haptoglobin, Coomb’s Treatment: stop transfusion, fluids to keep UOP

> 100 ml\hr, protect against pigment nephropathy (e.g Mannitol, urine alkalinization).

Complications

• Delayed hemolytic reactions: 0.025 of transfusions, mild and 35 %

asymptomatic, may produce jaundice and hemoglibnuria

No specific therapy

Febrile nonhemolytic reactions: 7% of transfusions, due to antileuckocyte

antibodies, self-limited, exclude hemolysis. Antipyretics as needed, avoided by leukoreduced

blood.

Complications

• Allergic reactions: Mild urticaria to anaphylaxis, if severe

reaction stop transfusion and Epinephrine may be used.

Volume overload: Expanding intravascular volume which is

potential cause of pulmonary edema. FFP higher incidence due to hyperoncotic state.

Complications

• Acute lung injury: Alloreactive plasma antibodies contained within red

blood cell products or fresh frozen plasma can lead to the agglutination and activation of leukocytes, which may result in acute lung injury and noncardiogenic pulmonary edema (ie, transfusion-related acute lung injury [TRALI]). Clinical findings range from mild increases in oxygen requirements to severe acute respiratory distress syndrome (ARDS). The full extent of pulmonary dysfunction may not manifest for hours to days after the transfusion was administered.