red cell transfusion: when do we transfuse? · red cell transfusion: when do we transfuse? dr wing...
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Red Cell Transfusion: When do
we transfuse?
Dr Wing RobertsHaematology Registrar
Nurse Authorisation Education Symposium
NHSBT, 25th February 2016
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Objectives
• Who do we transfuse?
• Hb trigger for transfusion?
• How much blood?
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Red cell transfusion
The theory:
• Increase oxygen carrying capacity of the blood
• Avoid tissue hypoxia
• Used in acute or chronic anaemia
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Why is appropriate transfusion
important?
• Lack of consensus in its use & variation in
practice
• Inappropriate use is widespread
• Safety of transfusion – both infectious & non-
infectious complications
• Limited resource
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Red cell issues
• 2.3 million units in 1999
• 1.7 million units in 2012
• Change in surgical practice
• Better blood transfusion
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Cases
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Case 1
• 32yr old lady presents feeling tired. History of
menorrhagia.
• Hb 69 g/L
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Case 2
• 75yr old gentleman Myelodysplastic
Syndrome, requires tranfusion every 4-6
weeks.
• Feeling tired and feels like he is ‘ready for next
tranfusion’
• Hb 89 g/L
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Case 3
• 67yr old lady with chronic kidney disease
• Feels tired
• Hb 82 g/L
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Case 4
• 81yr old gentleman who had a myocardial
infarction 2yrs ago
• Hb 80 g/L
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Case 5
• 65yr old lady awaiting bowel surgery in four
weeks time.
• Hb 87 g/L
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Who to transfuse?
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The Old Way
80yr old lady on MAU with LRTI & Hb 83 g/L
•Ward round: antibiotics, give 2 units, move on!
What’s the Problem?
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Considerations
• Why is she anaemic? Is there an alternative?
• Is she symptomatic
• Weight of patient ?90kg ?40kg
• Is she at risk of fluid overload?
• Does she consent?
• Special requirements
– Irradiation
– CMV negative
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‘Symptomatic Anaemia’
Its not feeling a bit tired!
•Unstable cardiac disease
•Orthostatic hypotension
•Tachycardia not responding to fluid
•Congestive cardiac failure
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Alternatives?
• Does something need to be replaced
– Iron replacement (oral/IV)
– Folate/B12
• Kidney failure
– Erythropoietin +/- iron
• Pre-operatively
– Iron (oral vs IV)
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Transfusion Triggers
• Should not be based solely on Hb reading
• Hb value used as a guide
• Decision should consider clinical situation, co-
morbidities and symptoms
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Blood TransfusionGuidelines
NICE guideline. Published: 18
November 2015
nice.org.uk/guidance/ng24
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Thresholds and targets
• Use restrictive RBC transfusion thresholds for
patients who do NOT:
– Have major haemorrhage
– Have acute coronary syndrome
– Need regular blood transfusions for chronic
anaemia
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Restrictive RBC transfusion threshold
• Threshold of 70g/litre
• Hb target of 70-90g/litre AFTER transfusion
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Acute coronary syndrome
• Threshold 80g/L
• Target of 80-100g/L post transfusion
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Transfusion for chronic anaemia
• For patients on regular transfusions
• Setting individual threshold and targets
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Alternatives to blood transfusion for
patients having surgery
• Intravenous and oral iron
– Oral iron before and after surgery to patients with iron-deficiency anaemia
– IV iron may sometimes be appropriate
• Cell salvage and tranexamic acid
– Tranexamic acid to adults who are expected to have moderate blood loss > 500ml
– Intra-operative cell salvage with tranexamic acid to those expected to have high volume of blood loss
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Critical Care
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Transfusion in critical care setting
• Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients
• British Journal of Haematology, 2013, 160, 445–464
• TRICC trial
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Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients
British Journal of Haematology
Volume 160, Issue 4, pages 445-464, 27 DEC 2012 DOI: 10.1111/bjh.12143
http://onlinelibrary.wiley.com/doi/10.1111/bjh.12143/full#bjh12143-fig-0001
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RBC transfusion in adult critically ill
patients
• Default threshold 70g/L or below, with a
target Hb of 70-90g/L unless there are specific
co-morbidities or acute illness-related factors
(see later)
• Transfusion triggers should not exceed 90g/L
in most critically ill patients
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Severe sepsis
• In early severe sepsis (first 6 hours) during
resuscitation phase, if evidence of inadequate
oxygen delivery
– Consider RBCs to target Hb of 90-100 g/L
• During later stages of sepsis
– more conservative approach, target Hb 70-90 g/L
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Neurological critical care
• Controversial – insufficient evidence
1.Traumatic brain injury and/or cerebral
ischaemia target Hb 90g/L
2.Subarachnoid haemorrhage target 80-100g/L
3.Acute ischaemic stroke in ICU, target Hb >
90g/L – both high and low Hb associated with
unfavourable outcome!
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Acute coronary syndrome (ACS)
• Threshold 80g/L, Hb target 80-90g/L
• Anaemic critically ill patients with STABLE
angina should have Hb maintained >70g/L,
transfusion to Hb >100 g/L has uncertain
benefit
• Further studies are needed to determine the
optimal transfusion threshold for patients
with Chronic cardiovascular disease
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Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients
British Journal of Haematology
Volume 160, Issue 4, pages 445-464, 27 DEC 2012 DOI: 10.1111/bjh.12143
http://onlinelibrary.wiley.com/doi/10.1111/bjh.12143/full#bjh12143-fig-0001
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Alternatives to RBC Transfusion in
critical care
• In the absence of clear evidence of iron deficiency, routine iron supplementation is not recommended during critical illness
– Patients do not respond to iron alone
– Excess iron may increase susceptibility to infections.
• Erythropoietin should not be used to treat anaemia in critically ill patients
– needs further safety and efficacy
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Alternatives to RBC Transfusion in
critical care
• Consider blood conservation devices to
reduce phlebotomy-associated blood loss
• Paediatric blood sampling tubes to reduce
iatrogenic blood loss
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Other situations
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FOCUS study – hip fracture
• Elderly patients (high risk) undergoing hip
fracture surgery
• No difference in mortality or CV complications
between liberal (Hb <100g/L) or restrictive
transfusion (Hb <80 g/L)
• Same in TRACs study in patients undergoing
cardiac surgery
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Acute upper GI bleed evidence
• NEJM 2013, Villanueva et al. Transfusion
strategies for acute upper gastrointestinal
bleeding.
• Excluded patients with major haemorrhage
• Restrictive transfusion safer than liberal
– Mortality
– Re-bleeding
– Complications
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Acute blood loss
• Transfuse if
– Blood loss > 30-40% TBV
– Blood loss < 30% and pre-existing anaemia or
severe cardiac/respiratory distress
– Hb < 70g/L in otherwise fit
– Hb < 80g/L in elderly/cardiac/respiratory distress
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Chronic anaemia
• Consider alternatives
• Maintain Hb just above lowest concentration
associated with no symptoms
• Quality of life
• Special groups e.g. Thalassaemia & sickle cell
anaemia who are transfusion dependent
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Cancer patients
• MDS & transfusion-dependent
– Quality of life and symptoms
• Post-chemo
– Hb 80-90g/L threshold
• Radiotherapy
– maintain Hb > 100g/ L (improved outcome in
cervical cancer patients)
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How much?
• If no active bleeding and haemodynamically
stable
– Give ONE unit and review
• Weight is crucial
– 4 ml / Kg raises Hb by approx 10g /L
• 1 unit ≠ 10g/L
– Give one unit and review
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Cases again
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Case 1
• 32yr old lady presents feeling tired. History of
menorrhagia.
• Hb 69 g/L
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Case 2
• 75yr old gentleman Myelodysplastic
Syndrome, requires tranfusion every 4-6
weeks.
• Feeling tired and feels like he is ‘ready for next
tranfusion’
• Hb 89 g/L
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Case 3
• 67yr old lady with chronic kidney disease
• Feels tired
• Hb 82 g/L
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Case 4
• 81yr old gentleman who had a myocardial
infarction 2yrs ago
• Hb 80 g/L
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Case 5
• 65yr old lady awaiting bowel surgery in
the four weeks time.
• Hb 87 g/L
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1. Who needs a red cell transfusion
– Symptomatic anaemia
– Consider alternatives
2. Hb trigger
– No universal trigger
– Restrictive transfusion threshold/trigger in general
– Hb <70g/L if no bleeding and haemo-dynamically stable
3. How much?
– Weight of patient
– Give one and review
Summary: When to Transfuse?
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Questions?
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References
1. NICE guideline. Published: 18 November 2015
• nice.org.uk/guidance/ng24
2. Guidelines on the management of anaemia and red
cell transfusion in adult critically ill patients. British
Journal of Haematology, 2013, 160, 445–464
3. Guidelines for the clinical use of red cell transfusions.
British Journal of Haematology 2001, 113: 24-31