Giora Netzer (@GioraNetzer) is one of those “evidence-based medicine” guys, who has an obsession with transplant medicine – to be more specific – blood transfusion strategies in the ICU. Â What are the actual transfusion risks in the modern era of blood transfusions? What are your “transfusion triggers”? Â Should we be lowering our hemoglobin threshold to 6 mg/dL? Â We need a TMN (Transfuse me now) test!!
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Etiologies of Anemia in the Non-hemorrhaging ICU
- Not making them (RBCs – decreased erythropoietin, RBC survival, & bone marrow suppression)
- Braking them (hemolysis)
- Shaking them (phlebotomy, surgical procedures, acute blood loss)
Transfusion Risks Today
- Most common reactions: fever, transfusion associated circulatory overload (TACO) occurs in about 1:100 (+) transfusions
- HIV/HCV infection & fatal hemolysis occurs in less than 1: 1,000,000 transfusions
- HBV transmission occurs in between 1:1,000,000 and 1:100,000 transfusions
Remember –Â A Transfusion is a Transplant!
- While RBCs are non-nucleated cells, leukocytes are – and are also pro-inflammatory
- Leukoreduction is not Leukoelimination – Packed-cell transfusions are still immunosuppressive
- Transfusion immunomodulation (TRIM) is a known, but incompletely understood entity
Unfortunately, we do not have a simple biomarker to guide transfusion such as the TMN blood test (Transfuse Me Now!)
— Dr. Jeff Carson
Transfusion Oct. 2010
What Should Our Transfusion “Triggers” Actually Be?
- Perhaps we should move from a numeric trigger to a symptomalogical trigger (i.e. symptomatic anemia)
- Cardiac chest pain
- Congestive HF
- Worsening tachycardia, tachypnea
- Hypotension
- We may be able to move the numeric trigger to 6 mg/dL in asymptomatic patients…
- What’s everyone else doing?
Afshar M, Netzer G. Update in critical care for the nephrologist: transfusion in nonhemorrhaging critically ill patients. Adv Chronic Kidney Dis. 2013;20(1):30-8.
Bottom Line:  In the non-hemorrhaging patient, whichever trigger you choose – give ONLY 1 unit of PRBCs at at time, then reassess.
References
- Hébert 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(6):409-17. [Free Full Text]
- Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365(26):2453-62. [Free Full Text]
- Carson JL, Kuriyan M. What should trigger a transfusion?. Transfusion. 2010;50(10):2073-5. [PubMed]
