Download Transfusion Triggers Review [2A05, 1E04]

Blood Transfusion
Consultant CPD, November 23rd 2016
Blood is good
Blood is good
DO2 = CO x CaO2
Blood is bad
Pull out Betty! You’ve hit an artery
Blood is bad
 Infections
 Transfusion reactions
 TRALI
 TACO
 Chemical effects due to storage
 Microcirculation
 Immunomodulation
Blood is bad
 Infections
 Transfusion reactions
 TRALI
 TACO
 Chemical effects due to storage
 Microcirculation
 Immunomodulation
Blood is bad
Happy medium?
Happy medium?
Restrictive transfusion
 The policy of giving blood only when benefits are
deemed to outweigh potential risks
Restrictive vs liberal
transfusion strategies
Restrictive vs liberal
transfusion strategies
The evidence
Restrictive vs liberal
transfusion strategies
 7 key RCTs
 General / critical care
population
 Cardiac patients
 [TBI and SAH]
The TRICC study
The TRICC study
 LIBERAL
 Hb 100 -120
 RESTRICTIVE
 Hb 70 -90
 OUTCOMES
 Death at 30 days & 60 days, organ failures
The TRICC study
 LIBERAL
 Hb 107 ± 7 (5.6 ± 5.3)
 RESTRICTIVE (2.6 ± 4.1)
 Hb 85 ± 7
 P<0.01
The TRICC study
The TRICC study
The TRICC study
The TRICC study
The TRICC study
The FOCUS study
The FOCUS study
 2016 pts
 >50yrs
 IHD or risk factors
 Hb <100
 ♯ hip
The FOCUS study
The FOCUS study
 LIBERAL
 Hb >100
 RESTRICTIVE
 Hb < 80 or signs & symptoms
 OUTCOMES
 Death at 60 days or inability to walk >10ft
The FOCUS study
The FOCUS study
The FOCUS study
The FOCUS (2)study
The FOCUS (2) study
The RELIEVE study
>55yrs
CCM
The RELIEVE study
 LIBERAL
 Hb>90 (91-110)
 RESTRICTIVE
 Hb>70 (71-90)
 OUTCOMES
 Difference in mean Hb, mortality, adverse events,
HRQoL
The RELIEVE study
The RELIEVE study
 No significant difference in mortality or
any of the other outcome measures
Ischaemic Heart Disease
IHD pts
Am Heart Journal 2011; 162:300
IHD pts
Hospital-acquired anemia was defined as development of
new anemia during hospitalization using age, gender, and
race specific criteria
Mild – less than normal - >110
Moderate – 90-110
Severe - <90
IHD pts
The MINT study
The MINT study
 STEMI
 Non STEMI
 Unstable angina
 Cardiac catheter
 Hb<100
The MINT study
 LIBERAL
 Hb >100
 RESTRICTIVE
 Symptomatic
 Hb < 80
 OUTCOMES
 Death, MI, unscheduled revascularisation
The MINT study
The MINT study
The TRACS study
The TRACS study
 LIBERAL
 Ht >30
 RESTRICTIVE
 Ht >24
 OUTCOMES
 Death, severe morbidity (CVS, RS, Renal)
The TRACS study
The TRACS study
The TRACS study
Upper GI bleed pts
Upper GI bleed pts
 LIBERAL
 Hb 90 -110
 RESTRICTIVE
 Hb 70 -90
 OUTCOMES
 Death at 45 days, re-bleed, in hospital complications
Upper GI bleed pts
No transfusion 51% vs 14%
Upper GI bleed pts
Upper GI bleed pts
The TRISS study
The TRISS study
The TRISS study
 LIBERAL
 Hb >90
 RESTRICTIVE
 Hb >70
 OUTCOMES
 Death at 90 days
The TRISS study
The TRISS study
The TRISS study
The TITRe2 study
The TITRe2 study
 LIBERAL
 Hb >90
 RESTRICTIVE
 Hb >75
 OUTCOMES
 10 - Sepsis, Ischaemic events within 3 months
 20 - ICU stay, all cause mortality
The TITRe2 study
 RESULTS
 10 outcome
 35% vs 33%
 20 outcome
 4.2 vs 2.6%
 Protocol violations
TBI & SAH patients
TBI & SAH patients
 Transfusion Medicine 2016
TBI & SAH patients
 Very sparse evidence
 For TBI Hb 70 – 90
 For SAH 80 - 100
TBI & SAH patients
 JAMA 2014
TBI & SAH patients
TBI & SAH patients
TBI & SAH patients
Cochrane review
Cochrane review
 19 trials
 6264 pts
Cochrane review
 Adverse events and other outcomes
None of the outcomes evaluated,
including mortality, cardiac morbidity,
infections and length of hospital stay,
appear to be adversely affected by the
lower use of red cell transfusions.
Cochrane review
In contrast, the evidence raises the
possibility of harm associated with liberal
transfusion.
 In-hospital mortality increased by 23%
 infections were increased by19%
.
Cochrane review
 In patients who do not have acute
coronary artery disease, blood
transfusion can probably be withheld in
the presence of haemoglobin levels as
low as 70 to 80 as long as there is no
notable bleeding.
NICE recommendations
Red blood cells
Thresholds and targets
Use restrictive red blood cell transfusion thresholds for
patients who need red blood cell transfusions and who do
not:
have major haemorrhage or
have acute coronary syndrome or
need regular blood transfusions for chronic anaemia.
.
NICE recommendations
Red blood cells
Thresholds and targets
When using a restrictive red blood cell transfusion threshold, consider a
threshold of 70 g/litre and a haemoglobin concentration target of
70–90 g/litre after transfusion.
Consider a red blood cell transfusion threshold of 80 g/litre and a
haemoglobin concentration target of 80–100 g/litre after transfusion for
patients with acute coronary syndrome.
Questions?