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Ré-évaluation du seuil transfusionnel

Philippe Van der Linden MD, PhD CHU Brugmann-HUDERF, Université Libre de Bruxelles. Ré-évaluation du seuil transfusionnel. Clinical scenario. 30-year-old woman. Cesarean section accompanied by profuse bleeding. Hemodynamically stable after crystalloid resuscitation.

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Ré-évaluation du seuil transfusionnel

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  1. Philippe Van der Linden MD, PhD CHU Brugmann-HUDERF, Université Libre de Bruxelles Ré-évaluation du seuil transfusionnel

  2. Clinical scenario 30-year-old woman Cesarean section accompanied by profuse bleeding Hemodynamically stable after crystalloid resuscitation Evidence of a slow ongoing blood loss Questions At what hemoglobin concentration would you transfuse the patient ? At this threshold, how many units of RBCs would you transfuse? Would you measure Hb concentration before transfusing? Blood Transfusion Practice in Patients Undergoing Cesarean Section P VdL

  3. Blood Transfusion Practice in Patients Undergoing Cesarean Section p<0.01 p<0.05 From Matot I et al. Am J Obstet Gynecol 190:462-7, 2004. P VdL

  4. E.U. prospective study (1999) 146 units; 3534 patients P VdL

  5. P VdL

  6. Effectiveness Risks associated of with blood transfusion blood transfusion Risks associated with anemia P VdL

  7. Complications (%) 12 9,4 10 7,4 8 6,6 6 4 1,6 2 1,2 0 Congestive heart failure Arrhythmia Pneumonia Wound infection Myocardial infarction Patient Outcome With Very Low Hb Level Retrospective cohort study Surgery from 1981 to 1994 Postop Hb level: 8 g/dl or less 1° outcome: 30-day mortality 2° outcome: 30-day morbidity From Carson JL et al. Transfusion 42:812-818, 2002. P VdL

  8. P VdL

  9. Patient Outcome With Very Low Hb Level Complications (%) Retrospective cohort study 12 Surgery from 1981 to 1994 9,4 10 Postop Hb level: 8 g/dl or less 7,4 8 6,6 1° outcome: 30-day mortality 6 2° outcome: 30-day morbidity 4 1,6 2 1,2 0 After adjusting for age, CVD,& APACHE II score, Congestive heart failure Arrhythmia the OR of death for each gram decrease Hb Pneumonia Wound infection was 2.1 (95% CI 1.7-2.6) Myocardial infarction From Carson JL et al. Transfusion 42:812-818, 2002. P VdL

  10. P VdL

  11. Anemia, Cardiovascular Disease (CVD), and Surgical Mortality Adjusted odds ratio for mortality by CVD and preop Hb 16 All surgeries except open-heart procedures 13 (N=1958) 1981-1994 10 7 CVD No CVD 4 1 6 7 8 9 10 11 12+ Preoperative hemoglobin (g/dl) From Carson JL et al. Lancet 348:1055-1060, 1996. P VdL

  12. P VdL

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  15. p=0.008 p=0.36 RCT: infants < 9 months Score - Hct 21.5 ± 2.9 % (N=74) 140 - Hct 27.8 ± 3.2 % (N=73) 120 Blood product use: similar Fluid balance: 100 519 ± 343 vs 337 ± 222 ml p<0.001 80 60 min after CPB Lower nadir CI in the low 60 hct group Higher lactate Psychomotor Mental Dev index Dev index (N=109) (N=112) Influence of Hemodilution on Outcome After Hypothermic Cardiopulmonary Bypass From Jonas RA et al. J Thorac Cardiovasc Surg 126:1765-1774, 2003. P VdL

  16. O2 Extraction Cardiac Output Tissue O2 Demand P VdL

  17. P VdL

  18. Effectiveness Risks associated of with blood transfusion blood transfusion Risks associated with anemia P VdL

  19. Transfusion Triggers: a Systematic Review 10 randomized trials comparing the effects of "liberal" vs "restrictive" transfusion strategy based on a specified hemoglobin (or hematocrit) concentration on short-term outcome (N=1780 patients) Surgical patients (N=5) Acute blood loss (N=3) ICU patients (N=2) Transfusion triggers: hemoglobin between 7 and 10 g/dl From Carson JL et al. Transfus Med Rev 16:187-199, 2002. P VdL

  20. P VdL

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  22. Retrospective analysis (N=78974) Blood transfusion decreased 30-day mortality in elderly patients with a primary diagnosis of AMI if their admission hematocrit was less than 33% (Wu WC et al. N Engl J Med 345:1230-1236, 2001) Observational study using prospectively collected data (N=24111) Blood Transfusion in the setting of acute coronary syndrome is not associated with improved survival when nadir hematocrit values are 20-25% (Rao SV et al. JAMA 292:1555-1562, 2004) Blood Transfusion and The Heart P VdL

  23. Transfused on day of admission vs not transfused Threshold Hb: 3.9 g/dl For Hb< 3.9 g/dl For Hb> 3.9 g/dl n=194 n=149 OR: 0.30 (0.14-0.61) OR: 1.88 (0.51-6.84) Effects of Blood Transfusion on Survival Probability of mortality 1.0 0.8 0.6 0.4 0.2 0 0 1 2 3 4 5 Admission hemoglobin (g/dl) From Lackritz EM et al. Lancet 340:524-528, 1992. P VdL

  24. Blood Transfusion For Severe Anemic Children Observational study (N=9968) Severely anemic children: 13% Mortality (%) Transfused: 65% (984/1516) 89 100 Mortality (multiple logistic regression) 80 prostration OR: 7.4 (4.2-13.1) 60 p=0.0002 respiratory distress: OR: 4.1 (2.2-7.4) 40 23 profound anemia: OR: 2.5 (1.4-4.5) blood transfusion: OR: 0.28 (0.15-0.53) 20 0 Not transfused Transfused Children with prostration, respiratory distress and Hb < 4 g/dl From English M et al. Lancet 359:494-495, 2002. P VdL

  25. P VdL

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  28. % p=0.017 Apnea episodes in 24 hours 50 43 1,6 Liberal Restrictive 40 1,4 30 1,2 20 20 p=0.012 1 12 10 p=0.003 0,8 0 0 0,6 Intravent hhage NS Subjects with or periventricular > 1 apnea / day leukomalacia 0,4 Before After transfusion transfusion Transfusion Strategy in Preterm Infants From Bell EF et al. Pediatrics 115:1685-1691, 2005. P VdL

  29. P VdL

  30. P VdL

  31. Blood Transfusion: "Storage Effects" Decreased 2, 3 - diphosphoglycerate (~ 0 after 15 days) Increased affinity of hemoglobin for oxygen Decreased in red blood cell ATP change in RBC shape (discoid to spherocytic) reduced cellular deformability Decreased tissue oxygen availability endothelial swelling and tissue edema in sepsis reduce capillary luminal diameter P VdL

  32. RBC Transfusion and Tissue Oxygenation: Effects of Storage Time Double-blind RCT Euvolemic anemic PgCO -PaCO (8.5 ± 0.8 g/dl) 2 2 (kPa) critically ill patients LD RBC transfusion: 2 U pHi - "fresh" blood: 2 days (2 - 3); N=10 - "old" blood: 28 days (22 - 32); N=12 Lactate No difference in any global (mM/l) oxygenation parameters -1 -0,5 0 0,5 1 RBC< 5 days RBC > 20 days From Walsh TS et al. Crit Care Med 32:364-371, 2004. P VdL

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  38. Dyspnea Tachycardia Hypotension ST-T Abnormalities PvO , SvO , O ER 2 2 2 Central venous O2 saturation ? Others (lactate) ? Transfusion Triggers P VdL

  39. P VdL

  40. Transfusion (%) 100 0 < 20% > 30% Hematocrit Perioperative Transfusion Trigger Adapted from Janvier G et Annat G. Ann Fr Anesth Réanim 14:9-20, 1995. P VdL

  41. Conclusions Humans exhibit a high tolerance to acute anemia, providing that "normovolemia" is maintained. It is unlikely that any level of hemoglobin can be used as a universal threshold for transfusion. Don't treat numbers, but patients using the available monitoring AND your clinical judgment P VdL

  42. P VdL

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