Impact of iatrogenic blood loss and red cell transfusion in critically ill patients

1. Impact of iatrogenic blood loss and red cell transfusion in critically ill patients • Dr.Anu Thomas, Dr.Aboobacker Mohamed Rafi, Dr. Susheela J Innah Department of Transfusion Medicine Jubilee Mission Medical College,Thrissur,Kerala

2. Introduction • Anemia is common in critically ill patients, constituting almost 95% of the total intensive care unit (ICU) admissions. • PRBC transfusions remain a cornerstone of critical care practice, but there is still a point of concern in the risk of anemia and the benefits of red cell transfusion.

3. More than 50% of patients admitted in the ICU with length of stay more than one week, receive PRBC transfusions during their ICU stay. • Phlebotomy for routine and specialised laboratory investigations in critically ill patients contributes to a mean daily loss of 40 to 70 ml of blood, exceeding the normal healthy replacement rate .

4. Background and rationale • Most of the studies regarding transfusions in ICU have been published from the developed world and few have been reported from the ICUs of the developing world. • With this background, the present study was to determine the Iatrogenic blood loss and red cell transfusion practices in ICU.

5. Aims • To find out the association between volume of sample taken for investigations and the level of hemoglobin. • To assess the relationship between the number of PRBC units transfused and the length of ICU stay. • To study the morbidity and mortality of ICU patients who required transfusion.

6. Methodology Type of study: Prospective observational study Study period: 1 year and 10 months Study setting: Department of Transfusion Medicine and Multi-disciplinary critical care unit (MCCU), Jubilee Mission Medical College, Thrissur Sample size: 100 patients

8. Data collection • All patients who received blood transfusions during the first 30-day stay in ICU were included for data collection • The amount of blood withdrawn for investigations from each patient was recorded • Clinical data including APACHE II score( Acute Physiology and Chronic Health Evaluation ) on admission to assess the severity of illness, diagnosis on admission, co-morbid illnesses and the daily haemoglobin level were collected.

9. Results • Out of the 100 patients admitted in MCCU , those required more transfusions were RTA followed with obstetrics and surgical cases.

10. The mean haemoglobin at the time of admission and discharge were 8.89g/dl and 8.83g/dl respectively. • The mean phlebotomy volume loss during ICU stay was 15.8 + 1.456 ml/day.

11. Iatrogenic blood loss and Hemoglobin drop

12. The mean PRBC units transfused during ICU stay were 3.68+ 2.52 units Std. Deviation Mean

13. ICU stay Vs iatrogenic blood loss and PRBC transfusion • Std. Deviation • Std. Deviation

14. PRBC transfusion Vs Mortality Survivor Non-survivor Mean

15. APACHE II score Vs Morbidity and Mortality *Chi-Square p value=0.0001

16. Discussion • Anemia is a common occurrence in the intensive care unit (ICU) and PRBC transfusions are the treatment for anemia in critical care. • Current study demonstrates: • >Higher number of PRBC units were transfused to RTA patients followed by obstetrics and general surgery cases (*comparable with CRIT study) • Patients who received 7-9 units of PRBC had more length of ICU stay- 14.50+5.260 days (*comparable to Corwin et al study -1 week)

17. Comparing Iatrogenic blood loss with several studies

18. Results of epidemiologic studies on anemia and blood transfusions in critical care • Mortality(75%) was seen higher amongst those who were transfused with more than 10 units of PRBC (* comparable to Napolitano et al study- ICU mortality 53%)

19. Limitation of the study • Limited sample size • Heterogeneous population • Variable distribution of population in each subgroup jeopardized subgroup analysis. • Mortality influenced by the disease per se of the patients. • No comparisons could be made with patients who did not receive blood transfusions to determine the risk factors associated with blood transfusion

20. Conclusion Venous arterial blood management protection systems • Iatrogenic blood loss is of no clinical significance in causing anemia among critically ill patients admitted in our tertiary care center. • Current study demonstrated that higher number of PRBC transfusion is associated with increased morbidity and mortality. tests

21. Take Home message • Given the risks associated with blood product administration and the intermittent shortage of blood supply, more attention is to be focused on restrictive transfusion policies and pharmacological strategies to prevent and treat anemia of critical illness.

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