5. Clinical practice guidelines
Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice guideline: red blood cell transfusion in
adult trauma and critical care. Crit Care Med 2009; 37:3124
7. TRICC Trial
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; 340:409.
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•
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•
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838 critically ill patients
418 - restrictive transfusion (Hb<7.0 gdL → 7.0 – 9.0)
420 - liberal strategy (Hb<10.0 gdL → 10.0 – 12.0 gdL)
30-day mortality was similar in the two groups (18.7%
vs.23.3%, P= 0.11)
Less acutely ill (APACHE II < 20) - 8.7% and 16.1% in
the; P=0.03
Age < 55 - 5.7% and 13.0%; P=0.02
Clinically significant cardiac disease (20.5% and 22.9%
P=0.69)
The mortality rate during hospitalization was significantly
lower
8.
9. Upper GI bleed
Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal
bleeding. N Engl J Med . 2013 Jan;368(1):11-21
• 921 patients with severe acute upper gastrointestinal
bleeding
• 461 to a restrictive strategy and 460 to a liberal strategy
• The probability of survival at 6 weeks was higher in the
restrictive-strategy group than in the liberal-strategy
group (95% vs. 91%; hazard ratio for death with
restrictive strategy, 0.55; 95% confidence interval [CI],
0.33 to 0.92; P=0.02).
• Conclusions: compared with a liberal transfusion
strategy, a restrictive strategy significantly improved
outcomes in patients with acute upper gastrointestinal
bleeding.
10. Indications - Plasma
• Controversial
• Generally indicated whenever hemostasis
is inadequate and the benefit of correcting
the insufficient hemostasis (ie, reduced
bleeding) is believed to outweigh the risks
of the plasma transfusion.
11. Is fresh-frozen plasma clinically effective? An
update of a systematic review of randomized
controlled trials.
Yang L, Stanworth S, Hopewell S, et al. Transfusion 2012; 52:1673.
• Trials involving transfusion of FP up to July 2011
• Covered prophylactic and therapeutic FP use in liver, in
cardiac surgery, for warfarin anticoagulation reversal, for
TTP treatment, for plasmapheresis, and in other settings,
including burns, shock, and head injury.
• CONCLUSION:
– Combined with the 2004 review, 80 RCTs have
investigated FP with no consistent evidence of
significant benefit for prophylactic and therapeutic use
across a range of indications evaluated.
12. Indications - Plasma
• Examples:
– Active bleeding in the setting of known or strongly
suspected coagulation abnormalities.
– Massive transfusion of packed red bloods cell
– Prior to invasive and surgical procedures for which
there is a HIGH risk of bleeding complications if the
patient has ANY potentially significant abnormality of
their coagulation tests
– Prior to invasive procedures for which there is a LOW
risk of bleeding complications if the patient has a
SEVERE abnormality of their coagulation tests
13. Indications - Platelets
• Patients with a platelet count <10 X
103 platelets/mL.
– The purpose is to prevent spontaneous hemorrhage.
• Patients with a platelet count <50 X 103
platelets/mL who are actively bleeding, are
scheduled to undergo an invasive procedure, or
have a qualitative intrinsic platelet disorder.
14. Indications - Platelets
• Patients with a platelet count <100 X 103 platelets/mL
who have a central nervous system injury, have
multisystem trauma, are undergoing neurosurgery, or
require an intrathecal catheter for anesthesia.
• Patients with a normal platelet count who have ongoing
active bleeding and a reason for platelet dysfunction,
such as a congenital platelet disorder,
chronic aspirin therapy, or uremia.
16. Complications
• Delayed hemolytic reactions:
0.025 of transfusions, mild and 35 %
asymptomatic, may produce jaundice and
hemoglibnuria
No specific therapy
Febrile nonhemolytic reactions:
7% of transfusions, due to antileuckocyte
antibodies, self-limited, exclude hemolysis.
Antipyretics as needed, avoided by
leukoreduced blood.
17. Complications
• Allergic reactions:
Mild urticaria to anaphylaxis, if severe
reaction stop transfusion and Epinephrine
may be used.
Volume overload:
Expanding intravascular volume which is
potential cause of pulmonary edema. FFP
higher incidence due to hyperoncotic state.
18. Complications
• Acute lung injury:
Alloreactive plasma antibodies contained
within red blood cell products or fresh frozen
plasma can lead to the agglutination and
activation of leukocytes, which may result in
acute lung injury and noncardiogenic
pulmonary edema (ie, transfusion-related
acute lung injury [TRALI]). Clinical findings
range from mild increases in oxygen
requirements to severe acute respiratory
distress syndrome (ARDS). The full extent of
