RBC TRANSFUSIONS IN THE

CRITICALLY ILL

Presented by: Heather LaPoint, RN, CCRN

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BACKGROUND
Original goals of transfusion:
1.
2.

Reverse anemia
Increase oxygen carrying capability to aid in tissue perfusion

This is now known to be more harmful than benefi cial

Transfusing blood in a critically ill patient is an independent
predictor of:
1.
2.
3.
4.
5.

Worsening clinical outcome

Multisystem organ failure
Increased length of stay in the ICU
Increased length of stay in the hospital
Mortality
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BACKGROUND
What causes anemia in an ICU patient?
1. Excessive phlebotomy
2. Active hemorrhage or other forms of blood loss
3. Decreased erythropoiesis

BACKGROUND
Concepts to consider when deciding to transfuse:
1.

120 days to RBC

2.

Normal patients can shift to the right

3.

Blood storage times, 2,3-DPG, and your patient shifting to

the left

4.

More blood = More mortality

POTENTIAL INJURIES IN
TRANSFUSION THERAPY FOR
CRITICALLY ILL PATIENTS
Infections
Transfusion Reactions, including Transfusion-Related
Acute Lung Injury (TRALI)
Transfusion-Associated Circulatory Overload (TACO)
Transfusion-Related Immunomodulation (TRIM)

INFECTIONS
Viral

(rare)

HIV
Hepatitis A- G
Syphilis
West Nile
Human T-Cell
Lymphotropic Virus
Chagas (parasite)

Bacterial

(more

common)

Gram (+)
Gram (-)

TRANSFUSION REACTIONS:
HEMOLYTIC
Acute

Delayed

During or immediately
following a transfusion
May receive as little as 520 mls of blood
Sxs: fever, headache,
anxiety, nausea, fl ushing,
hypotension, tachycardia,
myalgia
May progress to
coagulopathy and renal
failure
Supportive tx with pressors,
fl uids, and for DIC as
needed

1-4 weeks after

transfusion
Often undiagnosed & selflimiting
Sxs: asymptomatic.
Fever may be present.
Diagnosed via falling
hemoglobin levels,
increased lactate
dehydrogenase, and
increased bilirubin levels.
Tx is supportive with
PRBC as needed
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TRANSFUSION REACTIONS:
FEBRILE, NON-HEMOLYTIC
Most common
More often occurs when transfusing platelets
End of transfusion or within an hour of completion
Defi ned by rise of body temp by 1 degree C without other
causes
Patho: interaction of recipient antibodies and antigens on
donor leukocytes
Tx: Stop transfusion, antipyretics, antihistamines,
corticosteroids, lower temperature, Demerol for severe
rigors
Diff erential diagnosis of febrile reaction vs. bacterial
contamination once stable
If known reactor, order leuko-reduced blood products in
the future
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TRANSFUSION REACTIONS:
ALLERGIC/ANAPHYLACTIC
More common with FFP and platelets
Allergic symptoms are cutaneous responses to
infl ammatory mediators: local vasodilation, edema,
erythema, pruritus, urticaria, sometimes a headache.
Tx: slow infusion; Better plan to pretreat with
antihistamines or corticosteroids if known previous
reactant.
Anaphylactic sxs: dyspnea, hypotension,
bronchospasm, respiratory arrest, and shock
Tx: D/C transfusion, supportive measures to include
airway management, fl uid resuscitation, and
hemodynamic support
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TRANSFUSION-RELATED ACUTE
LUNG INJURY (TRALI)
Non-cardiogenic pulmonary edema that occurs within 6
hrs. of transfusion of any blood component
Most common with PRBCs, FFP, platelets
TRALI risk increased with age of stored blood. Leukocyte
reduction does not reduce the risk
TRALI diagnosis is one of exclusion. Often misdiagnosed
Sxs: cough, dyspnea, copious secretions usually present
within 2 hours of transfusion
pCxr = diff use bilateral pulmonary infi ltrates
Leukopenia, fever, hypo/hypertension, SaO2 <90%
Tx: supportive, d/c transfusion, may require O2, vent,
invasive monitoring, fl uid resuscitation, notify blood bank
Vent management is lung protective with low Tv and low
plateau pressures
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TRANSFUSION-ASSOCIATED
CIRCULATORY OVERLOAD (TACO)
Pulmonary edema caused by hydrostatic forces occurring
during the infusion of blood or blood components, may be in
relation to rapid administration of large volumes
One of the most common, but unrecognized transfusion
complications
Challenging to diff erentiate from TRALI as patients present
similarly.
Sxs: increased RR, dyspnea, orthopnea, cyanosis, systolic
hypertension, peripheral edema, an S3, JVD
pCxr = interstitial infi ltrates and enlarged cardiac silhouette
Seen within a few hours of transfusion
Tx: slow or terminate infusion, diuretics
Make sure TACO and NOT TRALI!
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TRALI VS. TACO

TRALI pulmonary edema =
non-cardi ogenic

TACO pulmona ry edema =

cardiogenic

Increased pulmonary
vascular permeability from
lung parenchymal injury

Increa sed hydrostatic forces

causes increa sed CVP, leads
to fl uid a ccumulation in the
alveolar spa ce

DO NOT treat with diuretics.

Will actually make patient
worse

Will not usually ha ve a fever

or hypotension
Will develop an S3 or
peripheral edema
More likely to have a history
of hea rt or rena l failure
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TRANSFUSION-RELATED
IMMUNOMODULATION (TRIM)
Transfusion-related immunosuppression
Process by which blood recipients develop down
regulation of their immune systems following the
infusion of the donor antigens
Increases the risk of developing some cancers or the
reoccurrence of a patients previously diagnosed
cancer
Increased risk of contraction of a
bacterial/nosocomial infection
More blood transfused = higher the risk of infection
Leuko-reduced blood has been shown to reduce this
risk
New evidence shows that transfusion avoidance may
also be playing a role in VAP reduction rates
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(nosocomial PNA)

TRIGGERS FOR TRANSFUSION

Hgb <7 g/dL
Goal of Hgb maintenance of 7-9 g/dL
Exceptions:
Active Hemorrhage
AMI
Lactic Acidosis

Always monitor entire clinical picture!

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