Академический Документы
Профессиональный Документы
Культура Документы
• Infection
• Transfusion reaction
• Immunomodulatory
• Volume-related
Blood Borne Infections
900
675
IL-6 (ng/ml)
No Transfusion
450 Transfusion
225
0
Pre X-on 0 0.5 4 8 18
Reperfusion (hrs)
Do the immune effect of blood
have clinical implications?
Transfusion and Outcomes
Colorectal Cancer
• Design: Retrospective
• Subjects: Colorectal cancer resection
• Comparison: transfused vs. non-transfused
• Endpoints: hospital charges and LOS
• Controlled for multiple confounders
(comorbidity, age, gender, ICU admission,
etc)
• n=487
Vamvakas et al, Arch Pathol Lab Med 1998; 122: 145.
Transfusion and Outcome
Transfused Not p
Transfused
Post-op 34.2% 19.0% 0.0004
Infection
LOS (days) 16.7 10.3 0.0001
Charges ($) 28,101 15,978 0.0001
• Design: Case-control
• Subjects: s/p CABG
• Endpoints: Nosocomial pneumonia
• n= 45 cases and 90 controls
12
Fresh Blood
ml )2/100 ml blood
9
1-Week-Old Blood Activated Blood
6
0
0 5 10 15 20 25
2,3 DPG (mmol/g Hb)
70
60
PaO2 mmHg
Optimal Hemoglobin
• Hemoglobin crucial for oxygen delivery
• O2 Delivery [DO2]=
C.O. x Sa02 x Hgb x 1.34 x 10
• Originally thought that increasing delivery would
improve outcomes (Shoemaker 1988)
• Multiple studies evaluated
– Increasing CO with dobutamine
– Increasing O2 carrying capacity with
transfusion
Supraphysiologic
O2 Delivery
Standard Rx EGDT p
• Multicenter, RCT
• Subjects
– Acutely ill in ICU, Hgb < 9.0
– Excluded if: chronic anemia, ongoing
bleeding, admission after CABG
• Randomized to 2 strategies
– Liberal strategy:
• Maintain Hgb between 10-12
– Restrictive strategy:
• Maintain Hgb between 7-9
• Endpoints
– All cause mortality, MSOF
– Predefined subgroups: age >
55, CAD, APACHE II > 20
Transfusion Requirements in
Critical Care
Restrictive Liberal p
(n=418) (n=420)
ICU mortality 13.4% 16.2% 0.29
90
Survival (%)
80 Restrictive
p=0.02 Liberal
70
60
50
0 5 10 15 20 25 30
Days
Transfusion Requirements in Critical
Care
80 Restrictive
p=0.02 Liberal
70
60
50
0 5 10 15 20 25 30
Days
Transfusion Requirements in
Critical Care
• Conclusions
– Lower transfusion threshold was as
effective as higher trigger
– Lower threshold superior in some
subgroups
– Mechanism of worse outcomes with
liberal strategy unclear (? promotes
cytokine cascade, increased risk of
ARDS)
Transfusion Requirements in
Critical Care
• Editorial comment in NEJM
“This study has made it clear that a
single threshold for transfusion in all
patients is not appropriate…… With this
knowledge, more physicians will be able
to follow the dictum “first do no harm,”
and we will have a surplus of blood
rather than a shortage.”
Ely et al. NEJM 1999: 340: 468.
Do not tranfuse for following
reasons !:
• to improve general sense of well
being
• as hematinic agent
• to expand vascular volume
• as prophylaxis if there is no risk
factor
Decision to transfuse RBC: Hb
is important
but not the sole deciding factor
• Sign & symptoms of hypoxia,
ongoing blood loss, the risk of
anemia & the risk of transfusion
• Cardio pulmonary reserve
• Volume of blood loss
• O2 consumption
• Atherosclerotic disease
Matur Suksma