Updated References: The ICU Book

RED BLOOD CELL TRANSFUSIONS

Increased Risk of Infection
Taylor RW, O'Brien J, Trottier SJ, et al. Red blood cell transfusions and nosocomial infection in critically ill patients. Crit Care Med 2006;34:2302-2308. [Link to Abstract] PMID: 16849995

Comment:
One of the unheralded complications of red blood cell transfusions is immunosuppression in the recipient (etiology unclear), which increases the risk of infection. A number of studies have shown that ICU patients who receive red blood cell transfusions have a higher incidence of nosocomial infections, and the study by Taylor et al provides further evidence for this association. This study included 2,000 medical and surgical patients in one multidisciplinary ICU. Patients who were transfused with packed red blood cells had a significantly higher incidence of nosocomial infections (14% vs 6%) and a higher mortality rate (22% vs 10%) than nontranfused patients. Controlling for other variables revealed that red cell transfusions were an independent risk factor for infection, with each unit transfused increasing the risk of infection by 10%. Removing white blood cells from the donated blood did not reduce the risk of infection in the recipient. This study provides further evidence that RBC transfusions promote immunosupression and an increased risk of infection. _______________________________________________________________________

Benefit vs Risk
Hebert PC, Tinmouth A, Corwin HL. Controversies in RBC transfusion in the critically ill. Chest 2007; 131:1583-1590. [Link to Abstract] PMID: 17494811 Comment: About 90% of RBC transfusions in critically ill patients are used to correct anemia in patients who are normovolemic and hemodynamically stable. However, this paper reveals that there is no convincing evidence that this practice provides a benefit, either physiologically or clinically. On the other hand, there is convinving evidence that RBC transfusions are harmful, and one of the major sources of harm is immunosuppression and an increased risk of nosocomial infections. ________________________________________________________________________

Clinical Practice Guideline

Napolitano L, Kurek S, Luchette FA, et. al. for the American College of Critical Care Medicine and the Eastern Association for the Surgery of Trauma Practice Management Workgroup. Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care. Crit Care Med 2009;37:3124-3157. [Link to Abstract] PMID: 19773646

Updated References: The ICU Book

Comment: This guideline contains a total of 33 evidence-based recommendations that focus primarily on the tranfusion of red blood cells to correct anemia in ICU patients who are euvolemic and hemodynamically stable. Many of the recommendations are aimed at limiting RBC transfusions because there is no evidence of benefit (either physiologically or clinically) and convincing evidence of harm associated with RBC transfusions to correct anemia in patients who are hemodynamically stable. The specific recommendations that deserve mention are listed below. Many of the recommendations are stated exactly as they appear in the paper. 1. RBC transfusions based solely on the plasma hemoglobin level is a practice that should be avoided. (This recommendation has appeared repeatedly over the past 25 years, yet the plasma hemoglobin level continues to be the standard transfusion trigger. In fact, many of the recommendations in this paper use the plasma hemoglobin as a tranfusion trigger!!) 2. For anemic patients who are hemodynamically stable, a restrictive transfusion strategy (transfuse when Hb < 7 g/dL) is as effective as a liberal transfusion strategy (transfuse when Hb < 10 g/dL),except possibly in patients with acute myocardial ischemia. 3. RBC transfusions may be beneficial in patients with acute coronary syndromes when the hemoglobin level is 8 g/dL on admission. 4. RBC transfusions should not be considered an effective method for improving tissue oxygen consumption in critically ill patients. 5. RBC transfusions should not be considered as a method to facilitate weaning from mechanical ventilation. 6. Unless there is active bleeding, RBC transfusions should be given as single units. 7. Transfusion-related acute lung injury has emerged as a leading cause of transfusionrelated morbidity and mortality. As such, all efforts should be made to avoid RBC transfusions in patients at risk for acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). 8. RBC transfusion is associated with increased risk of nosocomial infection, and RBC transfusion is an independent risk factor for systemic inflammatory response syndrome (SIRS) and multiorgan failure (MOF). 9. RBC transfusions are independently associated with longer ICU and hospital length of stay, increased complications, and increased mortality (Italics mine). ________________________________________________________________________