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Transfusion therapy of critically ill post-traumatic patient: volume resuscitated, normovolemic.
Transcript of Transfusion therapy of critically ill post-traumatic patient: volume resuscitated, normovolemic.
When can it be tolerated? Restrictive vs. Liberal
transfusion strategies beneficence. ACNP will inevitably use
RBC transfusion as a treatment modality. Restrictive, Anemia Management Programs. Liberal Strategy. transfuse if Hgb falls <7, to maintain Hgb 7 to 9g/dL Decreased VAP (8.1% --> 0.8%, p .002)
Decreased Transfusions (26.4-54% reduction of mean transfusion volume)
Decreased Red Cell exposure (33% reduction)
Decreased Cost (~21% per 6m study period) Every 3 seconds a transfusion is needed. = 32,000/day 60% of Americans can donate blood.
Only 5% do. saving 4.5 million lives every year Gilbert, E. (2012, May 23). 56 facts about blood and blood donation. Retrieved from http://www.bnl.gov/hr/blooddrive/56facts.asp The Nation Has a Major Blood Shortage. -abc NEWS Lifesouth: emergency blood shortage affecting area -FOX10tvNews.com Red Cross facing blood shortage across the south -The Marietta Daily Journal [transfusion] complication Risks: -febrile reactions
-transfusion associated lung injury
-graft vs. host reaction
-infections: Hep B&C, HIV, malaria Marini, J., & Wheeler, A. (2010). Critical care medicine, the essentials. (4th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins. [RBC transfusion] Independent predictor of worse clinical outcomes. -increased risk of complications
-longer ICU and hospital stay
-increased mortality Corwin, H., Gettinger, A., Levy MM, Corwin, H., Gettinger, A., Pearl, R., Fink, M., Levy, M., Abraham, E., MacIntyre, N., Shabot, M., Duh, M., & Shapiro, M. (2004). The CRIT study: anemia and blood transfusion in the critically ill: current clinical practice in the United States. Critical Care Medicine. 32(1), 39-52 3 hospital Retrospective study shows... 17.3% of RBC transfusions deemed INAPPROPRIATE. Crispin, P., Burgess, M., & Crispin, T. (2010). Transfusion demand control strategies: Potential efficacy of hospital and regional interventions. Transfusion and Apheresis Science, 43(3), 341-345. doi: 10.1016/j.transci.2010.10.005 Transfusion therapy of critically ill post-traumatic patient:
volume resuscitated, normovolemic. transfusions must be utilized with the utmost CAUTION & APPROPRIATENESS. -Jon Easterling RN, BSN Ultimate Goal: Tissue Perfusion & O2 Delivery
-decreasing risk of MODS & death. Tien, H., Nascimento, B., Callum, J., & Rizoli, S. (2007). An approach to transfusion and hemorrhage in trauma: current perspectives on restrictive transfusion strategies. Canadian Journal of Surgery, 50(3), 202-209. Retrieved from http://www.ncbi.nlm.nih.gov./pmc/articles/PMC2384284/ transfuse if Hgb falls <10, to maintain Hgb 10 to 12g/dL Study outcomes: No difference in- liberal vs. restrictive AMP ICU or hospital length of stay
risk of death
risk for MI Benefits of Restrictive Strategy- Earley, A., Gracias, V., Haut, E., Sicoutris, C., Wiebe, D., Reilly, P., & Schwab, W. (2006). Anemia maagement program reduces transfusion volumes, incidence of ventilator-asociated pneumonia, and cost in trauma patients. The Journal of Trauma: Injury, Infection, and Critical Care, 61(1), 1-7. doi: 10.1097/01.ta.0000225925.53583.27Herbert, P., Wells, G., Blajchman, M., Marshall, J., Martin, C.,
Pagliarello, G., Tweeddale, M., Schweitzer, I., & Yetisir, E. (1999). A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. transfusion requirements in critical care investigators, canadian critical care trials group. New England Journal of Medicine, 340(6), 409-417. doi: 10.1056/NEJM199902113400601n nonmaleficence. Hayden, S., Albert, T., Watkins, T., & Swenson, E. (2012). Anemia in critical illness: Insights into etiology, consequences, and management. Journal of Respiratory and Critical Care Medicine, 185(10), 1049-57. doi: 10.1164/rccm.201110-1915CI Hgb deficit <7g/dL should NOT be sole criteria to base transfusion decision. Heart Rate >120 bpm
SBP <90 mmHg
Right Ventricular End-diastolic Volume Index
Urine Output <15ml/hr
Elevated Lactate levels Additional Considerations: }
} assess metabolic acidosis
} *Tissue perfusion inadequacy must also be considered. Transfusion Recommendations - Hemodynamically stable anemia.
- Mechanically ventilated patients.
- Resuscitated critically ill trauma patients.
- Patients with stable cardiac disease. Napolitano, L., et al. (2009). Clinical practice guideline: red blood cell transfusion in adult trauma and critical care*. Critical Care Medicine, 37(12), 3124-3157. doi: 10.1097/CCM.0b013e3181b39f1b Restrictive shown as effective as Liberal: Resuscitation purposes.....INDICATED for hemorrhagic shock, acute hemorrhage, and hemodynamic instability. [Anemia Management Program] Clinical Bottom Line. Restrictive Blood Replacement Therapy SHOULD be utilized
because Liberal Strategies have not produced better outcomes. Benefits of Restrictive Therapy Reduced unneeded RBC exposure
Reduces risk of associated complications
Reduces healthcare costs
Preserves valuable limited resource ? questions ? Napolitano, L., et al. (2009). Clinical practice guideline: red blood cell transfusion in adult trauma and critical care*. Critical Care Medicine, 37(12), 3124-3157. doi: 10.1097/CCM.0b013e3181b39f1b