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Blood Transfusion:Blood Transfusion:

New GuidelinesNew Guidelines

Joint Surgery and Anesthesiology Grand RoundsJuly 2, 2009

Paul Picton MD

Lena M. Napolitano MD

Andrew Rosenberg MD



Perioperative TransfusionTriggers

Paul Picton MD MRP !RA

Assistant Pro"essor

Director, #ransplant Anest$esia



$anges in cardiac output %A& o'ygen e'traction %(& o'ygen deli)ery %& and

o'ygen consu*ption %D& as $e*oglobin decreases in $u*ans and ani*als

+lein -, et al. Lancet 200/ 0134526



Ane*ia in ealt$y Awa7e

8olunteers

ritical $e*oglobin t$res$old un7nown in

$u*ans

At 4 g:dL 5 8;2 *aintained but <#

c$anges %4=& and *e*ory "or*ation

i*paired At 6 g:dL 5 decline in cogniti)e "unction

Lieber*an, et al. Anest$esiology 2000



Do Not$ing <tudy

Retrospecti)e study o" 00 J> w$o underwent surgery"ro* 39?3 5 399

@)en a"ter adusting "or age, cardio)ascular disease and APA@ score, odds o" deat$ increased by 2.4 ti*es "oreac$ gra* o" b below ? g:dL

#rans"usion. 2002 Jul/2%&1?325?



Do Not$ing <tudy

Retrospecti)e study o" 00 J> w$o underwent surgery"ro* 39?3 5 399

@)en a"ter adusting "or age, cardio)ascular disease and APA@ score, odds o" deat$ increased by 2.4 ti*es "oreac$ gra* o" b below ? g:dL

#rans"usion. 2002 Jul/2%&1?325?



#$e #RB <tudy

erbert P, et al. N@JM 3999

@nrolled ?? eu)ole*ic, ane*ic, critically ill ptsw$o were ad*itted to 3 o" 24 anadian BCs

Patients were strati"ied according to center and

disease se)erity %APA@ BB& and placed intoone o" two groups Restrictive group1 #rans"use i" b E and *aintain

between and 9

Liberal group1 #rans"use i" b E 30 and *aintainbetween 30 and 32

#$e pri*ary outco*e *easure was deat$ "ro*all causes in t$e 0 days a"ter rando*iFation



#RB 5 Design



#$e #RB <tudy


No di""erence 0 day *ortality

Bn G$ealt$yH %APA@ BB E 20& and young

%E44yrs& patients#rans"usion increased *ortality



#$e #RB <tudy


8.7 vs !".! #.7 vs !$.%



#$e #RB <tudy

Average red cell units per patient&

2.6 I .3 )s. 4.6 I 4. %p E 0.03&

Average daily 'b concentrations&?.4 I 0. g:dl )s. 30. I 0. g:dl %p E 0.03&



#RB <ub -roup Analyses

Trau(a )n * +%$,McBntyre LA, et al. J #rau*a 200/4146546?

-oderate to severe head inury )n * "7,

McBntyre LA, et al. Neurocrit are 2006/04159

/ardiovascular disease )n * $#7,erbert P, et al. rit are Med 2003/ 29%2&12252

-echanical ventilation )n * 7!$,ebert P, et al. $est 2003 June/339%6&13?43.

0o difference in outco(es



GA restricti)e red blood cell trans"usion

strategy generally appears to be sa"e in

*ost critically ill patients wit$ cardio)ascular

diseasewit$ t$e possible e'ception o"

patients wit$ acute *yocardial in"arction and

unstable angina.H



RB# <tudy

Prospecti)e, *ultiple center, obser)ationalco$ort study o" ,?92 BC pts in t$e C<

Propensity score *atc$ed

Designed to e'a*ine t$e relations$ip o" ane*iaand R( trans"usion wit$ clinical outco*es

Al*ost 94= o" patients ad*itted to t$e BC $a)e

a b le)el below Gnor*alH by day

Bn total, 33,93 R( units were trans"used.

;)erall, = o" pts ad*itted to t$e BC recei)ed

one or *ore R( units w$ile in t$e BC

rit are Med. 200 Jan/2%3&19542





Hematocrit versus Postop Morbidity & Ischemia

Nelson A, !leisc$er L, et al. rit are Med 399

ST S1

n K 2 $ig$5ris7 pts

undergoing in"ra5inguinal

arterial bypass



2003

Retrospecti)e co$ort

ooperati)e ardio)ascular Proect ?,9 patients 64 yrs acute MB

0 day *ortality



2lood transfusion associated 3ith 4 (ortality if 'ct 5

$%





(lood #rans"usion and linical

;utco*e in Acute oronary <yndro*e

Rao <8 et al. JAMA. 2004;292:1555-1562

Transfusion

No Transfusion

Adustedha6ard ratio$.

)$.+"9.7#,



Meta5analysis o" obser)ational studies

4 studies 5 22,496 patients

Multi)ariate analysis correcting "or age andillness se)erity

;utco*e *easures1

Mortality

Bn"ection

Multi5organ dys"unction

ARD<

rit are Med 200?/6%9&12665



Results

rit are Med 200?/6%9&12665

Association between blood

trans"usion and t$e ris7 o"

deat$ %;R 94= B&. Pooled

;R 3. %94= B 3.53.9&

Association between blood

trans"usion and t$e ris7 o"

in"ectious co*plications %;R

94= B&. Pooled ;R 3.?

%94= B 3.452.2&



Results

rit are Med 200?/6%9&12665

Association

between blood

trans"usion and

t$e ris7 o" ARD<%;R 94= B&.

Pooled ;R 2.4%94= B 3.65.&







<u**ary

Post op 'ct !# 5 )ery $ig$ *ortality

At 'ct !8 5 cogniti)e dys"unction in $ealt$y

)olunteers

CtiliFation o" a trans"usion trigger +! )(ean 'ct+#, 5 con"ers sur)i)al bene"it "or t$ose E 44 yrs

and t$ose wit$ an APA@ E 20

A liberal trans"usion policy 5 trigger $% )(ean'ct $+, does not bene"it patients on critical care

At 'ct +7 5 <# c$anges in $ig$ ris7 patients.



<u**ary

#rans"usion *ay bene"it patients during

acute coronary syndro*es i" 'ct 5 +#9+

#$ere is only rarely an indication to

trans"use AN patient wit$ a 'ct : $%

(lood trans"usions are not ris7 "ree

Decreasing trans"usion *ay not onlydecrease cost but also i*pro)e outco*e



losing o**ents

-ood prospecti)e data li*ited to criticalcare setting

onsiderable scope "or di""erences in

opinion oncerning intra5operati)e trans"usion 5

best to co*e to so*e agree*ent pre op

and re*ain in co**unication -i)e R(Os as single units w$en possible

#reat t$e patient not t$e ct



;niv. -ichigan Adult 2lood;niv. -ichigan Adult 2loodTransfusion Guidelines& +%%Transfusion Guidelines& +%%

Lena M. Napolitano MD, !A<, !P, !M

Pro"essor o" <urgery

Di)ision $ie", Acute are <urgery

Depart*ent o" <urgery

Cni)ersity o" Mic$igan

Ann Arbor, MB



Adult 2lood TransfusionAdult 2lood Transfusion

/linical Guidelines/linical Guidelines



Plan and Guideline endorsed by <//A on -arch += +%%



Proect ;)er)iew <cope ;" >or7

Dr. #i* Laing, Bnternal Medicine:;A Dr. Rob Da)enport, (lood (an7

Lena Napolitano, MD5<urgeon:BC (ill PalaFFolo, Dir. Pre5;p linic

Paul Picton, MD5Anest:#ransplant <$on Dwyer, AD

Andrew Rosenburg, MD5Anest:arelin7 8inita (a$l, <M#

Je"" Ro$de, MD5Bnt. Medicine (rendon >eil, Lean oac$

Ryen !ons, ouse ;""icer5Anest. -ail <inwell, Lean oac$

Russel (utler, Per"usion, 8 (arb $ap*an, BD<<

Blood Utilization lean project wor wa! co""i!!ioned #$ #ot% &'A ()o!pital Ad"ini!tration* +nder t%e o,er!i%t o /r. ip 'a"p#ell

Team Make-Up

Proect -oal1 #o de)elop standard policies practices leading to1 i*pro)ed

patient outco*es t$roug$ t$e appropriate use o" blood products and gain

process e""iciencies by re*o)ing waste and delays in t$e blood dispensing

ad*inistration process



Guidelines for 2loodGuidelines for 2lood

Transfusion& PR2/sTransfusion& PR2/s

These guidelines are intended to ensure that the mostThese guidelines are intended to ensure that the most

appropriate, efficient and safe use of the blood supply isappropriate, efficient and safe use of the blood supply is

achievedachieved

To establish evidence-based criteria for the transfusion ofTo establish evidence-based criteria for the transfusion of

blood componentsblood components

Every indication for the use of blood products cannot beEvery indication for the use of blood products cannot be

anticipatedanticipated

These guidelines are not intended to override physicianThese guidelines are not intended to override physician

judgement judgement





Hemodynamically stable anemia without acute coronary syndrome:Hemodynamically stable anemia without acute coronary syndrome:

hemoglobin trigger less than 7 g/dhemoglobin trigger less than 7 g/d, with a transfusion goal to, with a transfusion goal to

maintain hemoglobin 7 ! " g/d#maintain hemoglobin 7 ! " g/d#

Acute hemorrhage with evidence of hemodynamic instability orAcute hemorrhage with evidence of hemodynamic instability orinadequate oxygen deliveryinadequate oxygen delivery

ymptomatic !tachycardia" tachypnea" postural hypotension# anemia !Hbymptomatic !tachycardia" tachypnea" postural hypotension# anemia !Hb

$ %& g'd(# not explained by other causes$ %& g'd(# not explained by other causes

Chronic )x*dependent bone marrow syndromes+ Hb $ %& g'd(.Chronic )x*dependent bone marrow syndromes+ Hb $ %& g'd(.

)ransfusion or exchange transfusion for severe sic,le syndromes.)ransfusion or exchange transfusion for severe sic,le syndromes.

Hemodynamically stable anemia with ischemic heart disease+ currentHemodynamically stable anemia with ischemic heart disease+ current

evidence does not support routine transfusion in non*) segmentevidence does not support routine transfusion in non*) segment

elevation acute coronary syndromes- although in )*segment elevationelevation acute coronary syndromes- although in )*segment elevation

myocardial infarction )x may be beneficial.myocardial infarction )x may be beneficial.



BCs should be administered asBCs should be administered as single unitssingle units for most operativefor most operative

and inpatient indications !transfuse and reassess strategy# exceptand inpatient indications !transfuse and reassess strategy# except

for ongoing blood loss with hemodynamic instability.for ongoing blood loss with hemodynamic instability.

)x decisions are clinical /udgments that should be based on the)x decisions are clinical /udgments that should be based on theoverall clinical assessment of the individual patient. )ransfusionoverall clinical assessment of the individual patient. )ransfusion

decisions should not be based on laboratory parameters alone.decisions should not be based on laboratory parameters alone.

outine premedication isoutine premedication is notnot advised unless the patient has aadvised unless the patient has a

history of previous transfusion reactions. 0remedication has nothistory of previous transfusion reactions. 0remedication has not been shown to reduce the ris, of transfusion reactions. been shown to reduce the ris, of transfusion reactions.



<AST > S//- 2l d T G id li<AST > S//- 2l d T G id li



<AST > S//- 2lood T1 Guidelines<AST > S//- 2lood T1 Guidelines/L?0?/AL PRA/T?/< G;?@<L?0<&

R<@ 2L@ /<LL TRA0SB;S?0 ?0 A@;LT TRA;-A and /R?T?/AL /AR<

Lena M. Napolitano MD<tanley +ure7 D;

!red A. Luc$ette MD!or t$e @A<# Practice Manage*ent >or7group and#$e A*erican ollege o" ritical are Medicine #as7"orce o" t$e <M

#$e @A<# Practice Manage*ent >or7group

-ary L. Anderson D;Mic$ael R. (ard MD

>illia* (ro*berg MD>illia* . $iu MD

Mar7 D. ipolle MD, P$D+eit$ D. lancy MDLawrence Diebel MD>illia* <. o"" MD

+. Mic$ael ug$es D;B*tiaF Muns$i MD

Donna Nayduc$ RN, M<N, ANPRo)inder <and$u MD

Jay A. elon MD

#$e A*erican ollege o" ritical are Medicine #as7"orce o" t$e <M

oward L. orwin MDP$ilip <. (arie MD

<a*uel A. #is$er*an MDPaul . ebert MD, M<c

?n press.0ove(ber +%%/rit /are -ed



Ris7s o" (lood #rans"usionRis7s o" (lood #rans"usion

1iral transmission Acute transfusion reactions

2mmunosuppression

Acute inflammatory response

Noninfectious Hazards Immunosuppression Infection





Ris7s o" #rans"usion1Ris7s o" #rans"usion1

Bn"ectious DiseaseBn"ectious Disease

H21 3 % in %.4 million

HC1 3 % in %.5 million

HB1 3 % in 66&"&&&

'?F * hu(an i((unodeficiency virus.'/F * hepatitis / virus.'2F * hepatitis 2 virus.

2usch -P= et al. JAMA. +%%$C+8&#9"+.



illia(son L-= et al. BMJ . !C$!&!"9.

<erious aFards o" #rans"usion<erious aFards o" #rans"usion

2ased on $"" spontaneously9reported2ased on $"" spontaneously9reporteddeaths>(aor co(plications bet3eendeaths>(aor co(plications bet3eenctober !" and Septe(ber !8ctober !" and Septe(ber !8in the ;H and ?reland.in the ;H and ?reland.

Transfusion9trans(ittedTransfusion9trans(ittedinfectionsinfections

Acute lung inuryAcute lung inury

Post9transfusionPost9transfusionpurpurapurpura

Graft vs hostGraft vs host

diseasedisease

@elayed@elayedtransfusiontransfusion

reactionreaction

AcuteAcutetransfusiontransfusion

reactionreaction

?ncorrect blood>?ncorrect blood>co(ponentco(ponenttransfusedtransfused

$$

""

8

+

!

!#

#$



Ris7s o" (lood #rans"usionRis7s o" (lood #rans"usion

Minor allergic reactions

Bacterial infection !platelets#

1iral hepatitis

Hemolytic transfusion reaction

H)(1 2'22 infectionAcute lung in/ury

Anaphylactic shoc,

7atal hemolytic reaction

8raft*vs*host disease

2mmunosuppression

%+%&&

%+6"9&&

%+9"&&&

%+5"&&&

%+6&&"&&&%+9&&"&&&

%+9&&"&&&

%+5&&"&&&

are

Un,nown

'TLF * hu(an T9cell leuDe(ia9ly(pho(a virus.

Hlein 'G. Am J Surg . !#. !7%C"A)suppl,&+!S9+"S.

TRAL? !&#=%%%





(lood #' Bncreases Ris7 o"(lood #' Bncreases Ris7 o"

Postoperati)e (acterial Bn"ectionPostoperati)e (acterial Bn"ection

6& peer*reviewed studies" %@45*6&&&

> 3 %<"%96 !)x 96%9" >o*)x @<#

%ssociation of &lood T' to $nfection

(ommon )* +# !range %.=<*%9.%9#

% of 6& studies with p $ &.&9

Trauma subgroup

(ommon )* #. !range 9.&<*9.=<#

All studies with p $ &.&9 !&.&&9 &.&&&%#

Blood )x associated with greater ris, in trauma pts

'ill G<= -inei JP et al. J Trauma 2003;54:908-914





%9"9@6 Cardiovascular operations

2nfection endpoints bacteremia" 2

99D of pts received 0BCs" 6%D plts" %<D

770" <D cryoprecipitate

2ncreased BC tx associated with increased

infection !p $ &.&&&%#" confirmed by

logistic regression analysis.

? Am Coll urg 6&&5-6&6+%<%*%<4



Reed >, et al. emin Hematol 6&&+==+6=*<%Utter 8 et al. )ransfusion 6&&5 >ov-=5!%%#+%45<*@

eu5oreduction does not diminish t'-associated 1icrochimerism



Gould S et al. Am J Crit Care; Jan !!";#$%#'()*+,



hy is blood transfusionhy is blood transfusion

0T associated 3ith0T associated 3ith

i(proved outco(ei(proved outco(e



<tored R(s<tored R(s

;ecreased BC deformability ;ecreased 6"<" ;08

Metabolic acidosis

Altered oxygen carrying capacity

2ncreased red cell death withincreased age of blood !E<&D dead#

>o improvement in oxygenutiliFation at the tissue level







chechter" 8ladwin" >?M April %&" 6&&<

@istribution of Transfused ;nits



@istribution of Transfused ;nitsby Age of 2lood I /R?T Study

P e r c e n t a g e

o f P a t i e n t s

ldest Age of 2lood in @ays

% 9 !% !% 9 +% +% 9 $% $% 9 % K %

5&D of Blood transfused

is G 6& days old

?n Trau(a Subset= "8 of blood is K +% days old



-arch +%= +%%8

)h di d ti f t



)he median duration of storagewas %% days for newer blood and6& days for older blood.

0atients who were given olderunits had higher rates of in*

hospital mortality !6.4D vs.%.D" 0 3 &.&&=#" intubation beyond 6 hours [email protected] vs.9.5D" 0$&.&&%#" renal failure!6.D vs. %.5D" 0 3 &.&&<#" andsepsis or septicemia !=.&D vs.6.4D" 0 3 &.&%#.

A composite of complicationswas more common in patientsgiven older blood !69.@D vs.66.=D" 0 3 &.&&%#.

imilarly" older blood wasassociated with an increase inthe ris,*ad/usted rate of thecomposite outcome !0 3 &.&<#.

At % year" mortality wassignificantly less in patientsgiven newer blood !.=D vs.%%.&D" 0$&.&&%#.



/o(posite utco(e&

?n9hospital (ortality

And /o(plications)STS,

%ge of &lood Evaluation 6%&E



%ge of &lood Evaluation 6%&E

%&E 8tudy-Hypothesis

)he use of fresh red cells as compared to standardissue red cells will lead to significant improvementin morbidity and mortality

Age of Blood valuation !AB(# in the

resuscitation of critically ill patients

2nternational tudy" C2H" >2H" others0ro/ected n 3 54&&



ABLE……Something about the design?

Study Design: andomiFed double blind‑

controlled clinical trial.

Setting: <& Canadian tertiary care intensive

care and trauma units. Additional study sitesin the U" UI" urope and Australia

Study Population: 54&& critically ill or

trauma victims who require at least one redcell unit within the first 6 hrs of acute care.

h S d



The Study Intervention

(eu,oreduced BCs

7reshO BCs defined as 4 days or less

0rimarily for feasibility as limited biological

rationale for cut*off

Control groupJstandard*issue BCs

!average age of 6% days#

(ocal transfusion guidelines'practices



A2/ Trial) t

/R?T StudyTrau(a

patients fro(TR?//

? ti t

0orth Tha(es2lood ?nterest

A2A-ulticenter

T i l G



)estern<urope, !M

/R?T Study);SA, +M

patients fro(/R?T Study

);SA, $M

?nvestigators)/anada, M

2lood ?nterestGroup );H,

#M

Trials Group);S= /anada,

"M

n $#$ 8+ #7" #+8 !+7 """

-ean ad(issionhe(oglobin )g>dL,

!!.$ N +.$ !!.% N +. !!.! N +. . N +.+ 9 9 9 9

Percentage ofpatients transfusedin ?/;

$7.% .! ##. +#.% #$. 7.7

-ean transfusionsper patient )units,

.8 N #.+ ." N . #.8 N #.# ." N ".7 #.7 N #.+ !$.7 N !.!

-ean pre9transfusionhe(oglobin )g>dL,

8. N !.$ 8." N !.7 8. N !.8 8." N !.$ 9 9 .$ N %.!

-ean ?/; length ofstay )days,

.# 7. N 7.$ . N 8." .8 N !+." 9 9 9 9

?/; (ortality !$.# !$.% 9 9 ++.% +!.# 9 9

'ospital (ortality +%.+ !7." . 9 9 9 9 +!.%

L% 1incent ?(" Baron ?7" einhart I" et al. ABC !Anemia and Blood )ransfusion in Critical Care # 2nvestigators. Anemia and blood transfusion in critically ill patients.

?AMA 6&&6-644+%=@@*%9&.

L6 Corwin H(" 8ettinger A" 0earl 8" et al. )he C2) tudy+ Anemia and blood transfusion in the critically ill current clinical practice in the United tates. Crit Care

Med 6&&=-<6+<@*96.

L< hapiro M?" 8ettinger A" Corwin H" >apolitano (M" (evy M" Abraham " 7in, M0" Mac2ntyre >" 0earl 8" habot MM. Anemia and blood transfusion in trauma

patients admitted to the intensive care unit. ? )rauma 6&&<-99+65@*6=.

L= Hebert 0C" Nells 8" Bla/chman MA" et al. A multicenter" randomiFed" controlled clinical trial of transfusion requirements in critical care. )ransfusion equireemtns in

Critical Care investigators" Canadian Critical Care )rials 8roup. > ngl ? Med %@@@-<=&+=&@*=%.

L9 ao M0" Boralessa H" Morgan C" et al and the >orth )hames Blood 2nterest 8roup. Blood component use in critically ill patients. Anaesthesia 6&&6 ?un-9!5#+9<&*=.

L5 0almieri )(" Caruso ;M" 7oster I>" et al and the American Burn Association !ABA# Multicenter )rials 8roup. ffect of blood transfusion on outcome after ma/or burn

in/ury+ A multicenter study. Crit Care Med 6&&5 ?un-<=!5#+%5&6*.



" (l d # " i d li i lStudies on R2/ transfusion and outco(e in ische(ic heart disease.



(lood #rans"usion and linical(lood #rans"usion and linical Eear Study

@esignn Patients Pri(ary Results

'ebert !7 Retrospective

/ritically ill patients 3ithcardiac disease= as part of aretrospective assess(ent of

transfusion practices in/anadian ?/;s

?ncreased survival 3ithtransfusion 3hen 'b 5 .#

g>dL

'ebert +%%!Prospective=

subgroupanalysis

$#7Subgroup of patients 3ithcardiac disease fro( the

TR?// trial

0o difference in (ortality?ncreased organ dysfunction

3ith transfusion

u+%%!

RetrospectiveAppro1

7=%%%

Patients aged :" years 3hohad been hospitali6ed 3ith a

disgnosis of acute -?=-edicare database

?ncreased survival 3ith

transfusion

Rao +%% RetrospectiveAppro1+=%%%

-eta9analysis of data thathad been collected as part ofthe G;ST ??b= P;RS;?T and

PARAG0 2 trials ofpatients 3ith A/S

?ncreased (ortality=co(bined death or -?

Sabatine +%%# Retrospective @ata fro( !" A/S studies@ecreased (ortality in ST<-?

?ncreased (ortality in non9ST9elevation A/S

Eang +%%# Retrospective

8#=!!!total

cohortC7=+7! no

/A2G

Patients 3ith non9ST9seg(ent elevation acute

coronary syndro(es

?ncreased (ortality=co(bined death or -?

Adapted in part fro(& Gerber @R. /rit /are -ed +%%8C$"),&!%"89!%7.

Studies on R2/ transfusion and outco(e in ische(ic heart disease.



Eear Study

@esignn Patients Pri(ary Results

Singla +%%7Prospective

database

Patients 3ith ane(ia andsuspected A/S receivingtransfusion= using data

prospectively collected aspart of an ongoing registry

?ncreased (ortality= recurrent-?

Aronson +%%8Prospective

database+$#8 Patients 3ith acute -?

?ncreased (ortality inpatients 3ith nadir 'b K

8g>dL

@ecreased (ortality inpatients 3ith nadir 'b 5

8g>dL

Ale1ander +%%8

Prospectivedatabase

/R;SA@<?nitiative

++Patients 3ith non9ST9

seg(ent elevation acutecoronary syndro(es

?ncreased (ortality inpatients 3ith nadir'e(atocrit K $%

@ecreased (ortality inpatients 3ith nadir'e(atocrit O +

Adapted in part fro(& Gerber @R. /rit /are -ed +%%8C$"),&!%"89!%7.

B/;SB/;S



B/;SB/;S >H(B2

)ransfusion)rigger for

7unctional

utcomes in

Cardiovascular

0atients

Undergoing

urgical Hip

7racture epair

>365&&

69 Med Ctrs

U" Canada

?.(. Carson M;

B/;SB/;S



B/;SB/;S 2nclusion criteria+

Undergo surgery for hip fracture Have a history of cardiovascular disease

Have a postoperative Hgb $ %& g'd(

*andomi9ed to 5eep Hgb ;2 g/d or not

T' permitted but not re<uired if Hgb = 4 g/d

0rimary outcome is ability to wal, %& feet without humanassistance at 5& days

>egative outcome is postoperative unstable angina" myocardialinfarction or death

M2 diagnosis based on = blood tests" < I8s" medical history )elephoned at <& and 5& days to determine functional capacity

and vital status.

(ong*term mortality by searching vital statistics registries in U..and Canada



<ffect of 2lood



Transfusion on Long9Ter( Survival

After /ardiacperation

3934 A(- pts

After correction forco(orbidities andother factors= t1 3asstill associated 3itha 7% increase in

(ortality )RR !.7C# /? !. to +.%C p%.%%!,.

Engoren 1( et al# 61(), Toledo

%nn Thorac 8urg .22.37:;;42!





Bnstitution5speci"ic protocols s$ould screen "or patients at $ig$ ris7 "or blood

trans"usion. A)ailable e)idence5based blood conser)ation tec$niQues include1

%3& drugs t$at increase preoperati)e blood )olu*e %eg, eryt$ropoietin& or decrease

postoperati)e bleeding %eg, anti"ibrinolytics&

%2& de)ices t$at conser)e blood %eg, intraoperati)e blood sal)age and blood sparing

inter)entions&

%& inter)entions t$at protect t$e patientOs own blood "ro* t$e stress o" operation %eg,

autologous predonation and nor*o)ole*ic $e*odilution&

%& consensus, institution5speci"ic blood trans"usion algorit$*s supple*ented wit$ point5

o"5care testing, and *ost i*portantly

%4& a *ulti*odality approac$ to blood conser)ation co*bining all o" t$e abo)e

<ociety o" #$oracic <urgeons (lood onser)ation -uideline #as7 !orce/ <ociety o" ardio)ascular Anest$esiologists <pecial tas7 !orce on (lood #rans"usion. Ann #$orac <urg 200/?1<25?6.



<fficacy of 2lood T1 in Sepsis



<fficacy of 2lood T1 in Sepsis

i((er(an JL. ;se of blood products in sepsis& An evidence9based revie3. /rit /are

-ed +%%C$+SupplMS#+9#7

Author and Eear Study population 0A(ount transfused

)units,

/hanges in (easure(ents of post9transfusion

Q 'b Q @+

Q F+ 4 Lactate



Ronco et al 3990 PP pneu*onia 4 3.4 Cnits es es Ees NA

!enwic7 et al 3990 ARD< 2 3.4 Cnits es es No No

Ronco et al 3993 ARD< 3 3.4 Cnits es es No NA

<$a$ et al 39?2 Post5trau*a ? 3 or 2 Cnits es No No NA

<te""es et al 3993 Postoperati)e and Post5trau*a 23 352 Cnits es es es No

(abineau et al 3992 Postoperati)e 3 2? I 9 *L es es No No

-ilbert et al 39?? <eptic 3 20 g:L es es No No

Dietric$ et al 3990 Medical s$oc7 %septic:cardiac& 2 4 *L es es No No

onrad et al 3990 <eptic s$oc7 39 0 g:L es es No No

Mari7 et al 399 <eptic 2 Cnits es es No No

Lorento et al 399 <eptic 36 2 Cnits es es No NA

Min7 et al 3990<eptic s$oc72 *o 6 y

? ?530 *L:7g ' 352 $ es es No NA

Luc7ing et al 3990<eptic s$oc7 *o 34 y

30534 *L:7g ' 35 $ es es Ees NA

<il)er*an et al 3992<eptic s$oc7

23 ?? y23 2 Cnits es es No No

-ra** et al 3996 <eptic s$oc76 I y

39 2 Cnits es No No NA

!ernandes et al 2003<eptic s$oc7

3?5?0y30 3 Cnits es No No No

+a$n et al 39?6 Acute respiratory "ailure 34 530 *L:7g es No No NA

asutt et al 3999Postoperati)e

25?3y6 6? I 30 *L es es No NA

>als$ et al 200

@u)ole*ic ane*ic critically illpatients wit$out ongoing

$e*orr$age

22 2 Cnits es NA NA No

5

<arly Goal9directed Therapy in the R1 of




Severe Sepsis and Septic ShocD

<e)ere sepsis and septic s$oc7 patients %nK26&

<BR< and <(P E 90** g or lactate S **ol:L

Prospecti)e, rando*iFed controlled trial

-oal5directed t$erapy )s. control %standard o" care&

Goal9directed therapy per"or*ed in @R prior to BC

Place*ent o" o'i*etric 8P line, 8P goal ?532, <c8;2 S 0=

-uidelines "or pressor and )asodilators, dobuta*ine, blood t'

Maintained "or at least 6 $ours

Ri)ers @ et al. N@JM 4%39& No)e*ber ?, 2003136?5






y py

Severe Sepsis and Septic ShocD

@arly -oal5directed #$erapy resulted in1

Reduced ?n9hospital (ortality= $%.# vs ".#

)p*%.%%%,

ig$er <c8;2, lower lactate, lower base de"icit

@arly goal5directed t$erapy pro)ides signi"icant

bene"its in outco*e in patients wit$ se)ere sepsisand septic s$oc7.

Ri)ers @ et al. N@JM 4%39& No)e*ber ?, 2003136?5

Falidation Study



y-ulticenter Trial

+% sites

@ereD Angus et al.;niv. of Pittsburgh

ProCSS Protocoli6ed /are for

<arly Septic ShocD0?'9sponsored

8. -illion

@A<#:<M (lood #' -uidelines



Reco((endations Regarding R2/

Transfusion in Sepsis

Level !

#$ere are insu""icient data to support Le)el 3

reco**endations on t$is topic.

Level +

#$e trans"usion needs "or eac$ septic patient *ust

be assessed indi)idually since opti*al trans"usiontriggers in sepsis patients are not 7nown and t$ereis no clear e)idence t$at blood trans"usionincreases tissue o'ygenation.

@A<#:<M (lood #' -uidelines

Ane*ia o" Ane*ia o"$ i$ i



$ronic$ronicDisease or Disease or

GAne*ia o"GAne*ia o"Bn"la**ationHBn"la**ationH

;ysregulation of iron

homeostasis

2mpaired proliferationof erythroid progenitor

cells

Blunted 0 response

>eiss and -oodnoug$.

nl J Med .2004/42%30&130335302.



<BC Patient $aracteristics<BC Patient $aracteristics



<BC 5 Patient $aracteristics<BC 5 Patient $aracteristics

200* 2005 200+ 2007 2008n 1*91 13+1 1353 135* 1275

AAC! %%% #)ore-Da( 1 *8.2 *8.3 *9.1 50.5 55.8

!os"ital /# 1*.1 1* 13.9 12.9 13.5

%C-/# *.1 *.7+ *.77 *.22 *.*9

Readissions Rates +.2 7.9 7.1 8.* 7.*

/evel of Tera"( on Adission

A)tive Treatent 5+4 514 574 +34 +*4

/o-Ris6 onitor 3*4 384 334 274 2*4

Ane*ia Manage*ent ProtocolAne*ia Manage*ent Protocol



Ane*ia Manage*ent Protocol Ane*ia Manage*ent Protocol

% Reduction in 2lood T1 in S?/;

ct9@ec +%% Jul9Sep +%%"

<BC (lood CtiliFation<BC (lood CtiliFation



<BC (lood CtiliFation<BC (lood CtiliFation

ct9@ec +%% Jul9Sep +%%"

Added to Heystone ?/; Reports



?/; -ortality



y

>< %.7! %.# %.7 %.!

+#+D

.227

#2D7#.;D

'ospital -ortality



p y

>< %.7 %.# %.## %.#"

#+D

.227

;2#4"D

"#7D

2lood @ashboard for /linical Services 9 @RABT



Trend Report of Percent of R2/Transfusions by Pre9Transfusion 'ct

/urrent -onth Snapshot ofPercent of R2/ Transfusions by Pre9Transfusion 'ct 3ith drill9do3n to

Patient9Level @etail

2lood @ashboard for /linical Services @RABT

<u**ary<u**ary



<u**ary<u a y

%nemia is common

Co evidence that blood t' for treatment of

anemia improves outcome

(ritically ill patients can tolerate Hb levelsas low as 7 mg/d

&lood should be transfused for physiologic

indications

Cew >1ich &lood T' ?uidelines



UM Carelin, upport for 2mproved)ransfusion 0ractice

Andrew osenberg M;

Medical ;irector" UM Carelin,

Chief" Critical Care ;ivision Anesthesiology

Clinical 2) supports good decisions" best



practices P institution policies

: 7or emergency transfusion call Blood Ban, : 0re*op requests for 0BCs on standby P

transfusion >) part of this process.

: UMC( !UM Carelin,#- 2s the primary method to order blood.

0rovides Clinical ;ecision upport QAlertsR

erves as a useful clinical database QKueriesR: Clinician feedbac, needed !5*6666" light bulb

icon in UMC(#







)ransfusion Alert ule (ogic



)ransfusion Alert ule (ogic

: Based on CCA )ransfusion 8uidelines Hemodynamically stable anemia w'out CA;

)ransfusion trigger3 Hg $ g'd(

Maintain Hg *@g'd(

: 7or 0BC rder set only

% or 6 units ordered !alert will >) fire for < or more units#

And Hemoglobin G g'd(

And'or Hg result G=4 hrs old' r no Hg result available

And 0t age G % yo.

Alert Box 2nformation



Alert Box 2nformation

7our Alert Messages



7our Alert Messages

$# Hgb =7 g/d but last Hgb result 4 hours#

: equest does not meet CCA 8uidelines when ordering % or 6 units 0BC

: (ast H8B is over =4 hours old

: H8B+ SS g'd( ;A)

: Confirm H8B before ordering or select override reason to complete order.

$$# Hgb 7g/d and H?& result = 4 hrs#

: )ransfusion may not be advised if the H8B is G g'd(

$$$# Hbg 7 g/d but H?& result 4 hrs#

: H8B is greater than g'd( and is over =4 hours old.

$# Co Hgb result available

: >o H8B result on file





verride easons



verride easons

%. Active Bleeding6. Cardiovascular disease

<. Hemoglobinopathy

=. Hemolysis

9. xygen carrying deficit

5. efractory Hypotension

. ymptomatic anemia

4. Attending 0hysician deems necessary





Documents

Prior Trials