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SPCI - Sociedade Portuguesa de Cuidados Intensivos

Revista Brasileira de Terapia Intensiva

AMIB - Associação de Medicina Intensiva Brasileira

OFFICIAL JOURNAL OF THE ASSOCIAÇÃO BRASILEIRA DE MEDICINA INTENSIVA AND THE SOCIEDADE PORTUGUESA DE CUIDADOS INTENSIVOS

ISSN: 0103-507X
Online ISSN: 1982-4335

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Miquilino MPV, Cardoso CE, Martins VCBF, Almeida SMS, Oliveira AC, Macedo GL. Gatilho transfusional de concentrados de hemácias na unidade de terapia intensiva de um hospital universitário. Rev Bras Ter Intensiva. 2020;32(1):159-160

 

 

2020 2020;32(1):159-160
LETTER TO THE EDITOR

10.5935/0103-507X.20200024

Packed red blood cell transfusion trigger in the intensive care unit of a university hospital

Gatilho transfusional de concentrados de hemácias na unidade de terapia intensiva de um hospital universitário

Maria Paulina Viana Miquilino1, Carlos Eduardo Cardoso1, Victória Castello Branco Fernandes Martins1, Sandra Mara Silva de Almeida1, Aparecida Carmem de Oliveira1, Gerson Luiz de Macedo1

1 Hospital Universitário de Vassouras, Universidade de Vassouras - Vassouras (RJ), Brazil.

Conflicts of interest: None.

Responsible editor: Thiago Costa Lisboa

Submitted on May 14, 2019
Accepted on August 05, 2019

Corresponding author: Maria Paulina Viana Miquilino, Hospital Universitário de Vassouras, Universidade de Vassouras, Rua Vicente Celestino, 201 - Madruga, Zip code: 24800-000 - Vassouras (RJ), Brazil. E-mail: [email protected]

 

To the Editor,

Anemia is a pathological condition with high prevalence and great importance in intensive care units (ICUs) because it increases mortality in critically ill patients. For this reason, the transfusion of packed red blood cells (PRBCs) is a routinely adopted practice, but the safe pre-transfusion hemoglobin (Hb) value indicative of transfusion is still discussed because, although the anemic condition increases the risk of death, blood transfusion is not without risk.(1-3) Recent studies comparing a restrictive transfusion strategy (Hb < 7g/dL) with a more liberal transfusion strategy (Hb < 10g/dL) concluded that, except in surgical patients and in patients with cardiac conditions, the restrictive strategy is possibly superior to the liberal strategy.(4,5)

To determine the transfusion trigger for PRBCs at Hospital Universitário de Vassouras (HUV), an analysis was conducted of the HUV Hemotherapy Center’s database of transfusions performed from January 2014 to July 2017.

Of the 611 patients who received transfusions in the ICU, 326 were male (53.4%), and the mean age of the sample was 59.9 years. The transfusion trigger for PRBCs at the HUV ICU was 6.9g/dL. The mean number of PRBC bags used was 1.9 units per patient. For better evaluation of the results, indications for PRBC transfusion were classified into four groups, as shown in figure 1: surgical patient (preoperative and postoperative), hemorrhage, critically ill patient (nonsurgical and nonhemorrhagic), and low Hb. The main indications were low Hb (22.1%), cardiac surgery (10.5%) and sepsis/septic shock (8.7%). The mean pretransfusion Hb level in patients undergoing cardiac surgery was 7.8g/dL.

Figure 1 - Indications for packed red blood cell transfusion in the intensive care unit.

The mean pretransfusion Hb level found (6.9g/dL) was lower than that reported in other international studies but is similar to the value found in studies in Brazilian ICUs. A recent retrospective study involving 730 ICUs from 84 countries reported a mean pretransfusion Hb value of 8.3g/dL, ranging from 7.8g/dL in Middle Eastern countries to 8.9g/dL in Eastern Europe.(3) Regarding the available data on Brazilian ICUs, a prospective multicenter study conducted in 19 ICUs found a transfusion trigger of 7.7g/dL,(1) while another prospective study conducted in five university hospital ICUs revealed a pretransfusion Hb value of 6.9g/dL.(6) Since the end of the 1990s, restrictive transfusion strategies in critically ill patients have gained greater credibility because they are associated with a lower mortality rate compared with that for more liberal strategies, with the exception of some patients, such as those with perioperative conditions.(2,4,5,7) Surgical patients have an oxygen demand that differs from that of critically ill patients because they are exposed to different conditions, such as surgery-related blood loss, vascular changes due to the effect of anesthesia and fluid changes.(7) In its PRBC transfusion guidelines published in 2016, the American Association of Blood Banks (AABB) recommends a restrictive strategy (Hb <7g / dL) for critically ill non-surgical patients and suggests that red blood cell transfusion is based on Hb level, in the clinical context and patient preferences, and that alternative therapies are considered.(8)

Of the main transfusion indications, cardiac surgery was the second most prevalent at HUV. The transfusion trigger of patients undergoing cardiac surgery was 7.8g/dL. Although the literature advocates the liberal strategy for PRBC transfusion in surgical patients, patients undergoing cardiac surgery deserve special attention. Some studies were inconclusive regarding the best transfusion strategy recommended for patients with cardiac comorbidities or undergoing cardiac surgery.(2,9) However, a recent meta-analysis involving 8,886 patients undergoing cardiac surgery showed that the restrictive strategy is as effective and safe as the liberal strategy, as no differences in 30-day mortality or in the morbidity of patients receiving either strategy were observed.(10)

To reduce the morbidity and mortality of critically ill patients related to transfusion practices, the pretransfusion Hb value is of great clinical relevance. In the present study, the PRBC transfusion trigger in the HUV ICU was 6.9g/dL. This value follows the restrictive standard recommended by the literature to reduce morbidity and mortality in critically ill patients.

REFERENCES

Lobo SM, Vieira SR, Knibel MF, Grion CM, Friedman G, Valiatti JL, et al. Anemia e transfusões de concentrados de hemácias em pacientes graves nas UTI brasileiras (pelo FUNDO-AMIB). Rev Bras Ter Intensiva. 2006;18(3):234-41. Link DOILink PubMed
Hébert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340(6):409-17. Link DOILink PubMed
Vincent JL, Jaschinski U, Wittebole X, Lefrant JY, Jakob SM, Almekhlafi GA, Pellis T, Tripathy S, Rubatto Birri PN, Sakr Y; ICON Investigators. Worldwide audit of blood transfusion practice in critically ill patients. Crit Care. 2018;22(1):102. Link DOILink PubMed
Fominskiy E, Putzu A, Monaco F, Scandroglio AM, Karaskov A, Galas FR, et al. Liberal transfusion strategy improves survival in perioperative but not in critically ill patients. A meta-analysis of randomised trials. Br J Anaesth. 2015;115(4):511-9. Link DOILink PubMed
Hovaguimian F, Myles PS. Restrictive versus liberal transfusion strategy in the perioperative and acute care settings: a context-specific systematic review and meta-analysis of randomized controlled trials. Anesthesiology. 2016;125(1):46-61. Link DOILink PubMed
Paula IC, Azevedo LC, Falcão LF, Mazza BF, Barros MM, Freitas FG, et al. Perfil transfusional em diferentes tipos de unidades de terapia intensiva. Rev Bras Anestesiol. 2014;64(3):183-9. Link DOI
Chong MA, Krishnan R, Cheng D, Martin J. Should transfusion trigger thresholds differ for critical care versus perioperative patients? A meta-analysis of randomized trials. Crit Care Med. 2018;46(2):252-63. Link DOILink PubMed
Carson JL, Guyatt G, Heddle NM, Grossman BJ, Cohn CS, Fung MK, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA. 2016;316(19):2025-35. Link DOILink PubMed
Curley GF, Shehata N, Mazer CD, Hare GM, Friedrich JO. Transfusion triggers for guiding RBC transfusion for cardiovascular surgery: a systematic review and meta-analysis. Crit Care Med. 2014;42(12):2611-24. Link DOILink PubMed
Chen QH, Wang HL, Liu L, Shao J, Yu J, Zheng RQ. Effects of restrictive red blood cell transfusion on the prognoses of adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials. Crit Care. 2018;22(1):142. Link DOILink PubMed

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