Guidelines on the Management of Anemia and Red Cell Tranfusion in Adult Critically Ill Patients

8/15/2019 Guidelines on the Management of Anemia and Red Cell Tranfusion in Adult Critically Ill Patients

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UIDELINES ON THE MANA EMENT OF

ANEMIA AND RED CELL TRANSFUSION IN

ADULT CRITICALLY ILL PATIENTS

Disusun Oleh:Mazen (0961050023)

Kepaniteraan Klinik Ilmu Anestesi

Periode 11 Mei 2015 – 13 Juni 2015

akultas Kedokteran !ni"ersitas Kristen Indonesia

Jakarta



FORWARD

• Pedoman berikut ini berkaitan dengan penggunaan sel darah merah

untuk manage anemia pada pasien kritis dimana tidak terdapat

perdarahan besar.• World Health Organization (!") mende#inisikan anemia sebagai

suatu keadaan dimana hemoglobin (!b) $130 g%l pada pria dan $120

g%l pada &anita' dan anemia berat ketika !b $0 g%l.

• nemia pada pasien*pasien kritis mempun+ai pre,alensi +ang tinggi.

!emodilusi' kehilangan darah' dan sampling darah adalahkontributor utama +ang penting untuk anemia pada pera&atan kritis.

-mpaired er+thropoiesis seondar+ to in#lammation is inreasingl+

important &ith prolonged illness.



METHODS



Transfusion triggers in genera

!riti!a !are "o"uations

• /alam penelitian Transfusion Requirements In Critical Care (TRICC), pasien*pasien

dengan !b 90 d%l dipilih seara aak untuk diberikan salah satu dari dua pilihan trans#usi

trans#usi dengan transfusion trigger $100 g%l dengan target 100*120 g%l (liberal group)'

dan trans#usi dengan transfusion trigger $0 g%l dengan target 0*90 g%l (restrictivegroup).

• ingkat mortalitas dalam 30 hari pada pasien +ang termasuk dalam liberal grou adalah

khas dari populasi umum di -4 (23'3)' tetapi hirt+*da+ mortalit+ in the liberal group

&as t+pial o# general -4 populations (23'3)' tetapi ada keendrungan non*signi#ikan

terhadap angka mortalitas +ang lebih rendah pada restrictive grou (1.' P 011)

•

Pasien dengan usia $55 tahun dan pasien dengan tingkat keparahan +ang lebih rendah(P!7 -- sore $20) +ang termasuk ke dalam restrictive grou mempun+ai resiko

kematian +ang lebih rendah. Pasien dengan usia $55 tahun +ang termasuk dalam

restrictive grou mempun+ai angka mortalitas sebesar 5'' sedangkan +ang termasuk

dalam liberal grou sebesar 13'0 895 on#idene inter,al (-) #or the absolute

di##erene 1'113'5 P 002:.



Transfusion triggers in genera

!riti!a !are "o"uations

• ngka ke;adian kegagalan organ baru pada restrictive grou ;uga lebih

rendah dibandingkan dengan liberal grou, dan ;uga lebih tinggin+a angka

ke;adian !cute Resirator" #istress $"ndrome pada liberal grou ('

,s. 11'<).

• he rans#usion =e>uirements #ter ardia ?urger+ (=?) stud+

#ound no di##erene in a omposite end*point o# 30*d mortalit+ and se,ere

omorbidit+ in ardia patients prospeti,el+ randomized to a liberal or

restriti,e trans#usion strateg+.

• Penelitian @A"4?B (Transfusion Trigger Trial for %unctional Outcomes inCardiovascular &atients 'ndergoing $urgical Hi %racture Reair )

terhadap trans#usi liberal dan restrictive pada pasien resiko tinggi usai

men;alani oprasi panggul menun;ukkan bah&a tidak terdapat perbedaan

angka mortalitas dan morbiditas.



re!o##en$ations

•

Transfusion trigger C0 g%l dengan target !b 0*90 g%lsebaikn+a men;adi standar pengobatan untuk pasien*

pasien kritis' keuali ;ika terdapat spei#i omorbidities

aute illness* related #ators modi#+ linial deision*

making (Drade 1E).

• Transfusion trigger sebaikn+a tidak lebih dari 90 g%l

untuk pasien*pasien kritis (Drade 1E).



Aternati%e to re$ !etransfusion

• ritiall+ ill patients do not generate a ph+siologial inrease in

er+thropoietin onentration in response to anaemia.• ombination o# iron supplementation and er+thropoietin therap+

an modestl+ derease trans#usion re>uirements' but the bene#its

beome negligible &hen a trans#usion trigger o# 0 g%l is used.

• 7r+thropoietin therap+ inreases deep ,ein thrombosis' espeiall+

&hen proph+laFis is not used.



re!o##en$ation

• 7r+thropoietin sebaikn+a tidak digunakan dalam

pengobatan anemia pada pasien kritis. (Drade 1E).



Aternati%e to re$ !etransfusion

•

7,idene o# absolute iron de#iien+ is absent in most patients' and patients do not respond to iron

supplementation alone.

• here are no large randomized trials o# iron monotherap+

in ritiall+ ill patients' and eFess iron ma+ inrease

suseptibilit+ to in#etion.



re!o##en$ation

• -n the absene o# lear e,idene o# iron de#iien+'

routine iron supplementation is not reommended during

ritial illness (Drade 2/).



&oo$ sa#"ing te!'ni(ues to

re$u!e iatrogeni! )oo$ oss

• ?e,eral studies ha,e assessed the impat o# blood onser,ation

de,ies.

•

&o sho&ed a signi#iant redution in blood loss' but &ithout ane##et on anaemia or =E use.

• "ne stud+ sho&ed a redution in the se,erit+ o# anaemia and redued

=E use &ith the Genous rterial blood Management Protetion

(GMP) s+stem (7d&ards Hi#esienes' -r,ine' ' 4?). 4se o#

this de,ie &as assoiated &ith dereased re>uirements #or =Etrans#usion (ontrol group 0'131 units ,s. ati,e group 0'06 units

=E%patient%d' P 002). he inter,ention group also had a smaller

redution in !b during -4 sta+' 1<'< I 20' ,s. 21'3 I 23'2 g%l P

0'02.



re!o##en$ation

• he introdution o# blood onser,ation sampling de,ies

should be onsidered to redue phlebotom+*assoiated

blood loss (Drade 1).

• Paediatri blood sampling tubes should be onsidered #or

reduing iatrogeni blood loss (Drade 2).



A$%erse !onse(uen!es asso!iate$

*it' R&C transfusion in !riti!a !are

• Most ohort studies sho& assoiations bet&een

trans#usion and ad,erse patient outomes' inludingdeath' organ #ailure progression' in#etion and prolonged

hospital sta+.

• -n ritiall+ ill patients' trans#usion*assoiated lung in;ur+

(=H-) and trans#usion*assoiated irulator+ o,erload(") are partiularl+ rele,ant ompliations.



Tranfusion+asso!iate$ !ir!uator,

o%eroa$ -TACO.

• ?!" de#ines " as aute respirator+ distress &ith pulmonar+

oedema' tah+ardia' inreased blood pressure' and e,idene o# a

positi,e #luid balane a#ter a blood trans#usion.• single large stud+ e,aluating the inidene o# " in ritiall+ ill

patients' de#ined the ondition as the onset o# pulmonar+ oedema

&ithin 6 h o# trans#usion &ith a Pa"2JAi"2 ratio o# $300 mm!g or

?a"2 o# $90 on room air' bilateral in#iltrates on a hest radiograph

in the presene o# liniall+ e,ident le#t atrial h+pertension.• -t reported di##erenes in inidene' ,ar+ing #rom one in e,er+ 35

units o# =Es trans#used' to the 2009 ?!" report' &hih identi#ied

3< ases o# "' 33 attributable to =Es' but onl+ #i,e ases

on#irmed as highl+ likel+.



Transfusion+reate$a!ute ung in/ur, -TRALI.

• =H- is de#ined as the onset o# pulmonar+ oedema&ithin 6 h o# trans#usion &ith a Pa"2JAi"2 ratio o# $300

mm!g in room air' bilateral in#iltrates on a hest

radiograph in the absene o# le#t atrial h+pertension.

• =ana et al (2006a) estimated the inidene o# =H- asin one in e,er+ 121 trans#usions.





re!o##en$ations

• Pre*trans#usion linial assessment should be undertaken inluding assessment

o# onomitant medial onditions that inrease the risk o# " (ardia

#ailure' renal impairment' h+poalbuminaemia' #luid o,erload) (Drade 1/).

• ttention to the rate o# trans#usion together &ith are#ul #luid balane and

appropriate use o# diureti o,er (e.g. #urosemide) an redue the risk o# "

(Drade 1/).

• Patients de,eloping aute d+spnoea &ith h+poFia and bilateral pulmonar+

in#iltrates during or &ithin 6 h o# trans#usion should be are#ull+ assessed #or the

probabil* it+ o# =H- and patients should be admitted to a ritial are area #or

supporti,e treatment and monitoring (Drade 1/).

• n+ ad,erse e,ents or reations related to trans#usion should be appropriatel+

in,estigated and reported ,ia s+stems #or loal risk management' and also to

Kational !aemo,igilane ?hemes (Drade 1/).



R&C storage $uration

• he maFimum duration o# storage ,aries #rom 35 to <2 d

bet&een ountries. +piall+' -4 patients reei,e =Es

stored #or 2< &eeks' in part beause blood banks o#ten issueolder =Es as the+ tend to be trans#used shortl+ a#ter issue.

• =E storage results in hanges that potentiall+ impair "2

release (2'3 /PD depletion) and limit apillar+ transit

(dereased nitri oFide prodution membrane hanges

dereased de#ormabilit+ inreased adherene to endothelium).umulation o# bioati,e substanes (+tokines' lipid

mediators) in the supernatant ould also ha,e ad,erse e##ets'

espeiall+ in ountries trans#using non*leuodepleted =Es.



re!o##en$ation

• he e,idene base is insu##iient to support the routine

administration o# @#resher bloodB to ritiall+ ill patients

(Drade 2E).



Criti!a, i "atients *it'se"sis

• 7,idene o# bene#it #rom =E trans#usion in earl+ sepsis omes #rom

a single entre stud+ o# goal*direted resusitation.

•

Eoth groups in the stud+ reei,ed #luid boluses and ,asopressordrugs to ahie,e resusitation targets omprising a entral ,enous

pressure L m !2" and mean arterial pressure L65 mm!g. he

goal*direted therap+ group &ere monitored during the #irst 6 h o#

treatment b+ measuring the entral ,enous oF+gen saturation

(?,"2).

• -n ases &here the ?,"2 &as $0' patients reei,ed blood

trans#usions to maintain a haematorit (!t) o# 0'30 (!b 100 g%l)

and%or dobutamine to inrease ardia. his inter,ention dereased

the absolute risk o# death in hospital b+ 16 (305 ,s. <65).



Criti!a, i "atients *it'se"sis

• urrent e,idene suggests that using =E trans#usions to

ahie,e a !b higher than 090 g%l has no linial bene#it

one the patient has established organ #ailure be+ond the

earl+ resusitation period.



re!o##en$ation

• -n the earl+ resusitation phase in patients &ith se,ere

sepsis' i# there is lear e,idene o# inade>uate /"2'trans#usion o# =Es to a target !b o# 90100 g%l should

be onsidered (Drade 2).

• /uring the later stages o# se,ere sepsis' a onser,ati,e

approah to trans#usion should be #ollo&ed &ith a target!b o# 090 g%l (Drade 1E).





re!o##en$ation

• -n patients &ith E- the target !b should be 090 g%l

(Drade 2/).

• -n patients &ith E- and e,idene o# erebral ishaemia

the target !b should be 90 g%l (Drade 2/).



Su)ara!'noi$'e#orr'age

• hile trans#usion impro,es erebral /"2 in anaemi

patients &ith ?!' it ma+ derease brain tissueoF+genation in others.

• on,ersel+ haemodilution' targeting a !t o#

approFimatel+ 030' has been used in ombination &ith

indued h+pertension and h+per,olaemia (triple*!

therap+) in the treatment and pre,ention o# erebral

,asospasm #ollo&ing ?!.



re!o##en$ation

• -n patients &ith ?! the target !b should be 0100 g%l

(Drade 2/).



Is!'ae#i! stro1e

• "bser,ational studies in patients &ith ishaemi stroke

suggest that the e##et o# !t on outome is u*shaped'&ith both high and lo& !b assoiated &ith un#a,ourable

outome.

• lthough high !ts predispose to erebral ishaemia and

redued reper#usion' =s ha,e #ailed to sho&signi#iant bene#it #rom modest haemodilution.



re!o##en$ation

• -n patients presenting to the -4 &ith an aute ishaemi

stroke the !b should be maintained abo,e 90 g%l (Drade

2/).



R&C transfusion for "atients *it'

is!'ae#i! 'eart $isease



re!o##en$ation

• naemi ritiall+ ill patients &ith stable angina should

ha,e a !b maintained 0 g%l' but trans#usion to a !b

100 g%l has unertain bene#it (Drade 2E).

• -n patients su##ering #rom ? the !b should be

maintained at 090 g%l (Drade 2).



Con!usion

• naemia is pre,alent in the ritiall+ ill and is assoiated &ith

ad,erse outomes.

•

he prospeti,e and obser,ational data that is a,ailable onsistentl+suggests that trans#usion o# =Es &hen the !b is &ithin the 090

g%l range has no bene#iial e##et on linial outomes either in the

general ritial are population' or in spei#i patient sub*groups #or

&hom a ph+siologial rationale #or redued anaemia tolerane eFists.

•

-n the #uture' large &ell designed' prospeti,e randomized ontroltrials are re>uired to #urther e,aluate the risk to bene#it balane o#

=E trans#usion in a range o# aute onditions resulting in ritial

illness.



THAN2 YOU

Documents

Guidelines on the Management of Anemia and Red Cell Tranfusion in Adult Critically Ill Patients