Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock (original) (raw)
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Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2014
Background: Treating anaemia with red blood cell (RBC) transfusion is frequent, but controversial, in patients with septic shock. Therefore we assessed characteristics and outcome associated with RBC transfusion in this group of high risk patients. Methods: We did a prospective cohort study at 7 general intensive care units (ICUs) including all adult patients with septic shock in a 5-month period. Results: Ninety-five of the 213 included patients (45%) received median 3 (interquartile range 2-5) RBC units during shock. The median pre-transfusion haemoglobin level was 8.1 (7.4-8.9) g/dl and independent of shock day and bleeding. Patients with cardiovascular disease were transfused at higher haemoglobin levels. Transfused patients had higher Simplified Acute Physiology Score (SAPS) II (56 (45-69) vs. 48 (37-61), p = 0.0005), more bleeding episodes, lower haemoglobin levels days 1 to 5, higher Sepsis-related Organ Failure Assessment (SOFA) scores (days 1 and 5), more days in shock (5 (3-10) vs. 2 (2-4), p = 0.0001), more days in ICU (10 (4-19) vs. 4 (2-8), p = 0.0001) and higher 90-day mortality (66 vs. 43%, p = 0.001). The latter association was lost after adjustment for admission category and SAPS II and SOFA-score on day 1.
Hemoglobin threshold for transfusion in septic shock
The New England journal of medicine, 2015
T h e ne w e ngl a nd jou r na l o f m e dicine c o r r e s p o n d e n c e Hemoglobin Threshold for Transfusion in Septic Shock To the Editor: Holst et al. (Oct. 9 issue) 1 found no significant differences in 90-day mortality and the rate of overt ischemic events between a lower and a higher hemoglobin threshold for transfusion in patients with septic shock. This study did not assess the occurrence of silent ischemic events that may have a substantial effect on long-term outcomes. Previous studies have shown that a low hemoglobin concentration is associated with silent cerebral ischemia in specific populations (e.g., patients with sickle cell anemia, those who require dialysis, and those with β-thalassemia). 2 In children with sickle cell anemia, silent cerebral infarction is associated with cognitive impairment and an increased risk of stroke. A recent controlled trial by DeBaun et al. showed that regular blood-transfusion therapy significantly reduced the incidence of recurrence of both silent and overt cerebral infarction in this group. 3 To rule out whether patients with septic shock who have a lower hemoglobin concentration are at risk for ischemic events such as silent cerebral ischemia and cognitive impairment, both brain imaging and cognitive-function tests after hospital discharge should be considered.
Blood transfusions in septic shock: is 7.0g/dL really the appropriate threshold?
Revista Brasileira de Terapia Intensiva, 2015
Objective: To evaluate the immediate effects of red blood cell transfusion on central venous oxygen saturation and lactate levels in septic shock patients with different transfusion triggers. Methods: We included patients with a diagnosis of septic shock within the last 48 hours and hemoglobin levels below 9.0g/dL Patients were randomized for immediate transfusion with hemoglobin concentrations maintained above 9.0g/dL (Group Hb9) or to withhold transfusion unless hemoglobin felt bellow 7.0g/ dL (Group Hb7). Hemoglobin, lactate, central venous oxygen saturation levels were determined before and one hour after each transfusion. Results: We included 46 patients and 74 transfusions. Patients in Group Hb7 had a significant reduction in median lactate from 2.44 (2.00-3.22) mMol/L to 2.21 (1.80-2.79) mMol/L, p = 0.005, which was not observed in Group Hb9 Conflicts of interest: None.
Red blood cell transfusion during septic shock in the ICU
Acta Anaesthesiologica Scandinavica, 2012
Background: Transfusion of red blood cells (RBCs) remains controversial in patients with septic shock, but current practice is unknown. Our aim was to evaluate RBC transfusion practice in septic shock in the intensive care unit (ICU), and patient characteristics and outcome associated with RBC transfusion. Methods: Prospective cohort study of all adult patients with septic shock (n = 164) in six general ICUs during a 3-month period. Characteristics, other treatments, monitoring and outcome were compared in RBC-transfused and -nontransfused patients. Results: Ninety-nine patients (95% confidence interval 87-111) received a median 900 ml (interquartile range 490-1405) of RBC during septic shock in ICU. Among transfused patients, there were more females [49/99 (49%) vs. 22/65 (34%), P = 0.048] and surgical patients [39/99 (39%) vs. 14/65 (22%), P = 0.02] than among patients not transfused. Also, admission simplified acute physiology score II was higher and minimal haemoglobin levels (days 1-3) were lower in transfused patients compared with those not transfused. In contrast, age, markers of shock and severity organ failure assessment score on day 1 and 90-day mortality did not differ between RBC-transfused and -nontransfused patients. Conclusions: Most patients with septic shock received RBCs during shock, and these patients had higher disease severity and lower haemoglobin levels than those not transfused. In spite of this, mortality did not differ between groups neither in the unadjusted or adjusted analyses. However, neither the design nor the sample size allows us to make inferences about treatment effects, which underlines the need for large randomised, clinical trials on transfusion in septic shock.
Transfusion of packed red blood cells is common during resuscitation of critically ill patients. However, the association between in-hospital mortality and blood transfusion among patients with severe sepsis during the first 24 hours of hospitalization has not yet been determined. A cohort study was conducted of adult nontrauma patients who visited the emergency department of a tertiary hospital and were diagnosed with severe sepsis. Propensity score (PS) matching was conducted, based on patient demographics, underlying illnesses, laboratory results, and vital signs presented at the emergency department, and multivariate logistic regression was performed to adjust for potential residual confounding between the 2 transfused and nontransfused groups to assess the risk of in-hospital mortality. Of 3448 patients included in this study, 265 underwent blood transfusion during the first 24 hours of hospitalization. Despite comparable severity of sepsis, patients who received transfusions tended to have lower mean arterial pressures (86 vs 98 mmHg) and hemoglobin levels (7.6 vs 11.2 g/dL), and were more likely to have chronic kidney disease (12% vs 6%) and hematologic organ dysfunction (57% vs 35%, all P < 0.001). Transfused patients tended to have higher mortality rates (26% vs 9%, respectively, P < 0.001). After PS matching, 177 pairs of transfused and nontransfused patients were analyzed. After adjusting for residual confounding factors by multivariate logistic regression in the matched patient pairs, no significant differences in in-hospital mortality were observed (odds ratio [OR] ¼ 1.52, 95% confidence interval: 0.92–2.51). In this PS-matched cohort study of adult nontrauma patients with severe sepsis, the in-hospital mortality rate was not significantly different in patients who received blood transfusions during the first 24 hours of hospitalization. (Medicine 95(4):e2601) Abbreviations: ARISE = Australasian Resuscitation In Sepsis Evaluation, ED = emergency department, EGDT = early goal-directed therapy, Hb = hemoglobin, MEDS scores = Mortality in Emergency Department Sepsis scores, pRBC = packed red blood cells, ProCESS = Protocol-Based Care for Early Septic Shock, PS = propensity score.
The International Annals of Medicine, 2017
Objective: To compare the outcome of early blood transfusion i.e. within 6hrs. (hours) of admission VS late blood transfusion (after 6 hrs.) in puerperal septic shock patients with anemia. Study design: A prospective quasiexperimental controlled trial in ICU(intensive care unit) of lady Willingdon hospital, a tertiary care hospital of Obstetrics and gynecology from Aug2013 to July 2016. Population: Patients admitted with septic shock and anemia during puerperium in ICU. Methods: 74 patients were included in the study by purposive sampling technique. Exclusion criteria were an irreversible shock, chronic lung, and heart disease or those requiring surgical intervention. Surviving sepsis campaign guidelines were followed for the management of these patients. Effect of blood transfusion on the recovery of these subjects was studied. The study group consisted of 43 patients in which blood was transfused within 6hrs. of admission. Control group had 31 patients in whom blood could not be transfused within this period. The demographic features and outcome of both groups were recorded and entered on spss20 statistical package. Results: The time of recovery from hypotension, tachycardia, pulmonary edema, ventilator and cardiac support was significantly shorter in the study group compared to the control. A lesser number of blood transfusions was required to treat anemia in the study group. Maternal mortality was less in the study group (23.25%) as compared to control group (48.39%) with an odds ratio of decrease in maternal mortality of 0.323(.119-.877). Conclusion: Early blood transfusion shortens the time of recovery and decreases maternal mortality and morbidity in puerperal septic shock patients with anemia.
Impact of national transfusion indicators on appropriate blood usage in critically ill patients
Transfusion, 2011
BACKGROUND: The objective was to investigate the impact of three national blood transfusion indicators (NBTIs) specifically designed for critical care regarding the appropriate blood transfusion indications. STUDY DESIGN AND METHODS: This was a prospective, single-center study, carried out at a university hospital. A total of 1808 patients admitted to the intensive care unit (ICU) in 1 year were included. RESULTS: The study consisted of four 90-day periods (P). P1 was a control period with no intervention. P2 followed the inclusion of NBTIs into the ICU database, aimed at reinforcing NBTI knowledge. After presenting and discussing the results of P1 and P2, the early (P3) and late (P4) impacts of NBTI knowledge were evaluated. All patients who were transfused with at least 1 unit of any blood component (33.3%) were included. Thirteen percent of red blood cell transfusions (RBCTs) were given outside of NBTI protocols (13% deviation of NBTIs for RBCTs) without a significant change throughout the duration of the study. Most RBCTs (95%) were prescribed for a hemoglobin threshold of less than 90 g/L. There was a steady and significant improvement in the adherence to NBTI guidelines for platelet concentrate transfusions (PCTs) from 36% (P1) to 52% (P4; p < 0.01). In contrast, the lack of adherence to NBTI guidelines for fresh-frozen plasma transfusions (FFPTs) remained high (74%) and stable throughout the study period. The most frequent reason for inappropriate use of FFPTs or PCTs was absence of severe bleeding. CONCLUSION: The introduction of NBTI guidelines demonstrated a variable impact on the appropriateness of blood component transfusions in critically ill patients. M ore than 35% of critically ill patients receive a transfusion of blood components during their intensive care unit (ICU) stay. 1,2 Ideally, these transfusions should be aimed at increasing oxygen consumption in anemic patients with an elevated oxygen tissue debt (red blood cell transfusion [RBCT]) and/or to diminish blood loss in bleeding patients with altered coagulation tests (fresh-frozen plasma transfusion [FFPT]) or low platelet (PLT) counts (PLT concentrate transfusion [PCT]). However, many blood component transfusions are given to increase hemoglobin (Hb), coagulation factor, and PLT levels despite a lack of evidence for tissue oxygen debt or bleeding. 3 As a result, patients may receive unnecessary transfusions, which are not risk-free interventions. Multiple studies have documented a close association between blood transfusions and poor clinical outcomes, including an increased length of ICU stay and increased ABBREVIATIONS: APACHE II = Acute Physiology and Chronic Health Evaluation II; aPTT = activated partial thromboplastin time; FFPT(s) = fresh-frozen plasma transfusion(s);