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Physiological triggers for  blood Transfusion in the ICU   Dr. T.R. Chandrashekar Intensivist K.R.Hospital Bangalore
Some facts about Blood transfusion ,[object Object],[object Object],[object Object],[object Object]
Transfusion Trigger  Acceptable hemoglobin concentration   Risk of blood transfusion Risk of low hemoglobin
Oxygen transport physiology
Oxygen transport physiology ,[object Object],[object Object],[object Object],[object Object]
Oxygendelivery CaO2 = (1.34 x Hb x SaO2) +dissolved O2 DO2 = CO X CaO2 Cardiac output= HR x SV Mitochondria in end organs
Oxygen extraction/ reserve ,[object Object],[object Object],[object Object],[object Object],[object Object]
Do2/Vo2 ,[object Object],Hb 7 g% 225ml normal O2 utilisation Reserve  Cannot be utilised   225ml normal O2 utilisation/ No reserve Hb 15g%
DO2/VO2 Patients have to be kept them well above the Critical Point so  that oxygenation of any tissue is not compromised Supply  dependent  area In critically ill  supply dependent  area
Factors that may result in a patient being potentially closer to the critical point than normal ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Factors that may result in a patient being potentially closer to the critical point than normal ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Increased oxygen consumption
Does old blood improve oxygen content?
Storage Defects and Microvascular Perfusion Decreased 2,3- DPG, ADP,NO Build-up of cytokines, Free Hb, K+, debris Poor deformability Will they improve oxygen content and delivery ? Immune suppression Infections  Clinical and animal studies report contradictory  findings about the oxygenation capacity of  stored RBCs
Transfusion “Trigger” Controversy Transfusion trigger: “ a particular hemoglobin level of discomfort in the Prescribing physician,  Not defined by clear Physiologic parameters” 8/24? 7/21? 10/30? Transfusion  paradigms
Sources of Variation in Transfusion Practice ,[object Object],[object Object],[object Object],[object Object]
Transfusion trigger (Crit Care Med 2009; 37:3124 –3157)
Recommendations Regarding Indications for RBC Transfusion in the General Critically Ill Patient ,[object Object],[object Object]
Indications for RBC Transfusion in the General Critically Ill Patient ,[object Object],[object Object],[object Object],[object Object]
Anemia in the ICU ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Why does patients become Anaemic in ICU ?
Causes of Anemia in the Critically Ill ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Physiological trigger ,[object Object],[object Object]
Physiological trigger ,[object Object],[object Object]
The physiologic effect of anemia ,[object Object],[object Object]
How well is anemia tolerated? Are the compensatory mechanisms working? Is their a Tissue oxygen deficit? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Anemia symptoms ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Points to consider before Blood transfusion ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Three possible scenarios in ICU ,[object Object],[object Object],[object Object]
Acute bleed  ,[object Object],[object Object],[object Object]
Septic shock-EGDT
Hemodynamically stable critically ill patient ,[object Object],[object Object]
CaO2 = (1.34 x Hb x SaO2) +dissolved O2 DO2 = CO X CaO2 Cardiac output Mitochondria in end organs 7 g % ALI/ARDS PE Sepsis induced myocardial depression Drugs  Inotropes  Pericardial effusion v MMDS-cannot extract O2 O 2 lactate CO 2 v a
Case scenario… ,[object Object],[object Object],[object Object],[object Object],[object Object]
Case scenario… ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case scenario… ,[object Object],[object Object],[object Object],[object Object]
Case scenario… ,[object Object],[object Object],[object Object],[object Object],[object Object]
Recommendations Regarding Strategies to Reduce RBC Transfusion ,[object Object],[object Object],[object Object],[object Object]
Conclusion  ,[object Object],[object Object],Require close monitoring and individualized  trade-off decisions between the risks of anemia vs.  the risks  and benefits of transfusion
Thank You

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Physiological triggers for blood transfusion in the icu

  • 1. Physiological triggers for blood Transfusion in the ICU Dr. T.R. Chandrashekar Intensivist K.R.Hospital Bangalore
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  • 3. Transfusion Trigger Acceptable hemoglobin concentration Risk of blood transfusion Risk of low hemoglobin
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  • 6. Oxygendelivery CaO2 = (1.34 x Hb x SaO2) +dissolved O2 DO2 = CO X CaO2 Cardiac output= HR x SV Mitochondria in end organs
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  • 9. DO2/VO2 Patients have to be kept them well above the Critical Point so that oxygenation of any tissue is not compromised Supply dependent area In critically ill supply dependent area
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  • 12. Does old blood improve oxygen content?
  • 13. Storage Defects and Microvascular Perfusion Decreased 2,3- DPG, ADP,NO Build-up of cytokines, Free Hb, K+, debris Poor deformability Will they improve oxygen content and delivery ? Immune suppression Infections Clinical and animal studies report contradictory findings about the oxygenation capacity of stored RBCs
  • 14. Transfusion “Trigger” Controversy Transfusion trigger: “ a particular hemoglobin level of discomfort in the Prescribing physician, Not defined by clear Physiologic parameters” 8/24? 7/21? 10/30? Transfusion paradigms
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  • 16. Transfusion trigger (Crit Care Med 2009; 37:3124 –3157)
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  • 31. CaO2 = (1.34 x Hb x SaO2) +dissolved O2 DO2 = CO X CaO2 Cardiac output Mitochondria in end organs 7 g % ALI/ARDS PE Sepsis induced myocardial depression Drugs Inotropes Pericardial effusion v MMDS-cannot extract O2 O 2 lactate CO 2 v a
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