2. WHO Health Emergencies program (WHE)
Learning objectives
Understand the definition and clinical picture of chronic anemia.
Know the cause of anemia in the ICU.
Understand the basics of blood transfuion complication.
Know the defention and management of massive transfusion.
3. WHO Health Emergencies program (WHE)
• Anemia can be defined as a decrease in the oxygen (O2) carrying
capacity of blood.
• Anemia is defined as a Hgb count less than 12 g/dL and is the most
common hematologic disorder.
• Its aetiology may be classified into :
• Disorders of RBC production
• Increased destruction of RBCs
• Acute blood loss.
Anemia Defenition
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Clinical manifestations may not be obvious until the Hgb level is less than 7 g/dl.
Cardiovascular
• Tachycardia, palpitations.
• Angina.
• Decreased capillary refill.
• Orthostatic hypotension.
• ECG abnormalities (arrhythmias, ischemic changes).
• Hypovolemic shock (hypotension, tachycardia, decreased cardiac output,
increased systemic vascular resistance).
Clinical Signs and Symptoms
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Respiratory
• Increased respiratory rate.
• Dyspnoea on exertion, progressing to dyspnoea at rest.
• Skin/Musculoskeletal.
• Pallor of skin and mucous membranes.
• Dusky nail beds.
• Decreased skin temperature.
Clinical Signs and Symptoms
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Neurologic
• Headache.
• Light-headedness.
• Ringing in the ears (tinnitus).
• Syncope.
• Irritability/agitation.
• Restlessness.
• Severe fatigue.
• Non-nutritional items: ice, clay, soil, paper).
Clinical Signs and Symptoms ( continued )
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Abdominal
• Enlarged liver and/or spleen.
• Anorexia, nausea, vomiting, pica (craving for inedible or non-nutritional
items: ice, clay, soil, paper).
Clinical Signs and Symptoms ( continued )
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Introduction
Anemia is almost universal in patients who spend a few days in the ICU
About 50% of ICU patients receive erythrocyte transfusions to alleviate anaemia
Transfusion practices that lack a scientific basis or justification should be avoided .
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The hematocrit and Hb concentration will overestimate the occurrence and severity of anemia.
(Increased plasma volume is common in critically ill patients)
Reference Ranges for Red Cell Parameters in Adults
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Two conditions have been implicated in the anemia that appears during the ICU stay :
systemic inflammation
Inflammation is responsible for the anemia of chronic disease ,mechanisms:
inhibition of erythropoietin release from the kidneys
reduced marrow responsiveness to erythropoietin
iron sequestration in macrophages
increased destruction of RBCs.
repeated phlebotomy for laboratory studies
An average of 40–70 mL of blood is withdrawn daily from each ICU patient to perform
laboratory tests (at least 4 times more than non-ICU patients).
can result in an iron-deficiency anemia.
The daily phlebotomy volume can be reduced by ordering fewer laboratory tests, and by
reducing the volume of blood discarded for each laboratory blood draw.
ICU-Related Anemia
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Minimizing Iatrogenic Blood Loss and
Reducing the Need for Transfusion
1. Use small volume collection tubes and microanalysis techniques.
2. Assess the need for routine and additional blood testing to decrease diagnostic blood loss.
3. Use blood salvage systems in surgical patients.
4. Assess the risk of GI bleeding and use prophylactic agents to reduce the risk of GI
bleeding if indicated.
5. Screen all patients for anticoagulants and bleeding risk prior to procedures.
6. Accept normovolemic anemia in hemodynamically stable, asymptomatic patients.
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Physiological Effects of Anemia
• Increase in cardiac output occurs in response to a progressive decrease in hematocrit.
• The progressive decrease in hematocrit is associated with a steady decrease in O2
delivery (DO2).
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1- Consider transfusion if Hb <7 g/dL in critically ill patients who require mechanical
ventilation.
2- Consider transfusion if Hb <7 g/dL in resuscitated critically ill trauma patients.
3- Consider transfusion if Hb <7 g/dL in critically ill patients with stable cardiac disease.
4-RBC transfusion may be beneficial in patients with acute coronary syndromes (ACS)
who are anemic (Hb <8 g/dL).
TRANSFUSION TRIGGERS
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Infusing Packed RBCs
Rapid infusion rates are not necessary when packed RBCs are used to alleviate anemia..
The gravity-driven flow rate of packed RBCs through an 18-gauge peripheral catheter is 5
mL/min, which corresponds to 70 minutes for the transfusion of one unit (350 mL) of packed RBCs.
This is well within the recommended transfusion time of 2 hrs per unit of packed RBCs for hemodynamically
stable patients.
Blood Filters
Standard blood filters (pore size 170 to 260 microns) are required for the transfusion of all blood products .
These filters trap blood clots and other debris, but they do not trap leukocytes, and are not effective for
leukocyte reduction).
These filters can become an impediment to flow as they collect trapped debris, and sluggish infusion rates
should prompt replacement of the blood filter.
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Acute Hemolytic Reactions
Caused by the transfusion of RBCs that are ABO incompatible with the recipient.
Antibodies in recipient blood bind to ABO antigens on the donor RBCs , and the ensuing lysis of donor RBCs
triggers a systemic inflammatory response that can be accompanied by hypotension and multiorgan failure.
These reactions are usually the result of human error.
Clinical Features
Abrupt onset of fever
Dyspnea
Chest pain
Low back pain
Hypotension within minutes after starting the transfusion.
consumptive coagulopathy and progressive multiorgan dysfunction(Severe reactions).
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Acute Hemolytic Reactions Management
1. If a hemolytic reaction is suspected, STOP the transfusion immediately and verify that
the correct blood was given to the correct patient.
2.The blood bank must be notified, and they will ask for blood samples to perform a plasma free
hemoglobin determination (for evidence of intravascular hemolysis) and a direct Coomb’s test (for
evidence of the anti-ABO antibody).
3. If an acute hemolytic reaction is confirmed, support blood pressure and ventilation as needed.
4.The management of severe hemolytic reactions is similar to septic shock (i.e., volume resuscitation
and a vasopressor, if necessary) because inflammation is the culprit in both conditions.
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Febrile Nonhemolytic Reactions
Definition : a temperature elevation >1°C
(1.8°F) that occurs during transfusion or up to 6 hours after transfusion, and is not
attributed to another cause (e.g., acute hemolytic reaction) .
The culprit is the presence of antileukocyte antibodies in recipient blood that react with antigens on donor
leukocytes.
Clinical Features
The fever typically does not appear in the first hour after the start of transfusion (unlike
the fever associated with acute hemolytic reactions), and it can be accompanied by rigors
and chills.
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Febrile Nonhemolytic Reactions (management)
1. The initial approach to transfusion-related fever is the same as described for hemolytic
transfusion reactions, even though the fever may not appear until after the transfusion
is completed.
2.The diagnosis is confirmed by excluding the presence of hemolysis with
the tests described previously.
3. The blood bank will perform a Gram stain on the donor blood, and may request blood
cultures on the recipient(To exclude infection)
4. If a second febrile reaction occurs, leukocyte-reduced RBCs are advised for all subsequent transfusions.
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Result of sensitization to plasma proteins in donor blood from prior transfusions.
Patients with IgA deficiency are prone to hypersensitivity transfusion reactions.
prior exposure to plasma products is not required.
Clinical Features
Mild urticaria that appears during the transfusion and is not accompanied by fever.
dyspnea ,laryngeal edema or bronchospasm.
hypotension and anaphylactic shock .
Hypersensitivity reactions
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Hypersensitivity reactions Management
1. Mild urticaria without fever does not require interruption of the transfusion.
2. popular practice is to stop the transfusion temporarily and administer an
antihistamine for symptom relief (e.g., diphenhydramine, 25–50 mg PO, IM, or IV).
3. Severe anaphylactic reactions should be managed and stop transfusion.
4. Washed RBCs should be used for all future transfusions in patients with hypersensitivity
reactions.
5. Patients who develop hypersensitivity reactions should be tested for an underlying IgA
deficiency.
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Transfusion-related acute lung injury (TRALI)
is an inflammatory lung injury associated with RBC and platelet transfusion, resembles ARDS.
Etiology
The prevailing theory is that TRALI is the result of antileukocyte antibodies in donor blood
that bind to antigens on circulating neutrophils in the recipient. This triggers neutrophil
activation, and the activated neutrophils become sequestered in pulmonary capillaries
and migrate into the lungs to produce the inflammatory injury.
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Transfusion-related acute lung injury (TRALI) Clinical Features
Signs of respiratory compromise (dyspnea, tachypnea,
hypoxemia, etc.) usually appear 1h-6 h after the
transfusion begins.
Fever is common
CXR: diffuse, homogeneous infiltrates in both lungs that
are indistinguishable from ARDS.
TRALI can be severe at the outset, and often requires
mechanical ventilation, but the condition typically
resolves within a week
Marino’s The ICU Book FOURTH EDITION
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Transfusion-related acute lung injury (TRALI) Management
1. If the transfusion is not completed, it should be stopped at the first signs of respiratory difficulty.
2.The blood bank should be notified for all cases of TRALI.
3. The management of TRALI is supportive, and is very similar to the management of ARDS .
4.Keep negative balance.
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Blood Replacement in Trauma cases
Crossmatched, Type-Specific, and Type O Blood
Fully crossmatched pRBCs are preferable for this purpose, but the complete crossmatching process
requires approximately 1 hour in most blood banks if crossmatched blood is unavailable, type O pRBCs
are indicated for patients with exsanguinating hemorrhage.
Prevent Hypothermia
Hypothermia must be prevented and reversed if a patient is hypothermic on arrival to the hospital.
If the patient is receiving massive resuscitation of crystalloid and blood , heat the fluid to 39C before infusing it.
Autotransfusion
This blood generally has only low levels of coagulation factors, so plasma and platelets may still be needed.
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A small subset of patients with shock will require massive transfusion, most often defined
The three most common definitions of MT in adult patients are:
1. transfusion of ≥10 Units of Packed Red Blood Cells (PRBCs), which approximates the Total
Blood Volume (TBV) of an average adult patient, within 24 hrs.
2. Transfusion of at least 4 Units of PRBCs in 1 h with anticipation of continued need for blood
product support.
3. replacement of 50% of the TBV by blood products within 3 hrs.
Massive Transfusion (MT)
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• Volume resuscitation is performed with RBC, FFP and platelets in a 1:1:1
fashion.
• Restrict crystalloid administration just to keep lines open.
• Colloids should be avoided.
• Ionised calcium levels must be monitored and maintained within the normal
range during massive transfusion.
• Early administration of pRBCs, plasma, and platelets in a balanced ratio to
minimize excessive crystalloid administration may improve patient survival.
• This approach has been termed “balanced,” “hemostatic,” or “damage
control” resuscitation.
Massive Transfusion (MT) Management
Source: ATLS 10 th edition
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Summary
1. Decisions regarding the need for transfusion of red blood cells should include
assessment of the patient's clinical status, patient preference, and alternative therapy.
2. For hospitalized patients, including the critically ill , who are Hemodynamically
stable, a restrictive transfusion threshold of 7 g/dl should be used. A threshold of B g/dl
Is recommended for patients with pre-existing cardiovascular disease and those
undergoing cardiac or orthopaedic surgery.
3. Regarding the storage time of blood, patients should receive units of blood selected at
any time within the licensed dating period (standard Issue).
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References
Society of Critical Care Medicine Fundamental Critical Care Support course (FCCS 7th Edition)
https://www.sccm.org/Fundamentals/Fundamental-Critical-Care-support
European Society of Intensive Care Medicine (ESICM) Academy ACE modules
https://academy.esicm.org/course/view.php?id=312
Marino’s The ICU Book FOURTH EDITION
