Patient Blood Management in Critically Ill Patients

1. Patient Blood Management
in Critically Ill Patients
By :
Dr. Tengku Abdul Kadir Bin Tengku Zainal Abidin.
Anaesthesiologist, HP UniSZA.

2. Join at slido.com
#1360238
ⓘ Start presenting to display the joining instructions on this slide.

3. 3 Pillars of Patient Blood Management
Blood conservation
Appropriate blood use through implementation of
evidence-based transfusion guidelines
Anemia management

4. 3 Pillars of Patient Blood Management
Blood conservation
Appropriate blood use through implementation of
evidence-based transfusion guidelines
Anemia management

5. Critically Ill Patients in ICU
• 2/3 have a hemoglobin concentration of less than 12
• 97% of the patients become anemic after a week in ICU.
• 30% to 50% of patients receive RBC transfusions while in the
ICU with an average of 5 units transfused during their ICU stay.

6. Anemia in ICU
• The etiologies of anemia in ICU.
• Loss of RBCs (phlebotomy, bleeding)
• Increased destruction of RBCs or RBC
precursor in the bone marrow (toxins
and drugs)
• Nutritional (iron, folic acid, vitamin B
12) deficiency.

7. Anemia in ICU
• Decreased production of RBCs due to suppression of bone marrow
(inflammatory cytokines, drugs, erythropoietin deficiency)
3 main abnormalities related to the host
inflammatory response:
(1) Dysregulation of iron homeostasis due to
increased hepcidin concentrations;
(2) Impaired proliferation of erythroid
progenitor cells; and
(3) Blunted erythropoietin response.

8. Transfuse or NOT?
Potential
Harm/Risks
Potential
Benefits
Cost Supply

9. Patophysiology of ICU patients
• Increase oxygen consumption and metabolic demand in critically ill
patients.
• Organ hypoperfusion, suboptimal resuscitation and inability of
patients to increase their cardiac output  multiorgan failure.

10. RBC transfusions to improve oxygen delivery
• Clinical trials of RBC transfusion to improve oxygen delivery and
mortality gave conflicting results.
• Tissue hypoxia in critically ill
• Poor cardiac output
• ODC curve abnormalities
• Ability of the tissue to extract O2
• Haterogenicity of patient in ICU
• Elderly
• Sepsis
• Cardiovascular disease
• TBI

12. Potential Hazard and Errors in Blood
Transfusions

13. TRICC Trial
7g/dL vs 10g/dL

16. • 45 Observational studies in Meta analysis
• Across a broad spectrum of high risk
hospitalized patients, RBC transfusions seem to
be associated with increased morbidity and
mortality.

20. Hukum Darah.
•
ِ‫ل‬ َّ‫ل‬ِ‫ه‬ُ‫أ‬ ‫ا‬َ‫م‬ َ‫و‬ ِ
‫ير‬ ِ
‫نز‬ ِ‫خ‬ْ‫ال‬ ُ‫م‬ْ‫ح‬َ‫ل‬ َ‫و‬ ُ‫م‬َّ‫د‬‫ال‬ َ‫و‬ ُ‫ة‬َ‫ت‬ْ‫ي‬َ‫م‬ْ‫ال‬ ُ‫م‬ُ‫ك‬ْ‫ي‬َ‫ل‬َ‫ع‬ ْ‫ت‬َ‫م‬ِِّ
‫ر‬ُ‫ح‬
ْ‫و‬َ‫م‬ْ‫ال‬ َ‫و‬ ُ‫ة‬َ‫ق‬ِ‫ن‬َ‫خ‬ْ‫ن‬ُ‫م‬ْ‫ال‬ َ‫و‬ ِ‫ه‬ِ‫ب‬ ِ‫ه‬‫ـ‬َّ‫الل‬ ِ
‫ْر‬‫ي‬َ‫غ‬
ُ‫ة‬َ‫ذ‬‫و‬ُ‫ق‬
ُ‫ة‬َ‫ي‬ِِّ‫د‬ َ‫ر‬َ‫ت‬ُ‫م‬ْ‫ال‬ َ‫و‬
‫ا‬ ‫ى‬َ‫ل‬َ‫ع‬ َ‫ح‬ِ‫ب‬ُ‫ذ‬ ‫ا‬َ‫م‬ َ‫و‬ ْ‫م‬ُ‫ت‬ْ‫ي‬َّ‫ك‬َ‫ذ‬ ‫ا‬َ‫م‬ َّ
‫َّل‬ِ‫إ‬ ُ‫ع‬ُ‫ب‬َّ‫س‬‫ال‬ َ‫ل‬َ‫ك‬َ‫أ‬ ‫ا‬َ‫م‬ َ‫و‬ ُ‫ة‬َ‫ح‬‫ي‬ِ‫ط‬َّ‫ن‬‫ال‬ َ‫و‬
ِ‫ب‬ُ‫ص‬ُّ‫ن‬‫ل‬
Maksudnya: “Diharamkan kepada kamu (memakan) bangkai (binatang yang
tidak disembelih), dan darah (yang keluar mengalir), dan daging babi
(termasuk semuanya), dan binatang-binatang yang disembelih kerana yang
lain dari Allah, dan yang mati tercekik, dan yang mati dipukul, dan yang mati
jatuh dari tempat yang tinggi, dan yang mati ditanduk, dan yang mati
dimakan binatang buas, kecuali yang sempat kamu sembelih (sebelum habis
nyawanya), dan yang disembelih atas nama berhala.” (Surah al-Maidah: 3)

21. •
ِ‫ت‬‫ا‬َ‫ور‬ُ‫ظ‬ْ‫ح‬َ‫م‬ْ‫ال‬ ُ‫ح‬‫ي‬ِ‫ب‬ُ‫ت‬ ُ‫ات‬َ‫ور‬ُ‫ر‬َّ‫ض‬‫ال‬
Maksudnya: “Perkara yang darurat boleh mengharuskan yang
haram.”
Diharuskan Penggunaan Ketika Darurat
Diharuskan Pada Kadarnya Sahaja
•
‫ا‬َ‫ه‬ ِ
‫ر‬ْ‫د‬َ‫ق‬ِ‫ب‬ ُ‫ر‬َّ‫د‬َ‫ق‬ُ‫ت‬ ُ‫ات‬َ‫ور‬ُ‫ر‬َّ‫ض‬‫ال‬
Maksudnya: “Perkara yang darurat hendaklah ditakdirkan berdasarkan
kadarnya sahaja.”

22. Diharuskan Untuk Menghilangkan Mudarat
Yang Lebih Besar.
َ‫ك‬ ‫ا‬َ‫ذ‬ِ‫إ‬ ‫ا‬َ‫م‬ُ‫ه‬ َ
‫َْل‬‫ع‬َ‫أ‬ ‫ع‬ْ‫ف‬َ‫د‬ ِ‫ل‬ْ‫ج‬َ‫أ‬ ْ‫ن‬ِ‫م‬ ‫ب‬َ‫ك‬َ‫ت‬‫ر‬ُ‫ي‬ ‫ين‬َ‫ت‬َ‫د‬َ‫س‬ْ‫ف‬َ‫م‬‫ال‬ ‫َى‬‫ن‬ْ‫د‬َ‫أ‬ َّ‫ن‬ِ‫إ‬
‫ا‬َ‫م‬ُ‫ه‬‫ا‬َ‫د‬ْ‫ح‬ِ‫إ‬ ِ‫ة‬َ‫ق‬َ‫ف‬‫ا‬ َ‫و‬ُ‫م‬ ْ‫ن‬ِ‫م‬ َّ‫د‬ُ‫ب‬ َ
‫َّل‬ َ‫ان‬
Maksudnya: “Sesungguhnya kerosakan yang lebih ringan di antara dua kerosakan itu dilakukan dengan
tujuan untuk mengelakkan kerosakan yang lebih besar apabila tidak boleh untuk diharmonikan antara
salah satu daripadanya” Rujuk al-Asybah wal-Nazhoir, al-Subki (1/45).
ِّ‫َف‬‫خ‬َ‫أل‬‫ا‬ ِ
‫ر‬َ‫ر‬َّ‫ض‬‫ال‬ِ‫ب‬ ‫ال‬َ‫ز‬ُ‫ي‬ ِّ‫د‬َ‫ش‬َ‫أل‬‫ا‬ ‫ر‬َ‫ر‬َّ‫ض‬‫ال‬
Maksudnya: “Kemudharatan yang lebih berat dihilangkan dengan kemudharatan yang lebih ringan”
Rujuk Syarh al-Qawa’id al-Fiqhiyyah (hlm. 199-200).

23. Transfuse or NOT?
Potential
Harm/Risks
Potential
Benefits
Cost Supply

24. You have patient in ICU. He is pale. His Hb
is 7.2g/dL. What will you do?
ⓘ Start presenting to display the poll results on this slide.

26. • ESICM Guidelines on blood transfusion in critically ill patients

27. A precautionary approach to the use of red cells
using a restrictive transfusion strategy is preferred
because liberal transfusion may carry increased risk
without delivering commensurate improvements in
patient outcomes.
‫ار‬َ‫ر‬ ِ
‫ض‬ َ
‫َّل‬ َ‫و‬ َ‫ر‬َ‫ر‬َ‫ض‬ َ
‫َّل‬
Maksudnya: “Janganlah memudaratkan diri sendiri dan memberi kemudaratan kepada orang
lain” Rujuk al-Asybah wa al-Nazha’ir oleh al-Suyuti (hlm.173-181)

28. Critically Ill Patients with ACS

30. • The primary outcome was a per‐protocol analysis of major adverse
cardiac events (MACE) defined as all‐cause death, MI, and
revascularization at 6 months.

31. • Liberal transfusion strategies
may decrease the risk for
long‐term MACE and MI

32. MINT Trial

33. Critically Ill Patients with TBI

34. Ongoing Trials for Transfusion Threshold in
TBI
• The TRAIN Trial - by the ESCIM - acutely brain injured patients (TBI,
SAH, and ICH), Glasgow Coma Score (GCS) of <12, and Hb level
<=9g/dl - either a restrictive,HB>7g/dl or liberal startegy, Hb > 9g/dl.
• The HEMOTION trial in Canada - blunt patients with TBI with a GCS at
least 12 and Hb level at least 10g/dl to a transfusion threshold of 7 or
10g/dl.
• SAHaRA study, for transfusion thresholds in SAH

35. • ESICM Guidelines on blood transfusion in critically ill patients

36. Blood Products Transfusion (FFP, Platelets, Cryo)
• No well conducted RCTs to date.
• Varies practice among clinician
• Risk of Blood Products Transfusion
• TRALI
• TACO
• Nasocomial infection
• Inrease ICU morbidity and mortality

38. Increased risk of death
or major bleeding in
critically ill neonates

39. Fresh Frozen Plasma Transfusion
• Wide variation in FFP use in ICU
• Studies  Not transfuse unless INR>2.5
•Society of Interventional Radiology
•Labarotory test is not routinely recommended for
low risk bleeding patient.
•INR 2-3 , Platelet > 20 for minor procedures

40. • ESICM Guidelines on blood transfusion in critically ill patients

41. Transfusion Avoidance Strategies
• ESA
• Erythropoietin stimulating agents
stimulate the division and differentiation
of erythroid progenitor cells thus
increasing the total body hemoglobin and
hematocrit.

42. ESA
• Benefit of ESA
• Improve patient’s HB
• reduce the need for blood
transfusion
• Risk of ESA
• mortality
• adverse events such as MI and DVT
especially patient with CKD and
Cancer

43. • Erythropoietin, compared with placebo or no intervention, had no statistically
significant effect on overall mortality.
• Erythropoietin, compared with placebo, significantly reduced the odds of a
patient receiving at least 1 transfusion but after implementation of restrictive
blood transfusion strategy reduced to 0.5/patient
• The largest study reported significantly increased rates of DVT and other clinically
relevant vascular events associated with erythropoietin use.

46. • Additional well-designed trials are needed to investigate the optimal
iron-dosing regimens in ICU patients and strategies to identify which
patients are most likely to benefit from iron, together with patient-
focused outcomes.

47. Cell Salvage

48. • ICS has been determined as a reliable method to replace lost blood
products without significant deleterious side effects.
• Have an indirect but positive effect on postoperative platelet
concentrations.
• An efficient alternative to conventional transfusions
• In patients with more than 3 units of autologous blood reinfused, this
method is cost effective.

49. Tranexamic Acid

51. In acutely bleeding critically ill trauma patients,
•Treatment with TXA within 3 hours of injury
reduces the risk of mortality
•Treatment with TXA do not affect allogenic
transfusion incidence
•Treatment with TXA does not have an effect on the
risk for stroke, PE, DVT and reduces the incidence of
MI

53. • Higher significance
incidence of VTE and
seizure in TXA group
• Tranexamic acid
should not be
recommended at
this time for patients
with acute
gastrointestinal
bleeding.

54. Small Volume Tubes
• Reduction in phlebotomy
for diagnostic laboratory
testing, which can
account for 40% of RBC
transfusion
requirements.
• Use of pediatric or low-
volume adult blood
sampling tubes instead
of conventional tubes

55. Considerations:
• Staff training
• Possibility of redrawing insufficient blood volume for analysis
• Less volume storage for further testing
• Need further study and evidence for recommendation.

56. How much blood need to be withdrawn for
blood investigation?

57. How much blood need to be withdrawn for
blood investigation?

60. Audience Q&A Session
ⓘ Start presenting to display the audience questions on this slide.