Patient Blood Management in Critically Ill Patient

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 .

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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: Dysregulation of iron homeostasis due to increased hepcidin concentrations; Impaired proliferation of erythroid progenitor cells; and 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

11. Potential Hazard and Errors in Blood Transfusions

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

13. 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.

14. Hukum Darah . حُرِّمَتْ عَلَيْكُمُ الْمَيْتَةُ وَالدَّمُ وَلَحْمُ الْخِنزِيرِ وَمَا أُهِلَّ لِغَيْرِ اللَّـهِ بِهِ وَالْمُنْخَنِقَةُ وَالْمَوْقُوذَةُ وَالْمُتَرَدِّيَةُ وَالنَّطِيحَةُ وَمَا أَكَلَ السَّبُعُ إِلَّا مَا ذَكَّيْتُمْ وَمَا ذُبِحَ عَلَى النُّصُبِ 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)

15.  الضَّرُورَاتُ تُبِيحُ الْمَحْظُورَاتِ Maksudnya : “ Perkara yang darurat boleh mengharuskan yang haram.”  Diharuskan Penggunaan Ketika Darurat Diharuskan Pada Kadarnya Sahaja الضَّرُورَاتُ تُقَدَّرُ بِقَدْرِهَا Maksudnya : “ Perkara yang darurat hendaklah ditakdirkan berdasarkan kadarnya sahaja . ”

16. Diharuskan Untuk Menghilangkan Mudarat Yang Lebih Besar . إِنَّ أَدْنَى المَفْسَدَتَين يُرتَكَب مِنْ أَجْلِ دَفْع أَعْلَاهُمَا إِذَا كَانَ لَابُدَّ مِنْ مُوَافَقَةِ إِحْدَاهُمَا 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). الضَّرَر الأَشَدّ يُزَال بِالضَّرَرِ الأَخَفّ Maksudnya :  “ Kemudharatan yang lebih berat dihilangkan dengan kemudharatan yang lebih ringan ” Rujuk   Syarh al- Qawa’id al- Fiqhiyyah  ( hlm . 199-200).

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

18. 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.

19. ESICM Guidelines on blood transfusion in critically ill patients

20. 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. لَا ضَرَرَ وَلَا ضِرَار Maksudnya :  “ Janganlah memudaratkan diri sendiri dan memberi kemudaratan kepada orang lain”  Rujuk   al- Asybah wa al- Nazha’ir oleh al- Suyuti (hlm.173-181)

21. Critically Ill Patients with ACS

22. 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.

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

24. MINT Trial

25. Critically Ill Patients with TBI

26. 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 <=9 g/dl - either a restrictive,HB >7 g/dl or liberal startegy , Hb > 9 g/dl. The HEMOTION trial in Canada - blunt patients with TBI with a GCS at least 12 and Hb level at least 10 g/dl to a transfusion threshold of 7 or 10 g/dl.   SAHaRA study, for transfusion thresholds in SAH 

27. ESICM Guidelines on blood transfusion in critically ill patients

28. 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

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

30. 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

31. ESICM Guidelines on blood transfusion in critically ill patients

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

33. 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

34. 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.

35. 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.

36. Cell Salvage

37. 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.

38. Tranexamic Acid

39. 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

40. 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.

41. 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

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

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

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

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