Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases?*

Background: There have been significant recent advances in the pharmacotherapeutic management of critically ill patients. The purpose of this article is to review and discuss the most pertinent published literature in the areas of neurology, cardiovascular diseases, infectious diseases, nephrology, hematology, and gastroenterology as it pertains to critical care in order to provide an update for the critical care practitioner. Methods: We performed a Medline search from July 1999 to December 2000 utilizing terms relating to the pharmacotherapy of the specific aforementioned topics in critical care medicine. We focused on English-language clinical studies performed in adult intensive care unit (ICU) patients. From these articles we selected those that would have a practical impact on drug therapy in the ICU or the development of drug usage guidelines for critically ill patients. Review articles were generally not included. Results: The following topics were found to be either new developments or of potentially significant impact in the management of adult critically ill patients. In the area of neurology, advances were found with respect to optimization of regimens for sedative and neuromuscular blocking agents, validation of sedation scales and tools, and in the treatment of head injury patients. In the cardiovascular diseases, most studies related to the hemodynamic support of septic shock. We focus on developments in fluid resuscitation, optimization of global and regional oxygen transport variables, the repositioning of vasopressor agents, and a return to the use of steroids. Given the high mortality rate associated with the development of acute renal failure in the ICU, there has been a consistent attempt to develop preventative and treatment strategies for these patients, including optimization of antimicrobial dosing methods. Several epidemiological and longitudinal studies document changes in multi-drug antimicrobial resistance patterns. The use of treatment guidelines for antimicrobials in the critically ill improves outcomes in most patients. Significant attention has focused on the characterization of anemia in the ICU and the development of alternative pharmacological strategies in its treatment. Finally, in gastroenterology, the main focus has been the investigation of methods to optimize the delivery of enteral nutrition given its proven benefits in critically ill patients. Conclusions: Significant advances in the areas of neurological, cardiovascular, infectious diseases, renal, hematological, and gastrointestinal issues in the pharmacotherapy of critically ill patients have been published over the course of the past year. Many of these studies have yielded data that may be incorporated into the pharmacotherapeutic management of ICU patients, hence maximizing outcomes.

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A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care

50 Studies Every Intensivist Should Know ◽

10.1093/med/9780190467654.003.0039 ◽

2018 ◽

pp. 235-240

Author(s):

Joseph R. Guenzer ◽

Andrew Vardanian

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Controlled Clinical Trial ◽

Large Trial ◽

Transfusion Threshold ◽

Transfusion Requirements ◽

Red Cell Transfusion ◽

Study Intervention ◽

The Impact

This chapter provides a summary of the landmark study known as the TRICC trial. Is a restrictive strategy of red-cell transfusion equivalent to a liberal transfusion strategy in critically ill patients? Starting with that question, the chapter describes the basics of the study, including funding, study location, who was studied, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism, and limitations. The chapter briefly reviews other relevant studies and information, discusses implications, and concludes with a relevant clinical case. Although this first large trial to examine the impact of transfusion thresholds on mortality in critically ill patients was underpowered, the trend toward decreased mortality in the restrictive group suggests that it is unlikely that the lower transfusion threshold subjects patients to increased harm. However, care must be taken in generalizing these results to cardiac surgery patients or to actively bleeding patients based on this study alone.

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P0610ACUTE KIDNEY INJURY IN CRITICALLY ILL PATIENTS IN THE ICU

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p0610 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Mira Markovic ◽

Violeta Knezevic ◽

Tijana Azasevac ◽

Aleksandar Knezevic ◽

Svetlana Stojkovic ◽

...

Keyword(s):

Cardiovascular Diseases ◽

Gastrointestinal Bleeding ◽

Renal Disease ◽

Arterial Hypertension ◽

Critically Ill ◽

Critically Ill Patients ◽

De Novo ◽

Kidney Injury ◽

Number Of Patients ◽

Prostate Diseases

Abstract Background and Aims Acute kidney injury (AKI) is common and serious complication in critically ill patients in intensive care unit (ICU). The rapid increase in aging populations with more comorbidities contribute to high incidence AKI in ICU. Incidence varies from 20% to as high as 70%. AKI in the ICU frequently requires costly supportive therapies, has high morbidity and it’s associated with poor outcomes. We aimed to determine incidence of AKI, causes, risk factors, treatment and outcomes of AKI in critically ill patients in ICU. Method We collected data prospectively from case records of adult patients (older than 18 years of age) admitted to the ICU at the Department of Internal medicine, Emergency Center, Clinical center of Vojvodina in Novi Sad, Serbia, during 3 months. We included patients who had at least two measurements of serum creatinine. Data on patient demographics, diagnosis at the time of ICU admission, complete blood count, biochemistry, comorbidities (diabetes mellitus, arterial hypertension, other cardiovascular diseases, renal disease, prostate diseases, dehydration, burns, gastrointestinal bleeding, pancreatitis, peritonitis, sepsis), use of nephrotoxic agents, radiological procedures and treatment of AKI were recorded. We excluded patients with chronic renal disease who were on hemodialysis. There were no interventions. Results Of the 44 patients included in the study, median age was 67+/-13,20 years (range: 21 to 88). Of those 44 patients 20% developed AKI. De novo AKI was diagnosed in 51,22% of those patients and 48,78% had chronic renal failure in acutisation. The most frequent etiology was pre-renal, in 80,95% of patients. Renal origin and obstructive (post-renal) causes were detected in the same number of patients, 9,52%. Comorbidities were present present in all patients. Most common comorbidity was arterial hypertension, in 52,4% of patients, other cardiovascular diseases in 47,6 % of patients, sepsis also in 47,6% of patients and gastrointestinal bleeding in 33,3% of patients. Complete recovery of kidney function was detected in 42,86% of patients. Mortality was 28,57%. During the hospitalisation 90,48% of patients were treated conservative and 9,52% of patients required renal replacement therapy. Conclusion De novo AKI occurred in approximately half of the critically ill patients in ICU. The most frequent etiology was pre-renal. AKI was mainly detected in older patients with comorbidities. Age and comorbidities were also associated with the poor outcome. Mortality was high.

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Transfusion Requirements in Critical Care (TRICC)

50 Studies Every Anesthesiologist Should Know ◽

10.1093/med/9780190237691.003.0022 ◽

2018 ◽

pp. 114-118

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Cardiac Ischemia ◽

Red Cell ◽

Transfusion Threshold ◽

Chronic Anemia ◽

Transfusion Requirements

This case focuses on red cell transfusions in critically ill patients by asking the question: When should patients in the intensive care unit (ICU) with anemia receive red cell transfusions? For most critically ill patients, waiting to transfuse red cells until the hemoglobin (Hgb) drops below 7 g/dL is at least as effective as, and likely preferable to, transfusing at an Hgb less than 10 g/dL. These findings may not apply to patients with chronic anemia, who were excluded from the trial. The results also may not apply to patients with active cardiac ischemia, who were poorly represented in the trial and had nonsignificantly worse outcomes with a transfusion threshold of 7.

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Transfusion practice in the non-bleeding critically ill: an international online survey—the TRACE survey

Critical Care ◽

10.1186/s13054-019-2591-6 ◽

2019 ◽

Vol 23 (1) ◽

Cited By ~ 8

Author(s):

Sanne de Bruin ◽

◽

Thomas W. L. Scheeren ◽

Jan Bakker ◽

Robin van Bruggen ◽

...

Keyword(s):

Blood Cell ◽

Critically Ill ◽

Red Blood Cell ◽

Critically Ill Patients ◽

Online Survey ◽

Transfusion Practice ◽

Red Blood Cell Transfusion ◽

Plasma Transfusion ◽

Transfusion Threshold ◽

Asymptomatic Patients

Abstract Background Over the last decade, multiple large randomized controlled trials have studied alternative transfusion strategies in critically ill patients, demonstrating the safety of restrictive transfusion strategies. Due to the lack of international guidelines specific for the intensive care unit (ICU), we hypothesized that a large heterogeneity in transfusion practice in this patient population exists. The aims of this study were to describe the current transfusion practices and identify the knowledge gaps. Methods An online, anonymous, worldwide survey among ICU physicians was performed evaluating red blood cell, platelet and plasma transfusion practices. Furthermore, the presence of a hospital- or ICU-specific transfusion guideline was asked. Only completed surveys were analysed. Results Nine hundred forty-seven respondents filled in the survey of which 725 could be analysed. Hospital transfusion protocol available in their ICU was reported by 53% of the respondents. Only 29% of respondents used an ICU-specific transfusion guideline. The reported haemoglobin (Hb) threshold for the general ICU population was 7 g/dL (7–7). The highest reported variation in transfusion threshold was in patients on extracorporeal membrane oxygenation or with brain injury (8 g/dL (7.0–9.0)). Platelets were transfused at a median count of 20 × 109 cells/L IQR (10–25) in asymptomatic patients, but at a higher count prior to invasive procedures (p < 0.001). In patients with an international normalized ratio (INR) > 3, 43% and 57% of the respondents would consider plasma transfusion without any upcoming procedures or prior to a planned invasive procedure, respectively. Finally, doctors with base specialty in anaesthesiology transfused critically ill patients more liberally compared to internal medicine physicians. Conclusion Red blood cell transfusion practice for the general ICU population is restrictive, while for different subpopulations, higher Hb thresholds are applied. Furthermore, practice in plasma and platelet transfusion is heterogeneous, and local transfusion guidelines are lacking in the majority of the ICUs.

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A UK national survey of prophylactic platelet transfusion thresholds in non-bleeding, critically ill adults

10.1101/2020.09.02.20186700 ◽

2020 ◽

Author(s):

Akshay Shah ◽

Doug W Gould ◽

James C Doidge ◽

Paul Mouncey ◽

David A Harrison ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Platelet Transfusion ◽

Online Survey ◽

Percutaneous Tracheostomy ◽

Transfusion Practice ◽

Research Centre ◽

Current Guideline ◽

Transfusion Threshold ◽

Platelet Transfusions

Thrombocytopaenia is common in critically ill patients and associated with poor clinical outcomes. Current guideline recommendations for prophylactic platelet transfusions, to prevent bleeding in critically ill patients with thrombocytopaenia, are based on observational data. Recent studies conducted in non-critically ill patients have demonstrated harm associated with platelet transfusions and have also called into question the efficacy of platelet transfusion. To date, there are no well-conducted randomised controlled trials (RCTs) evaluating platelet transfusion in critically ill patients. To inform the design of such an RCT, we sought to characterise current clinical practice across four commonly encountered scenarios in non-bleeding critically ill adult patients with thrombocytopaenia. An online survey link was sent to Clinical Directors and contacts of all adult general ICUs participating in the Intensive Care National Audit and Research Centre Case Mix Programme national clinical audit (n=200). The survey collected data regarding the respondents place of work, training grade and their current individual practice and possible limits of equipoise for prescribing prophylactic platelet transfusions across four scenarios: prophylaxis but with no procedure planned (NPP); ultrasound guided insertion of a right internal jugular central venous catheter (JVI); percutaneous tracheostomy (PT); and surgery with a low bleeding risk (SLBR). After excluding nine responses with missing data on all four of the main questions, responses were received from 99 staff, covering 78 ICUs (39.0% of 200 ICUs invited to participate). While nearly all respondents (98.0%) indicated a platelet transfusion threshold of 30 x 10^9/L or less for patients with no planned procedure, thresholds for planned procedures varied widely and centred at medians of 40 x 10^9/L for JVI (range: 10 to 70), 50 x 10^9/L for SLBR (range: 10 to 100) and 70 x 10^9/L for PT (range: 20 to greater than 100). Current platelet transfusion practice in UK ICUs prior to invasive procedures with relatively low bleeding risks is highly variable. Well-designed studies are needed to determine the optimal platelet transfusion thresholds in critical care.

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