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Conservation of Blood A Precious Resource James P. AuBuchon, MD E. Elizabeth French Professor and Chair of Pathology Professor of Medicine Dartmouth-Hitchcock.

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Presentation on theme: "Conservation of Blood A Precious Resource James P. AuBuchon, MD E. Elizabeth French Professor and Chair of Pathology Professor of Medicine Dartmouth-Hitchcock."— Presentation transcript:

1 Conservation of Blood A Precious Resource James P. AuBuchon, MD E. Elizabeth French Professor and Chair of Pathology Professor of Medicine Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire

2 Conservation of Blood A Precious Resource Why?AvailabilityExpenseOutcomesReactions How?IndicationsAlternativesSource

3 NOT INR = 1.5

4 Procoagulant ?Consumed Concentration in Coagulation Normal Necessary Fibrinogen Yes mg/d mg/dL Factor V Yes 1 U/mL 5-25% Factor VIII Yes 1 U/mL 15-25% Factor VII No 1 U/mL 5-20% Procoagulant ?Consumed Concentration in Coagulation Normal Necessary Fibrinogen Yes mg/d mg/dL Factor V Yes 1 U/mL 5-25% Factor VIII Yes 1 U/mL 15-25% Factor VII No 1 U/mL 5-20% Abnormality ≠ Clinical Deficiency

5

6 Problems Using Coagulation Tests as Transfusion Triggers Problems Using Coagulation Tests as Transfusion Triggers PT (sec) 50% FV 1:1 Mix (75% each ) 1:1 Mix (75% each ) 50% FVII Burnset al. AJCP1993;100:94-8. Burnset al. AJCP1993;100:94-8. Plasma

7 McVay PAet al. AJCP1990;94: McVay PAet al. AJCP1990;94: Test Group n Bleeding Hb Change Complications (g/dL) PT Normal 100 4% -0.3± % -0.2±0.8 PTT Normal 103 5% -0.3± % -0.1±0.6 Test Group n Bleeding Hb Change Complications (g/dL) PT Normal 100 4% -0.3±0.9  1.3*ULN 43 6% -0.2±0.8 PTT Normal 103 5% -0.3±0.9  1.3*ULN 34 3% -0.1±0.6 Effect of Mildly-Abnormal Coagulation Parameters Diagnosis of malignancy: 18x risk of bleeding Platelet count > 50,000/µL adequate Diagnosis of malignancy: 18x risk of bleeding Platelet count > 50,000/µL adequate Plasma

8 Effect of Coumadin Treatment on Surgical Blood Loss Rustad Het al. Acta Med Scand1963;173: Rustad Het al. Acta Med Scand1963;173: RBC Loss (mL) RBC Loss (mL) Operative 24 h Total 24 h Total 72 h Total 72 h Total Coumadin (therapeutic; n=20) Controls (n=20) Gastrectomy Patient Group RANGE Plasma

9 Storm Oet al. Circ1955;12: Storm Oet al. Circ1955;12: Group n Post-Op Blood Loss (mL) Controls ( ) Coumadin ( ) (therapeutic) Group n Post-Op Blood Loss (mL) Controls ( ) Coumadin ( ) (therapeutic) Effect of Coumadin Treatment on Post-Op Blood Loss Procedure: Mitral commissurotomy Plasma

10 PT as a Predictor of Bleeding Ewe K. Dig Dis Sci 1981;26: Liver Bleeding Time (min) Liver Bleeding Time (min) PT (% normal activity) Note: 10% change in activity = approximately 1 sec Mean LL RR Plasma

11 Ansell J. Chest.2001;119:22S-38S. GUIDELINES CLINICAL SITUATION GUIDELINES CLINICAL SITUATION Ansell J et al. Chest 2004;126(3Suppl):204S-233S. Correcting Over-Coumadinization Recommendations of American College of Chest Physicians

12 An Analysis of the Literature AngiographyAngiographyBronchoscopy Liver biopsy Liver laparoscopy Transjugular liver biopsy Para/thoracentesis Transjugular kidney biopsy Kidney biopsy RISK DIFFERENCE FAVORS TRANSFUSION FAVORS NO TRANSFUSION Segal and Dzik. Transfusion 2005;45: Normal vs. Abnormal Coagulation Tests

13 Plasma vs. Saline in Severe Head Trauma Glasgow coma scale ≤ 8 Note: 1.4 Note: 1.4 FFPSaline mL/kg mL/kg mL/kg mL/kg N CT: Worse 32% 15% p = 0.06 CT: Better 2.3% 2.2% Delayed hematoma 17% 0% p = Mortality 63% 35% p = Etemadrezaie H et al. Clin Neurol Neurosurg 2007;109:

14 Pretransfusion INR Change in INR post-transfusion And what if plasma is transfused? Holland LL et al. Transfusion 2005;45: Mean change: -0.03/unit

15 And what if plasma is transfused? Cheng CK, Sadek I. Transfusion 2007;47: INR Change after Transfusion

16 And what if plasma is transfused? Abdel-Wahab et al. Transfusion 2005;45:141A. 723 patients, PT 13-17sec  transfused Outcome PT decreased at least halfway to normal: 14.5% PT decreased to normal: 0.9% Mean decrease: 0.2 sec 78 patients had repeat PT within 8h of transfusion No correlation of PT with RBC usage

17 What is Gained with Plasma? PT (seconds) Factor activity 50% 10% 15 s 20 s 13s 30% LARGE GAIN SMALL GAIN And…as more plasma is given, greater plasma volume in which to increase factor concentration And…the half-life of Factor VII is 5h!

18 How much plasma should be transfused How much plasma should be transfused to correct a significant procoagulant deficiency? to correct a significant procoagulant deficiency? Calculations from Holland LL and Brooks JP. Am J Clin Pathol 2006; 126: “Therefore, transfusion for patients not meeting current FFP guidelines does not reliably reduce the INR and exposes patients to unnecessary risk.”

19 Why Don’t Cirrhotic Patients Bleed? Tripodi A et al. Hepatology 2005;41: REDUCED SYNTHESIS Protein C activation procoagulants procoagulants Protein C NORMAL CIRRHOTIC EQUAL OUTCOME Thrombin Generation (ETP as FU/mL) BALANCED REDUCTION IN CIRRHOTICS Actually, Fib:Prot C ratio increases by 20%

20 Cryoprecipitate Fibrinogen:< 100 mg/dL or 120 mg/dL and falling rapidly 120 mg/dL and falling rapidly vWF:If unresponsive to DDAVP Factor VIII:(None) Topical:As needed

21 Anemia: What is the Limit? Baboons: Hct = 4% Wilkerson.Surgery, Dogs: Hct = 7% Crystal. Am J Phsyiol, Healthy adults: Hb = 5 g/dL Botero. J Clin Anesth, van Woerkens. Anesth Analg, Peds card surg: Hb  3 g/dL Henling. J Thorac Cardiovasc Surg, Unselected adults: Carson. Lancet Lancet Hb > 8 g/dL  mortality = 6% Hb < 6 g/dL  mortality = 61%

22 Hct (%) Vasodilator Reserve Ratio Cardiac Response During Hemodilution Cardiac Response During Hemodilution Control Stenosis Levy et al.Am J Physiol 1993;265:H340. Levy et al.Am J Physiol 1993;265:H340. Anemia: What is the Limit?

23 19 dogs with critical stenosis of LAD  Lowest tolerated Hgb: 7.5 g/dL BUT 25% fatality at 9 g/dL 25% fatality at 9 g/dL Spahnet al. J Thorac Cardiovasc Surg 1993;105:694. Spahnet al. J Thorac Cardiovasc Surg 1993;105:694. Anemia: What is the Limit?

24 Effect of Co-Morbidities on Mortality Cardiovascular disease absent Cardiovascular disease present Adjusted odds ratio for perioperative mortality Adjusted odds ratio for perioperative mortality Preoperative hemoglobin (g/dL) Carson JL et al. Lancet 1996;348: Carson JL et al. Lancet 1996;348:

25 Johnson RGet al. J Thorac Cardiovasc Surg1992;104: Johnson RGet al. J Thorac Cardiovasc Surg1992;104: Parameter Transfusion Strategy "Liberal" (Hct = 32%) "Conservative" (Hct = 25%) Patients Post-op Transfusion 37 units/18 pts 20 units/15 pts Length of Stay ICU 3.3±3.4 d 3.2±0.7 d Total post-op 7.6±1.9 d 7.9±4.3 d Exercise Testing Mean duration #1 4.5±1.7 min 4.1±1.7 min Mean duration #2 5.4±1.5 min 5.1±2.1 min Parameter Transfusion Strategy "Liberal" (Hct = 32%) "Conservative" (Hct = 25%) Patients Post-op Transfusion 37 units/18 pts 20 units/15 pts Length of Stay ICU 3.3±3.4 d 3.2±0.7 d Total post-op 7.6±1.9 d 7.9±4.3 d Exercise Testing Mean duration #1 4.5±1.7 min 4.1±1.7 min Mean duration #2 5.4±1.5 min 5.1±2.1 min Effect of Post-CABG Transfusion Strategy

26 Effects of Post-CABG Transfusion Strategy Liberal:9 g/dL Conservative:8g/dL orbleeding > 750 mL acute respiratory failure inadequate cardiac output + pressors Liberal:1.4±1.8 units Conservative: 0.9±1.5 units No difference in morbidity, mortality, LOS Same fatigue assessment Bracey AW et al. Transfusion 1999; 39:

27 Effect of Post-CABG Hematocrit Spiess BD et al. J Thorac Cardiovasc Surg 1998;116: Post-Operative Hematocrit Post-Operative Hematocrit 33% 33% Patient distribution: 15% 68% 17% Q-wave MI: 3.6% 5.5% 8.3% LV dysfunction: 5.7% 7.4%11.7%

28 Lactate concentrations: Unchanged. Weiskopf R et al. JAMA 1998;279; Cardiovascular Effects of Isovolemic Anemia

29 Effects of Severe Anemia Weiskopf R et al. Anesthesiology 2000;92: Changes in Cognitive Function in Normal Subjects Similar results: Reaction time % 40% Changes in Error Rate Hemoglobin, g/dL *

30 Probability of Death or MI Besarab A et al. NEJM 1998;339: Months after Intervention Hct 42% Hct 30% RR: 1.3 ( ) Anemia: What is the Target? EPO in ESRD patients with CHF

31 Anemia: What is the Limit? Acute Myocardial Infarction Mortality in the Elderly Wu W-C et al. NEJM 2001;345: Proportion Surviving Days after Admission Hct > 39% Hct 30-33% Hct <24% Admission hematocrit For two-day survivors: Benefit of transfusion if Hct < 30%

32 Anemia: What is the Limit? Acute Myocardial Infarction Induced in Rats Xenocostas A et al. Blood 2007;110:140a. Hb 7-9 g/dL (compared to 14-15): Mortality doubled Transfusion immediately after MI: to 10 g/dL  No excess mortality to 12 g/dL  No improvement At 24h, anemic rats had↑ extent of infarct compared to area at risk ↓ LV contractility Transfusion immediately after MI:to 10 g/dL  Return to control to 12 g/dL  No further improvement to 12 g/dL  No further improvement

33 Anemia: What is the Limit? Transfusion in Acute Coronary Syndromes Rao SV et al. JAMA 2004;292: Secondary analysis of 24,112 enrollees 2,401 transfusion recipients 2,401 transfusion recipients from GUSTO IIb, PURSUIT and PARAGON B trials from GUSTO IIb, PURSUIT and PARAGON B trials Transfusion recipients: - Older - More co-morbidities at presentation

34 Anemia: What is the Limit? Transfusion in Acute Coronary Syndromes Rao SV et al. JAMA 2004;292: JAMA 2005;293: JAMA 2005;293: Adjusted Probability of Death (at 30 d) With and Without Transfusion by Nadir Hematocrit Hct = 20%Probability = % % % % % % 292 “We could not identify a hematocrit below which transfusion was beneficial…”

35 Anemia: What is the Limit? Associations of Anemia in Angioplasty Nikolsky E et al. J Am Coll Cardiol 2004;44: Analysis from the CADILLAC Study – 2,027 patient Multivariate Predictors of In-Hospital Mortality Ejection Fraction (lower)1.10 (p<0.0001) Creatinine clearance (lower)1.03 (0.02) Baseline anemia3.26 (0.048) Anemia but may be bad – but is transfusion good?

36 Nelson AHet al. Crit Care Med 1993;21: Nelson AHet al. Crit Care Med 1993;21: Anemic Morbidity in High-Risk Vascular Patients Anemic Morbidity in High-Risk Vascular Patients 23-25% 26-28% 29-31% 32-34% 35-37% 20% 40% 60% 80% 100% Myocardial ischemia Morbid cardiac event POD#1 Hct (0)

37 *All with prior EKG changes. Hct, POD#1 n Cardiac Events Hct < 28%* 13 non Q-wave MI 25.1(24-25) 27.5(27-28) 24.9(23-26) 27.6(26-29) unstable angina 26.2(22-30) ischemic pulm edema 25.2(22-29) ≥ 28% 14(none) Nelson AHet al. Crit Care Med 1993;21: Nelson AHet al. Crit Care Med 1993;21: *Note: More cases of pre-op anemia/ischemia *Note: More cases of pre-op anemia/ischemia Anemic Morbidity in High-Risk Vascular Patients Anemic Morbidity in High-Risk Vascular Patients

38 Grover et al. Vox Sang 2006;90: Anemia and Silent Myocardial Ischemia Patients undergoing arthroplasty – EKG monitoring “Conservative” “Liberal” “Conservative” “Liberal” Patients Hb trigger (g/dL) 8 10 Mean postop Hb Transfused34% - 89 units 43% units Silent ischemia19%24% Length of ischemia 0.48 min/h 1.51 min/h* Median post-op LOS * p<0.05

39 Transfusion Requirements in Critical Care Cooperative Study Assessing Red Cell Needs in Critically Ill Patients Assessing Red Cell Needs in Critically Ill Patients Multicenter, prospective, randomized study 838 patients in 25 centers Multicenter, prospective, randomized study 838 patients in 25 centers > 24 h ICU stay expected Hb < 9.0 g/dL within 72 h Volume resuscitated or normovolemic > 24 h ICU stay expected Hb < 9.0 g/dL within 72 h Volume resuscitated or normovolemic Restrictive: Maintain 7-9 g/dL (APACHE II: 20.8) Liberal: Maintain g/dL (APACHE II: 21.3) Restrictive: Maintain 7-9 g/dL (APACHE II: 20.8) Liberal: Maintain g/dL (APACHE II: 21.3)

40 Hébert PC et al. NEJM 1999;340: Assessing Red Cell Needs in Critically Ill Patients Assessing Red Cell Needs in Critically Ill Patients Liberal Restrictive p Units transfused 5.2± ± Mean Hb 10.7± ± Avoiding transfn 0 33%.0001 ICU mortality 15% 12% d mortality 24% 18%.05 MODS Liberal Restrictive p Units transfused 5.2± ± Mean Hb 10.7± ± Avoiding transfn 0 33%.0001 ICU mortality 15% 12% d mortality 24% 18%.05 MODS

41 Assessing Red Cell Needs in Critically Ill Patients Assessing Red Cell Needs in Critically Ill Patients LiberalRestrictive p Patients d mortality 21%26%0.38 ICU mortality 17%23%0.27 Hospital mortality 27%29%0.78 MODS LOS-ICU (d) LOS-total with Ischemic Heart Disease Hébert PC et al. Crit Care Med 2001;29:

42 Assessing Red Cell Needs in Critically Ill Patients Assessing Red Cell Needs in Critically Ill Patients LiberalRestrictive p Patients requiring ventilation Length of ventilation (d) NS Ventilator-free days NS Successful extubation 78% 82%NS Ventilation Outcomes Hebert PC et al. Chest 2001;119:

43 Hébert PC et al. NEJM 1999;340: Assessing Red Cell Needs in Less- Critically Ill Patients APACHE II < 20 Assessing Red Cell Needs in Less- Critically Ill Patients APACHE II < 20 Liberal Restrictive p ICU mortality 8.8% 4.4% d mortality 16.5% 9.2%.08 MODS Liberal Restrictive p ICU mortality 8.8% 4.4% d mortality 16.5% 9.2%.08 MODS

44 Hébert PC et al. NEJM 1999;340: Assessing Red Cell Needs in Critically Ill Patients Assessing Red Cell Needs in Critically Ill Patients With a restrictive trigger (Hb = 7 g/dL): 52% reduction in red cell transfusion Treat 12 patients => save 1 life Largest effect in healthier patients With a restrictive trigger (Hb = 7 g/dL): 52% reduction in red cell transfusion Treat 12 patients => save 1 life Largest effect in healthier patients

45 Hébert PC et al. Crit Care Med 2001;29: “…in patients with heart disease, the restrictive strategy [transfusion at Hb of 70 g/L] should be considered the approach of choice.” “...most hemodynamically stable, critically ill patients with cardiovascular disease may receive a transfusion safely when hemoglobin concentrations decrease to below 70 g/L and may be maintained at hemoglobin concentrations between 70 and 90 g/L.” [possible exception: unstable coronary ischemic syndromes] Assessing Red Cell Needs in Critically Ill Patients Assessing Red Cell Needs in Critically Ill Patients with Cardiovascular Disease

46 Bell EF et al. Pediatrics 2005;115: Liberal vs. Restrictive Triggers in Neonates 100 infants – g “Phase” “Phase” Intubated34%46% Supplemental O 2 28%38% No respiratory support22%30% Restrictive Liberal Restrictive Liberal Study transfusions 2.7± ±4.1 u * Donor exposures 1.8± ±2.5 Survival96%98% IV hemorrhage, Gr. 412% 0 >1 apneic episode/d43%20% * - requiring stim (median) * - requiring stim (median) * * p<0.05

47 Lacroix J et al. NEJM 2007;356: Pediatric Transfusion Strategies 637 critically ill children LiberalRestrictive 9.5 g/dL 7 g/dL Transfused 98% 46% p<0.001 Total transfusions units p<0.001 Death (all cause-28d) 4% 4% p=0.98 Nosocomial infections 25% 20% p=0.16 Mechanical ventilation6.0± ±5.9 d p=0.76 ICU LOS9.9± ±7.9 p=0.39

48 Suttner S et al. Anesth Analg 2004;99:2-11. Alternatives in O 2 Delivery Post-op CABG (intubated) RANDOMIZE: 1 unit RBC 2 units RBC 100% O 2 Hb 7.5 – 8.5 g/dL Outcome measures: O 2 delivery and consumption Deltoid tissue O 2 monitor Vascular and ventilatory parameters

49 Suttner S et al. Anesth Analg 2004;99: min DO min p ti O min VO RBC 2 RBC 100% O 2 Alternatives in O 2 Delivery Unit age: 10d (5-14) Lactate Cardiac index

50 Hb < 7 g/dL Transfusion often necessary Hb > 10 g/dL Transfusion rarely necessary Hb < 7 g/dL Transfusion often necessary Hb > 10 g/dL Transfusion rarely necessary Transfusion Guidelines

51 RBC Utilization Goldman M et al. Transfusion 2007;47:189-90A. Country > 60 yrs RBC/1000 pop’n Trend Country > 60 yrs RBC/1000 pop’n Trend Canada (CBS) 18% % ↑ 2001  2006 France20% % ↑ 2001  2006 Australia17% % ↑ 2003  2005 England+Wales21% % ↓ 2001  2005 Finland22% % ↓2001  2006 US (AABB Report) 17% % ↑ 2001  2004

52 Transfusion Guidelines Mortality Hematocrit 20%30% ICU PATIENT ACUTECORONARYSYNDROMEPATIENT after Daurat, 2005 NO COMORBIDITIES Perioperative deaths (France) due to transfusion: 2 Deaths due transfusions delayed/not given: 100

53 Storage Period (wks) % Day 0 Concentration % Day 0 Concentration ATP DPG Post-Transfusion Period (h) Red Cell Physiology and “The Storage Lesion”

54 Raat NJH and Ince C. Vox Sang 2007;93: NO Hb HYPOXIA ATP RELAXATION  INCREASED FLOW STORAGE: Fe +3 X X Reduced deformability ATP [ATP] ↓ CFTR: Cystic fibrosis trans- membrane conductance regulator

55 Red Cell Physiology and “The Storage Lesion” Bennett-Guerrera E et al. PNAS 2007;epub. Reynolds JD et al. PNAS 2007;epub. S-NO-Hb (% fresh) 100 Fresh 3h Day 1 Day 2 Day 3 Day 21 Re-nitrosylation Less NO release Less compensatory dilitation Canine coronary artery blood flow model 5% F i O 2 : Significant effect 5% F i O 2 : Significant effect 21% F i O 2 : No clinically significant change

56 Lactate (µmoles/g tissue) Hematocrit ATP (µmoles/g tissue) Hematocrit DPG-enriched RBC DPG-depleted RBC Kimura H et al. Stroke 1995;26: DPG Effect on Cerebral Metabolism Murine Exchange Transfusion  Carotid Occlusion Model

57 LEUKOREDUCED LEUKOREPLETE LEUKOREDUCED LEUKOREPLETE Sparrow RL et al. Transf Apher Sci 2006;34: Red Cell Surface Changes During Storage ↑ adhesive capabilities ↑ phagocytosis signals

58 Supernatant Young Old Leukoreplete Leukoreduced Sparrow RL et al. Transf Apher Sci 2006;34: Red Cell Surface Changes During Storage

59 Red Cell Storage and Blood Flow Adherence of RBCs to HUVECs with increasing storage time LEUKOREDUCED BUFFY COAT REMOVED STANDARD RBCs Increasing adherence with greater storage duration. Anniss AM, Sparrow RL. Transfusion 2006;46:

60 Red Cell Storage and Blood Flow Anniss AM, Sparrow RL. Am J Hematol 2007;82: Adherence of RBCs (D 42) to HUVEC at different shear stress Untreated HUVECs TNFα pre-treatment Endotoxin pretreatment With endotoxin exposure, greater force required to detach RBCs

61 Red Cell Storage and Blood Flow - 1 mL + 1 mL - fresh RBCs - fresh RBCs - old RBCs - old RBCs Arslan E et al. Am J Surg 2005;190: Reduction in capillary flow but not flow in arterioles but not flow in arterioles

62 Mitrofan-Oprea L et al. Transf Clin Biol 2007 (epub). Red Cell Surface Changes During Storage SECONDARY EFFECTS?

63 Red Cell/Leukocyte Interactions During Storage CD11b expression after incubation with RBC supernate Sparrow RL, Patton KA. Transfusion 2004;44: Storage (with leukocytes)  Pro-inflammatory response in PMNs

64 ELONGATION INDEX LESS DEFORMABLE Relevy H et al. Transfusion 2008;48: Storage: RBC Deformability

65 IRRADIATED NON- IRRADIATED - with ↑ PS exposure Storage: RBC Deformability Relevy H et al. Transfusion 2008;48:

66 Recovery from the Storage Lesion? Penuela O et al. Transfusion 2007;47:87A. + rHuEPO-β  Storage for 42d AS-5 RBC EPOControl EPOControl Hemolysis0.82%0.83% Non-discocytes 34% 30% Glucose mg/dL ATP mmol/gHb Lactate mM LDH IU/mL

67 Are Old Red Cell Units Dangerous? Red cell age Post-Trauma Mortality Red cell age MODS Retrospective Analyses

68 RBC Storage and MOF A cohort analysis in trauma Zallen G et al. Am J Surg 1999;178:570-2.

69 RBC Storage and Post-Traumatic Infection Observational analysis: ISS >15; 16-20U in 12 h; n=61 Offner PJ et al. Arch Surg 2002;137: Units ≥ 14 dUnits ≥ 21 d Serious Infection 11.7± ±1.0 No infection 8.7± ±0.1 BUT… Those developing infections received more blood. Those developing infections had higher ISS.* *although the authors claimed not… p < 0.05

70 Basran S et al. Anesth Analg 2006;103: In-hospital mortality Acute renal dysfunction Length of stay Oldest unit storage time RBC Storage in CABG Patients n=321 Confounding variables accounted for: - FFP, platelet transfusions - Number of RBCs transfused - Gender - NYHA class - Diabetes - LV EF - COPD - HTN - Hct - Cr - Procedure, times - Post-op inotropes

71 RBC Storage in CABG Patients n=2732 Van de Watering L et al. Transfusion 2006;46: No correlation between RBC storage time and - Mortality - ICU LOS Note: LR AS RBCs

72 RBC Storage in CABG Patients Koch CG et al. NEJM 2008;358: Retrospective analysis of 6002 patients Storage time:≤14d>14d In-hospital mortality1.7% 2.8% Intubation > 72h9.7% 5.6% Renal dysfunction1.6% 2.7% 1yr mortality7.4%11.0% Differences in:ABO group distribution ABO group usage (> distribution) LV dysfunction Mitral regurgitation; prior MI Body size NYHA class Peripheral vascular disease

73 Vamvakas EC, Carven JH. Transfusion 1999;39: Vamvakas EC, Carven JH. Transfusion 2000;40: Are there other factors not being accounted for that correlate with transfusion and are more important? Risk of pneumonia increased 1% per day of RBC storage Twenty factors correlated with LOS; transfusion still an independent predictor of LOS: 0.84% ↑ per unit. RBC Storage in CABG Patients

74 Fresh Blood Stored Blood Fresh Blood Stored Blood (2d) (28d) (2d) (28d) Gastric-arterial pCO 2 Gastric intramucosal pH Arterial pH Arterial lactate Walsh TS et al. Crit Care Med 2004;32: Fresh vs. Stored Red Cells in critically ill patients During transfusion and 5h after Our data do not support the hypothesis that transfusing stored red cells adversely affects tissue oxygenation in anemic, euvolemic, critically ill patients with no evidence of bleeding.

75 n=9 NORMAL SUBJECTS 3 wks Hb  7 g/dL Hb: 7.4  5.5 g/dL 5 hrs  7.5 g/dL -or – (RANDOMIZED) COGNITIVE TESTING Weiskopf R et al. Anesthesiology 2006; 104: Fresh vs. Stored Red Cells in normal, anemic subjects

76 Weiskopf R et al. Anesthesiology 2006; 104: Fresh vs. Stored Red Cells NO DIFFERENCE Reaction time (msec)

77 Raat NJ et al. Crit Care Med 2005;33:39-43, RBC Age Effect on Intestinal Ischemia Rat Exchange Transfusion Model RBC storage:< 1 wk 2-3 wks 5-6 wks Ischemia at Hct 30-34% NO NO NO Ischemia at Hct 13-15% NO NO YES Deformability NO CHANGE DPG Replete Absent Absent

78 Are Old Red Cell Units Dangerous? Prospective, Randomized (Pilot) Trial Hebert et al., Anesth Analg 2005;100: Group receiving “fresh” red cells (≤ 8d)) had higher mortality. RANDOMIZE YOUNG OLD vs.

79 Conservation of Blood A Precious Resource Why?AvailabilityExpenseOutcomesReactions How?IndicationsAlternativesSource Just do it!


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