Surgical ICU, Heart Institute University of São Paulo Ludhmila Hajjar, MD, PhD Surgical ICU, Heart Institute University of São Paulo

Mayo Clinic and the Origins of Blood Banking John Lundy, 1934: first blood banking (Mayo Clinic) Transfusion trigger (1942): hemoglobin of 10g/dL would be the goal in high risk patients 1970/1980’s: transfusion-related hepatitis in 45% of patients 1987: HIV infection – risks and benefits of transfusion (60% of critically ill patients) Lundy JS. Blood transfusion. Surg Clin North Am. 1934;14:721-7. Rabbitts JA, et al. Mayo Clinic and the origin of blood banking. Mayo Clin Proc. 2007;82(9):1117-8.

RISKS OF BLOOD TRANSFUSION Incompatibility reactions Early and late transfusional reactions Imunossupression Infections (bacterial, viral and prions) GVHD Imunommodulation Systemic inflammatory response syndrome Metabolic disorders (acidosis, hyperkalemia, hipothermy) Storage lesion Transfusion related acute lung injury (TRALI) Transfusion acute circulatory overload (TACO) Increased morbidity and mortality in medical and surgical patients Hajjar LA, Auler Jr JO, Galas F et al. Blood transfusion in critically ill patients: state of the art. Clinics. 2007;62(4):507-24. Goodnough LT. Anesthesiology Clin N Am. 2005;23:241-52.

The challenge of identifying the critical point Hébert P et al. Crit Care Clinics. 2004;20:187-212. Hébert P et al. Crit Care Clinics. 2004;20:187-212.

Liberal strategy: RBC transfusion when Hb < 10g/dL Restrictive strategy: RBC transfusion when Hb < 7g/dL n = 418 n = 420 DOUBTS ON TRANSFUSIONAL PRACTICE – trigger or individual-based  Hébert PC et al. N Engl J Med. 1999;340:409-17. N Engl J Med. 1999;340:409-17.

Cardiac Surgery and Red Blood Cell Transfusion Estratégias liberal vs. restritiva em cirurgia cardíaca Major cause of RBC transfusion Occurrence: 40 to 95% Aged patients, high percent of comorbidities, antiplatelet and anticoagulants use RBC transfusion rates with high variability – institutional “guidelines” Not standard indications Steiner ME et al. Transfusion algorithms and how they apply to blood conservation. Hematol Oncol Clin N Am 2007;21:177-84. Reeves BC and Murphy GJ. Current Opinion in Cardiology. 2008; 23:607-12.

11.963 patients (on pump CABG) RBC transfusion: increase in morbidity and mortality Koch CG et al. Crit Care Med. 2006;34:1608-16.

DESIGN Prospective and randomized controlled trial February 2009 to February 2010 Heart Institute, University of São Paulo HYPOTHESIS A restrictive strategy of RBC transfusion is as safe as a liberal one in cardiac surgery

Primary outcome: Composite end point that included 30-day all cause mortality and severe morbidity (cardiogenic shock, ARDS, or acute renal injury requiring dyalisis or hemofiltration) Secondary outcomes: All clinical complications during hospital stay, ICU and hospital lengths of stay Predictive factors for RBC transfusions Effects of transfusion on patient outcomes

Porcentage of patients who received RBC transfusion

Median levels of total transfused RBC units in liberal and restrictive-strategy groups

Kaplan-Meier Estimates of 30-Day Survival by Transfusion Strategy

PREDICTIVE FACTORS FOR RBC TRANSFUSION

PREDICTIVE FACTORS FOR COMPLICATIONS

PREDICTIVE FACTORS FOR DEATH AT 30 DAYS Hajjar, L. A. et al. JAMA 2010;304:1559-1567.

Kaplan-Meier Estimates of 30-Day Survival Based on Number of Red Blood Cell (RBC) Units Transfused Hajjar, L. A. et al. JAMA 2010;304:1559-1567.

CONCLUSIONS The restrictive-strategy patients received fewer RBC units and did not present higher incidence of clinical complications In our study, independent of treatment strategy, patients who received na RBC transfusion had higher rates of complications after surgery, including 30-day mortality The number of transfused RBC units was a predictive factor for 30-day mortality Using a noninferiority margin of -8%, the use of a restrictive transfusion strategy resulted in noninferior rates of the combined outcome of 30-day all-cause mortality and severe morbidity.

The study by Hajjar et al is a notable addition to the existing body of evidence on the narrow benefits of RBC transfusion and its effect on outcomes in patients without hemorrhage. These studies have suggested that reduction or avoidance of transfusion in cardiac patients is associated with improved outcomes. When evaluating a hemoglobin level, treating physicians must resist the temptation to "first do something" and temper this temptation with a philosophy of "first do no harm" to achieve the optimal balance of providing the best risk-benefit and cost-effective outcomes of transfusion therapy for patients. JAMA. 2010;304(14):1610-1611.