Transfusion strategies in non-bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine

Vlaar, Alexander P.J.; Oczkowski, Simon; Bruin, Sanne de; Wijnberge, Marije; Antonelli, Massimo; Aubron, Cécile; Aries, Philippe; Duranteau, Jacques; Juffermans, Nicole P.; Meier, Jens; Murphy, Gavin J.; Abbasciano, Riccardo; Muller, Marcella M.; Shah, Akshay; Perner, Anders; Rygaard, Sofie; Walsh, Timothy; Guyatt, Gordon; Dionne, Joanna C.; Cecconi, Maurizio

doi:10.1007/s00134-019-05884-8

Cited by 135 publications

(134 citation statements)

References 150 publications

(183 reference statements)

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“…Given that propensity score matching corrected for differences between the groups and that median hemoglobin level the rst day of ICU admission did not differ between groups (Figure 2), the results in the present study imply that any adverse effects of the RBC-transfusion itself are responsible for the worse outcomes in the RBC group. This has previously been suggested in several reports, studies and guidelines [1,3,4,11,[18][19][20][21]. In a retrospective registry study, similar to the present, Leal-Noval et al included moderately anemic non-bleeding critically ill patients and matched patients that received RBCtransfusion with non-transfused patients [4].…”

Section: Discussionsupporting

confidence: 59%

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Effects of Red Blood Cell Transfusions on Morbidity and Mortality in Non-Septic Critically Ill Patients; A Propensity Score Matched Study

Kander¹,

Nilsson²,

Larsson³

et al. 2020

Preprint

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BackgroundRBC-transfusions can be lifesaving, but are also associated with harm. To further examine any effect of red blood cell (RBC)-transfusions given to critically ill patients that were not exposed to the risks of anemia or sepsis, we designed this retrospective propensity score matched study. The aim was to compare mortality and morbidity in non-septic critically ill patients that were given low-grade RBC-transfusions at hemoglobin level > 70 g/L with patients without RBC-transfusions any of the first 5 days in intensive care.MethodsAdult patients admitted to a general 9-bed intensive care unit between 2007-2018 at a tertiary university hospital, were eligible for inclusion. Patients that received > 2 units RBC-transfusion during the first five days after admission, with pre-transfusion hemoglobin level <70 g/L or with severe sepsis or septic shock were excluded. Outcomes were 28-, 90- and 180-day mortality, highest acute kidney injury network (AKIN) score, days alive and free of organ support the first 28 days and highest sequential organ failure assessment score (SOFA-max).ResultsIn total 9491 admissions were recorded during the study period. Propensity score matching at 1:1 ratio resulted in two well matched group with 682 unique patients in each. Median pre-transfusion hemoglobin was 98 g/L (interquartile range 91-106 g/L). Mortality at the measured time points were higher in the RBC-group with an absolute risk increase for death at 180 days of 4.8% [95% confidence interval 2.5 to 7.2%], (p<0.001). Low grade RBC-transfusion was also associated with renal, circulatory and respiratory failure as well as higher SOFA-max score. ConclusionLow-grade leukoreduced RBC-transfusions given to non-septic critically ill patients without significant anemia, was strongly associated with increased mortality, increased kidney-, circulatory- and respiratory- failure as well as with higher SOFA-max score. These findings further strengthen the evidence supporting a restrictive use of RBC-transfusions in critically ill patients.

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Section: Discussionsupporting

confidence: 59%

“…Erythropoietin and iron supplementation have been studied in several RCTs but unfortunately without reduction in RBC-transfusions [27,28]. However, results of several ongoing trials on iron administration to critically ill patients are pending [21].…”

Section: Discussionmentioning

confidence: 99%

Effects of Red Blood Cell Transfusions on Morbidity and Mortality in Non-Septic Critically Ill Patients; A Propensity Score Matched Study

Kander¹,

Nilsson²,

Larsson³

et al. 2020

Preprint

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“…European Society of Intensive Care Medicine (ESICM) Guidelines [26]. The ESICM guidelines address transfusion strategies in non-bleeding critically ill patients.…”

Section: Society Of Cardiovascular Anesthesiologists (Sca)mentioning

confidence: 99%

Plasma Transfusion Practice in Adult Surgical Patients: Systematic Review of the Literature

Adam

Fischer

2020

Transfus Med Hemother

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Background: Plasma transfusions are most commonly used therapeutically for bleeding or prophylactically in nonbleeding patients prior to invasive procedures or surgery. Although plasma transfusions generally seem to decline, plasma usage for indications that lack evidence of efficacy prevail. Summary: There is wide international, interinstitutional, and interindividual variance regarding the compliance with guidelines based on published references, supported by appropriate testing. There is furthermore a profound lack of evidence from randomized controlled trials comparing the effect of plasma transfusion with that of other therapeutic interventions for most indications, including massive bleeding. The expected benefit of a plasma transfusion needs to be balanced carefully against the associated risk of adverse events. In light of the heterogeneous nature of bleeding conditions and their rapid evolvement over time, fibrinogen and factor concentrate therapy, directed at specific phases of coagulation identified by alternative laboratory assays, may offer advantages over conventional blood product ratio-driven resuscitation. However, their outcome benefit has not been demonstrated in well-powered prospective trials. This systematic review will detail the current evidence base for plasma transfusion in adult surgical patients.

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“…2a). The median number of transfused RBC units (8 units [5][6][7][8][9][10][11][12][13][14][15][16][17][18] vs. 13 units [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24], P = 0.01) and the median hemoglobin concentration within 28 days of ARDS therapy (9.1 g/dl [8.7-9.7] vs. 10.4 g/dl [9.9-11.1], P < 0.001) were lower in the lowerthreshold group compared to higher-threshold group (Fig. 2b, c).…”

Section: Hemoglobin Concentrations and Transfusionmentioning

confidence: 99%

“…Data for a target hemoglobin concentration and consecutive transfusion thresholds in patients with ARDS are poor. Current national and international guidelines on the management of patients with ARDS address this topic only vaguely or extrapolate recommendations for non-bleeding anemic, critically ill patients to patients with ARDS [6][7][8][9]. For ARDS patients treated with extracorporeal membrane oxygenation (ECMO), evidence is mainly based on case series and a recent large international survey demonstrated a high heterogeneity of the hemoglobin target concentration with most respondents using a higher transfusion threshold for patients on ECMO compared to other critically ill patients [10][11][12][13].…”

Section: Introductionmentioning

confidence: 99%

Lower versus higher hemoglobin threshold for transfusion in ARDS patients with and without ECMO

et al. 2020

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Background Efficacy and safety of different hemoglobin thresholds for transfusion of red blood cells (RBCs) in adults with an acute respiratory distress syndrome (ARDS) are unknown. We therefore assessed the effect of two transfusion thresholds on short-term outcome in patients with ARDS. Methods Patients who received transfusions of RBCs were identified from a cohort of 1044 ARDS patients. After propensity score matching, patients transfused at a hemoglobin concentration of 8 g/dl or less (lower-threshold) were compared to patients transfused at a hemoglobin concentration of 10 g/dl or less (higher-threshold). The primary endpoint was 28-day mortality. Secondary endpoints included ECMO-free, ventilator-free, sedation-free, and organ dysfunction-free composites. Measurements and main results One hundred ninety-two patients were eligible for analysis of the matched cohort. Patients in the lower-threshold group had similar baseline characteristics and hemoglobin levels at ARDS onset but received fewer RBC units and had lower hemoglobin levels compared with the higher-threshold group during the course on the ICU (9.1 [IQR, 8.7–9.7] vs. 10.4 [10–11] g/dl, P < 0.001). There was no difference in 28-day mortality between the lower-threshold group compared with the higher-threshold group (hazard ratio, 0.94 [95%-CI, 0.59–1.48], P = 0.78). Within 28 days, 36.5% (95%-CI, 27.0–46.9) of the patients in the lower-threshold group compared with 39.5% (29.9–50.1) of the patients in the higher-threshold group had died. While there were no differences in ECMO-free, sedation-free, and organ dysfunction-free composites, the chance for successful weaning from mechanical ventilation within 28 days after ARDS onset was lower in the lower-threshold group (subdistribution hazard ratio, 0.36 [95%-CI, 0.15–0.86], P = 0.02). Conclusions Transfusion at a hemoglobin concentration of 8 g/dl, as compared with a hemoglobin concentration of 10 g/dl, was not associated with an increase in 28-day mortality in adults with ARDS. However, a transfusion at a hemoglobin concentration of 8 g/dl was associated with a lower chance for successful weaning from the ventilator during the first 28 days after ARDS onset. Trial Registration: ClinicalTrials.gov NCT03871166.

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Transfusion strategies in non-bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine

Cited by 135 publications

References 150 publications

Effects of Red Blood Cell Transfusions on Morbidity and Mortality in Non-Septic Critically Ill Patients; A Propensity Score Matched Study

Effects of Red Blood Cell Transfusions on Morbidity and Mortality in Non-Septic Critically Ill Patients; A Propensity Score Matched Study

Plasma Transfusion Practice in Adult Surgical Patients: Systematic Review of the Literature

Lower versus higher hemoglobin threshold for transfusion in ARDS patients with and without ECMO

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