Using arterial-venous oxygen difference to guide red blood cell transfusion strategy

Abstract

Background: Guidelines recommend a restrictive red blood cell transfusion strategy based on hemoglobin (Hb) concentrations in critically ill patients. We hypothesized that the arterial-venous oxygen difference (A-V O 2diff), a surrogate for the oxygen delivery to consumption ratio, could provide a more personalized approach to identify patients who may benefit from transfusion. Methods: A prospective observational study including 177 non-bleeding adult patients with a Hb concentration of 7.0-10.0 g/dL within 72 h after ICU admission. The A-V O 2diff , central venous oxygen saturation (ScvO 2), and oxygen extraction ratio (O 2 ER) were noted when a patient's Hb was first within this range. Transfusion decisions were made by the treating physician according to institutional policy. We used the median A-V O 2diff value in the study cohort (3.7 mL) to classify the transfusion strategy in each patient as "appropriate" (patient transfused when the A-V O 2diff > 3.7 mL or not transfused when the A-V O 2diff ≤ 3.7 mL) or "inappropriate" (patient transfused when the A-V O 2diff ≤ 3.7 mL or not transfused when the A-V O 2diff > 3.7 mL). The primary outcome was 90-day mortality. Results: Patients managed with an "appropriate" strategy had lower mortality rates (23/96 [24%] vs. 36/81 [44%]; p = 0.004), and an "appropriate" strategy was independently associated with reduced mortality (hazard ratio [HR] 0.51 [95% CI 0.30-0.89], p = 0.01). There was a trend to less acute kidney injury with the "appropriate" than with the "inappropriate" strategy (13% vs. 26%, p = 0.06), and the Sequential Organ Failure Assessment (SOFA) score decreased more rapidly (p = 0.01). The A-V O 2diff , but not the ScvO 2 , predicted 90-day mortality in transfused (AUROC = 0.656) and non-transfused (AUROC = 0.630) patients with moderate accuracy. Using the ROC curve analysis, the best A-V O 2diff cutoffs for predicting mortality were 3.6 mL in transfused and 3.5 mL in non-transfused patients. Conclusions: In anemic, non-bleeding critically ill patients, transfusion may be associated with lower 90-day mortality and morbidity in patients with higher A-V O 2diff. Trial registration: ClinicalTrials.gov, NCT03767127. Retrospectively registered on 6 December 2018.

The Impact of Red Blood Cell Transfusion on Blood Lactate in Non-Bleeding Critically Ill Patients—A Retrospective Cohort Study

“…As RBCT did not normalise lactate even in patients with no limitations of its interpretation, we hypothesise that pre-transfusion lactate levels should not be used as a physiologic RBCT trigger in this group of patients. There are other surrogates of DO 2 -VO 2 balance that may be used as physiologic transfusion triggers, namely ScvO 2 [8] and A-V O 2diff [6].…”

“…These surrogates may be used as physiologic RBCT triggers. A-V O 2diff was shown to be a moderate independent predictor of 90-day mortality in transfused and non-transfused patients [6]. With stable cardiac output (CO) and arterial saturation (SaO 2 ), O 2 ER is calculated according to the equation O 2 ER = (SaO 2 − SvO 2 )/SaO 2 .…”

The Underestimated Role of Platelets in Severe Infection a Narrative Review

“…These factors, combined with a hypofibrinolytic status, leads to a postoperative hypercoagulable state. Fluid infusion, in particular the administration of colloids, during surgery is associated with a prolongation of standard clotting times (CTs) and a decrease in plasma levels of coagulation factors and inhibitors of coagulation [92,93]. FVIII and von Willebrand factor (VWF) show a gradual increase during surgery-probably secondary to increases in stress hormones, including epinephrine and vasopressin-to inflammatory responses and endothelial activation.…”

Correction: Using arterial-venous oxygen difference to guide red blood cell transfusion strategy

“…In the publication of this article [ 1 ], in the Methods Section, there was an error in the following formulae: …”