Consultant CPD, November 23rd 2016 Blood Transfusion Consultant CPD, November 23rd 2016

Blood is good

Blood is good DO2 = CO x CaO2

Blood is bad Pull out Betty! You’ve hit an artery

Blood is bad Infections Transfusion reactions TRALI TACO Chemical effects due to storage Microcirculation Immunomodulation

Blood is bad Infections Transfusion reactions TRALI TACO Chemical effects due to storage Microcirculation Immunomodulation

Blood is bad

Happy medium?

Restrictive transfusion Happy medium? The policy of giving blood only when benefits are deemed to outweigh potential risks Restrictive transfusion

Restrictive vs liberal transfusion strategies

Restrictive vs liberal transfusion strategies

Restrictive vs liberal transfusion strategies The evidence Restrictive vs liberal transfusion strategies 7 key RCTs General / critical care population Cardiac patients [TBI and SAH]

The TRICC study

The TRICC study LIBERAL RESTRICTIVE OUTCOMES Hb 100 -120 Hb 70 -90 Death at 30 days & 60 days, organ failures

The TRICC study LIBERAL RESTRICTIVE (2.6 ± 4.1) P<0.01 Hb 107 ± 7 (5.6 ± 5.3) RESTRICTIVE (2.6 ± 4.1) Hb 85 ± 7 P<0.01

The TRICC study

The TRICC study

The TRICC study

The TRICC study

The TRICC study

The FOCUS study

The FOCUS study 2016 pts >50yrs IHD or risk factors Hb <100 ♯ hip

The FOCUS study

The FOCUS study LIBERAL RESTRICTIVE OUTCOMES Hb >100 Hb < 80 or signs & symptoms OUTCOMES Death at 60 days or inability to walk >10ft

The FOCUS study

The FOCUS study

The FOCUS study

The FOCUS (2)study

The FOCUS (2) study

The RELIEVE study >55yrs CCM

The RELIEVE study LIBERAL RESTRICTIVE OUTCOMES Hb>90 (91-110) Difference in mean Hb, mortality, adverse events, HRQoL

The RELIEVE study

The RELIEVE study No significant difference in mortality or any of the other outcome measures

Ischaemic Heart Disease

IHD pts Am Heart Journal 2011; 162:300

IHD pts Hospital-acquired anemia was defined as development of new anemia during hospitalization using age, gender, and race specific criteria Mild – less than normal - >110 Moderate – 90-110 Severe - <90

IHD pts

The MINT study

The MINT study STEMI Non STEMI Unstable angina Cardiac catheter Hb<100

The MINT study LIBERAL RESTRICTIVE OUTCOMES Hb >100 Symptomatic Death, MI, unscheduled revascularisation

The MINT study

The MINT study

The TRACS study

The TRACS study LIBERAL RESTRICTIVE OUTCOMES Ht >30 Ht >24 Death, severe morbidity (CVS, RS, Renal)

The TRACS study

The TRACS study

The TRACS study

Upper GI bleed pts

Upper GI bleed pts LIBERAL RESTRICTIVE OUTCOMES Hb 90 -110 Hb 70 -90 Death at 45 days, re-bleed, in hospital complications

Upper GI bleed pts No transfusion 51% vs 14%

Upper GI bleed pts

Upper GI bleed pts

The TRISS study

The TRISS study

The TRISS study LIBERAL RESTRICTIVE OUTCOMES Hb >90 Hb >70 Death at 90 days

The TRISS study

The TRISS study

The TRISS study

The TITRe2 study

The TITRe2 study LIBERAL RESTRICTIVE OUTCOMES Hb >90 Hb >75 10 - Sepsis, Ischaemic events within 3 months 20 - ICU stay, all cause mortality

The TITRe2 study RESULTS 10 outcome 35% vs 33% 20 outcome 4.2 vs 2.6% Protocol violations

TBI & SAH patients

TBI & SAH patients Transfusion Medicine 2016

TBI & SAH patients Very sparse evidence For TBI Hb 70 – 90 For SAH 80 - 100

TBI & SAH patients JAMA 2014

TBI & SAH patients

TBI & SAH patients

TBI & SAH patients

Cochrane review

Cochrane review 19 trials 6264 pts

Cochrane review Adverse events and other outcomes None of the outcomes evaluated, including mortality, cardiac morbidity, infections and length of hospital stay, appear to be adversely affected by the lower use of red cell transfusions.

Cochrane review In contrast, the evidence raises the possibility of harm associated with liberal transfusion. In-hospital mortality increased by 23% infections were increased by19% .

Cochrane review In patients who do not have acute coronary artery disease, blood transfusion can probably be withheld in the presence of haemoglobin levels as low as 70 to 80 as long as there is no notable bleeding.

NICE recommendations Red blood cells Thresholds and targets Use restrictive red blood cell transfusion thresholds for patients who need red blood cell transfusions and who do not: have major haemorrhage or have acute coronary syndrome or need regular blood transfusions for chronic anaemia. .

NICE recommendations Red blood cells Thresholds and targets When using a restrictive red blood cell transfusion threshold, consider a threshold of 70 g/litre and a haemoglobin concentration target of 70–90 g/litre after transfusion. Consider a red blood cell transfusion threshold of 80 g/litre and a haemoglobin concentration target of 80–100 g/litre after transfusion for patients with acute coronary syndrome.

Questions?