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

2. Blood is good

3. Blood is good
DO2 = CO x CaO2

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

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

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

7. Blood is bad

8. Happy medium?

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

10. Restrictive vs liberal transfusion strategies

11. Restrictive vs liberal transfusion strategies

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

13. The TRICC study

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

15. 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

16. The TRICC study

17. The TRICC study

18. The TRICC study

19. The TRICC study

20. The TRICC study

21. The FOCUS study

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

23. The FOCUS study

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

25. The FOCUS study

26. The FOCUS study

27. The FOCUS study

28. The FOCUS (2)study

29. The FOCUS (2) study

30. The RELIEVE study
>55yrs
CCM

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

32. The RELIEVE study

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

34. Ischaemic Heart Disease

35. IHD pts
Am Heart Journal 2011; 162:300

36. 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 –
Severe - <90

37. IHD pts

38. The MINT study

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

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

41. The MINT study

42. The MINT study

43. The TRACS study

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

45. The TRACS study

46. The TRACS study

47. The TRACS study

48. Upper GI bleed pts

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

50. Upper GI bleed pts
No transfusion 51% vs 14%

51. Upper GI bleed pts

52. Upper GI bleed pts

53. The TRISS study

54. The TRISS study

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

56. The TRISS study

57. The TRISS study

58. The TRISS study

59. The TITRe2 study

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

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

62. TBI & SAH patients

63. TBI & SAH patients
Transfusion Medicine 2016

64. TBI & SAH patients Very sparse evidence For TBI Hb 70 – 90
For SAH

65. TBI & SAH patients
JAMA 2014

66. TBI & SAH patients

67. TBI & SAH patients

68. TBI & SAH patients

69. Cochrane review

70. Cochrane review
19 trials
6264 pts

71. 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.

72. 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% .

73. 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.

74. 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. .

75. 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.

77. Questions?