Transfusion Medicine in Emergency Medicine Scott Koepsell M.D., Ph.D. March 7, 2015 I have no...
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Transcript of Transfusion Medicine in Emergency Medicine Scott Koepsell M.D., Ph.D. March 7, 2015 I have no...
Transfusion Medicine in Emergency MedicineScott Koepsell M.D., Ph.D.
March 7, 2015
I have no conflicts of interest to disclose
Agenda
• Transfusion history/components
• Trauma/hemorrhage versus anemic patients
• Evidence based recommendations
• Questions/Discussion
Blood Bank History
• 1936 Chicago’s Cook County Hospital
• 1941 Irwin Memorial Blood Bank, SF
• WWII – Returning surgeons demanded blood– Initially whole blood in glass bottles, but also
lyophilized plasma as well
• 1970s – component blood products
Blood Components
Plasma can be manufactured into cryo
Blood Components: RBCs
• Uncrossmatched RBCs, Group O– 0.4% chance of acute hemolytic reaction– 2.6% chance of delayed hemolytic reaction
• O-positive for males and woman >50 usually ok
AJCP 2010;134:202-206
Blood Components
• Plasma – AB or A– Group A plasma usually has low anti-B– Only about 10% of population is Group B or AB– Group A plasma is likely safe for all adult
patients
• Platelets or cryoprecipitate – Any typeJ Trauma Acute Care Surg 2012; 74:69-75
Blood Components
• What product to give to which patients?
– Trauma with bleeding– Non-trauma with bleeding– Anemia
Severely Injured or Trauma Patients
• Warm Fresh Whole Blood (WFWB) has been shown to increase survival with combat-related injuries
• Not really available in USA, but early administration of plasma in trauma likely lowers mortality
J Trauma 2009:6(S4):S69-76
Reviewed in Hematology 2013: 656-659
Severely Injured or Trauma Patients
• Many hospitals have adopted a massive transfusion policy that includes plasma and platelets– Subject to logistics and cost
• PROPPR trial showed 1:1:1 resuscitation or 1:1:2 had equivalent mortality at 24 hours and at 30 days
JAMA 2015: 313(5):471-482
Non-trauma bleeding patient
• 48 yo male presents to ED with coffee-ground emesis– PMH: EtOH abuse, cirrhosis– Vitals: T 37.5 P 105 R 18 BP 110/70– PE: spider angiomata, ascites– Lab: INR 1.7, Na 130, Hgb 7.5
Non-trauma bleeding patient
• NG tube placed: blood-tinged fluid returned (~20 mL)
• GI consulted and on their way
• Would you transfuse this patient (Hgb 7.5 g/dL)?
Evidence Based Transfusion Medicine
• Prospective, randomized trial of 921 patients with severe acute upper GI bleeding– 461 Restrictive (<7 g/dL)– 460 Liberal (<9 g/dL)
NEJM 2013; 368: 11-21
Evidence Based Transfusion Medicine
NEJM 2013; 368: 11-21
Evidence Based Transfusion Medicine
NEJM 2013; 368: 11-21
Evidence Based Transfusion Medicine
NEJM 2013; 368: 11-21
• Major complication in the liberally transfused was further bleeding– 45/444 vs 71/445, p=0.01
• Hepatic hemodynamic studies showed an increased portal pressure in the transfused group
Non-trauma bleeding patient
• Not a lot of data exists, and clinical judgment that integrates laboratory and physical exam findings is key
• In some cases (stable upper GI bleeding), transfusion may be harmful
• Questions or comments?
Non-trauma patients
• In 1942 Dr. John Lundy • “When the concentration of hemoglobin is less
than 8 to 10 grams per 100 cubic centimeters of whole blood, it is wise to give a blood transfusion…”
• No data given for basis of recommendation
Blood transfusion dogma
• If < 10 g/dL then give 2 units– 2 Unit dose of RBCs
• Based off hospital utilization guidelines in the mid-20th century
• Donating 1 units seems benign, so how could 1 unit transfusion help?
• If you are going to transfuse, then transfuse!!
– Perpetuated in medical education for years– Empiric
Anemia, Case 1
• 68 year-old male presents to ED for SOB– PMH: COPD, HTN, DM, CKD, EtOH abuse
– Vitals: T 38.1 P 98 BP 150/80 R 20 O2 89% NC
– PE: In mild distress, decreased R breath sounds & wheezing, clubbing, dry mucous membranes
– Labs: WBC 13K, Hgb 9.0 g/dL, Cr 1.6
– Imaging: RLL consolidation
Case 1
• While waiting for the patient to be admitted, would you transfuse this patient with RBCs at this point (Hgb 9.0 g/dL)?
• Would you transfuse this patient with RBCs if the Hgb 7.9 g/dL?
• Would you transfuse this patient with RBCs if the Hgb 7.0 g/dL?
Evidence Based Transfusion Medicine
Evidence Based Transfusion Medicine
• Prospectively randomized 838 ICU patients– Restrictive transfusion: <7.0 g/dL
• Average Hgb 8.5 +/- 0.7 g/dL• 2.6 +/- 4.1 RBC units transfused
– Liberal transfusion: <10.0 g/dL• Average Hgb 10.7 +/- 0.7 g/dL• 5.6 +/- 5.3 RBC units transfused
NEJM: TRICC Trial
NEJM: TRICC Trial
Evidence Based Transfusion Medicine
• Cochrane Reviews (2012)– 19 trials involving 6264 patients
• Restrictive transfusion (7-8 g/dL)– Reduces risk of blood transfusion 39%– Reduces in hospital mortality (RR 0.77)– No impact on adverse events (mortality, cardiac events,
myocardial infarction, stroke, pneumonia, thromboembolism)
Evidence Based Transfusion Medicine
• 18 randomized trials involving 7593 patients– Restrictive transfusion (7-8 g/dL)
• Reduces risk of health care-associated infections (RR 0.82) with NNT 38
– Restrictive transfusion (<7 g/dL)• Reduces risk of health care-associated infections (RR 0.80)
with NNT: 20
– Most pronounced in patients presenting with sepsis
JAMA 2014; 311:1317-1326
Anemia, Case 1
• Questions or comments?
Anemia, Case 2• 72 yo female presents to ED for SOB, fatigue,
weight gain– PMH: CHF, CAD, HTN, CKD, anemia of chronic
disease– Vitals: T 37.1 P 80 R 18 BP 135/75 O2 94%– PE: S3, pitting edema, crackles– Labs: Heart failure peptide 800 pg/mL, Hgb 7.2– Imaging: CXR: Cardiomegaly, Kerley lines in lungs
Anemia, Case 2
• While waiting for admission for diuresis/treatment of CHF would you transfuse for Hgb of 7.2 g/dL?
Evidence Based Transfusion Medicine
• CCM 2001; 29: 227-234
TRICC subset analysis of patients with pre-existing heart disease
Evidence Based Transfusion Medicine
• AABB– Adhere to a restrictive transfusion strategy (7-
8 g/dL) for hospitalized, stable patients– For stable patients with pre-existing
cardiovascular disease, 8 g/dL
– Transfuse slowly in patients with fluid overload
Ann Intern Med 2012;157:49-58
Anemia, Case 2
• Questions or comments?
Anemia, Case 3
• 61 yo male presents to ED with chest pain– PMH: HTN, CKD, DM, anemia of chronic
disease– Vitals: T 37.5 P 95 R 18 BP 110/70– PE: diaphoretic– Lab: elevated troponin, Cr 2.9, Hgb 8.2– ECG: no ST-segment elevation noted
Anemia, Case 3
• 61 yo male with acute MI
– Would you transfuse this patient (Hgb 8.2)?
– If so, 1 or 2 units?
Evidence Based Transfusion Medicine
JAMA 2013;173(2):132-139
• Meta analysis of 10 studies– “blood transfusion was associated with a
higher risk for mortality independent of baseline hemoglobin level, nadir hemoglobin level, and change in hemoglobin level during the hospital stay. Blood transfusion was also significantly associated with a higher risk for subsequent myocardial infarction (risk ratio, 2.04; 95% CI, 1.06-3.93; P=.03)”
Evidence Based Transfusion Medicine
Am J Cardiol 2011; 108:1108-1111
• CRIT Trial– 45 patients with acute MI and hemoglobin <10
g/dL on admission prospectively randomized• Transfuse at hgb <10 (liberal)• Transfuse at hgb <8 (restrictive)
Am J Cardiol 2011; 108:1108-1111
Anemia, Case 3
• No definite guidelines exist in the setting of ACS
• Volume status is likely an important variable
• Questions or comments?
Risk versus Benefit of RBC transfusion
• Blood transfusions carry more risk than previously appreciated– Not transfusion-transmitted infections
• i.e. risk of TT-Hepatitis B is 1:282,000 transfusions
– Not well understood• Why more end-organ failure and in hospital mortality
with increasing transfusions?• Why more infections?
• Storage lesion of RBCs in bag may be the reason– 42-day shelf life means increases in:
• Free iron (supports microbial growth)• Free hemoglobin (vasoconstricts)• Lipid microparticles (thrombogenic)• No 2,3-DPG (requires 24 hours for equilibration)• Damaged RBCs (overwhelms reticuloendothelial
system)• Less deformable RBCs (cannot flow through
microvasculature)
Transfusion Threshold
• 7 – 8 grams/dL represents a balance– Benefit: increased oxygen carrying capacity
for tissues– Risk: increased complications (infection, fluid
overload, etc)
Risk versus Benefit of RBC transfusion• Bottom line
– Restrictive transfusion thresholds (7-8 g/dL) improve non-trauma patient outcomes (even ICU patients, or upper GI bleed, or CAD)
– Many hospitals have implemented restrictive transfusion policies for years without deleterious effects
– Any transfusion for a hemoglobin > 8 g/dL ought to have evidence-based rationalization documented in the medical chart The appropriate dose is almost always 1 unit unless bleeding
Change is coming…
Discussion?
Ebola virus disease
• Categories of patients– Patient with febrile illness
• Patients under investigation for EVD• Unknown or unsuspected EVD
– Patient without illness but high level risk– Patient with confirmed EVD
• In all cases, history (travel/contact) is important in risk stratification
Ebola virus disease
• Healthcare works encounter highly-infectious fluids (blood, urine etc) from patients with EVD– Remain highly infectious for weeks
• J Appl Microbiol. 109(5): 1531-9
– Viral loads reported to be up to 108 per ml– Infectious dose as few as 1 to 10 virions
• JAMA 1997: 278,(5),399-411
Ebola virus disease
• CDC guidance on PPE (recently updated to increase protection)
• Treatment largely remains supportive (electrolyte replacement, IV hydration)– Experimental therapies
• Convalescent plasma• Antivirals• ZMapp
Ebola virus disease - CP
Ebola virus disease - CP
Ebola virus disease - CP
• Currently, Phase I safety trial of passive immune therapy during acute EVD– Clinicaltrials.gov NCT02295501
• Online Ebola information (PPE, education etc)• http://www.nebraskamed.com/biocontainment-
unit/ebola