Anemia frequently occurs in alarmingly ill patients, affecting added than 90% of patients accepted to accelerated affliction units (ICUs) by the third day.1 The affidavit for anemia in alarmingly ill patients are multifactorial and accommodate astute claret accident (e.g., from trauma, anaplasty or gastrointestinal bleeding), iatrogenic claret accident from ytic testing and blunted red claret corpuscle production. Abounding alarmingly ill patients accept claret transfusions for the assay of low claret levels due to either astute claret accident or subacute anemia associated with ytical illness. In 2 ample multicentre accomplice studies, 45% of patients in ICUs in the United States1 and 37% of those in ICUs in Western Europe2 accustomed claret transfusions.
Although claret transfusions accept accurate to be life-saving over about 100 years of admixture practice, the allowances in cases of balmy to abstinent anemia are still debated.3 A ample anatomy of abstract abstracts the abounding abeyant harms associated with claret transfusions.4 In this review, we yze the account and abridge the affirmation for claret attention strategies to abate astute claret accident and anticipate subacute anemia in alarmingly ill patients (Table 1 and Table 2). (A description of the chase action we acclimated to yze the studies included in this assay appears in Appendix 1.)
Red claret beef are the capital carriage apparatus for oxygen commitment to the anatomy tissues. The affiliation amid oxygen commitment and oxygen burning is biphasic.5 In accustomed physiologic states, oxygen commitment is absolute of consumption, back the bulk of oxygen delivered exceeds comatose oxygen requirements by a agency of 2 to 4.6 However, if oxygen commitment decreases sufficiently, oxygen burning can be bound by delivery; this point is alleged the anaerobic threshold. Added decreases in oxygen commitment could cede tissues ischemic and accord to assorted agency failure. A -to-be abstraction involving 2069 patients with assorted agony showed that a worse abject deficit, a abettor admeasurement of tissue ischemia, during the time amid hospital acceptance and ICU acceptance was acerb and decidedly activated with added in-hospital bloodshed (13% v. 45% amid patients with a abject arrears of ≤ 6 v. > 6 respectively, p < 0.0001).7 Red claret beef are about alloyed to access oxygen commitment and abate tissue ischemia; however, the adeptness of red claret corpuscle transfusions to access oxygen burning has not been acutely demonstrated.6
Allogeneic red claret corpuscle admixture is associated with acclaimed adverse furnishings (Table 3).8,9 Communicable risks accommodate accessible viral, bacterial, abject or prion transmission. Noninfectious risks, which accommodate febrile, allergic/ anaphylactic and hemolytic admixture reactions, transfusion-related astute lung abrasion (TRALI) and transfusion-associated circulatory afflict (TACO), are added accepted than communicable risks and advance to greater anguish and mortality.8 In addition, abounding empiric studies and a randomized ytic balloon involving alarmingly ill patients accept apparent an affiliation amid claret transfusions and added accident of infection, abiding automatic ventilation, multiple-organ dysfunction and death.4,10 Although the exact apparatus for the added anguish and bloodshed associated with claret transfusions is unknown, immunomodulation11–13 and the red claret corpuscle accumulator bane (decreased adeptness of stored red claret beef to transport, absolution or bear oxygen) are believable explanations.4
A cardinal of claret attention strategies accept been acclimated in the assay of astute claret accident in alarmingly ill patients (Table 1 and Table 2). They accommodate the use of hemostatic agents (e.g., antifibrinolytic agents, desmopressin and recombinant activated agency VII [recombinant agency VIIa]), bogus oxygen carriers (e.g., claret substitutes) and claret accretion techniques. These strategies are about accessory measures that accompaniment the primary assay aimed at accomplishing hemostasis (i.e., surgery, endoscopy). Accomplishing surgical hemostasis is the best ytical agency in endlessly bleeding and abbreviation the charge for claret transfusions. Similarly, aliment of optimal hemostatic altitude is ytical and includes the adapted use of hemostatic claret articles (platelets, arctic claret and cryoprecipitate) and advancement accustomed pH, temperature and calcium levels.14
Antifibrinolytic agents are accepted hemostatic agents that arrest the breakdown of claret clots. They are acclimated in a array of medical altitude to abate bleeding. A meta-ysis of the perioperative use of antifibrinolytic agents adapted that the use of tranexamic acid, epsilon aminocaproic acerbic or aprotinin in called cases can abate the charge for claret transfusions and reoperation afterwards accretion the accident of adverse events.15 The affiliated estimates adapted that aprotinin may abate the charge for claret transfusions and reoperation as compared with tranexamic acerbic and epsilon aminocaproic acid, but added studies are required. Added recently, assurance apropos associated with aprotinin accept been raised.16,17 Preliminary after-effects from a ample appearance III balloon comparing the use of 3 antifibrinolytic agents in high-risk cardiac anaplasty patients advance an added accident of afterlife associated with aprotinin.17 The about capability of these altered agents and the abeyant adverse furnishings will be bigger accepted back the complete after-effects of this balloon are available. The generalizability of the allegation from the appearance III balloon for the assay of bleeding in added alarmingly ill accommodating populations is uncertain.
A ytical assay of tranexamic acerbic for hemostasis in patients with akin aerial gastrointestinal bleeding accustomed a abridgement in the ceremony of bleeding and in mortality.18 However, the incremental allowances back accumulated with newer endoscopic therapies and proton pump inhibitor assay accept not been evaluated.
Trauma patients may additionally account from the use of antifibrinolytic agents. Two trials19,20 evaluated the use of aprotinin in patients with agony and alarming academician injury; however, they were baby (n = 77 for accumulated trials) and did not accommodate acceptable affirmation to abutment or abnegate the drug’s role.21 A ample multicentre randomized controlled balloon evaluating the aftereffect of tranexamic acerbic on bloodshed and admixture requirements amid 20 000 agony patients at accident of drain (CRASH II study) is underway.22
On the base of these studies, the use of antifibrinolytic agents may be advantageous for authoritative bleeding in called alarmingly ill patients. However, the capability of these agents in abbreviation admixture requirements and the accident of thrombotic complications and afterlife in a ample spectrum of alarmingly ill patients charcoal unclear.
Desmopressin acetate (1-deamino-8-D-arginine vasopressin [DDAVP]) is a constructed alternation of arginine vasopressin. It induces the absolution of stored agency VIII and von Willebrand agency from endothelial cells. A dosage of 0.3 μg/kg accustomed subcutaneously usually after-effects in a 3- to 5-fold access in levels of agency VIII and von Willebrand factor.23 For this reason, desmopressin assay is able in authoritative and preventing bleeding in patients with balmy hemophilia A and von Willebrand’s ache and in patients who are hemophilia carriers.23 It has additionally been apparent to be able in authoritative and preventing bleeding in patients who accept complete platelet disorders and those who accept platelet dysfunction associated with renal failure.24 However, alarmingly ill patients about accept animated levels of agency VIII and von Willebrand factor, both astute appearance reactants, and the antithesis of allowances and abeyant harms of desmopressin for these patients is unclear. A meta-ysis of desmopressin in the assay of perioperative bleeding showed alone a small, nonsignificant abridgement in claret accident afterwards affirmation of a abridgement in the charge for claret transfusions.25 Desmopressin accordingly may not be able in convalescent hemostasis or in abbreviation astute claret accident in alarmingly ill patients who do not accept specific bleeding disorders such as balmy hemophilia A, von Willebrand’s ache and uremia.
Recombinant activated agency VII (recombinant agency VIIa) is a agglomeration agency apply that is accustomed for use apple advanced in patients with agency deficiencies (hemophilia) and in Europe for use in patients with complete platelet disorders.26 Numerous case letters and alternation accept arise bargain claret accident associated with the use of recombinant agency VIIa in surgical patients, agony patients, patients accepting massive transfusions, those with alarmist ache and patients with gastrointestinal bleeding.26 A few randomized controlled trials evaluating the ytic capability of recombinant agency VIIa accept complex alarmingly ill patients, including patients with trauma,27 those with gastrointestinal bleeding,28 those adeptness cardiac surgery29 or alarmist transplantation30,31 and patients with intracranial hemorrhage.32 A contempo ytical assay advised the affirmation for antibacterial and ameliorative use of recombinant agency VIIa in patients afterwards hemophilia and assured that its capability as a hemostatic abettor charcoal uncertain.33 In that review, the affiliated estimates for adverse outcomes showed nonsignificant trends for added thromboemic complications (relative accident 1.28, 95% aplomb breach [CI] 0.84–1.95, p = 0.3), cardiovascular contest (relative accident 2.18, 95% CI 0.82–5.79, p = 0.1) and achievement (relative accident 2.02, 95% CI 0.57–7.17, p = 0.3).
Boffard and colleagues27 afresh arise 2 parallel, multicentre randomized controlled trials that advised the use of recombinant agency VIIa against placebo in patients with edgeless (n = 143) and biting (n = 134) trauma. Patients who accustomed 8 units of claret were about assigned to accept either recombinant agency VIIa (initial dosage of 200 μg/kg added additional doses of 100 μg/kg 1 and 3 hours later) or placebo. Overall, there was no cogent aberration amid the assay and placebo groups in the cardinal of units of claret afterwards alloyed (primary aftereffect measure). Amid patients who survived added than 48 hours, recombinant agency VIIa was associated with a abridgement in the cardinal of transfusions by 2.6 units (90% CI 0.7– 4.6, p = 0.02) in the edgeless agony accumulation and by 1.0 assemblage (90% CI 0.0–4.6, p = 0.10) in the biting agony group. No differences in bloodshed or thromboemic contest amid the groups were noted, but the balloon was not powered to appraise these end points.
Bosch and colleagues28 evaluated the use of recombinant agency VIIa in a randomized controlled balloon involving 245 patients with aerial gastrointestinal bleeding and cirrhosis. In accession to endoscopy and accepted care, patients were about assigned to accept either 8 doses of recombinant agency VIIa (100 μg/kg each) or placebo over 30 hours. No differences amid the 2 groups were empiric in authoritative bleeding aural 24 hours afterwards the aboriginal dose, the accident of alternate bleeding amid 24 hours and day 5, the cardinal of claret transfusions or the cardinal of deaths aural 5 days.
Among 399 patients with intracranial hemorrhage, a appearance II multicentre randomized double-blind dose-finding abstraction of recombinant agency VIIa showed a abridgement in bloodshed (overall allowance arrangement 1.8, 95% CI 1.1–3.0, p = 0.02) and in disability, application the adapted Rankin account (odds arrangement 2.2, 95% CI 1.3– 3.8, p = 0.004).32 Alone patients who were apparent aural 4 hours afterwards the access of affection and who had a Glasgow blackout account of added than 5 and no history of cardiac or thromboemic ache were included. The board begin a nonsignificant access in thrombotic contest amid patients accepting recombinant agency VIIa. Preliminary after-effects from accession multicentre randomized controlled balloon of recombinant agency VIIa involving patients with intracranial drain (n = 821) did not appearance agnate allowances in abbreviation anguish and mortality.34 Pending the abounding advertisement of these results, the role of recombinant agency VIIa will charge to be re-evaluated.
On the base of the studies to date, the accepted use of recombinant agency VIIa in alarmingly ill patients cannot be recommended. However, use in specific patients who accept massive amoral bleeding and who do not acknowledge to accepted treatments and accepted claret apparatus may still be a reasonable option, afterwards abeyant allowances and risks of thrombotic complications are weighed.35
Hemoglobin substitutes may adjournment or abate the acknowledgment to allogeneic claret transfusions in agony patients with astute claret loss. These articles can alter the use of claret articles during astute claret accident and, back accumulated with astute normovolemic hemodilution in the perioperative setting, could abate the charge for claret transfusions. Their use in alarmingly ill patients could abate the charge for claret in patients astute massive transfusions. There are 2 classes of claret substitutes: adapted hemoglobins and the perfluorocarbons.36 The bogus claret solutions are either recombinant articles or are acquired from anachronous animal red claret beef or bovine hemoglobin. The abeyant advantages of claret substitutes accommodate their availability afterwards charge for cross-matching, a continued shelf life, the adeptness to abundance the articles at allowance temperature and a bargain accident of ache transmission.36,37 Disadvantages accommodate their almost abbreviate half-life afterwards administering (24– 48 hours), their arrest with chic claret measurements, renal baneful effects, and adverse furnishings on vascular accent and claret pressure. The best contempo ancestors of hemoglobin-based oxygen carriers accept been adapted to anticipate accelerated break and abbreviate half-life, to abstain renal baneful furnishings and to abate vasoconstriction by abbreviating nitric oxide scavenging.
Despite the antecedent affiance of diaspirin cross-linked claret in abbreviation the charge for claret admixture in cardiac and noncardiac anaplasty patients,38,39 a appearance III randomized controlled balloon involving agony patients was chock-full afterwards an acting assay showed college bloodshed in the assay accumulation than in the ascendancy accumulation (38% v. 15% at 48 hours, p = 0.01; 46% v. 17% at 28 days, p = 0.003).40 Although the basal acumen for the added bloodshed is unclear, diaspirin cross-linked claret has been removed from the market. Added claret substitutes currently beneath assay in appearance III ytic trials absorb the polymerization of claret cells, which is declared to abate vasoconstriction by abbreviation the accident of extravasation of the artefact and thereby attached the scavenging of nitric oxide.37 These articles accommodate Polyheme, acquired from anachronous animal blood, and Hemopure, acquired from bovine hemoglobin.37 In appearance II ytic trials, Polyheme was associated with a bargain charge for claret transfusions in astute agony and burning anaplasty patients41 and was not associated with either systemic or pulmonary avenue hypertension.41,42 A cardinal appearance III multicentre randomized controlled balloon comparing Polyheme and accepted crystalloid in prehospital resuscitation has afresh been completed. Preliminary after-effects arise by the architect showed a abatement in the charge for allogeneic claret transfusions in the Polyheme group, but the abstraction bootless to authenticate non-inferiority in bloodshed as compared with accepted treatment.43 In appearance II trials, Hemopure was associated with a abridgement in the charge for claret transfusions in patients adeptness constituent orthopedic,44 cardiac45 and noncardiac surgery.46 These allegation accept resulted in the product’s approval in South Africa as an accession to claret transfusions, and Hemopure is currently beneath assay by the US Food and Drug Administration. The use of adapted claret substitutes for the assay of alarmingly ill patients holds promise, but added assay on the ability and assurance of these articles is required.
Perfluorocarbons are accession chic of claret acting that are adorable because they carriage both oxygen and carbon dioxide and can absolution oxygen to the tissues at a bulk of about alert that of hemoglobin. Perfluorocarbons accept the advantage of a continued shelf activity and no accident of manual of blood-borne infections. However, because of the beeline affiliation amid the fractional burden of oxygen in claret and the oxygen agreeable on perfluorocarbons, patients accept to be accustomed 100% oxygen to accommodate able oxygenation with this product.47 Such aerial aggressive oxygen concentrations may abet astute lung injury.48 To date, perflubron (Oxygent) has been activated in aggregate with astute normovolemic hemodilution in a appearance III balloon involving patients adeptness constituent noncardiac surgery.49 Overall, the patients who accustomed perflubron accustomed beneath allogeneic claret transfusions than the ascendancy patients. The abounding ability and assurance contour of perfluorocarbon-based claret substitutes and their abeyant role in alarmingly ill patients charcoal to be antiseptic through approaching studies.
Intraoperative red claret corpuscle deliver is able-bodied accustomed as a claret attention strategy,50 but it has bound account in alarmingly ill patients. Postoperative accretion and admixture of claret from antiseptic surgical drains in cardiac anaplasty has apparent alone bordering abridgement in admixture requirements (relative accident 0.85, 95% CI 0.79–0.92).51 The achievability and capability of claret accretion techniques for added alarmingly ill patients with astute claret accident are added limited.
Diagnostic testing is an important account of claret accident in alarmingly ill patients.1,2,52 Claret samples for ytic testing are frequently taken up to 24 times per day depending on accommodating affliction acuity, affluence of sampling and institutional practice. In-dwelling axial venous or arterial catheters accord to added sampling and claret accident because of the affluence of sampling and because of the added claim to abandon the aboriginal few millilitres of infusate-blood admixture acquired back accession claret from a fluid-infusing catheter.53–55 Studies from the 1980s arise a beggarly claret accident per accommodating of 377 mL/d in cardiothoracic ICUs, 240 mL/d in accepted surgical ICUs and 41.5 mL/d in medical–surgical ICUs.53,56 A added contempo abstraction involving 1136 patients in 145 western European ICUs begin ample claret accident through claret sampling, averaging 41.1 mL/d per patient.2 In one abstraction involving patients accepted to an ICU for added than 3 days, claret sampling accounted for 17% of the absolute claret loss.57 In 2 American studies, accessory assay articular that claret sampling accounted for 50% of the aberration in the bulk of red claret beef transfused.53,54 Not surprisingly, there appears to be a alternation amid the severity of affliction and both the cardinal of claret draws and the absolute bulk of claret sampled.2,55 This added claret accident through ytic testing places the best acutely ill patients at added accident of anemia and exposes them to the accessory risks of claret transfusion.
Approaches to abate iatrogenic claret accident in alarmingly ill patients accept included the use of small-volume (pediatric) claret accumulating tubes, the aishment or abridgement of alone claret back accession claret from in-dwelling catheters and the altering of test-ordering behaviour.58
In 2 studies, the use of pediatric claret accumulating tubes bargain the aggregate by 37Y and 47` respectively. In the aboriginal study, this was associated with a cogent abridgement in the admeasurement of patients astute claret transfusions.59 The accession of point-of-care testing could added abate the aggregate of samples drawn. In accession to bigger turnaround time and decreased cadre time, these bedside ytic tests about crave beneath than 0.5 mL. As the believability and affordability of these technologies improve, they may become a admired accession to claret attention strategies.
Current technology already exists to annihilate the accident of alone claret associated with claret sampling from in-dwelling catheters. Application a simple address with a 3-way stopcock, the sample is fatigued into a antiseptic syringe afore demography the ytic samples and again reinfused into the patient. This action can abate the beggarly bulk of claret absent through claret sampling by 50%.61 Agnate reductions in claret accident associated with ytic testing accept been accustomed with the use of automatic bankrupt arterial systems.62–64 In best of the studies,61,63,64 eliminating the accident of alone claret afore ytic testing was associated with college claret levels than levels in ascendancy patients, but none of the studies arise a abridgement in claret transfusions. Although this may accept been due to the baby cardinal of patients included in these studies, the bulk of claret adored with these techniques alone may not be ample abundant to abstain the charge for claret admixture in alarmingly ill patients.
Recombinant erythropoietin and added erythropoietin-receptor agonists are frequently acclimated in patients who accept abiding renal abortion or blight with cartilage bottom suppression, to access claret levels and abstain the charge for claret transfusions. Recombinant erythropoietin has additionally been acclimated in alarmingly ill patients for the aforementioned purpose.65 In the best afresh arise trial, Corwin and colleagues66 about assigned 1460 alarmingly ill patients to accept either 40 000 units of recombinant erythropoietin or placebo account for up to 3 weeks. The access in claret absorption at day 29 was greater in the erythropoietin accumulation than in the placebo accumulation (mean 16 [SD 20] g/L v. 13 [SD 18] g/L, p < 0.001). However, in adverse to allegation from antecedent trials, there was no aberration amid the 2 groups in the cardinal of patients accepting claret transfusions or in the cardinal of units transfused. This abortion to affect admixture requirements was attributed to the use of a added akin admixture strategy. Overall, there was no cogent aberration in bloodshed at day 29 amid the 2 groups (hazard arrangement 0.79, 95% CI 0.56–1.10). However, in a subgroup ysis, bloodshed was decidedly lower amid agony patients in the erythropoietin accumulation than amid agony patients accepting placebo. These allegation from the subgroup assay should be advised alone as antecedent generating, but because they are constant with those from a antecedent ample balloon of erythropoietin in alarmingly ill patients, added assay is warranted. Importantly, there was a cogent access in the bulk of abysmal attitude occlusion amid patients accepting erythropoietin (hazard arrangement 1.41, 95% CI 1.06–1.86).
In a ytical assay of 9 studies, including the best contempo abstraction by Corwin and colleagues,66 Zarychanski and coauthors65 evaluated the use of erythropoietin in alarmingly ill patients. They begin a cogent abridgement in the allowance of a accommodating accepting at atomic 1 red claret corpuscle admixture (odds arrangement 0.73, 95% CI 0.64– 0.84).65 There were no differences empiric in bloodshed or accident of abysmal attitude thrombosis. On the base of these findings, erythropoietin appears able in accretion claret levels in alarmingly ill patients and may aftereffect in a bargain abundance of claret transfusions, but this closing aftereffect is acceptable abrogated by the use of a akin admixture strategy. In addition, the use of erythropoietin does not abate mortality, and apropos abide apropos the abeyant added accident for thrombotic events.65
The use of lower claret thresholds as akin admixture triggers in alarmingly ill patients has been abundantly studied. Three ample randomized controlled trials advised the furnishings of akin admixture practices in adult,10 pediatric67 and neonatal accommodating populations.68 All 3 showed that akin admixture practices bargain admixture requirements afterwards accretion anguish or mortality. Because patients with astute bleeding were afar in these studies, the after-effects may not be generalizable to patients with astute claret loss.
In a randomized controlled balloon involving 838 euvolemic alarmingly ill adults whose claret absorption was beneath 90 g/L, Hébert and colleagues10 about assigned patients to be managed with either a akin admixture action (target claret absorption 70–90 g/L with a claret admixture beginning of 70 g/L) or a advanced admixture action (target claret absorption 100– 120 g/L with a claret admixture beginning of 100 g/L). Compared with patients in the advanced action arm, those in the akin action arm had a lower beggarly claret akin (85 [SD 7] v. 107 [SD 7] g/L, p < 0.01), accustomed beneath transfusions (2.6 [SD 4.1] v. 5.6 [SD 5.3] units per patient, p < 0.01) and had a lower bloodshed at 30 canicule (18.7% v. 23.3%, p = 0.11). The after-effects from this balloon accustomed that a akin admixture action would abate admixture requirements and would be as safe as, and possibly bigger than, a added advanced action for alarmingly ill adults.10 From subgroup yses of the after-effects of this study, the allegation arise to be constant beyond best accommodating groups, with the accessible barring of patients with cardiac disease,10 the alone subgroup that did not appearance bigger adaptation with the akin admixture strategy. The after-effects of a ample accessory empiric abstraction adapted that admixture at college claret thresholds may be benign in patients with astute myocardial infarction,69 but this was not accurate in a consecutive study, in which admixture was associated with added mortality.70 Added studies are adapted in this accommodating accumulation to actuate whether a lower claret admixture activate is safe.
In a afresh arise randomized controlled balloon involving 637 pediatric ICU patients, Lacroix and colleagues67 begin that a claret beginning of 70 g/L, compared with a added advanced beginning of 95 g/L, bargain admixture requirements by 44% (0.9 [SD 2.6] v. 1.7 [SD 2.2] units per patient, p < 0.001) afterwards differences in bloodshed or in new or accelerating multiple-organ dysfunction amid the 2 groups. Agnate after-effects were begin in the PINT (Premature Breed in Charge of Transfusion) study, which complex 451 abortive breed (< 31 weeks’ gestation) with acutely low bearing weights (< 1000 g).68 In this study, claret thresholds assorted according to age (days), adjustment of claret sampling (capillary v. axial catheter) and charge for respiratory support. The differences in the claret thresholds for the akin and advanced admixture strategies were amid 9 g/L and 20 g/L. Compared with the breed in the advanced action arm, those in the akin action arm had a lower beggarly claret akin and a trend against decreased cardinal of transfusions (4.9 [SD 4.2] v. 5.7 [SD 5.0] per infant, p = 0.07). Breed in the akin action arm were apparent to beneath red claret corpuscle donors (2.1 [SD 2.0] v. 2.6 [SD 2.7], p = 0.035). The 2 groups did not alter in the primary accumulated aftereffect of afterlife or adaptation with bronchopulmonary dysplasia, astringent retinopathy of prematurity or academician injury. Similarly, in a antecedent single-centre abstraction involving 100 preterm infants, Bel and colleagues71 begin no differences in survival, apparent autography arteriosis, retinopathy or bronchopulmonary dysplasia amid the abstraction groups, but they did acquisition an access in apneic and neurologic contest in the akin action group.
Taken together, these 3 multicentre studies accommodate able affirmation that a akin admixture action with a bargain claret beginning is safe10,67,68 and is possibly above to a advanced admixture action with a college claret threshold.72 In general, a claret beginning of 70 g/L appears to be adapted for alarmingly ill developed and pediatric patients, and antecedent notions of college thresholds should be alone in best accommodating groups.
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