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      The effect of age and clinical circumstances on the outcome of red blood cell transfusion in critically ill patients

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          Abstract

          Introduction

          Whether red blood cell (RBC) transfusion is beneficial remains controversial. In both retrospective and prospective evaluations, transfusion has been associated with adverse, neutral, or protective effects. These varying results likely stem from a complex interplay between transfusion, patient characteristics, and clinical context. The objective was to test whether age, comorbidities, and clinical context modulate the effect of transfusion on survival.

          Methods

          By using the multiparameter intelligent monitoring in intensive care II database (v. 2.6), a retrospective analysis of 9,809 critically ill patients, we evaluated the effect of RBC transfusion on 30-day and 1-year mortality. Propensity score modeling and logistic regression adjusted for known confounding and assessed the independent effect of transfusion on 30-day and 1-year mortality. Sensitivity analysis was performed by using 3,164 transfused and non-transfused pairs, matched according the previously validated propensity model for RBC transfusion.

          Results

          RBC transfusion did not affect 30-day or 1-year mortality in the overall cohort. Patients younger than 55 years had increased odds of mortality (OR, 1.71; P < 0.01) with transfusion. Patients older than 75 years had lower odds of 30-day and 1-year mortality (OR, 0.70; P < 0.01) with transfusion. Transfusion was associated with worse outcome among patients undergoing cardiac surgery (OR, 2.1; P < 0.01). The propensity-matched population corroborated findings identified by regression adjustment.

          Conclusion

          A complex relation exists between RBC transfusion and clinical outcome. Our results show that transfusion is associated with improved outcomes in some cohorts and worse outcome in others, depending on comorbidities and patient characteristics. As such, future investigations and clinical decisions evaluating the value of transfusion should account for variations in baseline characteristics and clinical context.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s13054-014-0487-z) contains supplementary material, which is available to authorized users.

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          Most cited references23

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          Transfusion strategies for acute upper gastrointestinal bleeding.

          Càndid Villanueva, Alan Colomo, Alba Bosch … (2013)
          The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy. We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis. A total of 225 patients assigned to the restrictive strategy (51%), as compared with 61 assigned to the liberal strategy (14%), did not receive transfusions (P<0.001) [corrected].The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child-Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy. As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundació Investigació Sant Pau; ClinicalTrials.gov number, NCT00414713.).
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            The CRIT Study: Anemia and blood transfusion in the critically ill--current clinical practice in the United States.

            Howard Corwin, Andrew Gettinger, Ronald G Pearl … (2004)
            To quantify the incidence of anemia and red blood cell (RBC) transfusion practice in critically ill patients and to examine the relationship of anemia and RBC transfusion to clinical outcomes. Prospective, multiple center, observational cohort study of intensive care unit (ICU) patients in the United States. Enrollment period was from August 2000 to April 2001. Patients were enrolled within 48 hrs of ICU admission. Patient follow-up was for 30 days, hospital discharge, or death, whichever occurred first. A total of 284 ICUs (medical, surgical, or medical-surgical) in 213 hospitals participated in the study. A total of 4,892 patients were enrolled in the study. The mean hemoglobin level at baseline was 11.0 +/- 2.4 g/dL. Hemoglobin level decreased throughout the duration of the study. Overall, 44% of patients received one or more RBC units while in the ICU (mean, 4.6 +/- 4.9 units). The mean pretransfusion hemoglobin was 8.6 +/- 1.7 g/dL. The mean time to first ICU transfusion was 2.3 +/- 3.7 days. More RBC transfusions were given in study week 1; however, in subsequent weeks, subjects received one to two RBC units per week while in the ICU. The number of RBC transfusions a patient received during the study was independently associated with longer ICU and hospital lengths of stay and an increase in mortality. Patients who received transfusions also had more total complications and were more likely to experience a complication. Baseline hemoglobin was related to the number of RBC transfusions, but it was not an independent predictor of length of stay or mortality. However, a nadir hemoglobin level of <9 g/dL was a predictor of increased mortality and length of stay. Anemia is common in the critically ill and results in a large number of RBC transfusions. Transfusion practice has changed little during the past decade. The number of RBC units transfused is an independent predictor of worse clinical outcome.
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              Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.

              Ludhmila Hajjar, Jean-Louis Vincent, Filomena R B G Galas … (2010)
              Perioperative red blood cell transfusion is commonly used to address anemia, an independent risk factor for morbidity and mortality after cardiac operations; however, evidence regarding optimal blood transfusion practice in patients undergoing cardiac surgery is lacking. To define whether a restrictive perioperative red blood cell transfusion strategy is as safe as a liberal strategy in patients undergoing elective cardiac surgery. The Transfusion Requirements After Cardiac Surgery (TRACS) study, a prospective, randomized, controlled clinical noninferiority trial conducted between February 2009 and February 2010 in an intensive care unit at a university hospital cardiac surgery referral center in Brazil. Consecutive adult patients (n = 502) who underwent cardiac surgery with cardiopulmonary bypass were eligible; analysis was by intention-to-treat. Patients were randomly assigned to a liberal strategy of blood transfusion (to maintain a hematocrit ≥30%) or to a restrictive strategy (hematocrit ≥24%). Composite end point of 30-day all-cause mortality and severe morbidity (cardiogenic shock, acute respiratory distress syndrome, or acute renal injury requiring dialysis or hemofiltration) occurring during the hospital stay. The noninferiority margin was predefined at -8% (ie, 8% minimal clinically important increase in occurrence of the composite end point). Hemoglobin concentrations were maintained at a mean of 10.5 g/dL (95% confidence interval [CI], 10.4-10.6) in the liberal-strategy group and 9.1 g/dL (95% CI, 9.0-9.2) in the restrictive-strategy group (P < .001). A total of 198 of 253 patients (78%) in the liberal-strategy group and 118 of 249 (47%) in the restrictive-strategy group received a blood transfusion (P < .001). Occurrence of the primary end point was similar between groups (10% liberal vs 11% restrictive; between-group difference, 1% [95% CI, -6% to 4%]; P = .85). Independent of transfusion strategy, the number of transfused red blood cell units was an independent risk factor for clinical complications or death at 30 days (hazard ratio for each additional unit transfused, 1.2 [95% CI, 1.1-1.4]; P = .002). Among patients undergoing cardiac surgery, the use of a restrictive perioperative transfusion strategy compared with a more liberal strategy resulted in noninferior rates of the combined outcome of 30-day all-cause mortality and severe morbidity. clinicaltrials.gov Identifier: NCT01021631.
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                Author and article information

                Contributors
                Andre Dejam: adejam@bidmc.harvard.edu
                Brian E Malley: bmalley@alum.mit.edu
                Mengling Feng: mfeng@mit.edu
                Federico Cismondi: cismondi@mit.edu
                Shinhyuk Park: shin.park@emc.com
                Saira Samani: ssamani@mah.harvard.edu
                Zahra Aziz Samani: zahra.aziz.samani@gmail.com
                Duane S Pinto: dpinto@bidmc.harvard.edu
                Leo Anthony Celi: lceli@mit.edu
                Journal
                Journal ID (nlm-ta): Crit Care
                Title: Critical Care
                Publisher: BioMed Central (London )
                ISSN (Print): 1364-8535
                ISSN (Electronic): 1466-609X
                Publication date (Electronic): 30 August 2014
                Publication date PMC-release: 30 August 2014
                Publication date (Print): 2014
                Volume: 18
                Issue: 4
                Electronic Location Identifier: 487
                Affiliations
                [ ]Beth Israel Deaconess Medical Center, Boston, MA 02215 USA
                [ ]Harvard-MIT Division of Health Sciences & Technology, Cambridge, MA 02139 USA
                [ ]Oakland University William Beaumont School of Medicine, Rochester, MI 48309 USA
                [ ]Mount Auburn Hospital, Cambridge, MA 02138 USA
                [ ]Aga Khan University Medical College, Karachi, 74800 Pakistan
                [ ]Institute for Infocomm Research, Singapore, 138632 Singapore
                Article
                Publisher ID: 487
                DOI: 10.1186/s13054-014-0487-z
                PMC ID: 4174663
                PubMed ID: 25175389
                SO-VID: cff00f26-71f8-4fc2-b763-5d9de99fe048
                Copyright © © Dejam et al.; licensee BioMed Central Ltd. 2014
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 16 December 2013
                Date accepted : 1 August 2014
                Categories
                Subject: Research
                Custom metadata
                issue-copyright-statement © The Author(s) 2014

                ScienceOpen disciplines: Emergency medicine & Trauma
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma

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