Anemia and blood transfusion practices in the critically ill: A prospective cohort review

doi:10.1016/j.hrtlng.2009.07.002

Heart & Lung

Volume 39, Issue 3, May–June 2010, Pages 217-225

https://doi.org/10.1016/j.hrtlng.2009.07.002 Get rights and content

Background

Nearly 75% of critically ill patients develop anemia in the intensive care unit (ICU). Anemia can be treated with red blood cell (RBC) transfusions, although evidence suggests that lower hemoglobin levels are tolerated in the critically ill. Despite such recommendations, variation exists in clinical practice.

Methods

A prospective cohort was assessed for anemia and RBC transfusion practices in 100 consecutive adults admitted to our General Systems ICU.

Results

The prevalence of anemia in this cohort was 98%. Mean blood loss via phlebotomy was 25±10.3 mL per patient per day. The RBC transfusion rate for the ICU stay was 40%, increasing to 70% in patients whose ICU stay was >7 days. The mean pretransfusion level of hemoglobin was 7.35±0.47 mg/dL for the total cohort, and 8.2±0.65 mg/dL for those with a history of cardiovascular disease.

Conclusion

Anemia was common in this critically ill cohort, with hemoglobin levels continuing to drop with ICU stay. Pretransfusion hemoglobin levels were lower than reported by others, yet the RBC transfusion rate was comparable. There was no association between anemia and phlebotomy practices in our ICU.

Section snippets

Background

Two main factors contribute to anemia in the critically ill: insufficient production of red blood cells,1, 6, 17 and blood loss.4, 18 Underproduction anemia is commonly referred to as the anemia of chronic inflammatory disease. It is attributable to abnormal serum erythropoietin (EPO) concentrations, with a minimal reticulocyte response to endogenous EPO because of inhibition of the EPO gene by inflammatory mediators such as interleukin-1α, tumor necrosis factor-α, tumor growth factor-β, and

Purpose of Study

Our primary objective was to examine current RBC transfusion practices for critically ill adults admitted to our General Systems ICU. We addressed the specific questions: 1) What is the prevalence of anemia? 2) What is the rate of RBC transfusion? 3) What are the reported indications for RBC transfusions? 4) What are the factors associated with anemia and RBC transfusions?

Methods

A cohort was used to examine RBC transfusion practices in our ICU, and to assess the relationship between anemia and RBC transfusion practices in critically ill adults. Consecutive patients (n = 100) admitted to the ICU over a 2-month period were included. Excluded were patients: 1) less than 18 years of age, 2) who remained in the ICU for less than 24 hours, 3) with chronic endstage renal disease receiving exogenous erythropoietin, 4) of the Jehovah's Witnesses, who declined blood products,

Patient characteristics

The mean age of patients was 56.5 ± 14.8 (SD) years (range, 18 to 85 years), with 19% (n = 19) above 70 years of age. Men accounted for 57% of this cohort. The most frequent admitting diagnosis was of complications related to the respiratory system (41%). Of the comorbidities documented, a cardiac history accounted for 16% of patients. The mean admission APACHE II score was 15 ± 7, (SD) with a range of 3 to 36. The mean ICU length of stay was 7.7 ± 6.6 (SD) days, with a range of 1 to 28 days;

Discussion

The prevalence of anemia in this ICU cohort was similar to rates reported in other studies.2, 4 Furthermore, patients with lower admission hemoglobin levels became more anemic as their length of ICU stay progressed (r = −.66, P < .01). Patients with lower admission hemoglobin levels had a longer ICU stay (r = −.16, P < .01) and higher admission APACHE II scores (r = −.17, P < .01). Gender, age, admission diagnoses, comorbidities, and phlebotomy practices did not influence the rate of anemia.

Conclusion

Anemia occurred in 98% of critically ill patients, and hemoglobin levels continued to drop with ICU stay. Despite phlebotomy-related blood loss, there was no correlation between anemia and phlebotomy practices. However, this finding should not preclude strategies to reduce phlebotomy-related blood loss. These include using multichannel microchemistry instruments for point-of-care testing, pediatric tubes for blood collection, inline blood-conservation devices to eliminate discard volumes, the

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Issues in Critical CareAnemia and blood transfusion practices in the critically ill: A prospective cohort review

Background

Methods

Results

Conclusion

Section snippets

Background

Purpose of Study

Methods

Patient characteristics

Discussion

Conclusion

Mayo Clin Proc

Chest

Semin Hematol

Anemia management, and evidence-based critical care medicine

Crit Care Med

Anemia and blood transfusion in critically ill patients

JAMA

Red blood cell transfusion in critically ill patients: emerging risks and alternatives

Crit Care Nurse

Important role of nondiagnostic blood loss and blunted erythropoietic response in the anemia of medical intensive care patients

Crit Care Med

Evaluating laboratory usage in the intensive care unit: patient and institutional characteristics that influence frequency of blood sampling

Crit Care Med

Conserving blood in the intensive care unit

Crit Care Nurse

Is blood transfusion good for the heart?

Crit Care Med

Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases?

Crit Care Med

A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care

N Engl J Med

Expert working group: guidelines for red blood cell and plasma transfusion for adults and children

Can Med Assoc J

Canadian survey of transfusion practices in critically ill patients

Crit Care Med

A survey of physicians' attitudes to transfusion practice in critically ill patients in the UK

Anaesthesia

Efficacy of recombinant human erythropoietin in critically ill patients: a randomized controlled trial

JAMA

Should patients in intensive care units receive erythropoietin [editorial]?

JAMA

Understanding and managing anemia in critically ill patients

Crit Care Nurse

Issues in Critical Care
Anemia and blood transfusion practices in the critically ill: A prospective cohort review