Critical care clinics
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Critical care clinics · Apr 2004
ReviewEfficacy of red blood cell transfusion in the critically ill.
This article has evaluated the published data regarding the efficacy of RBC transfusions in the critically ill. Taken together, these studies generally support conservative RBC transfusion strategies in critical care to reduce the risk of transfusion-related adverse effects. The TRICC trial has established the safety ofa restrictive transfusion strategy, suggesting that physicians could minimize exposure to allogeneic RBCs by lowering their transfusion threshold. ⋯ RBC transfusion is not associated with improvements in clinical outcome in the critically ill and may result in worse outcomes in some patients. 3. Specific factors that identify patients who will improve from RBC transfusion are difficult to identify. 4. Lack of efficacy of RBC transfusion likely is related to storage time, increased endothelial adherence of stored RBCs, nitric oxide binding by free hemoglobin in stored blood, donor leukocytes, host inflammatory response, and reduced red cell deformability.
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The role of transfusion in surgery and trauma continues to evolve with our greater understanding of the true indications for and effects of transfusion. The potential adverse immune consequences and end-organ effects of blood transfusion must be weighed against the need for replacement of blood volume and oxygen-carrying capacity. The techniques to conserve blood and avoid transfusion play an important role in caring for the bleeding surgical patient. The future holds great promise for the possibility of redefining the art of blood transfusion and perhaps one day replacing it entirely.
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Critical care clinics · Apr 2004
ReviewClinical consequences of anemia and red cell transfusion in the critically ill.
Despite the frequent use of red cell transfusions, only one large randomized trial has examined red cell administration perioperative and in the critical care setting. However, the TRICC Trial does not provide sufficient evidence to determine optimal transfusion practice in postoperative care, in critically ill children, or in patients with a myocardial infarction or acute coronary syndromes. In addition, most transfusion practice guidelines published before the completion of the TRICC Trial are now dated and need to have expert opinion informed by solid evidence in diverse clinical settings. ⋯ For example, two transfusion studies will be evaluating transfusion triggers, including one in premature infants and the other in critically ill children. At this juncture, high-quality clinical evidence is not yet available for many decisions related to red cell transfusions. We anticipate that risks and benefits of red cells and alternatives will be elucidated in the coming years.
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The anemia of critical illness is a distinct clinical entity with characteristics similar to that of chronic disease anemia. Several solutions to the processes of anemia, such as blunted erythropoietin production and erythropoietin response and abnormalities in iron metabolism have been developed. The transfusion of RBCs provides immediate correction of low hemoglobin levels, which may be of value in patients with life-threatening anemia. ⋯ Accumulating evidence suggests that anemia in critically ill patients is common and correlated with poor outcomes. The management of anemia can improve outcomes; however, the optimal management of anemia is not performed universally. New approaches, continued research, and an understanding of anemia may result in more consistent and improved outcomes for critically ill patients.
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Critical care specialists should be familiar with the initial management of injured patients. Dividing the evaluation and treatment of the patient into the primary, secondary, and tertiary surveys ensures that the multiply injured patient will be managed expeditiously. ⋯ The secondary survey identifies the remaining major injuries and sets priorities for definitive management. The tertiary survey identifies occult injuries before they become missed injuries.