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2012, Number 4

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Rev Hematol Mex 2012; 13 (4)

Treatment alternatives to blood transfusion in critically ill individuals

Gallardo-García MB, Gallardo-Pedrajas F, Cabra-Bellido MJ, Sánchez-Gallegos P, Bondia-Navarro JA

Language: Spanish
References: 47
Page: 153-164
PDF size: 262.60 Kb.


ABSTRACT

Background: Anemias are blood disorders most often seen in critically ill patients admitted to intensive care units. The most frequent causes are the type iron deficiency and anemia of chronic disease. Parenteral iron therapy, with / without recombinant human erythropoietin as a therapeutic alternative to allogeneic blood transfusions can be beneficial in these patients, avoiding the need and complications of blood transfusion.
Objective: To prevent allogeneic blood transfusions (TSA) and post-transfusion complications in critically ills patients admitted to the ICU and to promote other alternative therapies.
Patients and methods: We studied 167 patients admitted to the Intensive Care Unit (ICU), 150 of them underwent surgical treatment of his basic pathologic process (cancer) and 17 septic patients, 11 of them were operated urgently due to infections severe (peritonitis, mediastinitis, cellulitis ...) and 6 patients with medical septic etiology (bacterial meningitis caused by Gram. (+), Gram. (-), fungi). All patients were being admitted to the unit, we made complete blood count (formula and cell count), serum iron, ferritin, transferrin, transferrin saturation index (TSI) and red cell index and performed classical score Acute Physiology and Chronic Health Evaluation II (APACHE II). The sample was split into two groups: surgical patients (n = 150) and septic patients (n = 17).
Results. Anemia (hemoglobin ‹ 12.5 g/dL) was found in 60.4% of all patients, 89 surgical patients (89/150, 59.3%) and 12 septic patients (12/17, 70.5%).The severity of anemia was 18 patients with severe anemia (hemoglobin < 10 g/dL and 83 patients with moderate anemia (hemoglobin between 10 and 12.4 g/ dL). In the group of surgical patients, along with laboratory findings of anemia, was observed also low iron levels (serum iron), transferrin, transferrin saturation (SAT %) and low, normal or high serum ferritin. In septic patients, referred with anemia, we found low levels of iron, transferrin, SAT%, and very high serum ferritin levels in relation to the surgical group. (p ‹ 0.0001). Four patients received transfusion of packed red blood cells, with mean hemoglobin pre-transfusion of 8.7 g/dL, without any post-transfusion complications. Ferroterapic treatment was performed (200 mg of iron in continuous perfusion for 90 minutes) in 9 anemic surgical patients (9/89: 10.1%) with very low levels of ferritin (mean ferritin plasma 16 ± 7 ng / mL) and low SAT% (‹ 20%) noting improvement in hemoglobin the order of 0.6 to 0.7 g/dL, without any complications to treatment. No ferroterapic treatment was performed in anemic septic patients, with low SAT% (‹ 20%) with mean ferritin levels very high (476 ± 351 ng / mL). Other findings was the low iron levels in surgical patients (66.3%) and septic (75%), the presence of functional iron deficiency (FID) in 19% and 66.7 % of surgical and septic patients, respectively, and the presence of mixed type anemia (F.A + A.E.C) in anemic patients (26.9%) and septic patients groups (8.3%). The APACHE II, the mean age and stay of septic patients was significantly higher (p ‹ 0.0001) than the group of surgical patients. Four patients died, two in the surgical group and two in the septic group, who’s APACHE II and mean hospital stay was greater than that of the survivors.
Conclusions: Anemia’s are a very common problem in critically ills patients admitted to UCI´s, basically iron deficiency anemia (A.F) or anemia of critically ill patients (A.P.C), hematologically similar to the anemia of chronic disease (A.E.C). As a therapeutic alternative to allogeneic blood transfusions (TSA), ferroterapic treatment, (with / without recombinant human erythropoietin) can prevent or reduce the transfusion requirements in anemic patients admitted to the ICU, avoiding the needs and complications of red blood cells transfusion, considering this treatment a valid and correct therapeutic option.



REFERENCES

  1. DeAngelo A, Bell D, Quinn M, Ebert Long D, Ouellette D. Erythropoietin response in critically ill mechanically ventilated patients: A prospective observational study. Crit Care 2005;9(3):R172-R176.

  2. Raghavan M, Marik P. Anaemia, allogenic blood transfusion and immunomodulation in the critically ill. Chest 2005;127:295-307.

  3. Ouellete D. The impact of anaemia in patients with respiratory failure. Chest 2005;128:576-582.

  4. Piagnerelli M, Vincent JL. Role of iron in anaemia critically ill patients: it’s time to investigate. Critical Care 2004;8:306-307.

  5. Pieracci F, Barie P. Diagnosis and management of iron-related anaemia’s in critical illness. Crit Care Med 2006;34(7):1-8.

  6. Bellamy MC, Gedney JA. Unrecognized iron deficiency in critical illness. Lancet 1998;352:1903.

  7. Patteril MV, Davey-Quinn AP, Gedney JA, Murdoch SD, Bellamy M. Functional iron deficiency, infection and systemic inflammatory response syndrome in critical illness. Anaesth Intensive Care 2001;29(5):473-478.

  8. Darveau M, Denault A, Blais N, Notebaert E. Bench-to-bedside review: Iron metabolism in critically patients. Critical Care 2004;8(5):356-362.

  9. Lapointe M. Iron supplementation in the intensive care unit: when, how much, and by what route? Critical Care 2004;8(2):S37-S41.

  10. Weiss G, Goodnough L. Anaemia of chronic disease. N Engl J Med 2005;352(10):1011-1023.

  11. Van Iperen CH, Gaillard C, Kraaijenhagen R, Braam B, Marx J, Van de Wiel A. Response of erythropoiesis and iron metabolism to recombinant human erythropoietin in intensive care unit patients. Crit Care Med 2000;28(8): 2773 -2778.

  12. Eckardt KU. Anaemia in critical illness. Wien Klin Wochenschr 2001;15:84-89.

  13. Von Ahsen, Muller N, Serhe C, Frei S, et al. Important role of nondiagnostic blood loss and blunted erythropoietic response in the anaemia of medical intensive care patients. Crit Care Med 2001;29(9):S141-S150.

  14. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, et al. Anaemia and blood transfusion in critically ill patients. JAMA 2002;288(12):1499-1507.

  15. Corwin H, Gettinger A, Pearl R, Fink M, Levy M, et al. Efficacy of recombinant human erythropoietin in critically ill patients. JAMA 2002;288(22):2827-2835.

  16. Ba VN, Bota DP, Melot C, Mscibiosta V, Vincent JL. Time course oh haemoglobin concentrations in nonbleeding intensive care unit patients. Crit Care Med 2003;31(2):406-410.

  17. Scharte M, Fink M. Red blood cell physiology in critical illness. Crit Care Med 2003;31(12):S651-S657.

  18. Singh J, Wax R. Anaemia in the critically ill patient: An examination of the rationale for recombinant erythropoietin. Critical Care 2004;5:1.

  19. Walsh T, Lee R, MacIver C, Garrioch M, Mackirdy, Binning A, et al. Anaemia during and at discharge from intensive care: the impact of restrictive blood transfusion practice. Intensive Care Med 2006;32:100-109.

  20. Corwin H, Krantz S. Anaemia of the critically ill. “Acute” anaemia of chronic disease. Crit Care Med 2001;29(9):S199-200.

  21. Rana R, Afessa B, Keegan M, Keegan M, Whalen F, Nuttal G, et al. Evidence-based red cell transfusion in the critically ill: Quality improvement using computerized physician order entry. Crit Care Med 2006;34(7):1892-1897.

  22. Shorr A, Jackson W. Transfusion practice in the ICU. Chest 2005;127:702-705.

  23. Rudis M, Jacobi J, Hassan E, Dasta J. Managing anaemia in the critically ill patient. Pharmacotherapy 2004;24(2):229-247.

  24. Brock JH. Benefits and dangers of iron during infection. Clinical Nutrition&Metabolic Car 1999;2(6):507-510.

  25. Brugnara C. Iron deficiency and erythropoiesis: new diagnostic approaches. Clinical Chemistry 2003;49(10):1573-1578.

  26. Shander A. Anaemia in the critically ill. Crit Care Clin 2004;20(2):159-178.

  27. Means R. Hepcidin and cytokines in anaemia. Haematology 2004;9:357-362.

  28. Josephson D. Blood Transfusions may increase the risk of death in critically ill patients. BMJ 2002;325:735.

  29. Copplestone A. Changes in blood supplies, regulations, and transfusion practice. BMJ 2005;330:268-269.

  30. Gallardo García M, Navarro Piñero A, Buendía Pérez E, Oliva Muñoz H, De la Fuente Perucho A, Muñoz López A. Valoración diagnóstica y terapéutica de los traumatismos hepáticos. Rev Esp Enf Digest 1991;79:105-111.

  31. Hebert P, Wells G, Blajchman M, Marshall J, Martin C, Pagharello G, et al. A multicenter, randomized, controlled clinical trial of transfusions requirements in critical care. N Engl J Med 1999;340(6):409-417.

  32. Shorr A, Jackson W, Kelly K, Min Fu, Marin H. Transfusion practice and blood stream infections in critically ill patients. Chest 2005;127:1722-1728.

  33. Auerbach M, Ballard H, Tront R, Mac Ilwain M, Ackerman A, Bahrain H, et al. Intravenous iron optimizes the response to recombinant human erythropoietin in cancer patients with chemotherapy-related anaemia: A multicenter, open-label, randomized trial. J Clin Oncol 2004;22(7):1301-1307.

  34. Andrews N. Disorders of iron metabolism. N Engl J Med 1999;341(26):1986-1995.

  35. Spahn D, Casutt M. Eliminating blood transfusions. Anaesthesiology 2000;93 (1):242-255.

  36. Vamvakas E, Blajchman M. Deleterious clinical effects of transfusion-associated immunomodulation: fact or fiction? Blood 2001;97:1180-1195.

  37. Gallardo F, Gallardo MB, Ramírez D, Atencia J, Fernández S, Lebron M. Alteraciones inmunológicas en pacientes anémicos. Inmunologia 2008;27:55-62.

  38. Spivak JL. Iron and the anaemia of chronic disease. Oncology 2002;16(9-10): 25-33.

  39. Fleming R, Bacon B. Orchestration of iron homeostasis. N Engl J Med 2005; 352(17):1741-1744.

  40. Fitzsimons EJ, Brock JH. The anaemia of chronic disease. BMJ 2001;322:811-812.

  41. Andrews N. Anaemia of inflammation: the cytokine-hepcidin link. J Clin Invest 2004;113:1251-1253.

  42. Gallardo F, Gallardo MB, Cabra MJ, Ramírez G, Barón JJ, Prieto MA. Alteraciones del metabolismo del hierro y anemia en pacientes críticos. ANEMIA 2009;2(3):97-102.

  43. Gallardo F, Gallardo MB, Cabra MJ, Curiel E, Arias MD, Muñoz A, y col. Nutrición y anemias en pacientes graves. Nutr Hosp 2010;25(1):99-106.

  44. John M, Hoerning S, Doehner W, Okonko D, UIT C, Anker S. Anaemia and inflammation in COPD. Chest 2005;127:825-829.

  45. Gabay C, Kushner I. Acute phase proteins and other systemic response to inflammation. N Engl J Med 1999;340(6):448-454.

  46. Muñoz M, Leal-Noval SR, García-Erce, Naveira E. Prevalencia y tratamiento de la anemia en el paciente crítico. Med Intensiva 2007;31(7):388-398.

  47. Cortés-Berdonces M, García Martín A, León Sanz M. Anemia del paciente crítico y quirúrgico; tratamiento con hierro intravenoso. Nutr Hosp 2012;27(1):7-12.




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