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Blood Transfusion Thresholds in Medical Patients with
Coronary Artery Disease Internal Medicine Resident Grand Rounds December 4,
2001 Alexander Hadley, MD
,
Case Presentation Mr. C is a 56-year-old male who presented to the ED at WFUBMC with several days of severe sub-sternal chest pain.
His pain and associated symptoms were classic for unstable angina. He had a past history of
HTN, tobacco abuse and a family h/o
CAD. ,Case Presentation
ROS:
Three months of gross hematuria.
Slowly progressive weakness and short of breath. Several episodes of exertional angina over the previous weeks. ,Case Presentation
Physical Exam
BP 126/61
Pulse 77
R 16 T 98.8
Orthostatic vitals: negative Oral:
Mucosa moist Gen: pallor, ill appearing
Cardiac: Reg, no murmurs
Lungs:
CTA Ext.: no edema ,Case Presentation
Labs
Hemoglobin 5.6 g/dl
Cardiac enzymes normal.
EKG Anterior Q-waves.
No acute ischemic changes. ,Case Presentation Mr. C
Ruled out for an acute MI.
He received four units of packed red blood cells and his hemoglobin became stable at 8.9 g/dl. He had no more chest pain but did have persistent hematuria. ,Case Presentation A
DSE was performed which showed a small area of inducible ischemia in his anterior / lateral wall.
Ultrasound of the abdomen showed normal kidneys but a mass in the bladder worrisome for transitional cell carcinoma. ,Case Presentation It was suggested that we should transfuse him to keep his hemoglobin above 10 g/dl because of his known CAD.
Is that right? ,Clinical
Questions Is there any evidence to support using specific hemoglobin or hematocrit targets as criteria to transfuse asymptomatic patients with anemia?
Should we use different transfusion thresholds for people with coronary artery disease or acute coronary syndromes? ,
Introduction In
1997 11.4 million units of red blood cells were transfused in the
United States.
This number is slightly down from a decade ago when
12.2 million units were transfused. ,Introduction Several investigators have reviewed the transfusions practices at hospitals and concluded that many transfusions are done without proper indications.
They estimate 25% of transfusions were inappropriate. ,Introduction Conventional
Wisdom has taught that:
hemoglobin levels should be kept above some minimum value such as 7 or 8 g/dl
patients with coronary artery disease need higher values to maintain myocardial oxygen supply (such as 10 g/dl or hematocrit of 30%). This has been called the 10 / 30
Rule. ,Why keep heart patients at higher Hg. / Hct. Values? Patients with anemia have decreased oxygen carrying capacity.
The body compensates in two ways: Increased cardiac output.
Increased release of oxygen from hemoglobin. ,Why keep heart patients at higher Hg. / Hct. Values? ,Why keep heart patients at higher Hg. / Hct. Values? In anemia,
2,3-DPG shifts the curve to the right.
,Why keep heart patients at higher Hg. / Hct. Values?
Problem 1: The increased cardiac output in anemia leads to increased oxygen demand.
Problem 2: At baseline the myocardium extracts a very high percentage of oxygen. Therefore the heart must increase blood flow to increase oxygen supply. Problem 3: Coronary stenosis may limit blood flow. ,Why keep heart patients at higher Hg. / Hct. Values? Problem 1 + Problem 2 + Problem 3 = Ischemia. (
Maybe)
,Why limit transfusions?
Limited supply
Blood donation has dropped from 14 million units in
1986 to 12 million units in 1997.
The increasing proportion of elderly in the US. Is projected to lead to serious shortages.
Costs $155 per unit on blood
12 million transfusions per year $1.86 billion per year ,Risks of
Transfusion Infectious
Viral
CMV
Hepatitis A, B, and C
HIV HTLV Types I and II Bacterial
Contamination ,Risks of Transfusion Immunologic Reactions
Non-hemolytic reaction (fever, chills, urticaria)
Acute hemolysis
Delayed hemolysis
Transfusion related lung injury (
ARDS) Transfusion
Related Immunomodulation (
TRIM) ,“
Current”
Guidelines Most
- published: 21 Jun 2016
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