Wednesday, November 17, 2010

ICU Rounds Report - November 17th 2010

The TRACS trial is here! More than 10 years after the publication of the TRICC trial, we're finally getting some more proper, randomized data about blood transfusion in critical care. JAMA last month published the long awaited results of a single center RCT in Brazil involving over 500 patients randomized to liberal (transfuse to >30% hematocrit) vs conservative (>24%) transfusion strategy in patients undergoing routine CABG and/or valve surgery requiring bypass. The intervention significantly reduced PRBCs transfusion (78% and 47% receiving, respectively). Morbidity and mortality was the same in both groups.

Unlike our practice at UVa, all the blood given was young (median age 3 days) and not leukodepleted. Older blood, as is frequently transfused here, has been associated with worse outcome while leukodepletion (standard here) appears to improve outcomes.

In the same issue of JAMA, researches using the STS database found transfusion practices among 700 US hospitals for 100,000 patients undergoing CBP showed wide variance in the rates of product transfusion (RBC (7.8%-92.8%), plasma (0%-97.5%), and platelet (0.4%-90.4%)). These differences persisted after adjusting for hospital and patients factors. Like the TRACS trial, there was no apparent difference in mortality or morbidity.

Taken together, these results point to a continued epidemic of costly, unnecessary and potentially dangerous over-utilization of blood products. Previously, this was, in part, due to a lack of RCT-based evidence in this patient group. Now, this is no longer true. We can say with assurance that transfusion of even a single PRBC unit has real risks that must be carefully balanced against benefits which, while real, are increasingly harder to find.
Hajjar LA, Vincent J-L, Galas FRBG; et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010;304(14):1559-1567
Bennett-Guerrero E, Zhao Y, O'Brien SM; et al. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA. 2010;304(14):1568-1575.

A FAST HUG Every 5.7 weeks on rounds, someone mentions the mnemonic developed by critical care god Jean Louis Vincent, FAST HUGS. Here it is written down so you have a nice reference to check in case you fancy yet forget it. You can add (although Jean Louis doesn't think you should) a BID, to emphasize this should be done at least twice a day.

F Feeding
A Analgesia
S Sedation
T Thromboembolic prophylaxis

H Head of bed elevation
U Ulcer (stress) prophylaxis
G Glycemic control
S Spontaneous breathing trial

B Bowel regimen
I Indwelling catheter removal
D De-escalation of antibiotics
Vincent JL: Give your patient a FAST HUG (at least) once a day. Crit Care Med 2005; 33:1225–1229

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