Anemia, Bleeding, and Blood Transfusion in The Intensive Care Unit: Causes, Risks, Costs, and New Strategies

ANEMIA, BLEEDING, AND
BLOOD TRANSFUSION IN
THE INTENSIVE CARE UNIT:
CAUSES, RISKS, COSTS,
AND NEW STRATEGIES
1.
Describe the physiological effects,

treatments,and potential outcomes associated
with anemia in intensive care unit (ICU) patients.
2.
2. Identify the increased mortality and morbidity

associated with anemia in ICU patients and the
patients most at risk for these adverse
outcomes.
3.
3. Discuss strategies and tools for prevention of

anemia, early recognition of bleeding, and
avoidance of unnecessary blood transfusions in
Anemia
Defined by the World Health

Organization as a hemoglobin level
less than 13 g/dL in men and less
than 12 g/dL in women
The definition of anemia is varies

with the sex, age, and ethnicity of
patient
Anemia in intensive care

patient
Type
Cause
Nutritional deficiencies
Low iron level

Low folate level
Low vitamin B level
Erytropoetin deficiencies
Anemia of chronic disease

Renal insufficiency
Infection
Endocrine disorder
Hemolysis
Drug reactions
Toxins
Coagulation abnormalities
Trombocytopenia
Sepsis syndrome
Liver disease
Viral infection
Splenomegaly
Blood loss
Phlebotomy
Trauma
Surgery
Gastrointestinal bleeding
Nutritional Deficiency Anemia
Although iron deficiency may affect up to 40% of

critically ill patients
In a healthy person, a significant inverse relationship

exists between hemoglobin concentration and levels
of erythropoietin
When oxygen tension in the tissue is low because of

low hemoglobin concentration, erythropoietin levels
increase to stimulate increased RBC production
(erythropoiesis)
absolute iron deficiency (serum

ferritin <30 g/L
and/or transferrin saturation <20%)
treated with :
oral iron or with intravenous iron if
oral iron is not tolerated
Anemia of Chronic
Disease
Up to 90% of patients have anemia by day 3 in

the intensive care unit.
Anemia in the ICU may be nutritional, a result of

chronic disease, or hospital acquired.
Release of imflammatory cytokines reduced

renal erythropoetin production activation of
RBC destruction by macrophages (erytosis)
Absolute number of RBC and responsiveness

of the bone marrow decrease and RBC life
span is reduce
Hepcidin the regulator of iron metabolism
May elevated during inflammatory states, such

as occurs with rheumatologic disease,
inflammatory bowel disease, infection, critical
illness.
Effect Hepcidin elevated

1. reduced iron absorbtion by gut
2. increase iron sequestration by macrophag
Phlebotomy
Blood loss
Phlebotomy can result in a mean daily loss up to 70 ml

of blood/day
Strategy :
1.reduce
diagnostic blood sampling include switching to
small-volume or pediatric phlebotomy tubes,

2.replacing
routine multiple daily phlebotomies for blood
sampling only when clinical signs indicate the need,

3.and
implementing closed-loop systems that return
blood that is ordinarily wasted back to the patient.
Point-of-care and inline bedside

microanalysis of blood or noninvasive
hemoglobin monitoring with pulse cooximetry are other ways to monitor
hemoglobin for anemia while
minimizing blood loss
Drugs reaction
By 2 patways
1. hemolysis
ex : piperacillin, cefotetan,
ceftriaxone
2. suppressing normal renal release
of erytropoetin
ex : ACE-i, ARB, Calsium canal
blocker, teophilin, B- adrenergik
blocker
Bleeding Complication in ICU
Coagulation abnormalities
1.Trombocytopenia
2.Consumtion
clotting factor
3.DIC
.
Strategies
1.Preventing
hypothermia and acidosis (which can compromise
thrombin-generation kinetics and fibrinogen metabolism),

2.revising
blood component therapy so that RBCs, fresh frozen
plasma, and platelets are transfused in a 1:1:1 ratio
stress induced gastrointestinal bleeding
result of the stress and the intervention itself
Mechanical ventilation for more than 48 hours and

coagulopathy
Other risk factors include traumatic and

nontraumatic brain injury, renal failure, liver disease,
and gastric ulcers
Therapy :
H2-receptor antagonists
and proton pump inhibitors
Costs Associated With Anemia and

Bleeding
Both anemia and bleeding are associated with

significantly higher health care resource use and
costs than those for patients without these
conditions
Increased costs are most often due to longer stays

and costs associated with blood transfusion and
the attendant complications
Risks and Benefits of Blood

Transfusions
RBC transfusion is the most common and fastest

means of increasing hemoglobin level, with more
than one-third of all ICU patients receiving 1 or
more units of RBCs
Outcome measures were mortality, infections,

multiorgan dysfunction syndrome, and acute
respiratory distress syndrome.
Additionally, repeated transfusions of RBCs for

treatment of chronic conditions can lead to iron
overload and result in end-organ damage.
The risks of transfusion of blood components

therefore must be weighed against the risks of
anemia and the risks of other treatments for
anemia such as administration of ESA or iron.
TRALI
is the most easily identifiable cause of transfusionrelated morbidity and mortality in the United States
characterized by pulmonary edema, hypoxemia,

respiratory distress, and radiographic evidence of
new bilateral pulmonary infiltrates
Signs and symptoms may also include fever,

tachycardia, cyanosis, hypotension, and frothy
sputum
pathogenesis of TRALI is still being elucidated but is thought to

be a 2-hit process,
with the first hit being the presence of an inflammatory

condition in the patient that primes monocytes
In the presence of matched class II human leukocyte

antibodies in the transfused blood product (the second hit),
monocytes become activated and turn activate neutrophils to

release oxidases and other reactive substances that attack the
capillary membrane.
TACO
TACO occurs when a patient is unable

to compensate for rapid or highvolume infusions of blood products.
After TRALI, TACO was the most
common cause of transfusion-related
mortality reported to the Food and
Drug Administration in 2010
Signs and symptoms of TACO may include

lung
crackles and rales,
elevated
jugular venous pressure,
dyspnea,
orthopnea,
wheezing,
tightness
in the chest,
cough,
cyanosis,
tachypnea,
rapid
and
increase in blood pressure,
distended neck veins.
TRIM
The risk of disease transmission

through blood transfusions has
decreased significantly since the mid1980s because of the adoption of
pathogen-reduction technologies and
sophisticated hemovigilance systems.
Strategies to Prevent Unnecessary

Blood Transfusion
Practice guidelines for RBC transfusion in ICU patients, issued jointly by

the Eastern Association for the Surgery of Trauma and the Society of
Critical Care Medicine in 2009,
recognized the value of transfusion for hemodynamically unstable,

acute hemorrhagic shock states and for patients with low oxygen
delivery.
The guidelines cautioned against use of hemoglobin as a transfusion

trigger and recommended against transfusion to facilitate ventilator
weaning, recognizing that any transfusion has clear risks and
complications. Excepting active acute hemorrhage, RBCs should be
transfused 1 unit at a time followed by careful reassessment
Patient Safety Science and Technology

Summit (2013)
restrictive transfusion practices
documenting hemoglobin level before

each unit of blood is transfused,
and using noninvasive and

continuous hemoglobin monitoring.
The College of American Pathologists, the American Society of

Anesthesiologists, Society of Critical Care Medicine,and the
American Association of Blood Banks
published transfusion guidelines that promote restrictive transfusion

triggers for most patients. Although many transfusion guidelines start
with addressing surgical patients (eg, treating perioperative anemia
and coagulopathy and reducing surgical blood loss), some of the
proposed strategies are also relevant to critical care, for example,
withholding plasma transfusion in the absence of coagulopathy or high
risk for bleeding, use of single-donor platelets collected from male
donors, avoidance of pooled blood products,minimizing blood loss due
to phlebotomy, and the close monitoring of postoperative bleeding.
Conclusion
Anemia and internal bleeding are significant

patient care issues associated with increased use
of clinical resources, poorer outcomes, and
increased costs for patients
Blood transfusion, the most common treatment

for severe anemia of any kind, has been linked to
significant morbidity and mortality in critically ill
patients
Practice changes to avoid anemia and blood

transfusions include
1.
intravenous iron therapy,
2.
reducing diagnostic blood sampling,
3.
using small volume phlebotomy tubes,
4.
minimizing or replacing routine phlebotomy,
5.
and using point-of-care or inline microanalysis of

blood or noninvasive hemoglobin monitoring to
measure hemoglobin levels
Strategies to prevent unnecessary transfusions in

the ICU include restrictive transfusion practices,
documenting hemoglobin level before each unit of
blood is transfused, and using noninvasive and
continuous hemoglobin monitoring.

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ANEMIA, BLEEDING, AND

Describe the physiological effects,

2. Identify the increased mortality and morbidity

3. Discuss strategies and tools for prevention of

Defined by the World Health

The definition of anemia is varies

Anemia in intensive care

Low iron level

Anemia of chronic disease

Nutritional Deficiency Anemia

Although iron deficiency may affect up to 40% of

In a healthy person, a significant inverse relationship

When oxygen tension in the tissue is low because of

absolute iron deficiency (serum

Up to 90% of patients have anemia by day 3 in

Anemia in the ICU may be nutritional, a result of

Release of imflammatory cytokines reduced

Absolute number of RBC and responsiveness

Hepcidin the regulator of iron metabolism

May elevated during inflammatory states, such

Effect Hepcidin elevated

Phlebotomy can result in a mean daily loss up to 70 ml

diagnostic blood sampling include switching to

small-volume or pediatric phlebotomy tubes,

routine multiple daily phlebotomies for blood

sampling only when clinical signs indicate the need,

implementing closed-loop systems that return

blood that is ordinarily wasted back to the patient.

Point-of-care and inline bedside

Bleeding Complication in ICU

hypothermia and acidosis (which can compromise

thrombin-generation kinetics and fibrinogen metabolism),

blood component therapy so that RBCs, fresh frozen

plasma, and platelets are transfused in a 1:1:1 ratio

stress induced gastrointestinal bleeding

result of the stress and the intervention itself

Mechanical ventilation for more than 48 hours and

Other risk factors include traumatic and

Costs Associated With Anemia and

Both anemia and bleeding are associated with

Increased costs are most often due to longer stays

Risks and Benefits of Blood

RBC transfusion is the most common and fastest

Outcome measures were mortality, infections,

Additionally, repeated transfusions of RBCs for

The risks of transfusion of blood components

characterized by pulmonary edema, hypoxemia,

Signs and symptoms may also include fever,

pathogenesis of TRALI is still being elucidated but is thought to

with the first hit being the presence of an inflammatory

In the presence of matched class II human leukocyte

monocytes become activated and turn activate neutrophils to

TACO occurs when a patient is unable

Signs and symptoms of TACO may include

crackles and rales,

jugular venous pressure,

increase in blood pressure,

distended neck veins.