Abstract
BackgroundOver the last decade, multiple large randomized controlled trials have studied alternative transfusion strategies in critically ill patients, demonstrating the safety of restrictive transfusion strategies. Due to the lack of international guidelines specific for the intensive care unit (ICU), we hypothesized that a large heterogeneity in transfusion practice in this patient population exists. The aims of this study were to describe the current transfusion practices and identify the knowledge gaps.MethodsAn online, anonymous, worldwide survey among ICU physicians was performed evaluating red blood cell, platelet and plasma transfusion practices. Furthermore, the presence of a hospital- or ICU-specific transfusion guideline was asked. Only completed surveys were analysed.ResultsNine hundred forty-seven respondents filled in the survey of which 725 could be analysed. Hospital transfusion protocol available in their ICU was reported by 53% of the respondents. Only 29% of respondents used an ICU-specific transfusion guideline. The reported haemoglobin (Hb) threshold for the general ICU population was 7 g/dL (7–7). The highest reported variation in transfusion threshold was in patients on extracorporeal membrane oxygenation or with brain injury (8 g/dL (7.0–9.0)). Platelets were transfused at a median count of 20 × 109 cells/L IQR (10–25) in asymptomatic patients, but at a higher count prior to invasive procedures (p < 0.001). In patients with an international normalized ratio (INR) > 3, 43% and 57% of the respondents would consider plasma transfusion without any upcoming procedures or prior to a planned invasive procedure, respectively. Finally, doctors with base specialty in anaesthesiology transfused critically ill patients more liberally compared to internal medicine physicians.ConclusionRed blood cell transfusion practice for the general ICU population is restrictive, while for different subpopulations, higher Hb thresholds are applied. Furthermore, practice in plasma and platelet transfusion is heterogeneous, and local transfusion guidelines are lacking in the majority of the ICUs.
Highlights
As critically ill patients frequently develop anaemia, thrombocytopenia or coagulopathy [1,2,3], transfusion of blood components is a frequent intervention in the intensive care unit (ICU)
Higher Hb transfusion thresholds were reported in patients with acute coronary syndrome (ACS), septic shock, acute brain injury, those receiving extracorporeal membrane oxygenation (ECMO), with acute respiratory distress syndrome (ARDS), age over 65 years and with prolonged weaning (p < 0.001 for all patient populations, see Fig. 1)
The main findings of this study are (1) a high Hb threshold variation between ICU subpopulations; (2) the platelet transfusion threshold prior to invasive procedures differs greatly between and within the procedures; (3) plasma is considered by a large number of physicians in non-bleeding patients even in the absence of an invasive procedure; (4) base specialty of physicians is associated with variation in transfusion practices; and (5) worldwide, institutions lack local ICU-specific transfusion guidelines
Summary
As critically ill patients frequently develop anaemia, thrombocytopenia or coagulopathy [1,2,3], transfusion of blood components is a frequent intervention in the intensive care unit (ICU). From 2002 to 2012, the incidence of RCC transfusion in critically ill patients has dropped from 37 [9] to 26% [1] during ICU admission This reduction coincided with the publication of multiple large international randomized controlled trials (RCTs) showing the safety of a restrictive transfusion strategy [8, 10, 11]. Thrombocytopenic patients are transfused at higher platelet counts prior to CVC placement (p = 0.002) and prior to tracheotomy (p = 0.007, Additional file 1: Table S7) when treated by a physician with the base specialty in anaesthesiology. Physicians with a base specialty in anaesthesiology transfuse plasma prophylactically more frequently (Additional file 1: Figure S3)
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