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Optimizing Blood Transfusion Practices in Traumatic Brain Injury and Subarachnoid Hemorrhage

  • Neuroanesthesia (M Smith, Section Editor)
  • Published:
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Abstract

Purpose of Review

Anemia is a frequent complication in patients suffering from traumatic brain injury (TBI) or subarachnoid hemorrhage (SAH) and has been associated with poor outcome. Interestingly, red blood cell transfusion (RBCT), which is the most common therapeutic intervention in anemic brain-injured patients, was also reported as an independent predictor of mortality in several studies. The aim of this review was to summarize the current literature on the use of RBCT in brain-injured patients and to provide some insights on how to optimize their use in this setting.

Recent Findings

In moderately anemic TBI/SAH patients, RBCT could increase hemoglobin (Hb) levels while the effects on cerebral oxygenation were modest and inconsistent, raising serious concerns about the effectiveness and the risk/benefit ratio of this intervention. The optimal Hb level to trigger RBCT in TBI and SAH patients has not been defined yet. Thus, in those patients who are awake and without any further neurological deterioration, RBCT should be initiated as in other critically ill patients, e.g., for Hb levels below 7 g/dL. In case of poor-grade clinical status, the use of indicators of inadequate systemic oxygen delivery (e.g., low venous hemoglobin saturation or high lactate levels) or of brain hypoxia (e.g., low regional hemoglobin saturation or brain oxygen pressure) may be helpful to guide RBCT. Nevertheless, there is no evidence to provide strong recommendations based on this strategy to initiate transfusions in this patients’ population.

Summary

Few good quality data exist about the effects of RBCT on the outcome of TBI and SAH patients. While randomized trials will be initiated, the optimal Hb level to trigger RBCT in these patients may be related to the clinical status or on systemic and/or cerebral monitoring values.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Phelan HA, Richter AA, Scott WW, Pruitt JH, Madden CJ, Rickert KL, Wolf SE. Does isolated traumatic subarachnoid hemorrhage merit a lower intensity level of observation than other traumatic brain injury? J Neurotrauma. 2014;31(20):1733–6.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Drazin D, Rosner J, Nuño M, Alexander MJ, Schievink WI, Palestrant D, Lyden PD, Miller C. Type of admission is associated with outcome of spontaneous subarachnoid hemorrhage. Int J Stroke. 2015;10(4):529–33.

    Article  PubMed  Google Scholar 

  3. Alonso A, Ebert AD, Kern R, Rapp S, Hennerici MG, Fatar M. Outcome predictors of acute stroke patients in need of intensive care treatment. Cerebrovasc Dis. 2015;40(1–2):10–7.

    Article  PubMed  Google Scholar 

  4. Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, Jane JA, Marmarou A, Foulkes MA. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34(2):216–22.

    Article  CAS  PubMed  Google Scholar 

  5. Hare GM, Tsui AK, McLaren AT, Ragoonanan TE, Yu J, Mazer CD. Anemia and cerebral outcomes: many questions, fewer answers. Anesth Analg. 2008;107(4):1356–70.

    Article  PubMed  Google Scholar 

  6. Benson AB, Moss M, Silliman CC. Transfusion-related acute lung injury (TRALI): a clinical review with emphasis on the critically ill. Br J Haematol. 2009;147(4):431–43.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, Meier-Hellmann A, Nollet G, Peres-Bota D. Anemia and blood transfusion in critically ill patients. JAMA. 2002;288(12):1499–507.

    Article  PubMed  Google Scholar 

  8. Walsh TS, Saleh EE. Anaemia during critical illness. Br J Anaesth. 2006;97(3):278–91.

    Article  CAS  PubMed  Google Scholar 

  9. Raghavan M, Marik PE. Anemia, allogenic blood transfusion, and immunomodulation in the critically ill. Chest. 2005;127(1):295–307.

    Article  PubMed  Google Scholar 

  10. Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med. 2008;36(9):2667–74.

    Article  PubMed  Google Scholar 

  11. Vamvakas EC, Blajchman MA. Transfusion-related immunomodulation (TRIM): an update. Blood Rev. 2007;21(6):327–48.

    Article  PubMed  Google Scholar 

  12. Li G, Rachmale S, Kojicic M, Shahjehan K, Malinchoc M, Kor DJ, Gajic O. Incidence and transfusion risk factors for transfusion-associated circulatory overload among medical intensive care unit patients. Transfusion. 2011;51(2):338–43.

    Article  PubMed  Google Scholar 

  13. Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion requirements in critical care investigators, Canadian critical care trials group. N Engl J Med. 1999;340(6):409–17.

    Article  CAS  PubMed  Google Scholar 

  14. Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, Nemo G, Dragert K, Beaupre L, Hildebrand K, Macaulay W, Lewis C, Cook DR, Dobbin G, Zakriya KJ, Apple FS, Horney RA, Magaziner J. FOCUS investigators. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365(26):2453–62.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Holst LB, Haase N, Wetterslev J, Wernerman J, Guttormsen AB, Karlsson S, Johansson PI, Aneman A, Vang ML, Winding R, Nebrich L, Nibro HL, Rasmussen BS, Lauridsen JR, Nielsen JS, Oldner A, Pettilä V, Cronhjort MB, Andersen LH, Pedersen UG, Reiter N, Wiis J, White JO, Russell L, Thornberg KJ, Hjortrup PB, Müller RG, Møller MH, Steensen M, Tjäder I, Kilsand K, Odeberg-Wernerman S, Sjøbø B, Bundgaard H, Thyø MA, Lodahl D, Mærkedahl R, Albeck C, Illum D, Kruse M, Winkel P, Perner A. TRISS trial group; Scandinavian critical care trials group. lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med. 2014;371(15):1381–91.

    Article  CAS  PubMed  Google Scholar 

  16. Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(1):11–21.

    Article  CAS  PubMed  Google Scholar 

  17. Lacroix J, Hébert PC, Hutchison JS, Hume HA, Tucci M, Ducruet T, Gauvin F, Collet JP, Toledano BJ, Robillard P, Joffe A, Biarent D, Meert K, Peters MJ. TRIPICU investigators; Canadian critical care trials group; pediatric acute lung injury and sepsis investigators network. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med. 2007;356(16):1609–19.

    Article  CAS  PubMed  Google Scholar 

  18. Murphy GJ, Pike K, Rogers CA, Wordsworth S, Stokes EA, Angelini GD, Reeves BC. TITRe2 investigators. Liberal or restrictive transfusion after cardiac surgery. N Engl J Med. 2015;372(11):997–1008.

    Article  CAS  PubMed  Google Scholar 

  19. Al-Dorzi HM, Al-Humaid W, Tamim HM, Haddad S, Aljabbary A, Arifi A, Arabi YM. Anemia and blood transfusion in patients with isolated traumatic brain injury. Crit Care Res Pract. 2015;2015:672639.

    PubMed  PubMed Central  Google Scholar 

  20. • Sekhon MS, McLean N, Henderson WR, Chittock DR, Griesdale DE. Association of hemoglobin concentration and mortality in critically ill patients with severe traumatic brain injury. Crit Care. 2012;16(4):R128. One recent study evaluating the impact of anemia and red blood cells transfusion in a large cohort of TBI patients.

  21. • Griesdale DE, Sekhon MS, Menon DK, Lavinio A, Donnelly J, Robba C, Sekhon IS, Taylor A, Henderson WR, Turgeon AF, Gupta AK. hemoglobin area and time index above 90 g/L are associated with improved 6-month functional outcomes in patients with severe traumatic brain injury. Neurocrit Care. 2015;23(1):78–84. This study evaluated the time exposure of TBI patients to low (<9 g/dL) haemoglobin levels and found that this variable was significantly associated with poor outcome.

  22. Salim A, Hadjizacharia P, DuBose J, Brown C, Inaba K, Chan L, Margulies DR. Role of anemia in traumatic brain injury. J Am Coll Surg. 2008;207(3):398–406.

    Article  PubMed  Google Scholar 

  23. Okoye O, Inaba K, Kennedy M, Salim A, Talving P, Plurad D, Lam L, Demetriades D. The impact of anemia in moderate to severe traumatic brain injury. Eur J Trauma Emerg Surg. 2013;39(6):627–33.

    Article  CAS  PubMed  Google Scholar 

  24. • Sun J, Tan G, Xing W, He Z. Optimal hemoglobin concentration in patients with aneurysmal subarachnoid hemorrhage after surgical treatment to prevent symptomatic cerebral vasospasm. Neuroreport. 2015;26(5):263–6. In this study, the authors yielded that low haemoglobin levels were an independent predictor of poor outcome in SAH patients developing cerebral vasospasm.

  25. Bell DL, Kimberly WT, Yoo AJ, Leslie-Mazwi TM, Rabinov JD, Bell JE, Mehta BP, Hirsch JA. Low neurologic intensive care unit hemoglobin as a predictor for intra-arterial vasospasm therapy and poor discharge modified Rankin scale in aneurysmal subarachnoid haemorrhage-induced cerebral vasospasm. J Neurointerv Surg. 2015;7(6):438–42.

    Article  PubMed  Google Scholar 

  26. Stein M, Brokmeier L, Herrmann J, Scharbrodt W, Schreiber V, Bender M, Oertel MF. Mean hemoglobin concentration after acute subarachnoid hemorrhage and the relation to outcome, mortality, vasospasm, and brain infarction. J Clin Neurosci. 2015;22(3):530–4.

    Article  CAS  PubMed  Google Scholar 

  27. Naidech AM, Drescher J, Ault ML, Shaibani A, Batjer HH, Alberts MJ. Higher hemoglobin is associated with less cerebral infarction, poor outcome, and death after subarachnoid hemorrhage. Neurosurgery. 2006;59(4):775–9.

    Article  PubMed  Google Scholar 

  28. Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, et al. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2012;157(1):49–58.

    Article  PubMed  Google Scholar 

  29. • Smith MJ, Stiefel MF, Magge S, Frangos S, Bloom S, Gracias V, Le Roux PD. Packed red blood cell transfusion increases local cerebral oxygenation. Crit Care Med. 2005;33(5):1104–8. This is one of the first studies evaluating the effects of red blood cells transfusion on cerebral oxygenation in TBI patients. The results showed an increase in tissue oxygen pressure after transfusion, however the change was modest and not reported in all patients.

  30. Zygun DA, Nortje J, Hutchinson PJ, Timofeev I, Menon DK, Gupta AK. The effect of red blood cell transfusion on cerebral oxygenation and metabolism after severe traumatic brain injury. Crit Care Med. 2009;37(3):1074–8.

    Article  CAS  PubMed  Google Scholar 

  31. • Yamal JM, Rubin ML, Benoit JS, Tilley BC, Gopinath S, Hannay HJ, Doshi P, Aisiku IP, Robertson CS. Effect of hemoglobin transfusion threshold on cerebral hemodynamics and oxygenation. J Neurotrauma. 2015;32(16):1239–45. The authors of this study showed that older blood transfusions had no adverse effect in severe traumatic brain injury.

  32. • Kurtz P, Helbok R, Claassen J, Schmidt JM, Fernandez L, Stuart RM, Connolly ES, Lee K, Mayer SA, Badjatia N. The effect of packed red blood cell transfusion on cerebral oxygenation and metabolism after subarachnoid hemorrhage. Neurocrit Care 2016;24(1):118–21. In this study, red blood cells transfusions resulted in an improvement of cerebral oxygenation without a clear effect on cerebral metabolism among SAH patients.

  33. Dhar R, Zazulia AR, Videen TO, Zipfel GJ, Derdeyn CP, Diringer MN. Red blood cell transfusion increases cerebral oxygen delivery in anemic patients with subarachnoid hemorrhage. Stroke. 2009;40(9):3039–44.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. •• Dhar R, Scalfani MT, Zazulia AR, Videen TO, Derdeyn CP, Diringer MN: Comparison of induced hypertension, fluid bolus, and blood transfusion to augment cerebral oxygen delivery after subarachnoid hemorrhage. J Neurosurg. 2012;116(3):648–56. In this study, blood transfusions had a more significant impact on the improvement of oxygen delivery to vulnerable brain regions at risk for ischemia after SAH than intravenous fluids or vasopressor therapy.

  35. Warner MA, O’Keeffe T, Bhavsar P, Shringer R, Moore C, Harper C, Madden CJ, Sarode R, Gentilello LM, Diaz-Arrastia R. Transfusions and long-term functional outcomes in traumatic brain injury. J Neurosurg. 2010;113(3):539–46.

    Article  CAS  PubMed  Google Scholar 

  36. George ME, Skarda DE, Watts CR, Pham HD, Beilman GJ. Aggressive red blood cell transfusion: no association with improved outcomes for victims of isolated traumatic brain injury. Neurocrit Care. 2008;8(3):337–43.

    Article  PubMed  Google Scholar 

  37. Tseng MY, Hutchinson PJ, Kirkpatrick PJ. Effects of fluid therapy following aneurysmal subarachnoid haemorrhage: a prospective clinical study. Br J Neurosurg. 2008;22(2):257–68.

    Article  PubMed  Google Scholar 

  38. Kramer AH, Gurka MJ, Nathan B, Dumont AS, Kassell NF, Bleck TP. Complications associated with anemia and blood transfusion in patients with aneurysmal subarachnoid hemorrhage. Crit Care Med. 2008;36(7):2070–5.

    Article  PubMed  Google Scholar 

  39. Broessner G, Lackner P, Hoefer C, Beer R, Helbok R, Grabmer C, Ulmer H, Pfausler B, Brenneis C, Schmutzhard E. Influence of red blood cell transfusion on mortality and long-term functional outcome in 292 patients with spontaneous subarachnoid hemorrhage. Crit Care Med. 2009;37(6):1886–92.

    Article  PubMed  Google Scholar 

  40. •• Naidech AM, Shaibani A, Garg RK, Duran IM, Liebling SM, Bassin SL, Bendok BR, Bernstein RA, Batjer HH, Alberts MJ. Prospective, randomized trial of higher goal hemoglobin after subarachnoid hemorrhage. Neurocrit Care. 2010;13(3):313–20. This is the only randomized clinical trial evaluating the effects of two different haemoglobin thresholds to initiate transfusions in SAH patients and their impact on outcome.

  41. •• Robertson CS, Hannay HJ, Yamal JM, Gopinath S, Goodman JC, Tilley BC, Baldwin A, Rivera Lara L, Saucedo-Crespo H, Ahmed O et al. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. JAMA. 2014;312(1):36–47. This is the only randomized clinical trial evaluating the effects of two different haemoglobin thresholds to initiate transfusions in TBI patients and their impact on outcome.

  42. • Sena MJ, Rivers RM, Muizelaar JP, Battistella FD, Utter GH: Transfusion practices for acute traumatic brain injury: a survey of physicians at US trauma centers. Intensive Care Med 2009;35(3):480–8. The only survey conducted in North America to evaluate the transfusion policy of different physicians to treat TBI patients.

  43. • Kramer AH, Diringer MN, Suarez JI, Naidech AM, Macdonald LR, Le Roux PD: Red blood cell transfusion in patients with subarachnoid hemorrhage: a multidisciplinary North American survey. Crit Care. 2011;15(1):R30. The only survey conducted in North America to evaluate the transfusion policy of different physicians to treat SAH patients.

  44. Nichol A, French C, Little L, Haddad S, Presneill J, Arabi Y, Bailey M, Cooper DJ, Duranteau J, Huet O, Mak A, McArthur C, Pettilä V, Skrifvars M, Vallance S, Varma D, Wills J, Bellomo R. EPO-TBI investigators; ANZICS clinical trials group. Erythropoietin in traumatic brain injury (EPO-TBI): a double-blind randomised controlled trial. Lancet. 2015;386(10012):2499–506.

    Article  CAS  PubMed  Google Scholar 

  45. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–77.

    Article  CAS  PubMed  Google Scholar 

  46. Gaieski DF, Band RA, Abella BS, Neumar RW, Fuchs BD, Kolansky DM, Merchant RM, Carr BG, Becker LB, Maguire C, et al. Early goal-directed hemodynamic optimization combined with therapeutic hypothermia in comatose survivors of out-of-hospital cardiac arrest. Resuscitation. 2009;80(4):418–24.

    Article  PubMed  Google Scholar 

  47. Walters EL, Morawski K, Dorotta I, Ramsingh D, Lumen K, Bland D, Clem K, Nguyen HB. Implementation of a post-cardiac arrest care bundle including therapeutic hypothermia and hemodynamic optimization in comatose patients with return of spontaneous circulation after out-of-hospital cardiac arrest: a feasibility study. Shock. 2011;35(4):360–6.

    Article  PubMed  Google Scholar 

  48. Mazza BF, Freitas FG, Barros MM, Azevedo LC, Machado FR. Blood transfusions in septic shock: is 7.0 g/dL really the appropriate threshold? Rev Bras Ter Intensiva. 2015;27(1):36–43.

  49. Sakr Y, Chierego M, Piagnerelli M, Verdant C, Dubois MJ, Koch M, Creteur J, Gullo A, Vincent JL, De Backer D. Microvascular response to red blood cell transfusion in patients with severe sepsis. Crit Care Med. 2007;35(7):1639–44.

    Article  PubMed  Google Scholar 

  50. Cem A, Serpil UO, Fevzi T, Murat O, Umit G, Esin E, Pinar U, Sahin S, Hasan K, Cem A. Efficacy of near-infrared spectrometry for monitoring the cerebral effects of severe dilutional anemia. Heart Surg Forum. 2014;17(3):E154–259.

    Article  PubMed  Google Scholar 

  51. Dani C, Pratesi S, Fontanelli G, Barp J, Bertini G. Blood transfusions increase cerebral, splanchnic, and renal oxygenation in anemic preterm infants. Transfusion. 2010;50(6):1220–6.

    Article  PubMed  Google Scholar 

  52. Quinn CT, Dowling MM. Cerebral tissue hemoglobin saturation in children with sickle cell disease. Pediatr Blood Cancer. 2012;59(5):881–7.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Green DW. A retrospective study of changes in cerebral oxygenation using a cerebral oximeter in older patients undergoing prolonged major abdominal surgery. Eur J Anaesthesiol. 2007;24(3):230–4.

    Article  CAS  PubMed  Google Scholar 

  54. Citerio G, Cormio M, Portella G, Vascotto E, Galli D, Gaini SM. Jugular saturation (SjvO2) monitoring in subarachnoid hemorrhage (SAH). Acta Neurochir Suppl. 1998;71:316–9.

    CAS  PubMed  Google Scholar 

  55. Schoon P, Benito Mori L, Orlandi G, Larralde C, Radrizzani M. Incidence of intracranial hypertension related to jugular bulb oxygen saturation disturbances in severe traumatic brain injury patients. Acta Neurochir Suppl. 2002;81:285–7.

    CAS  PubMed  Google Scholar 

  56. Hare GM, Mazer CD, Hutchison JS, McLaren AT, Liu E, Rassouli A, Ai J, Shaye RE, Lockwood JA, Hawkins CE, Sikich N, To K, Baker AJ. Severe hemodilutional anemia increases cerebral tissue injury following acute neurotrauma. J Appl Physiol. 2007;103(3):1021–9 (1985).

  57. Davie SN, Grocott HP. Impact of extracranial contamination on regional cerebral oxygen saturation: a comparison of three cerebral oximetry technologies. Anesthesiology. 2012;116(4):834–40.

    Article  CAS  PubMed  Google Scholar 

  58. Gopinath SP, Valadka AB, Uzura M, Robertson CS. Comparison of jugular venous oxygen saturation and brain tissue PO2 as monitors of cerebral ischemia after head injury. Crit Care Med. 1999;27(11):2337–45.

    Article  CAS  PubMed  Google Scholar 

  59. • Oddo M, Levine JM, Kumar M, Iglesias K, Frangos S, Maloney-Wilensky E, Le Roux PD. Anemia and brain oxygen after severe traumatic brain injury. Intensive Care Med 2012;38(9):1497–504. This is the first study showing that only when anemia (haemoglobin <9 g/dL) was associated with tissue hypoxia (low cerebral oxygen pressure), this was an independent predictor of poor outcome.

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  1. Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium

    Ilaria Alice Crippa, Angels Lozano-Roig & Fabio Silvio Taccone

  2. Laboratoire de Médecine Expérimentale, CHU Charleroi (Hôpital André Vésale), Université Libre de Bruxelles (ULB) - Unité 222, Rue de Gozée 706, Montigny-Le-Tilleul, Belgium

    Christophe Lelubre

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  1. Ilaria Alice Crippa
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Crippa, I.A., Lelubre, C., Lozano-Roig, A. et al. Optimizing Blood Transfusion Practices in Traumatic Brain Injury and Subarachnoid Hemorrhage. Curr Anesthesiol Rep 6, 250–256 (2016). https://doi.org/10.1007/s40140-016-0169-2

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