Conclusion and Recommendations
The TRICC trial [104] demonstrated that a transfusion trigger of 7.0 g/dl and maintenance of hemoglobin concentrations between 7.0 and 9.0 g/dl was at worst equivalent and very likely superior to the more liberal use of red cells. A restrictive strategy is truly a superior therapy because clinical outcomes are superior, transfusions are decreased by 54% and costs are minimized. Given conflicting evidence, the optimal transfusion policy for septic patients is not known. The increased demands imposed by sepsis along with its impairment of the normal adaptive process to anemia would suggest that severely infected patients should have a more liberal transfusion practice as compared to nonseptic patients. The potential problems with allogeneic blood products however limits one’s enthusiasm for an aggressive transfusion practice. Thus, the best approach would be to limit the need to transfuse but to transfuse the best product available if a transfusion is required. We anxiously await the results of further trials with EPO, different RBC products, and other studies to confirm the results observed in the TRICC trial.
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References
Rangel-Frausto MS, Pittet D, Costigan M, Hwang T, Davis CS, Wenzel RP. The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study. JAMA 1995; 273:117–123
Friedman G, Silva E, Vincent JL. Has the mortality of septic shock changed with time. Crit Care Med 1998; 26:2078–2086
Bordin JO, Heddle NM, Blajchman MA. Biologic effects of leukocytes present in transfused cellular blood products. Blood 1994; 84:1703–1721
van de Watering LMG, Hermans J, et al. Beneficial effects of leukocyte depletion of transfused blood on postoperative complications in patients undergoing cardiac surgery. Circulation 1998; 97:562–568
Hebert PC, Hu LQ, Biro GP. Review of physiologic mechanisms in response to anemia. Can Med Assoc J 1997; 156:S27–S40.
Barcroft J: The respiratory function of the blood. Part I: lessons from high altitudes. Cambridge University Press, 1925
Tuman KJ: Tissue oxygen delivery. The physiology of anemia. Anesth Clin N Am 1990; 8:451–469
Hall JB, Schmidt GA, Wood LDH. Principles of Critical Care, edn 1. Jeffers JD, McCurdy P (eds) McGraw-Hill, Inc., 1992
Turner A, Tsamitros M, Bellomo R. Myocardial cell injury in septic shock. Crit Care Med 1999; 27:1775–1780
Bernstein D, Sibbald WJ. Circulatory disturbances in multiple systems organ failure. Crit. Care Clin. 1989, 5:223–254
Hebert PC, Thompson CR, Gillis RP, Walley KR, Schellenberg RR. Histamine H2 stimulation decreases left ventricular contractility in humans. Circulation 2001 (In Press)
Walley KR, Hebert PC, Wakai Y, Wilcox PG, Road JD, Cooper DJ. Decrease in left ventricular contractility after tumor necrosis factor-alpha infusion in dogs. J Appl Physiol 1994; 76:1060–1067
Natanson C. Studies using a canine model to investigate the cardiovascular abnormality of, and potential therapies, for septic shock. Clin Res 1990; 38:206–214
Natanson C, Eichenholz PW, Danner RL. Endotoxin and tumor necrosis factor challenges in dogs simulate the cardiovascular profile of human septic shock. J Exp Med 1989; 169:823–832
Natanson C, Fink MP, Ballantyne HK, MacVittie TJ, Conklin JJ, Parrillo JE. Gram-negative bacteremia produces both severe systolic and diastolic cardiac dysfunction in a canine model that simulates human septic shock. J Clin Invest 1986; 78:259–270
Suffredini AF, Fromm RE, Parker MM, et al. The cardiovascular response of normal humans to the administration of endotoxin. N Engl J Med 1989; 321:280–287
Bersten AD, Sibbald WJ, Hersch M, Cheung H, Rutledge FS. Interaction of sepsis and sepsis plus sympathomimetics on myocardial oxygen availability. Am J Physiol 1992; 262:H1164–H1173
Lam C, Tyml K, Martin C, Sibbald W. Microvascular perfusion is impaired in a rat model of normotensive sepsis. J Clin Invest 1994; 94:2077–2083
Eklöf B, Neglén P, Thomson D. Temporary incomplete ischemia of the legs induced by aortic clamping in man: effects on central hemodynamics and skeletal muscle metabolism by adrenergic block. Ann Surg 1981; 193:89–98
Bersten AD, Sibbald WJ, Hersch M, Cheung H, Rutledge FS. Interaction of sepsis and sepsis plus sympathomimetics on myocardial oxygen availability. Am J Physiol 1992; 262:H1164–H1173
Sibbald WJ, Fox G, Martin CM. Abnormalities of vascular reactivity in sepsis syndrome. Chest 1991; 100(Suppl):S155S–S159S
Rackow EC, Astiz ME, Weil MH. Cellular oxygen metabolism during sepsis and shock. The relationship of oxygen consumption to oxygen delivery. JAMA 1988; 259:1989–1993
Czer LSC, Shoemaker WC. Optimal hematocrit value in critically ill postoperative patients. Surg Gynecol Obstet 1978; 147:363–368
Tuchschmidt J, Fried J, Astiz ME, Rackow E. Elevation of cardiac output and oxygen delivery improves outcome in septic shock. Chest 1992; 102:216–220
Bihari D, Smithies M, Gimson A, Tinker J. The effects of vasodilation with prostacyclin on oxygen delivery and uptake in critically ill patients. N Engl J Med 1987; 317:397–403
Ronco JJ, Fenwick JC, Wiggs BR, Phang PT, Russell JA, Tweeddale MG. Oxygen consumption is independent of increases in oxygen delivery by dobutamine in septic patients who have normal or increased plasma lactate. Am Rev Respir Dis 1993; 147:25–31
Ronco JJ, Fenwick JC, Tweeddale MG, et al. Identification of the critical oxygen delivery for anaerobic metabolism in critically ill septic and nonseptic humans. JAMA 1993; 270:1724–1730
Boyd O, Ground M, Bennett D. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA 1993; 270:2699–2707
Hayes MA, Timmins AC, Yau EHS, Palazzo M, Hinds CJ, Watson D. Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med 1994; 330:1717–1722
Gattinoni L, Brazzi L, Pelosi P, et al. A trial of goal-oriented hemodynamic therapy in critically ill patients. N Engl J Med 1995; 333:1025–1032
Gutierrez G, Pohil RJ. Oxygen consumption is linearly related to O2 supply in critically ill patients. J Crit Care 1986; 1:45–53
Ronco JJ, Montaner JSG, Fenwick JC, Ruedy J, Russell JA. Pathologic dependence of oxygen consumption on oxygen delivery in acute respiratory failure secondary to AIDS-related Pneumocystis carinii pneumonia. Chest 1990; 98:1463–1466
Conrad SA, Dietrich KA, Hebert CA, Romero MD. Effect of red cell transfusion on oxygen consumption following fluid resuscitation in septic shock. Circ Shock 1990; 31:419–429
Fenwick JC, Dodek PM, Ronco JJ, Phang PT, Wiggs B, Russell JA. Increased concentrations of plasma lactate predict pathologic dependence of oxygen consumption on oxygen delivery in patients with adult respiratory distress syndrome. J Crit Care 1990; 5:81–86
Gilbert EM, Haupt MT, Mandanas RY, Huaringa AJ, Carlson RW. The effect of fluid loading, blood transfusion, and catecholamine infusion on oxygen delivery and consumption in patients with sepsis. Am Rev Respir Dis 1986; 134:873–878.
Kariman K, Burns SR. Regulation of tissue oxygen extraction is disturbed in adult respiratory distress syndrome. Am Rev Respir Dis 1985; 132:109–114
Dietrich KA, Conrad SA, Hebert CA, Levy GL, Romero MD. Cardiovascular and metabolic response to red blood cell transfusion in critically ill volume-resuscitated nonsurgical patients. Crit Care Med 1990; 18:940–944
Heyland DK, Cook DJ, King D, Kernerman P, Brun-Buisson C. Maximizing oxygen delivery in critically ill patients: a methodologic appraisal of the evidence. Crit Care Med 1996; 24:517–524
Silverman HJ, Slotman G, Bone RC, et al. Effects of prostaglandin El on oxygen delivery and consumption in patients with the adult respiratory distress syndrome. Chest 1990; 98:405–410
Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee T-S. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 1988;94:1176–1186
Shoemaker WC, Appel PL, Kram HB. Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients. Chest 1992; 102:208–215
Gutierrez G, Palizas F, Doglio G, et al. Gastric intramucosal pH as a therapeutic index of tissue oxygenation in critically ill patients. Lancet 1992; 339:195–199
Marik PE, Sibbald WJ. Effect of stored-blood transfusion on oxygen delivery in patients with sepsis. JAMA 1993; 269:3024–3029
Stuart J, Nash GB. Red cell deformability and haematological disorders. Blood Rev 1990; 4:141–147
Apstein CS, Dennis RC, Briggs L, Vogel WM, Frazer J, Valeri CR. Effect of erythrocyte storage and oxyhemoglobin affinity changes on cardiac function. Am J Physiol 1985; 248:H508–H515
Regan FAM, Hewitt P, Barbara JAJ, Contreras M, on behalf of the current TTI Study. Prospective investigation of transfusion transmitted infection in recipients of over 20000 units of blood. Br Med J 2000; 320:403–406
Opelz G, Sengar DPS, Mickey MR, Terasaki PI. Effect of blood transfusions on subsequent kidney transplants. Transplant Proc 1973; 5:253–259
Keown PA, Descamps B. Improved renal allograft survival after blood transfusion: a nonspecific, erythrocyte-mediated immunoregulatory process? Lancet 1979; 1:20–22
Kaplan J, Sarnaik S, Gitlin J, Lusher J. Diminished helper/suppressor lymphocyte ratios and natural killer activity in recipients of repeated blood transfusions. Blood 1984; 64:308–310
Kessler CM, Schulof RS, Goldstein AL, et al. Abnormal T-lymphocyte subpopulations associated with transfusions of blood-derived products. Lancet 1983; 1:991–992
Tartter PI, Quintero S, Barron DM. Perioperative transfusions associated with colorectal cancer surgery: clinical judgement versus the hematocrit. World J Surg 1986; 10.516–521
Fielding LP. Red for danger. blood transfusion and colorectal cancer. Br Med J 1985; 291:841–842
Nichols RL, Smith JW, Klein DB, et al. Risk of infection after penetrating abdominal trauma. N Engl J Med 1984; 311:1065–1070
Fischer E, Lenhard V, Seifert P, Kluge A, Johannsen R. Blood transfusion-induced suppression of cellular immunity in man. Hum Immunol 1980; 3:187–194
Lenhard V, Maassen G, Grosse-Wilde H, Wermet P, Opelz G. Effect of blood transfusions on immunoregulatory cells in prospective transplant recipients. Transplant Proc 1983; 5:1011–1015
Heiss MM, Memple W, Jauch K-W, et al. Beneficial effects of autologous blood transfusion on infectious complications after colorectal cancer surgery. Lancet 1993; 342:1328–1333
Tartter PI. Blood transfusion and postoperative infections. Transfusion 1989; 29:456–459
Mezrow CK, Bergstein I, Tartter PI. Postoperative infections following autologous and homologous blood transfusions. Transfusion 1992; 32:27–30
Murphy P, Heal JM, Blumberg N. Infection or suspected infection after hip replacement surgery with autologous or homologous blood transfusions. Transfusion 1991; 31:212–217
Murphy PJ, Connery C, Hicks GL Jr, Blumberg N. Homologous blood transfusion as a risk factor for postoperative infection after coronary artery bypass graft operations. J Thorac Cardiovasc Surg 1992; 104:1092–1099
Pinto V, Baldonedo R, Nicolas C, Barez A, Perez A, Aza J. Relationship of transfusion and infectious complications after gastric carcinoma operations. Transfusion 1991; 31:114–118
Jensen LS, Andersen AJ, Christiansen PM, et al. Postoperative infection and natural killer cell function following blood transfusion in patients undergoing elective colorectal surgery. Br J Surg 1992; 79:513–516
Marshall JC, Sweeney D. Microbial infection and the septic response in critical surgical illness. Sepsis, not infection, determines outcome. Arch Surg 1990; 125:17–23
Marshall JC. A scoring system for multiple organ dysfunction syndrome. In Sepsis. Current perspectives in pathophysiology and therapy. Edited by Reinhart K, Eyrich K, Sprung C. Berlin: Springer-Verlag, 1994:38–49
Crosby ET. Perioperative haemotherapy: I. Indications for blood component transfusion. Can J Anesth 1992; 39:695–707
Vamvakas E, Moore SB. Perioperative blood transfusion and colorectal cancer recurrence: a qualitative statistical overview and meta-analysis. Transfusion 1993; 33:754–765
Houbiers JGA, Brand A, van de Watering LMG, et al. Randomised controlled trial comparing transfusion of leucocyte-depleted or buffy-coat-depleted blood in surgery for colorectal cancer. Lancet 19%; 344:573–578
van de Watering LMG, Houbiers JGA, et al. Leukocyte depletion reduces postoperative mortality in patients undergoing cardiac surgery. Br J Haematol 1996; 93:312 (Abst)
Jensen LS, Kissmeyer-Nielsen P, Wolff B, Qvist N. Randomised comparison of leucocyte-depleted versus buffy-coat-poor blood transfusion and complications after colorectal surgery. Lancet 1996; 348:841–845
Houbiers JG, van de Velde CJ, van de Watering LM, et al. Transfusion of red cells is associated with increased incidence of bacterial infection after colorectal surgery: a prospective study. Transfusion 1997; 37:126–134
Busch ORC, Hop WCJ, Hoynck van Papendrecht MAW, Marquet RL, Jeekel J. Blood transfusions and prognosis in colorectal cancer. NEngl J Med 1993; 328:1372–1376
McAlister FA, Clark HD, Wells PS, Laupacis A. Perioperative allogeneic blood transfusion does not cause adverse sequelae in patients with cancer: a meta-analysis of unconfounded studies. Br J Surg 1998; 85:171–178
Chin-Yee I, Arya N, D’Almeida M. The red cell storage lesion and its implication for transfusion. Transfus Sci 1997; 18:447–458
Card RT. Red cell membrane changes during storage. Trans Med Rev 1988; 2:40–47
Wolfe LC. The membrane and the lesions of storage in preserved red cells. Transfusion 1985; 25:185–203
Greenwalt TJ, Bryan DJ, Dumaswala UJ. Erythrocyte membrane vesiculation and changes in membrane components during storage in citrate-phosphate-dextrose-adenine-1. Vox Sang 1984; 47:261–270
Snyder LM, Fairbanks G, Trainor J, Fortier NL, Jacobs JB, Leb L. Properties and characterization of vesicules released by young and old human red cells. Br J Haematol 1985; 59:513–522
Wagner GM, Chiu DTY, Yee MC, Lubin BH. Red cell vesiculation-a common membrane physiologic event. J Lab Clin Med 1986; 108:315–324
Knight JA, Voorhees RP, Martin L, Anstall H. Lipid peroxidation in stored red cells. Transfusion 1992; 32:354–357
Card RT, Mohandas N, Perkins HA, Shohet SB. Deformability of stored red blood cells. Relationship to degree of packing. Transfusion 1982; 22:96–101
Card RT, Mohandas N, Mollison PL. Relationship of post-transfusion viability to deformability of stored red cells. Br J Haematol 1983; 53:237–240
Card RT, Fergusson DJ. Relationship of stored red cell deformability to survivability following transfusion: In vitro prediction of in vivo viability. Blood 1987; 70:327a (Abst)
Valeri CR, Rorth M, Zaroulis CG, Jakubowski MS, Vescera SV. Physiologic effects of transfusing red blood cells with high or low affinity for oxygen to passively hyperventilated, anemic baboons: systemic and cerebral oxygen extraction. Ann Surg 1975; 181:106–113
Valeri CR, Hirsh NM. Restoration in vivo of erythrocyte adenosine triphosphate, 2.3-diphosphoglycerate, potassium ion, and sodium ion concentrations following the transfusion of acid-citrate-dextrose-stored human red blood cells. J Lab Clin Med 1969; 73:722–733
Chaplin HJr, Beutler E, Collins JA, Giblett ER, Polesky HF. Current status of red-cell preservation and availability in relation to the development National Blood Policy. N Engl J Med 1974; 291:68–74
Bunn HF, May MH, Kocholaty WF, Shields CE. Hemoglobin function in stored blood. J Clin Invest 1969; 48:311–321
Sugerman HJ, Davidson DT, Vibul S, Delivoria-Papadopoulos M, Miller LD, Oski FA. The basis of defective oxygen delivery from stored blood. Surg Gynecol Obstet 1970; 137:733–741
Valeri CR, Collins FB. The physiologic effect of transfusing preserved red cells with low 2,3-diphosphoglycerate and high affinity for oxygen. Vox Sang 1971; 20:397–403
Latham JTJr, Bove JR, Weirich FL. Chemical and hematologic changes in stored CPDA-1 blood. Transfusion 1982; 22:158–159
Heddle NM. Febrile nonhemolytic transfusion reactions to platelets. Curr Opin Hematol 1995; 3:478–483
Smith KJ, Sierra ER, Nelson EJ. Histamine, IL-lb, and IL-8 increase in packed RBCs stored for 42 days but not in RBCs leukodepleted pre-storage. Transfusion 1993; 33:53S (Abst)
Miletic VD, Popovic O. Complement activation in stored platelet concentrates. Transfusion 1993; 33:150–154
Schleuning M, Bock M, Mempel W. Complement activation during storage of single-donor platelet concentrates. Vox Sang 1994; 67:144–148
Silliman CC, Clay KL, Thurman GW, Johnson CA, Ambruso DR. Partial characterization of lipids that develop during the routine storage of blood and prime the neutrophil NADPH oxidase. J Lab Clin Med 1994; 124:684–694
Muylle L, Peetermans ME. Effect of prestorage leukocyte removal on the cytokine levels in stored platelet concentrates. Vox Sang 1994; 66:14–17
Martin CM, Sibbald WJ, Lu X, Hebert P, Schweitzer I. Age of transfused red blood cells is associated with ICU length of stay. Clin Invest Med 1994; 17:124 (Abst)
Purdy FR, Tweeddale MG, Merrick PM. Association of mortality with age of blood transfused in septic ICU patients. Can J Anaesth 1997; 44:1256–1261
Vamvakas EC, Carven JH. Transfusion and postoperative pneumonia in coronary artery bypass graft surgery: effect of the length of storage of transfused red cells. Transfusion 1999; 39:701–710
Corwin HL, Parsonnet KC, Gettinger A. RBC transfusion in the ICU. Is there a reason? Chest 1995; 108:767–771
Smoller BR, Kurskall MS, Horowitz GL. Reducing adult phlebotomy blood loss with the use of pediatric sized blood collection tubes. Am J Clin Pathol 1989; 91:701–703
Corwin HL, Gettinger A, Rodriguez RM, et al. Efficacy of recombinant human erythropoietin in the critically ill patient. a randomized double blind placebo controlled trial. Crit Care Med 1999; 27:2346–2350
Huet C, Salmi LR, Fergusson D, Koopman-van Gemert AWMM, Rubens F, Laupacis A. A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopedic surgery. Anesth Analg 1999; 89:861–869
Laupacis A, Fergusson D. Drugs to minimize perioperative blood loss in cardiac surgery: meta-analyses using perioperative blood transfusion as the outcome. Anesth Analg 1997; 85:1258–1267
Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999; 340:409–417
Ronco JJ, Phang PT, Walley KR, Wiggs B, Fenwick JC, Russell JA. Oxygen consumption is independent of changes in oxygen delivery in severe adult respiratory distress syndrome. Am Rev Respir Dis 1991; 143:1267–1273
Shah DM, Gottlieb ME, Rahm RL, et al. Failure of red blood cell transfusion to increase oxygen transport or mixed venous PO2 in injured patients. J Trauma 1982; 22:741–746
Steffes CP, Bender JS, Levison MA. Blood transfusion and oxygen consumption in surgical sepsis. Crit Care Med 1991; 19:512–517
Babineau TJ, Dzik WH, Borlase BC, Baxter JK, Bistrian BR, Benotti PN. Reevaluation of current transfusion practices in patients in surgical intensive care units. Am J Surg 1992; 164:22–25
Lorente JA, Landin L, De Pablo R, Renes E, Rodriguez-Diaz R, Liste D. Effects of blood transfusion on oxygen transport variables in severe sepsis. Crit Care Med 1993; 21:1312–1318
Mink RB, Pollack MM. Effect of blood transfusion on oxygen consumption in pediatric septic shock. Crit Care Med 1990; 18:1087–1091
Lucking SE, Williams TM, Chaten FC, Metz RI, Mickell JJ. Dependence of oxygen consumption on oxygen delivery in children with hyperdynamic septic shock and low oxygen extraction. Crit Care Med. 1990; 18:1316–1319
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Neilipovitz, D., Hébert, P.C. (2002). Blood Transfusion and Sepsis. In: Vincent, JL., Carlet, J., Opal, S.M. (eds) The Sepsis Text. Springer, Boston, MA. https://doi.org/10.1007/0-306-47664-9_23
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