Department of Intensive and Perioperative Care, Skåne University Hospital and Lund University, Lund, Sweden.
Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden.
Acta Anaesthesiol Scand. 2024 Jul;68(6):812-820. doi: 10.1111/aas.14402. Epub 2024 Mar 7.
Randomized controlled trials relatively consistently show that restrictive red blood cell (RBC) transfusion strategies are safe and associated with similar outcomes compared to liberal transfusion strategies in critically ill patients. Based on these data, the general threshold for RBC transfusion was changed to 70 g/L at a 9-bed tertiary level intensive care unit in September 2020. Implementation measures included lectures, webinars and feedback during clinical practice. The aim of this study was to investigate how implementation of a restrictive transfusion strategy influenced RBC usage, haemoglobin trigger levels and adherence to prescribed trigger levels.
In this registry-based, observational study, critically ill adult patients without massive bleeding were included and divided into a pre-cohort, with admissions prior to the change of transfusion strategy, and a post-cohort, with admissions following the change of transfusion strategy. These cohorts were compared regarding key RBC transfusion-related variables.
In total 5626 admissions were included in the analyses (pre-cohort n = 4373, post-cohort n = 1253). The median volume (interquartile range, IQR) of RBC transfusions per 100 admission days, in the pre-cohort was 6120 (4110-8110) mL versus 3010 (2890-4970) mL in the post-cohort (p < .001). This corresponds to an estimated median saving of 1128 € per 100 admission days after a restrictive RBC transfusion strategy was implemented. In total, 26% of the admissions in the pre-cohort and 19% in the post-cohort (p < .001) received RBC transfusion(s) during days 0-10. Both median (IQR) prescribed trigger levels (determined by intensivist) and actual haemoglobin trigger levels (i.e., levels prior to actual administration of transfusion) were higher in the pre- versus post-cohort (90 [80-100] vs. 80 [72-90] g/L, p < .001 and 89 [82-96] g/L vs. 83 [79-94], p < .001, respectively). Percentage of days without compliance with the prescribed transfusion trigger was higher in the pre-cohort than in the post-cohort (23% vs. 14%, p < .001). Sensitivity analyses, excluding patients with traumatic brain injury, ischemic heart disease and COVID-19 demonstrated similar results.
Implementation of a restrictive transfusion trigger in a critical care setting resulted in lasting decreased RBC transfusion use and costs, decreased prescribed and actual haemoglobin trigger levels and improved adherence to prescribed haemoglobin trigger levels.
随机对照试验较为一致地表明，在危重病患者中，与宽松输血策略相比，限制性红细胞（RBC）输血策略是安全的，并且具有相似的结果。基于这些数据，2020 年 9 月，在一个有 9 张床位的三级重症监护病房，将 RBC 输血的一般阈值改为 70g/L。实施措施包括讲座、网络研讨会和临床实践中的反馈。本研究旨在调查限制性输血策略的实施如何影响 RBC 的使用、血红蛋白触发水平和对规定触发水平的遵守情况。
在这项基于登记的观察性研究中，纳入了没有大出血的重症成年患者，并分为预组，即输血策略改变前的入院患者，和后组，即输血策略改变后的入院患者。比较两组关键 RBC 输血相关变量。
共纳入 5626 例入院患者进行分析（预组 n=4373，后组 n=1253）。预组每 100 个入院日的 RBC 输注中位数（四分位距，IQR）为 6120（4110-8110）mL，后组为 3010（2890-4970）mL（p<0.001）。这相当于实施限制性 RBC 输血策略后，每 100 个入院日估计可节省 1128 欧元。在预组中，有 26%的入院患者和后组中 19%的入院患者（p<0.001）在入院第 0-10 天接受了 RBC 输血。在预组和后组中，中位数（IQR）规定的触发水平（由重症监护医生确定）和实际的血红蛋白触发水平（即实际输血前的水平）均较高（90[80-100]g/L 与 80[72-90]g/L，p<0.001；89[82-96]g/L 与 83[79-94]g/L，p<0.001）。前组无遵医嘱输血触发的天数百分比高于后组（23%与 14%，p<0.001）。排除创伤性脑损伤、缺血性心脏病和 COVID-19 患者的敏感性分析显示出类似的结果。
在重症监护环境中实施限制性输血触发策略，可持续降低 RBC 输血的使用和成本，降低规定的和实际的血红蛋白触发水平，并提高对规定的血红蛋白触发水平的遵守程度。
