February 19, 1999

Critically ill patients to reap benefits of close look at transfusion outcomes

Critically ill patients to reap benefits of close look at transfusion outcomes

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Dr. Gordon Bernard

Taking a closer look at the practice of transfusion and its outcomes in intensive care units should prove to be highly instrumental in improving the care of critically ill patients, a Vanderbilt University physician reports.

In last week's issue of the New England Journal of Medicine, Dr. Gordon R. Bernard, professor of Medicine, applauded a recent study of the fluid administration and hemodynamic support of critically ill patients. The comments were co-written by Dr. E. Wesley Ely, assistant professor of Medicine. The study's findings, reported in the same issue, show that by using a more restrictive transfusion strategy, the number of transfusions decreased.

The trial, initiated by researchers in the Canadian Critical Care Trials Group, also attempted to break down the commonly used diagnostic and therapeutic practice of supply-dependency during a critical illness ‹ that is, the more oxygen delivered to tissues, the greater the likelihood of survival.

Earlier theories suggested that maximizing oxygen delivery in critically ill patients would help prevent "oxygen debt."

It is "this line of reasoning that led to the common practice of maintaining hemoglobin values at a level of 10 or even 12 grams per deciliter or higher in critically ill patients," Bernard writes. "Transfusion practice is a striking example of how some patterns of treatment in critical care may have been set prematurely.

"This is an important investigation that promises to improve the care of critically ill patients. By challenging current practice, these and other investigators have made it clear that a single threshold for transfusion in all patients is not appropriate."

The randomized trial evaluated two groups. One received a liberal transfusion strategy in which hemoglobin levels were maintained between 10 and 12 grams per deciliter, while the other group was assigned a restrictive transfusion strategy, with hemoglobin levels between 7 and 9 grams per deciliter.

It was found that the restrictive group of patients received three fewer units of blood than those patients in the liberal strategy group.

Bernard said that if the practice of restrictive-transfusion were widely used, it would result in cost savings as well as the protection of blood supplies ‹ both worthy achievements.

"With such knowledge, more physicians will be able to adhere to the dictum, Œfirst, do no harm,¹ and we will have a surplus of blood for transfusions rather than a shortage."