Transfusiones de glóbulos rojos en pacientes críticos

Carolina Ruiz Balart

Resumen


La anemia es muy frecuente en los pacientes críticos,  pudiendo estar presente en casi el 100% después una semana de hospitalización enla Unidadde Cuidados Intensivos (UCI). Se ha descrito que la anemia es un factor de riesgo de mayor mortalidad y morbilidad para los pacientes críticos. La etiología de la anemia en UCI es multifactorial, destacando la anemia de la inflamación, los déficits nutricionales, la hemodilución y el aumento de las pérdidas. Dentro del aumento de las pérdidas destaca la toma seriada de exámenes de sangre.

A pesar de lo deletéreo de la anemia, no se ha demostrado que las transfusiones de glóbulos rojos (GR) puedan mejorar el pronóstico de los pacientes con anemia. Por el contrario, hay estudios que han descrito un aumento de las complicaciones y mortalidad asociadas al aporte de GR. La evidencia actual sugiere que en pacientes críticos estables y que no presentan sangrado activo, las transfusiones deberían evitarse si la concentración de hemoglobina es mayor a 7 g/dL. Sin embargo, un umbral transfusional estricto puede no ser adecuado para todos los pacientes, por lo que también deberían considerarse las alteraciones de la perfusión y la condición cardíaca y respiratoria en la decisión de transfundir GR.


Palabras clave


Anemia; glóbulos rojos; transfusión; enfermedad crítica; hemoglobina; unidad de cuidados intensivos.

Texto completo:

PDF

Referencias


Carson J, Brooks MM, Abbott JD, Chaitman B, Kelsey SF & Triulzi DJ. (2013). Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease. American Heart Journal 165, 964-971.

Carson J, Stanworth S, Roubinian N, Fergusson D, Triulzi D, Doree C, & Hebert P. (2016a). Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database of Systematic Reviews 10, CD002042

Carson J, Guyatt G, HeddLe N, Grossman B, Cohn C, Fung M, Gernsheimer T, Holcomb J, Kaplan L, Katz L, Peterson N, Ramsey G, Rao S, John D. Roback J, Shander A & Tobian A. (2016b). Clinical Practice Guidelines From the AABB. Red Blood Cell Transfusion Thresholds and Storage. JAMA 316, 2025-2035.

Cooper H, Rao S, Greenberg M, Rumsey M, Mckenzie M & Alcorn K. (2011). Conservative versus liberal red cell transfusion in acute myocardial infarction (the CRIT randomized pilot study). American Journal of Cardiology 108, 1108-1111.

Corwin H, Gettinger A, Pearl R, Fink M, Levy M, Abraham E, MacIntyre N, Shabot M, Duh M & Shapiro M. (2004). The CRIT Study: anemia and blood transfusion in the critically ill—current clinical practice in the United States. Crit Care Med 32, 39-52.

Dejam A, Malley B, Feng M, Cismondi F, Park S, Samani S, Samani Z, Pinto D & Celi L. (2014). The effect of age and clinical circumstances on the outcome of red blood cell transfusion in critically ill patients. Crit Care 18, 487.

Dellinger P, Levy M, Rhodes A, Annane D, Gerlach H, Steven M. Opal S & Surviving Sepsis Campaign Guidelines Committee. (2013). Crit Care Med 41, 580-637.

Hayden Sh, Timothy A, Watkins T & Swenson R. (2012). Anemia in Critical Illness. Am J Respir Crit Care Med 185, 1049-1057.

Hebert PC, Wells G, Tweeddale M, Martin C, Marshall J, Pham B, Blajchman M, Schweitzer I & Pagliarello G. (1997). Does transfusion practice affect mortality in critically ill patients? Transfusion Requirements in Critical Care (TRICC) Investigators and the Canadian Critical Care Trials Group. Am J Respir Crit Care Med 155, 1618-1623.

Hebert PC, Wells G, Blajchman M, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E & Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care Trials Group. (1999). A Multicenter Randomized Controlled Clinical Trial of Transfusion Requirements in Critical Care. N Engl J Med 340, 409-417.

Holst L, Nicolai N, Wetterslev J, Wernerman J, Guttormsen A, Karlsson S & TRISS Trial Group for the Scandinavian Critical Care Trials Group. (2014). Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock. N Engl J Med 371,1381-1391.

Khamiees M, Raju P, De Girolamo A, Amoateng-Adjepong Y & Manthous C. (2001). Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest 120, 1262-1270.

Kramer A & Zygun D. (2009). Anemia and red blood cell transfusion in neurocritical care. Critical Care 13, R89.

Kulvatunyou N & Heard S. (2004). Care of the injured Jehovah's Witness patient: case report and review of the literature. J Clin Anesth 16, 548-53.

Lacroix J, Hébert P, Fergusson D, Tinmouth A, Cook D, Marshall J, Clayton L, McIntyre L, Callum J, Turgeon A, Blajchman M, Walsh T, Stanworth S, Campbell H, Capellier G, Tiberghien P, Bardiaux L, van de Watering L, van der Meer NJ, Sabri E, Vo D & ABLE Investigators for the Canadian Critical Care Trials Group. (2015). Age of Transfused Blood in Critically Ill Adults. N Engl J Med 372, 1410-1418.

Marik P & Corwin L. (2008). Efficacy of red blood cell transfusion in the critically ill: A systematic review of the literatura. Crit Care Med 36, 2667–2674.

Napolitano L. (2004). Scope of the problem: epidemiology of anemia and use of blood transfusions in critical care. Critical Care 8, S1-S8.

Nguyen B, Bota D, Melot C & Vincent J. (2003). Time course of hemoglobin concentrations in non bleeding intensive care unit patients. Crit Care Med 31, 406-410.

Nichol A. (2008). Restrictive red blood cell transfusion strategies in critical care: does one size really fit all? Crit Care Resusc 10, 323–327.

Pape A, Stein P, Horn O & Habler O. (2009). Clinical evidence of blood transfusion effectiveness. Blood Transfus 7, 250-258.

Parsons E, Hough C, Seymour C, Cooke C, Rubenfeld G, Watkins T & NHLBI ARDS Network. (2011). Red blood cell transfusion and outcomes in patients with acute lung injury, sepsis and shock. Critical Care 15, R221.

Plurad D, Belzberg H, Schulman I, Green D, Salim A, Inaba K, Rhee P, Demetriades D. (2008). Leukoreduction is associated with a decreased incidence of late onset acute respiratory distress syndrome after injury. Am Surg 74,117-123.

Prakash D. (2012). Anemia in the ICU. Crit Care Clin 28, 333-343.

Rao M, Boralessa H, Morgan C, Soni N, Goldhill DR, Brett SJ, Boralessa H & Contreras M. (2002). Blood component use in critically ill patients. Anaesthesia 57, 530-534.

Roberson R & Bennett-Guerrero. (2012). Impact of red blood cell transfusión on global and regional measures of oxygenation. Mt Sinai J Med 79, 66–74.

Robertson C, Hannay J, Yamal JM, Gopinath S, Goodman C, Barbara C, Tilley B & the Epo Severe TBI Trial Investigators. (2014). Effect of erythropoietin administration and transfusión threshold on neurological recovery after traumatic brain injury. JAMA 312, 36-47.

Ruiz C & Andresen M. (2014). Reanimación con fluidos y hemoderivados en trauma. Rev Med Chile 142, 758-766.

Ruiz C. (2015). Rol de la microcirculación en la sepsis. En Tratado de Medicina Intensiva 2º edición, ed. G Bugedo, pp. 433-441. Editorial Mediterráneo.

Sakr Y, Lobo S, Knuepfer S, Esser E, Bauer M, Settmacher U, Dagmar B & Reinhart K. (2010). Anemia and blood transfusion in a surgical intensive care unit. Critical Care 14, R92.

Shehata N, Forster A, Lawrence N, Ducharme R, Fergusson D, Chassé M, Rothwell D, Hébert P, Tinmouth A, & Wilson K. (2015). Transfusion Patterns in All Patients Admitted to the Intensive Care Unit and in Those Who Die in Hospital: A Descriptive Analysis. PLoS ONE 10: e0138427.

Thomas J, Jensen L, Nahirniak S, & Gibney R. (2010). Anemia and blood transfusion practices in the critically ill: a prospective cohort review. Heart Lung 39, 217–225.

Vincent J, Baron J, Reinhart K, Gattinoni L, Thijs L, Webb A, Meier-Hellmann A, Nollet G & Peres-Bota D & ABC (Anemia and Blood Transfusion in Critical Care) Investigators. (2002). Anemia and blood transfusion in critically ill patients. JAMA 288, 1499–1507.

Vincent J, Sakr Y, Sprung CH, Harboe S, Damas P & Sepsis Occurrence in Acutely Ill Patients (SOAP) Investigators. (2008). Are Blood Transfusions Associated with Greater Mortality Rates? Anesthesiology 108, 31-39.

Vincent J. (2015). Which carries the biggest risk: Anaemia or blood transfusion? Transfusion Clinique et Biologique 22, 148-150.

Walsh T. (2010). Red cell transfusion triggers in critically ill patients: time for some new TRICCs? Critical Care 14,170.

Walsh T, Boyd J, Watson D, Hope D, Lewis S, Krishan A, Forbes J, Ramsay P, Pearse R, Wallis Ch, Cairns C, Cole S & Wyncoll D. (2013) Restrictive Versus Liberal Transfusion Strategies for Older Mechanically Ventilated Critically Ill Patients: A Randomized Pilot Trial. Crit Care Med 41, 2354-2363.

Wang D, Sun J, Solomon S, Klein H & Natanson Ch. (2012). Transfusion of older stored blood and risk of death: a meta-analysis. Transfusion 52, 1184-1195.

Watkins T, Rubenfeld G, Martin T, Nester T, Caldwell E, Billgren J, Ruzinski J, Nathens A. (2008). Effects of leukoreduced blood on acute lung injury after trauma: a randomized controlled trial. Crit Care Med 36, 1493-1499.

Weiskopf R, Kramer J, Viele M, Neumann M, Feiner J, Watson J, Hopf HW & Toy p. (2000). Acute severe isovolemic anemia impairs cognitive function and memory in humans. Anesthesiology 92,1646-1652.




DOI: http://dx.doi.org/10.11565/arsmed.v42i3.935



Copyright (c) 2017 ARS MEDICA Revista de Ciencias Médicas

Licencia de Creative Commons
Este obra está bajo una licencia de Creative Commons Reconocimiento 4.0 Internacional.

ISSN: 1234-5678 © Dirección de Extensión y Educación Continua, Escuela de Medicina, Pontificia Universidad Católica de Chile. http://www.arsmedica.cl

Journal Supported by Chimera Innova Group