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The CRIT Study: Anemia and blood transfusion in the critically ill—Current clinical practice in the United States*

Corwin, Howard L. MD; Gettinger, Andrew MD; Pearl, Ronald G. MD, PhD; Fink, Mitchell P. MD; Levy, Mitchell M. MD; Abraham, Edward MD; MacIntyre, Neil R. MD; Shabot, M. Michael MD; Duh, Mei-Sheng MPH, ScD; Shapiro, Marc J. MD

doi: 10.1097/01.CCM.0000104112.34142.79
FEATURE ARTICLES

Objective To quantify the incidence of anemia and red blood cell (RBC) transfusion practice in critically ill patients and to examine the relationship of anemia and RBC transfusion to clinical outcomes.

Design Prospective, multiple center, observational cohort study of intensive care unit (ICU) patients in the United States. Enrollment period was from August 2000 to April 2001. Patients were enrolled within 48 hrs of ICU admission. Patient follow-up was for 30 days, hospital discharge, or death, whichever occurred first.

Setting A total of 284 ICUs (medical, surgical, or medical-surgical) in 213 hospitals participated in the study.

Patients A total of 4,892 patients were enrolled in the study.

Measurements and Main Results The mean hemoglobin level at baseline was 11.0 ± 2.4 g/dL. Hemoglobin level decreased throughout the duration of the study. Overall, 44% of patients received one or more RBC units while in the ICU (mean, 4.6 ± 4.9 units). The mean pretransfusion hemoglobin was 8.6 ± 1.7 g/dL. The mean time to first ICU transfusion was 2.3 ± 3.7 days. More RBC transfusions were given in study week 1; however, in subsequent weeks, subjects received one to two RBC units per week while in the ICU. The number of RBC transfusions a patient received during the study was independently associated with longer ICU and hospital lengths of stay and an increase in mortality. Patients who received transfusions also had more total complications and were more likely to experience a complication. Baseline hemoglobin was related to the number of RBC transfusions, but it was not an independent predictor of length of stay or mortality. However, a nadir hemoglobin level of <9 g/dL was a predictor of increased mortality and length of stay.

Conclusions Anemia is common in the critically ill and results in a large number of RBC transfusions. Transfusion practice has changed little during the past decade. The number of RBC units transfused is an independent predictor of worse clinical outcome.

From the Dartmouth-Hitchcock Medical Center, Lebanon, NH (HLC, AG); Stanford University Medical Center, Palo Alto, CA (RGP); University of Pittsburgh Medical Center, Pittsburgh, PA (MPF); Rhode Island Hospital, Providence, RI (MML); St. Louis University Health Science Center, St. Louis, MO (MJS); University of Colorado Medical Center, Denver, CO (EA); Duke University Medical Center, Durham, NC (NRM); Cedar-Sinai Medical Center, Los Angeles, CA (MMS); and Analysis Group, Boston, MA (MSD).

Supported, in part, by Ortho Biotech Products, L. P.

Address requests for reprints to: Howard L. Corwin, MD, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756. E-mail: howard.l.corwin@hitchcock.org

Anemia is common in the critically ill and results in a large number of red blood cell transfusions.

The value of red blood cell (RBC) transfusion in clinical practice was unchallenged through most of this century (1). However, in the early 1980s, transfusion practice began to come under systematic scrutiny (2–4). Initially, the primary concerns related to the risks of transfusion-related infections, particularly human immunodeficiency virus and hepatitis. However, the issues are now much more complex. The examination and debate over RBC transfusion risks during the last two decades has led to a more critical examination of transfusion benefits. Further complicating these issues has been the growing shortage of RBCs available for transfusion.

The issues surrounding RBC transfusion are particularly important in the critically ill. Anemia is very common in the critically ill; almost 95% of patients admitted to the intensive care unit (ICU) have a hemoglobin level below normal by ICU day 3 (5). As a consequence of this anemia, critically ill patients receive a large number of RBC transfusions. More than 50% of patients admitted to the ICU receive RBC transfusions during their ICU stay (6, 7). In those patients with an ICU length of stay (LOS) of >1 wk, the proportion of patients transfused increases to 85% (6). In a survey of ICUs across the United States conducted a decade ago, 14% of ICU patients on the day of the survey received at least one unit of transfused RBCs (8).

Recent data suggest that many critically ill patients can tolerate hemoglobin levels as low as 7 g/dL and that a “liberal” RBC transfusion strategy may in fact lead to worse clinical outcomes (9). However, a hemoglobin level of 7 g/dL represents a threshold or “trigger” for transfusion that is much lower than the level generally regarded as standard practice (6, 7). The impact of the scrutiny of transfusion practice during the last decade on current clinical practice is not known. The present study was undertaken to determine current transfusion practice in ICUs in the United States and to examine the impact of anemia and RBC transfusion on the clinical outcomes of critically ill patients.

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METHODS

Design.

The study was a prospective, multiple center, observational study of ICU patients in the United States. The enrollment period was August 2000 through April 2001. Patients were enrolled within 48 hrs of ICU admission. Inclusion criteria included: age of ≥18 yrs; admission to a medical, surgical, or combined medical-surgical ICU; anticipated ICU stay of >48 hrs; and informed consent. Exclusion criteria included: admission to a pediatric, cardiothoracic, cardiac, neurologic, or burn ICU; renal failure on dialysis; patients prohibited from receiving RBC transfusions; and patients involved in other transfusion research protocols. Patients were followed for either 30 days or until hospital discharge or death if these occurred before day 30. The study protocol was approved by the institutional review board of each participating institution.

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Data Collection.

Data collected included: hospital and ICU characteristics; patient demographics; admitting diagnostic categories; co-morbidities; ICU admission Acute Physiology and Chronic Health Evaluation (APACHE) II score; ICU admission and weekly Sequential Organ Failure Assessment (SOFA) scores; RBC transfusions; age of each RBC unit transfused; baseline (value closest to enrollment), weekly, and pretransfusion hemoglobin levels; mortality; ventilator days; ICU and hospital LOS; and clinical complications (see “APPENDIX 1 ” for definitions).

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Statistical Analysis.

The primary end point of the study was to quantify the RBC transfusion practice in critically ill patients. The secondary end point was to describe the clinical outcomes and complications associated with anemia and RBC transfusions in these patients. SAS PROC MEANS procedure (SAS Institute, Cary, NC) was used to analyze the mean, standard deviation, and median of continuous variables, such as age and hemoglobin level. The significance of differences between two continuous measurements was determined by Student’s t-test. Analysis of variance (ANOVA) was used when more than two measurements were compared. Results are presented as mean ± sd. SAS PROC FREQ procedure (SAS Institute) was used to tabulate the frequencies of categorical variables, such as number of transfusions and number of complications. Chi-square tests were used to test statistical significance. Pearson’s correlation coefficients were used to assess the degree of linear correlation between two continuous variables. A two-sided alpha error of <.05 was considered to indicate statistical significance. Bonferroni adjustment was used when multiple comparisons were made.

Accelerated failure time models were used (PROC LIFEREG procedure, SAS Institute) to assess the factors associated with ICU LOS or hospital LOS. Adjustment was made for potential confounding factors, including patient demographic characteristics, RBC transfusion, nadir hemoglobin level or baseline hemoglobin level, the difference between the maximum and minimum hemoglobin values, mean age of blood transfused, mechanical ventilation status, baseline APACHE II and SOFA scores, origin of admission (e.g., emergency room, operating room), admitting diagnoses, and medical history. The median ICU and hospital LOS by transfusion status were generated conditional on the average values of other covariates in the model.

Mortality was analyzed and presented using two different models. First, logistic regression (PROC LOGISTIC procedure, SAS Institute) was used to examine transfusion and covariate effects after controlling for the duration on study. In a further confirmatory analysis of transfused patients, a Kaplan-Meier survival analysis and log-rank test (PROC LIFETEST procedure, SAS Institute) was performed, after 1:1 matching of transfused patients with nontransfused patients using propensity scores technique. Because the assignment of transfusion vs. no transfusion could not be randomized, potential selection bias was addressed by developing a propensity score for transfusion. Baseline attributes, including patient demographics, baseline APACHE II and SOFA scores, origin of admission, admitting diagnoses, medical history, and hospital LOS, that are potentially associated with receiving a transfusion were gathered into a single composite-predicted probability in logistic regression that summarized the likelihood for a patient with a given set of characteristics to receive a transfusion. A transfused patient was then matched to a nontransfused patient who had similar propensity (i.e., conditional probability) to receive a blood transfusion, using a greedy matching method. In this study, a subcohort of 44.8% of transfused patients had a match from the nontransfused patients. The remaining transfused patients with whom none of the nontransfused patients had a similar propensity to match were excluded from the propensity score analysis because their great baseline differences from the nontransfused patients hampered the ability to investigate the independent effect of transfusion on mortality.

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RESULTS

Institution/ICU Characteristics.

A total of 284 ICUs in 213 hospitals participated in the study. Hospital and ICU size are displayed in Table 1. Of the 213 hospitals, 70% were characterized as urban, 26% suburban, and 4% rural. Of the ICUs, 31% were medical, 29% were surgical, and 40% were medical-surgical. Seventy-one percent of the ICUs were managed as “open” units. There was a full-time ICU director in 84% of the ICUs. Residents and fellows were present in 76% and 39% of ICUs, respectively. Only 19% of hospitals had an institutional transfusion protocol in place at the time of the study.

Table 1

Table 1

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Patient Characteristics.

During the 9-month study period, a total of 4,892 patients were enrolled in the study. Patient characteristics are summarized in Table 2. The mean age of the patients was 60 ± 18 yrs; 35% were >70 yrs old, and 30% were <50 yrs of age. The mean ICU LOS was 7.4 ± 7.3 days; 39% of patients remained in the ICU for ≤3 days, 36% stayed in the ICU for >1 wk, and 15% stayed for >2 wks. Admitting diagnostic categories and co-morbidities are shown in Tables 3 and 4, respectively. Sixty-one percent of patients required mechanical ventilatory support during their ICU stay, and 46% were mechanically ventilated at the time of ICU admission. The mean duration of mechanical ventilation was 7.1 ± 7.4 days for ventilated patients. ICU and hospital mortality rates for patients were 13% and 18%, respectively.

Table 2

Table 2

Table 3

Table 3

Table 4

Table 4

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RBC Transfusion.

RBC transfusions performed in the ICU, after ICU discharge, and during the combined ICU and post-ICU periods are summarized in Table 5. In total, 11,391 RBC units were transfused during the study period, including 9,990 RBC units in the ICU and 1,401 RBC units after ICU discharge. Overall, 44% of patients admitted to the ICU received one or more RBC units while in the ICU. The mean time to first transfusion was 2.3 ± 3.7 days (median, 1.0; lower quartile, 0.0; upper quartile, 3.0). More RBC transfusions were given in week 1; however, in subsequent weeks, patients received one to two RBC units per week (Fig. 1). Longer ICU stays were associated with both a higher percentage of patients transfused and more RBC units transfused per patient (Figs. 2 and 3, respectively). Thirteen percent of patients received one or more RBC units after ICU discharge. Among these patients, 60% also received an RBC transfusion while in the ICU. Transfusion indications are shown in Table 6. The most common indication (90%) reported was for low hemoglobin level.

Table 5

Table 5

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

Table 6

Table 6

Patients who were transfused had more total complications and were more likely to experience a complication (Table 7). Approximately 4% of RBC transfusions were associated with a transfusion-related complication. The most common transfusion-related complications reported were fever (1.9%), fluid overload (1.7%), and hypotension (1%). The number of RBC units transfused was directly related to mortality. Mortality was 10% for patients who received no transfusions and 25% among patients who received six or more RBC units.

Table 7

Table 7

The pretransfusion hemoglobin levels are shown in Figure 4. The mean pretransfusion hemoglobin was 8.6 ± 1.7 g/dL. The same value pertained, irrespective of whether transfusions were given during the ICU stay or after discharge from the ICU (Table 5). The pretransfusion hemoglobin was remarkably consistent across the range of ICU characteristics (Table 8). The pretransfusion hemoglobin was also comparable for all transfusions (e.g., first, second, third) and ICU LOS. There were no clinically meaningful differences associated with age, sex, diagnostic category, APACHE II, or baseline SOFA score.

Figure 4

Figure 4

Table 8

Table 8

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Baseline Hemoglobin Levels.

The mean hemoglobin level at baseline was 11.0 ± 2.4 g/dL, and almost two thirds of patients had a baseline hemoglobin level of <12 g/dL. Hemoglobin level decreased throughout the duration of the study (Fig. 5). Individuals with a lower baseline hemoglobin level were more likely to receive an RBC transfusion. Almost 90% of patients with a baseline hemoglobin of ≤8 g/dL received an RBC transfusion. In contrast, only 20% of patients with a baseline hemoglobin of >12 g/dL received an RBC transfusion. Both time to first ICU transfusion (1.8 ± 1.7 days for baseline hemoglobin of ≤8 g/dL vs. 6.3 ± 6.2 days for baseline hemoglobin of >12 g/dL, p < .05) and total RBC units transfused (6.3 ± 7.1 units for baseline hemoglobin of ≤8 g/dL vs. 4.6 ± 4.4 units for baseline hemoglobin of >12 g/dL, p < .05) were significantly different between the low and high baseline hemoglobin groups.

Figure 5

Figure 5

Patients with a low baseline hemoglobin level (≤8 g/dL) presented with more hemodynamic instability, sepsis, and gastrointestinal bleeding, whereas patients with a higher baseline level (>12 g/dL) presented with more respiratory and cardiovascular problems (Table 9). Similarly, a lower baseline hemoglobin level was associated with preexisting anemia or conditions often associated with anemia (e.g., cancer, renal disease), whereas a higher baseline hemoglobin level was associated with more pulmonary disease (Table 10). Baseline hemoglobin levels of ≤10 g/dL were associated with higher APACHE II and SOFA scores and higher mortality and complication rates.

Table 9

Table 9

Table 10

Table 10

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Age, Co-morbidity, and Admitting Diagnosis.

There was little association between age and either RBC transfusion rate (42% for patients of ≤50 yrs vs. 47% for patients of ≥70 yrs) or pretransfusion hemoglobin concentration (8.5 g/dL for patients of ≤50 yrs vs. 8.7 g/dL for patients of ≥70 yrs). In general, the incidence of RBC transfusion was relatively consistent across the co-morbidities; however, patients with preexisting anemia and hematologic disease tended to receive transfusions more frequently (58.3% and 58.7%, respectively), whereas patients with preexisting pulmonary disease tended to receive transfusions less frequently (37.5%). This pulmonary group tended to have a relatively higher proportion of patients with a baseline hemoglobin level of >12 g/dL and a lower proportion of patients with a baseline hemoglobin level of ≤8 g/dL (Table 10). On the other hand, transfusions were much more frequent in patients with an admitting diagnosis of gastrointestinal hemorrhage (80%) and less frequent in patients admitted with a pulmonary (35%) or neurologic diagnosis (30%).

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APACHE II and SOFA.

The mean baseline APACHE II and SOFA scores were 19.7 ± 8.2 and 6.2 ± 3.7, respectively. Both baseline APACHE II and SOFA score were significantly higher for patients with a baseline hemoglobin level of ≤10 g/dL. Low baseline APACHE II (≤15) and low baseline SOFA (≤6) scores were associated with a significantly decreased likelihood of RBC transfusion and fewer total RBC units transfused. There was a significant association between mean SOFA score during the course of the ICU stay and the number of RBC units transfused (no transfusions, SOFA scores 4–5; one to six RBC units, SOFA scores 6–7; more than six RBC units, SOFA scores 8–9).

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Age of RBC Units Transfused.

The distribution of the age of RBC units transfused is shown in Figure 6. The mean age of all RBC units transfused was 21.2 ± 11.4 days. There was no difference in the age of RBC units whether transfused within or outside of the ICU, nor was there any difference in the age of RBC units transfused among different types of institutions or ICUs. There was no difference between the median age of the RBC units a patient received and any clinical outcome.

Figure 6

Figure 6

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Multivariate Analyses.

The number of RBC units transfused was significantly associated with increased ICU and hospital LOS compared with patients who did not receive transfusions (Table 11). Patients with a transfusion amount of 1–2, 3–4, and >4 units had a corresponding increase in median ICU LOS of 2.1, 3.8, and 10.1 days, respectively; and an increase in median hospital LOS of 3.5, 6.7, and 16.6 days, respectively, as compared with the median ICU LOS of 4.6 days and hospital LOS of 11.0 days observed in the patients who did not receive transfusions. Baseline hemoglobin level was not statistically significantly associated with ICU or hospital LOS; however, a separate analysis shows that lower nadir hemoglobin levels were correlated with longer LOS.

Table 11

Table 11

RBC transfusion was also independently associated with higher mortality rates (Table 12). Neither a baseline hemoglobin level of <10 g/dL nor a mean age of RBC units transfused of >2 wks was independently associated with an increase in mortality. However, in a separate model, nadir hemoglobin of <9.0 g/dL was associated with an increase in mortality. For the analysis using matching by propensity score to study mortality rate, 1,059 transfused patients (44.8%) were matched to 1,059 patients (41.8%) who did not receive transfusions. After adjusting for the propensity for receiving a blood transfusion, RBC transfusion remained statistically significantly associated with an increased risk for death (adjusted mortality ratio, 1.65; 95% confidence interval, 1.35–2.03; log-rank, p < .001) (Fig. 7).

Table 12

Table 12

Figure 7

Figure 7

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DISCUSSION

Anemia is common in critically ill patients and is seen early in their ICU course. By 48 hrs after ICU admission, almost 70% of patients admitted to the ICU had a baseline hemoglobin level of <12 g/dL, and half of these had a level of <10 g/dL. The anemia in these critically ill patients persisted throughout the duration of their ICU and hospital stay, with or without RBC transfusion. The extent of anemia observed is consistent with previous studies (6).

Transfusion practice in response to this anemia has changed little over the last decade. Based on our survey, almost 50% of patients admitted to ICUs across the United States today receive transfusions. Although the initial RBC transfusion tended to occur early in the ICU stay (<3 days), there were ongoing RBC transfusions in these patients throughout their ICU stay. These observations are virtually identical to those made in earlier studies (6–8). Similarly, the mean pretransfusion hemoglobin observed (i.e., the transfusion trigger) was 8.6 ± 1.7 g/dL in the present study, a value that is comparable with that described in earlier reports (6, 7). RBC transfusions were not restricted to the ICU. Thirteen percent of patients discharged from the ICU received an average of 2.7 ± 2.8 units after ICU discharge. Post-ICU RBC transfusions increased the total number of RBC units transfused by almost 15% and therefore had a significant impact on the total number of RBC units consumed by critically ill patients.

The ICUs and institutions that participated in the study are a representative cross-section of ICUs in the United States, including large and small hospitals and teaching and nonteaching hospitals. Therefore, the results of the study likely reflect general transfusion practice patterns in ICUs in the United States today. A minority of ICUs (<20%) participating in the current study had an institutional or ICU transfusion protocol in place at the time of the study; however, the existence of such a protocol did not seem to affect transfusion-related practices. Although transfusion practice was reasonably consistent across institutions and ICUs, surgical patients tended to receive transfusions more frequently. This observation is consistent with the study by Groeger et al. (8), which reported that as many as 25% of patients in surgical ICUs receive transfusions on any given day, as compared with 14% in the overall population.

Recently, a similar observational study of transfusion practice in ICUs across Western Europe was performed (9). Data were collected on 3,534 patients admitted to ICUs during a 2-wk period in late 1999. The similarity of the results of this study with our study is striking and suggests a remarkable consistency in current transfusion practice within the critical care community. A total of 37% of patients received transfusions of a mean of 4.8 RBC units while in the ICU, and 12.7% of patients received transfusions in the post-ICU period. In total, 42% of patients received transfusions during the 28-day study period. The mean pretransfusion hemoglobin level was 8.4 g/dL.

The magnitude of RBC transfusion in the critically ill today is surprising, given the scrutiny to which transfusion practice has been subjected during the last decade. In a prospective randomized study of critically ill patients, Hebert et al. (10) demonstrated that maintaining hemoglobin levels in the 7–9 g/dL range is at least equivalent, and in some patients (APACHE II of ≤20 or age of <55 yrs) superior, to maintaining hemoglobin levels of >10 g/dL with RBC transfusion. This finding also seemed to apply to patients with underlying cardiac disease, although other data suggest that patients with active ischemic cardiac disease may require a higher hemoglobin level (11). The studies by Hebert et al. (10, 11) and Dietrich et al. (12) have raised questions regarding the validity of the historic assumption that RBC transfusion is beneficial for all critically ill patients with anemia. Recent recommendations have advocated that empirical automatic transfusion thresholds be abandoned in favor of a practice of RBC transfusion only for defined physiologic need (2, 3). However, the suggestion for a more conservative approach to RBC transfusion does not as yet seem to have resulted in any major alteration in practice patterns.

Decisions about transfusing RBCs are often made without a complete understanding of the risks and benefits of transfusion (13). Although a much clearer understanding of the risks of RBC transfusion has developed since the 1980s, the risks of anemia and the benefit of RBC transfusion are much less well characterized. For more than five decades, a hemoglobin level of 10 g/dL and a hematocrit of 30% were generally accepted minimum levels, particularly in the surgical setting. First proposed in 1942 (14), the “10/30” rule has become more a matter of faith than data. Although it is clear that transfusions at hemoglobin levels in the 10 g/dL range are much less common today, we observed that only about 25% of RBC transfusions occur in a range consistent with the findings reported by Hebert et al (10).

This transfusion behavior is consistent with previous studies, which noted that transfusion decisions tend to be driven by individual transfusion triggers rather than specific physiologic indications (6). In these studies, pretransfusion hematocrit was the same, regardless of transfusion indication. In the present study, there was little evidence that either age or co-morbidities significantly influenced transfusion practice. On the other hand, a low baseline hemoglobin level was associated with more RBC transfusions. The time to first transfusion was significantly longer in those patients who presented with a high baseline hemoglobin level (1.8 ± 1.7 days with baseline hemoglobin of ≤8 g/dL vs. 6.3 ± 6.2 days with baseline hemoglobin of >12 g/dL, p < .05). These results support the hypothesis that RBC transfusion in many critically ill patients is driven by arbitrary transfusion triggers rather than physiologic findings (6). The fact that a low hemoglobin level was noted as one of the transfusion indications in 90% of transfusions is consistent with this hypothesis. The similarity between the apparent transfusion thresholds in the ICU and after ICU discharge also supports the view that hemoglobin level rather than clinical or physiologic factors drives transfusion decisions.

In general, more severely ill patients, as measured by either APACHE II or SOFA score, had a low baseline hemoglobin level and received more RBC transfusions. However, after correcting for baseline hemoglobin level and severity of illness, more RBC transfusions were independently associated with worse clinical outcomes. This is similar to the finding by Vincent et al (9). On the other hand, although both studies found that baseline hemoglobin level was not associated with mortality, we did find that a nadir hemoglobin level of <9 g/dL was associated with a higher mortality. Given the observational design of these studies, these findings should be interpreted with caution. However, the transfusion results are consistent with recent data suggesting that a liberal RBC transfusion policy may be deleterious for some critically ill patients (10, 15).

Why RBC transfusions are associated with worse clinical outcomes is unclear. A substantial amount of literature has developed since the early 1980s suggesting that exposure to allogeneic leukocytes in transfusions may trigger an immune system response in the recipient leading to increased risk of infection, earlier recurrence of malignancy, and increased likelihood of mortality (16). A significant association between the number of RBC transfusions and risk of subsequent infection has been reported in patients after trauma, burns, and a variety of surgical procedures, both elective and emergency (17–19). In the critically ill, Taylor et al. (20) demonstrated an association between RBC transfusion and nosocomial infection and mortality in the critically ill. These data have in turn led to the hypothesis that giving patients transfusions with leuko-reduced blood should result in reduced morbidity and mortality compared with patients receiving transfusions with non–leuko-reduced blood. However, most of the studies bearing on these questions have been flawed by retrospective design and inadequate consideration of the effects of co-morbidities, whereas the few prospective studies in specific patient populations have reached contradictory conclusions. Meta-analyses of this substantial literature have failed to identify a statistically significant effect of leuko-reduction (16, 21, 22). A recent study evaluating clinical outcomes after the institution of a universal leuko-reduction program in Canada noted a reduction in hospital mortality after introduction of this program (23). On the other hand, a randomized prospective study comparing outcomes in patients receiving either leuko-reduced or non–leuko-reduced RBCs failed to demonstrate any beneficial effect of leuko-reduction on clinical outcome (24). The question therefore still remains as to whether there are in fact clinical benefits associated with leuko-reduction of transfused RBCs (25). We do not have data from the current study that would allow us to answer this question.

Recent data have also raised the issue that transfusion of “old” blood may be associated with worse outcomes (26, 27). The current study provides robust data regarding the age of RBCs critically ill patients receive. The mean age of RBCs transfused was 3 wks, and >25% of transfused RBCs were >1 month old. This is somewhat older than the mean 16 ± 6.7 days for RBCs transfused in Western Europe (9). There were no differences in the age of RBCs transfused across institutions or ICUs. Although there was a trend toward worse clinical outcome among patients receiving transfusions with relatively old blood, this relationship was weak and did not achieve statistical significance. The clinical significance of the age of blood remains controversial and will require further study.

Why critically ill patients are anemic is multifactorial. Phlebotomy and blood loss undoubtedly play a role (6, 9). Nevertheless, a number of studies suggest that an underproduction of erythrocytes similar to that observed in chronic inflammatory diseases significantly contributes to the anemia in critical illness (28). More than 90% of ICU patients have low serum iron, total iron binding capacity, and iron–total iron binding capacity ratio (5, 29). In addition, these patients typically have an elevated serum ferritin level (5, 19). At a time when the iron studies are abnormal, serum erythropoietin levels are only mildly elevated, with little evidence of a reticulocyte response to endogenous erythropoietin (5). Therefore, the anemia of critical illness is a distinct clinical entity characterized by a blunted erythropoietin production and abnormalities in iron metabolism. This is reflected in the fall in hemoglobin level observed during the course of a patient’s critical illness.

The data from this study should be interpreted recognizing that this is an observational study. Although the analysis attempted to control for confounding factors, it was limited to only the factors recorded. Given the complexity of critical illness, all of the factors influencing outcome may not have been included. For example, although there are considerable baseline clinical data available, fewer data are available regarding a patient’s clinical status at the time of a RBC transfusion. The inferences drawn between variables can only indicate association not causation.

In conclusion, anemia is common in the critically ill patient, and persists throughout the ICU and hospital stay. Despite the scrutiny of transfusion practice during recent years, practice in the United States in 2000–2001 is little changed as compared with the preceding decade (6–8). Transfusion practice in the United States is also very similar to transfusion practice as recently reported in Western Europe (9). Current data regarding RBC transfusion thresholds and risks of RBC transfusion have not as yet significantly altered practice patterns (10). RBC transfusions seem to be associated with worse clinical outcomes. Clearly, approaches to reduce RBC transfusion would be desirable (10, 30). However, further study is required to more fully explore the risk of anemia, optimal hemoglobin level, and the risk and efficacy of RBC transfusion in the critically ill.

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FOOTNOTES

*See also p. 290.

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APPENDIX 1

Definitions of Terms

Acute Respiratory Distress Syndrome.

Acute respiratory distress syndrome manifested by acute onset, Pao2/Fio2 of ≤200 torr, bilateral infiltrates on frontal chest radiograph, pulmonary artery occlusion pressure of ≤18 mm Hg when measured, or no clinical evidence of left atrial hypertension.

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Deep Vein Thrombosis.

Clinical suspicion of deep vein thrombosis confirmed by either duplex ultrasonography or venography.

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Pulmonary Embolism.

Clinical suspicion of pulmonary embolism confirmed by either ventilation/perfusion scan or pulmonary angiogram, particularly in the presence of deep vein thrombosis.

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Organ Failure/Dysfunction.

Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention; Sequential Organ Failure Assessment scoring was used in this study to track organ failure/dysfunction.

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Infection.

Microbial phenomenon characterized by an inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by those organisms.

  • Bacteremia: positive blood cultures for bacteria.
  • Wound infection: presence of signs and symptoms consistent with a wound infection (erythema, edema, tenderness, and pus) along with positive wound cultures.
  • Catheter infection: confirmed using semiquantitative cultures of the catheter portion residing in the intracutaneous area with ≥15 colony-forming units present.
  • Pneumonia: presence of fever, leukocytosis, purulent secretions, new or progressive chest radiograph infiltrates, or pathologic bacteria in tracheobronchial secretions.
  • Urinary tract infection: presence of signs/symptoms consistent with a urinary tract infection (e.g., pyuria, dysuria, frequency, urgency, flank pain) along with positive urine cultures (from a good-quality specimen) containing >100,000 colony-forming units, >5 white blood cells per high-power field.
  • Fungal infection: presence of fungi as determined by culture from any sterile site (e.g., blood, cerebrospinal fluid, urine, sputum).
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Reintubation.

Intubation occurring after extubation by a healthcare professional.

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Failed Weaning Attempt.

Failed definitive attempt to remove patient from ventilatory support.

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Respiratory Failure.

Presence of one or more of the following: 1) respiratory rate of ≤5 breaths/min or ≥49 breaths/min, 2) Paco2 of ≥50 torr (≥6.7 kPa), 3) alveolar-arterial oxygen tension difference (P[a-a]o2) of ≥350 torr (P[a-a]o2 = 713 Fio2 − Paco2 − Pao2), or 4) dependent on ventilator on day 4 of organ system failure (e.g., not necessarily applicable for the initial 72 hrs of organ system failure).

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Acute Lung Injury.

Acute onset, Pao2/Fio2 of ≤300 torr, bilateral infiltrates on frontal chest radiograph, pulmonary artery occlusion pressure of ≤18 mm Hg, or no clinical evidence of left atrial hypertension (not as serious as acute respiratory distress syndrome).

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Pulmonary edema.

Edema in the lung tissues, best evidenced by chest radiograph.

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Sepsis.

Known or suspected infection. The systemic response to infection, manifested by two or more of the following conditions as a result of infection: 1) temperature of >38°C (100.4°F) or <36°C (96.8°F); 2) heart rate of >90 beats/min; 3) respiratory rate of >20 breaths/min or Paco2 of <32 torr; and 4) white blood cell count of >12,000/mm3, <4,000/mm3, or >10% immature (band) forms.

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Septic Shock.

Sepsis-induced hypotension or the requirement for vasopressors/inotropes to maintain blood pressure despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or acute alteration in mental status.

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Systemic Inflammatory Response Syndrome.

The systemic inflammatory response to a variety of severe clinical insults. The response is manifested by two or more of the following conditions: 1) temperature of >38°C (100.4°F) or <36°C (96.8°F); 2) heart rate of >90 beats/min; 3) respiratory rate of >20 breaths/min or Paco2 of <32 torr (<4.3 kPa); or 4) white blood cell count of >12,000 cells/mm3, <4000 cells/mm3, or >10% immature (bands) cells.

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Cardiac Arrest.

Arrest of cardiac function, even if patient is successfully resuscitated.

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Myocardial Infarction.

Electrocardiographic and laboratory (creatine kinase, isoenzyme of creatine kinase with muscle and brain subunits, troponin) abnormalities suggestive of myocardial infarction.

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Cerebrovascular Accident.

Diagnosis confirmed by computed tomographic scan.

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Disseminated Intravascular Coagulopathy.

Clinical suspicion of disseminated intravascular coagulopathy confirmed with the following laboratory tests: prolonged prothrombin time, activated partial thromboplastin time, and thrombin time; decreased fibrinogen and platelets; positive fibrin degradation products, d-dimer; and decreased factors V, VIII, and II (late).

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Major Bleed on Study.

Significant bleeding (>1 unit of blood) from a single source, typically resulting in a decrease in hemoglobin/hematocrit and the need for transfusion.

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APPENDIX 2

List of Investigators.

  • Alabama
  • Gaeton D. Lorino, MD: Providence Hospital, surgical intensive care unit (SICU) and medical intensive care unit (MICU), Mobile
  • Arizona
  • Richard W. Carlson, MD, PhD: Maricopa Medical Center, MICU, SICU, Phoenix
  • Philip J. Fracica, MD: St. Joseph’s Hospital and Medical Center, MICU, SICU, Phoenix
  • Robert Kearl, MD: St. Luke’s Medical Center, combined, Phoenix
  • Mohamed Y. A. Rady, MD, PhD: Mayo Clinic Hospital, Combined, Phoenix
  • Jeffrey G. Ronn, MD: Walter O. Boswell Memorial Hospital, MICU, SICU, Sun City
  • Ronald J. Servi, DO: Good Samaritan Regional Medical Center, MICU, SICU, and Thunderbird Samaritan Medical Center, MICU, SICU, Phoenix
  • Arkansas
  • Neal Beaton, MD: Baptist Medical Center, MICU, SICU, Little Rock
  • Robert V. Sanders III, MD: St. Edward Mercy Medical Center, combined, Ft. Smith
  • California
  • Elizabeth Beale, MD: County-USC Medical Center, SICU, Los Angeles
  • Christopher R. Brown, MD: California Pacific Medical Center, combined, San Francisco
  • Lawrence A. Cone, MD, DSc: Eisenhower Medical Center, MICU, Rancho Mirage
  • Bertrand DeSilva, MD: Western Medical Center/Santa Ana, combined, Santa Ana
  • Peter F. Fedullo, MD: UCSD Medical Center, combined, San Diego
  • Gregory L. Hirsch, MD: Palomar Medical Center, combined, Escondido
  • Allen L. Hoffman, MD, FACS: St. Vincent Medical Center, combined, Los Angeles
  • Kenneth G. Kalassian, MD: White Memorial Medical Center, combined, Los Angeles
  • Krista L. Kaups, MD, FACS: University Medical Center, SICU, Fresno
  • James J. Krueger, MD: Long Beach Memorial Hospital, combined, Long Beach
  • Louis McNabb, MD: St. Jude Medical Center, combined, Anaheim
  • James N. Nishio, MD: Sutter General Hospital, combined, Sacramento
  • Ashok Raheja, MD: St. Francis Medical Center, combined, Lynwood
  • Adarsh Sharma, MD: Hoag Memorial Hospital, combined, Newport Beach
  • John P. Sherck, MD: Santa Clara Valley Medical Center, SICU, MICU, San Jose
  • Susan Sprau, MD: St. John’s Health Center, combined, Santa Monica
  • Jack O. Stewart, MD: St. Joseph Hospital, combined, Orange
  • “Raj” E. V. Sunderrajan, MD, FCCP: Fountain Valley Regional Hospital, combined, Fountain Valley
  • Robert S. Wright, MD, FACP: Santa Barbara Cottage Hospital, combined, Santa Barbara
  • Colorado
  • Steven M. Weiss, MD: Presbyterian/Saint Lukes Denver Hospital, Denver
  • Connecticut
  • Carlos Barba, MD, FRCS (C), FACS: St. Francis Hospital and Medical Center, SICU, Hartford
  • John Bonadies, MD: Hospital of St. Raphaels, SICU, MICU, New Haven
  • Kevin Keating, MD: Hartford Hospital, SICU, MICU, Hartford
  • Constantine Manthous, MD: Bridgeport Hospital, MICU, Bridgeport
  • Mark Siegel, MD: Yale New Haven Hospital, SICU, MICU, New Haven
  • District of Columbia
  • Charles A. Read Jr, MD: Georgetown University Medical Center, combined, Washington
  • Michael Seneff, MD: George Washington University Hospital, combined, Washington
  • Florida
  • Sigfredo Aldarondo, MD: Florida Hospital, SICU, Orlando
  • Theodore R. Amgott, MD: Holmes Regional Medical Center, MICU, Melbourne
  • Keane L. Arney, MD, FCCP: Sacred Heart Hospital, MICU, SICU, Pensacola
  • Francis J. Averill, MD, FCCP: Largo Medical Center, combined, Largo
  • Stephen M. Cohn, MD, FACS: Jackson Memorial Hospital, SICU, Miami
  • Francisco Calimano, MD: Florida Hospital Altamonte, combined, Orlando
  • Daniel Haim, MD: Florida Hospital, MICU, Orlando
  • Eloise M. Harman, MD: Shands Hospital, MICU, Gainesville
  • Emran R. Imami, MD, FACS: Holmes Regional Medical Center, SICU, Melbourne
  • Daniel Kett, MD: Jackson Memorial Hospital, MICU, Miami
  • Martin A. Kubiet, MD: Orlando Regional Medical Center, MICU, Orlando
  • Lawrence Lottenberg, MD, FACS: Memorial Regional Hospital, SICU, Hollywood
  • Mario J. Mangas, MD: Kendall Regional Medical Center, combined, Miami
  • Ressa M. McDonald, MD: Morton Plant Hospital, combined, Clearwater
  • Timothy G. Moriarty, MD: Bay Medical Center, SICU, MICU, Panama City
  • Carlos Sklaver, MD: Cedars Medical Center, combined, Miami Beach
  • Bahman Venus, MD: Memorial Hospital of Jacksonville, combined, Jacksonville
  • Georgia
  • Michael L. Hawkins, MD: Medical College of Georgia Research Institute, Augusta
  • I. Marc Moss, MD: Grady Memorial Hospital, MICU, and Crawford Long Hospital, MICU, Atlanta
  • Hawaii
  • Larry J. Kaufman, MD: St. Francis Medical Center/University of Hawaii, Honolulu
  • Janice E. Manjuck, MD: Queens Medical Center, MICU, Honolulu
  • Idaho
  • Thomas O. Kraner, MD: St. Aphonsus Regional Medical Center, combined, Boise
  • Illinois
  • Thomas Corbridge, MD, FCCP: Northwestern Memorial Hospital, MICU, Chicago
  • Kimberly A. Davis, MD: Loyola University Medical Center, SICU, Maywood
  • Elamin M. Elamin, MD: Memorial Hospital, combined, Springfield
  • Andrew Fischer, MD: Lutheran General, MICU, SICU, Park Ridge
  • Don R. Fishman, MD: Christ Hospital and Medical Center, SICU, Oak Lawn
  • Nathan Lidsky, MD: Northwest Community Hospital, combined, Arlington Heights
  • Jacob Samuel, DO: Cook County Hospital, MICU, Chicago
  • Philip H. Sheridan Jr, MD: St. Francis Hospital/Evanston, combined, Melrose Park
  • William P. Tillis, MD: St. Francis Medical Center, MICU, SICU, and Methodist Medical Center of Illinois, MICU, Peoria
  • James Unti, MD: St. Joseph Hospital, MICU, Chicago
  • John M. Walsh, MD: Provena St. Joseph Medical Center, MICU, SICU, Joliet
  • Indiana
  • H. Scott Bjerke, MD, FACS: Methodist Hospital, MICU, Indianapolis
  • Robert S. Joseph, MD: Community Hospital East, combined, Indianapolis
  • Karen M. Wolf, MD: Wishard Memorial Hospital, MICU, SICU, Indianapolis
  • Iowa
  • Gregory A. Hicklin, MD: Methodist Hospital-Iowa Lung Center, combined, Des Moines
  • Akshay Mahadevia, MD: Genesis Medical Center, MICU, Davenport
  • Gregory E. Peterson, DO: Mercy Medical Center, MICU, SICU, Des Moines
  • Kentucky
  • Rolando Berger, MD: University of Kentucky Medical Center, MICU, Lexington
  • Antara Mallampalli, MD: University of Louisville, MICU, Louisville
  • Betty Tsuei, MD: University of Kentucky Medical Center, SICU, Lexington
  • Yuri Villaran, MD: Central Baptist Hospital, combined, MICU, Lexington
  • Louisiana
  • Richard Casey, MD: North Oaks Rehabilitation Center, combined, and St. Tammany Parish Hospital, Covington
  • Steven A. Conrad, MD: Louisiana State University Health Sciences, MICU, SICU, Shreveport
  • Richard W. Kearley, MD: Our Lady of the Lake Medical Center, combined, Baton Rouge
  • Kevin Kovitz, MD: Medical Center of Louisiana–Tulane University, New Orleans
  • Kenneth B. Smith, MD: East Jefferson General Hospital, combined, Metarie
  • Maryland
  • George Bedon, MD: Greater Baltimore Medical Center, MICU, Baltimore
  • Wilhemina M. Cruz, MD: Doctors Community Hospital, combined, Clinton
  • Steven R. Gambert, MD: Sinai Hospital, MICU, Baltimore
  • Lena Napolitano, MD, FACS: R. W. Cowley Shock Trauma, Trauma, Baltimore VA Medical Center, MICU, and University of Maryland Medical Center, SICU, Baltimore
  • Carl B. Shanholtz, MD: University of Maryland Medical Center, MICU, Baltimore
  • Massachusetts
  • Thomas Higgins, MD: Baystate Medical Center, combined, Springfield
  • David A. Kaufman, MD, FRCP: Saint Vincent Hospital at Worcester Medical Center, Worcester
  • Howard Kesselman, MD: Massachusetts General Hospital, MICU, Boston
  • Andrew Villanueva, MD: Lahey Clinic Medical Center, MICU, SICU, Burlington
  • Michigan
  • Lisa L. Allenspach, MD: Henry Ford Hospital, MICU, Detroit
  • Adeeb Atassi, MD: Oakwood Hospital and Medical Center, combined, Dearborn
  • Michael DeJong, MD: St. Mary’s Hospital, combined, Grand Rapids
  • Angela DeSantis, MD: Oakwood Hospital and Medical Center, combined, Dearborn
  • Scott Dulchavsky, MD: Detroit Receiving Hospital and University, SICU, Detroit
  • Jorge A. Guzman, MD: Detroit Receiving Hospital and University, Detroit
  • Michael Harrison, MD: Spectrum Health/Downtown Campus, MICU, SICU, Grand Rapids
  • Greg R. Neagos, MD: St. Joseph Mercy Hospital, MICU, Ann Arbor
  • Charles J. Shanley, MD: St. Joseph Mercy Hospital, SICU, Ann Arbor
  • Jeffrey Wilt, MD: Spectrum Health East Campus, MICU, SICU, Grand Rapids
  • Minnesota
  • Timothy Aksamit, MD: Mayo Clinic, MICU, Rochester
  • David Ingbar, MD: University of Minnesota Pulmonary, MICU, SICU, Minneapolis
  • Avi Nahum, MD, PhD: Regions Hospital, MICU, St. Paul
  • Corydon W. Siffring, MD: Duluth Clinic, MICU, SICU, Duluth
  • Michael West, MD: Hennepin County Medical Center, SICU, Minneapolis
  • Mississippi
  • James Rish, MD: North Mississippi Medical Center, MICU, SICU, Tupelo
  • Missouri
  • Diana S. Dark, MD: St. Luke’s Hospital Medical Education, MICU, SICU, Kansas City
  • Robert V. Griesbaum, MD: St. Anthony’s Medical Center, MICU, SICU, St. Louis
  • Garth F. Harrison, MD: Research Medical Center, combined, Kansas City
  • Marin Kollef, MD: Washington University School of Medicine, St. Louis
  • Isabelle Kopec, MD: DePaul Health Center, combined, Bridgeton
  • Joan Shaffer, MD: St. John’s Mercy Medical Center, combined, St. Louis
  • Nevada
  • William C. Brandes, MD: Sunrise Hospital and Medical Center, MICU, SICU, Las Vegas
  • New Jersey
  • Hormoz Ashtyani, MD: Hackensack University Medical Center, MICU, SICU, Hackensack
  • James Brody, MD: Jersey Shore Medical Center, MICU, SICU, Neptune
  • Aloysius Cuyjet, MD: University of Medical/Dentistry of New Jersey, MICU, Newark
  • Dennis Filippone, MD: St. Barnabas Medical Center, combined, Livingston
  • Anne Mosenthal, MD: University of Medicine/Dentistry of New Jersey, SICU, Newark
  • New York
  • Michael J. Apostolakos, MD: University of Rochester/Strong Memorial, Rochester
  • Ernest Benjamin, MD: Mt. Sinai Medical Center, SICU, New York
  • Mary C. Birmingham, PharmD: Millard Fillmore Gates Hospital, SICU, Buffalo
  • Collin Brathwaite, MD: SUNY Stony Brook Hospital, SICU, Stony Brook
  • Charles M. Carpati, MD: St. Vincents Hospital and Medical Center, SICU, New York
  • C. Gene Cayten, MD: Our Lady of Mercy Medical Center, SICU, Bronx
  • Robert Cherry: Lincoln Hospital, SICU, Bronx
  • Ali El-Solh, MD: Erie County Medical Center, MICU, Buffalo
  • Liziamma George, MD: Nassau County Medical Center, MICU, East Meadow
  • David C. Kaufman, MD: University of Rochester/Strong Memorial, Rochester
  • Hassan Khouli, MD: Roosevelt Hospital, combined, and St. Luke’s Hospital, combined, New York
  • Linda Kirschenbaum, DO: St. Vincents Hospital and Medical Center, MICU, New York
  • James Lampasso, MD: Millard Fillmore Gates Hospital, MICU, Buffalo
  • Stuart G. Lehrman, MD: Westchester County Medical Center, MICU, Valhalla
  • William Marino: Our Lady of Mercy Medical Center, MICU, Bronx
  • Jeffrey Marsh, MD: Wilson Memorial Hospital, combined, Johnson City
  • Marvin A. McMillen, MD: Montefiore Medical Center, SICU, Bronx
  • David Nierman, MD: Mt. Sinai Medical Center, MICU, NY
  • Patricia O’Neill, MD: Kings County Hospital, combined, Brooklyn
  • Cuthbert O. Simpkins, MD: Nassau County Medical Center, SICU, East Meadow
  • Edward D. Sivak, MD: SUNY Upstate Medical Center, MICU, Syracuse
  • Thomas C. Smith, MD: Albany Medical College, MICU, Albany
  • Sophia Socaris, MD: Albany Medical Center, SICU, Albany
  • Mohammad Zaman, MD: Brookdale Medical Center, MICU, Brooklyn
  • North Carolina
  • Webster Carlyle Bazemore Jr: Mission–St. Joseph’s Hospital, combined, Asheville
  • Shannon S. Carson, MD: University of North Carolina Hospitals, MICU, Chapel Hill
  • R. Duncan Hite, MD: Wake Forest Baptist Medical Center, MICU, Winston-Salem
  • Milton L. McPherson Jr, MD: Northeast Medical Center, combined, Concord
  • David B. Simonds, MD: Moses Cone Hospital, combined, Greensboro
  • North Dakota
  • Mark Tieszen, MD: MeritCare Medical Group, combined, Fargo
  • Ohio
  • James N. Allen, MD: Ohio State University Medical Center, MICU, Columbus
  • Robert Barker, MD: Kettering Medical Center, SICU, Dayton
  • Charles Cook, MD: Ohio State University Medical Center, SICU, Columbus
  • Kenneth Davis Jr, MD, FACS: University of Cincinnati Medical Center, SICU, Cincinnati
  • David K. Epperson, MD: Toledo Hospital, SICU, Toledo
  • Shahpour Esfandiari, MD: Cleveland Clinic Foundation, MICU, SICU, Cleveland
  • William F. Fallon Jr, MD: MetroHealth Medical Center, SICU, Cleveland
  • Darell E. Heiselman, DO, FAC: Akron General Medical Center, MICU, Akron
  • Bradley R. Martin, MD: Akron City Hospital, combined, Akron
  • Hugo D. Montenegro, MD: University Hospitals of Cleveland, MICU, SICU, Cleveland
  • Farid F. Muakkassa, MD: Akron General Medical Center, SICU, Akron
  • Lisa A. Patterson, MD: Miami Valley Hospital, combined, Dayton
  • Douglas B. Paul, DO: Good Samaritan Hospital/Dayton, combined, Dayton
  • John Porter, MD: St. Elizabeth’s Health Center, SICU, Youngstown
  • Joseph Sopko, MD: St. Vincent Charity Hospital, MICU, SICU, Cleveland
  • Kwang Suh, MD: Grant Medical Center, SICU, Columbus
  • Sheldon M. Traeger, MD: Akron City Hospital, combined, Akron
  • Ronald Wainz, MD: Toledo Hospital, MICU, Toledo
  • Oklahoma
  • Steven Katsis, MD: St. Francis Medical Center, combined, Tulsa
  • Oregon
  • Michael Lewis, MD: Legacy Emanuel Hospital, combined, and Good Samaritan Hospital, MICU, Portland
  • Pennsylvania
  • Sandralee A. Blosser, MD: Hershey Medical Center/Penn State College, SICU, Hershey
  • Murray Cohen, MD: Thomas Jefferson University Hospital, SICU, Philadelphia
  • Richard A. Damian, MD: Robert Packer Hospital–Guthrie Clinic, combined, Sayre
  • Barry Fuchs, MD: Hospital of the University of Pennsylvania, MICU, Philadelphia
  • Susan A Gregory, MD: Pennsylvania Hospital, combined, Philadelphia
  • John W. Hoyt, MD: St. Francis Medical Center, combined, Pittsburgh
  • Joan L. Huffman, MD: Crozer-Chester Medical Center, combined, Upland
  • Michael S. Sherman, MD: MCP/Hahnemann University, MICU, Philadelphia
  • Margaret Wojnar, MD: Hershey Medical Center/Penn State College, MICU, Hershey
  • Rhode Island
  • Vera A. De Palo, MD: Memorial Hospital of Rhode Island, combined, Pawtucket
  • South Carolina
  • Lloyd E. Hayes Sr, MD: Greenville Memorial Medical Center, combined, Greenville
  • Harold G. Morse, MD, FACP: Anderson Area Medical Center, combined, Anderson
  • Wilson P. Smith Jr, MD: Spartanburg Regional Medical Center, combined, Spartanburg
  • Tennessee
  • Suresh Enjeti, MD: Erlanger Health Systems, MICU, Chattanooga
  • Amado X. Freire, MD: The Regional Medical Center, MICU, Memphis
  • Emmel B. Golden Jr, MD: Baptist Memorial Hospital East, MICU, SICU, combined, and Baptist Memorial Restorative Care, combined, Memphis
  • Bruce S. Grover, MD: Wellmont Holston Valley Hospital, combined, Kingsport
  • Richard W. Light, MD: St. Thomas Hospital, combined, Nashville
  • Charles M. Richart, MD: Erlanger Health Systems, SICU, Chattanooga
  • Elise Schriver, MD: University of Tennessee Medical Center, MICU, SICU, Knoxville
  • D. Matthew Sellers, MD: Fort Sanders Regional Medical Center, combined, MICU, Knoxville
  • Texas
  • Victor Cardenas, MD: University of Texas Medical Branch at Galveston, MICU, Galveston
  • Christine S. Cocanour, MD: University of Texas–Houston Medical Center, Houston
  • Peter Fornos, MD: Baptist Medical Center, MICU, San Antonio
  • Joyce T. Hohn, MD: Methodist Medical Center, combined, and Charlton Methodist Hospital, combined, Dallas
  • David I. Jones, MD: East Texas Medical Center, combined, Tyler
  • William W. Lunn, MD: East Texas Medical Center, combined, Tyler
  • John G. Myers, MD: University Health System (UTHSCSA), SICU, San Antonio
  • Prakash Palimar, MD: McAllen Medical Center, combined, McAllen
  • Craig Rhyne, MD: Covenant Medical Center, MICU, SICU, Lubbock
  • Jesus Sahad, MD: Baptist St. Anthony’s Health System, MICU, SICU, Amarillo
  • Louis Sloan: Baylor University Medical Center, combined, Dallas
  • Lisa Weavind, MD: Anderson, MICU, Houston
  • Jordan S. Weingarten, MD: Brackenridge Hospital, combined, and Seton Medical Center, combined, Austin
  • Michael W. Wooley, MD: Southwest Texas Methodist Hospital, MICU, SICU, San Antonio
  • Daniel W. Ziegler, MD: John Peter Smith Hospital, combined, Ft. Worth
  • Utah
  • Edward J. Kimball, MD: University of Utah Medical Center, SICU, Salt Lake City
  • John Michael, MD: University of Utah Medical Center, MICU, Salt Lake City
  • Vermont
  • Katherine Habeeb, MD: Fletcher Allen Health Care, MICU, Colchester
  • Mark A. Healey, MD: Fletcher Allen Health Care, SICU, Burlington
  • Virginia
  • Alfred Randolph Garnett, MD: Sentara Norfolk General Hospital, combined, Norfolk
  • Rao Ivatury, MD: Medical College of Virginia, SICU, Richmond
  • William Lee, MD: Rockingham Memorial Hospital, combined, Harrisonburg
  • Mary Therese O’Donnell, MD: Inova Fairfax Hospital, combined, Falls Church
  • Washington
  • Daniel R. Coulston, MD: Deaconess Medical Center, combined, Spokane
  • Rolf H. O. Holle, MD: Providence Everett Medical Center, combined, Seattle
  • Samuel G. Joseph, DO: Sacred Heart Medical Center, combined, Spokane
  • Edward LeDoux, MD: Tacoma General, combined, Tacoma
  • Phillip I. Menashe, MD, FCCP: Providence Yakima Medical Center, combined, Yakima
  • Curtis Veal Jr, MD: Swedish Medical Center, MICU, Seattle
  • West Virginia
  • Harakh V. Dedhia, MD: West Virginia University Hospital, SICU, MICU, Morgantown
  • Wisconsin
  • Nicholas Omdahl, MD: St. Mary’s Medical Center, combined, Racine
  • Mark D. Plumb, MD: West Allis Memorial Hospital, combined, West Allis
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REFERENCES

1. Spence RK, Cernaianu AC, Carson J, et al: Transfusion and surgery. Curr Probl Surg 1993; 30: 1101–1180
2. Consensus Conference: Perioperative red blood cell transfusion. JAMA 1988; 260: 2700–2703
3. American College of Physicians: Practice strategies for elective red blood cell transfusion. Ann Intern Med 1992; 116: 403–406
4. Welch HG, Meehan KR, Goodnough LT: Prudent strategies for elective red blood cell transfusion. Ann Intern Med 1992; 116: 393–402
5. Rodriguez RM, Corwin HL, Gettinger A, et al: Nutritional deficiencies and blunted erythropoietin response as causes of the anemia of critical illness. J Crit Care 2001; 16: 36–41
6. Corwin L, Parsonnet KC, Gettinger A: RBC transfusion in the ICU: Is there a reason? Chest 1995; 108: 767–771
7. Littenberg B, Corwin H, Gettinger A, et al: A practice guideline and decision aide for blood transfusion. Immunohematology 1995; 11: 88–92
8. Groeger JS, Guntupalli KK, Strosberg M, et al: Descriptive analysis of critical care units in the United States: Patient characteristics and intensive care unit utilization. Crit Care Med 1993; 21: 279–291
9. Vincent JL, Baron JF, Gattinoni L, et al: Anemia and blood transfusions in the critically ill: An epidemiological, observational study. JAMA 2002; 288: 1499–1507
10. 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
11. Hebert PC, Yetisir E, Martin C, et al: Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care Trials Group Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases?. Crit Care Med 2001; 29: 227–234
12. Dietrich KA, Conrad SA, Hebert CA, et al: Cardiovascular and metabolic response to red blood cell transfusion in critically ill volume-resuscitated patients. Crit Care Med 1990; 18: 940–944
13. Salem-Schatz SR, Avorn J, Soumerai SB: Influence of clinical knowledge, organizational context, and practice style on transfusion decision making: Implications for practice change strategies. JAMA 1990; 264: 476–483
14. Adam RC, Lundy JS: Anesthesia in cases of poor risk: Some suggestions for decreasing the risk. Surg Gynecol Obstet 1942; 74: 1011–1101
15. Hardy JF, Martineau R, Couturier A, et al: Influence of haemoglobin concentration after extracorporeal circulation on mortality and morbidity in patients undergoing cardiac surgery. Br J Anaesth 1998; 81: 38–45
16. Vamvakas EC, Blajchman: Deleterious clinical effects of transfusion-associated immunomodulation: Fact or fiction. Blood 2001; 97: 1180–1195
17. Blumberg N, Heal JM: Effects of transfusion on immune function. Arch Pathol Lab Med 1994; 118: 371–379
18. Landers DF, Hill GE, Wong KC, et al: Blood transfusion-induced immunomodulation. Anesth Analg 1996; 82: 187–204
19. Mickler TA, Longnecker DE: The immunosuppressive aspects of blood transfusion. J Intensive Care Med 1992; 7: 176–188
20. Taylor RW, Manganaro L, O’Brien J, et al: Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient. Crit Care Med 2002; 30: 2249–2254
21. Vamvakas EC, Blajchman: Universal WBC reduction: The case for and against. Transfusion 2001; 41: 691–712
22. McAlister FA, Clark HD, Wells PS, et al: 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
23. Hebert PC, Fergusson D, Blajchman MA, et al: Clinical outcomes following institution of the Canadian universal leukoreduction program for red blood cell transfusions JAMA 2003; 289: 1941–1949
24. Dzik WH, Anderson JK, O’Neill EM et al: A prospective, randomized clinical trial of universal WBC reduction. Transfusion 2002; 42: 1114–1122
25. Corwin HL, Aubuchon JP: Is leukoreduction of blood components for everyone? JAMA 2003; 289: 1993–1995
26. Marik PE, Sibbald WJ: Effect of stored-blood transfusion on oxygen delivery in patients with sepsis. JAMA 1993; 269: 3024–3029
27. Fitzgerald RD, Martin CM, Dietz GE, et al: Transfusing red blood cells stored in citrate phosphate dextrose adenine-1 for 28 days fails to improve tissue oxygenation in rats. Crit Care Med 1997; 25: 726–732
28. Corwin HL, Krantz SB: Anemia of the critically ill: “Acute” anemia of chronic disease. Crit Care Med 2000; 28: 3098–3099
29. Van Iperen CE, Gaillard CAJM, Kraaijenhagen RJ, et al: Response of erythropoiesis and iron metabolism to recombinant human erythropoietin in intensive care unit patients. Crit Care Med 2000; 28: 2773–2778
30. Corwin HL, Gettinger A, Pearl RG, et al: Efficacy of recombinant human erythropoietin in the critically ill patient: A randomized double blind placebo controlled trial. JAMA 2002; 288: 2827–2835

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Keywords:

anemia; blood transfusion; transfusion practice; transfusion risks

© 2004 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins