Publications of the Week, March 2

2020-03-02

Transfusion strategies in nonbleeding critically ill adults: European guidelines in a nutshell. Part 2 

Vlaar AP, Oczkowski S, de Bruin S, et al. Transfusion strategies in non-bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2020 Jan 7. doi: 10.1007/s00134-019-05884-8. [Epub ahead of print] PubMed PMID: 31912207.

The guidelines from the European Society of Intensive Care Medicine (ESICM) provide recommendations and suggestions (conditional or weak recommendations) on the transfusion of different blood products, including platelets and plasma, in nonbleeding critically ill adults.

Strong recommendations are issued when most individuals would want the recommended course of action. Clinicians should adhere to this course of action in most situations and would need a compelling reason not to follow it. These recommendations may also provide a framework for hospital-based transfusion policies and benchmarks for performance measures. With weak recommendations (suggestions), th majority of patients would want the suggested course of action but many would not, and clinicians should tailor their actions to individual circumstances and to patient values and preferences. This recommendation scheme is part of the widely used GRADE system.

The ESICM guideline authors state that although benefits of blood product transfusion may be intuitive, they are also associated with risks, including hemolysis, acute lung injury, and volume overload.

For part 1 of the recommendations, see Publications of the Week, February 17.

Suggestions concerning transfusion of other blood components in nonbleeding critically ill patients:

  • Against using prophylactic platelet transfusions unless the platelet count is <10 × 109/L (very low confidence).
  • Against prophylactic platelet transfusions in patients undergoing percutaneous tracheostomy or central line insertion for a platelet count between 50 × 109/L and 100 × 109/L (very low confidence) and in patients undergoing invasive procedures for platelet counts >100 × 109/L (recommended, but low confidence). There is no opinion on what to do for platelet counts between 10 × 109/L and 50 × 109/L.
  • Against using prophylactic plasma transfusion in patients with coagulopathy (very low confidence).
  • Against using prophylactic plasma transfusion prior to invasive bedside procedures (very low confidence).

Suggestions concerning the prevention of anemia and red blood cell transfusion:

  • In favor of using blood conservation devices versus conventional blood sampling (low confidence).
  • In favor of using small-volume blood collection tubes to prevent anemia (very low confidence).
  • Against the routine use of oral or intravenous iron therapy (low confidence).
  • Against the use of erythropoietin to prevent transfusion (low confidence).
  • Against the routine use of a combination of erythropoietin and iron (very low confidence).

What platelet counts are acceptable when performing thoracentesis or lumbar puncture? Click here to submit your answers via MetaClinician and see what your peers would do.

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