Transfusion in the mechanically ventilated patient
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NARRATIVE REVIEW
Transfusion in the mechanically ventilated patient Nicole P. Juffermans1,2, Cécile Aubron3, Jacques Duranteau4, Alexander P. J. Vlaar1,5, Daryl J. Kor6, Jennifer A. Muszynski7, Philip C. Spinella8 and Jean‑Louis Vincent9* © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Abstract Red blood cell transfusions are a frequent intervention in critically ill patients, including in those who are receiving mechanical ventilation. Both these interventions can impact negatively on lung function with risks of transfusionrelated acute lung injury (TRALI) and other forms of acute respiratory distress syndrome (ARDS). The interactions between transfusion, mechanical ventilation, TRALI and ARDS are complex and other patient-related (e.g., presence of sepsis or shock, disease severity, and hypervolemia) or blood product-related (e.g., presence of antibodies or biologi‑ cally active mediators) factors also play a role. We propose several strategies targeted at these factors that may help limit the risks of associated lung injury in critically ill patients being considered for transfusion. Keywords: Acute respiratory distress syndrome, Anemia, Hypervolemia, Inflammatory response, Oxygen delivery, Transfusion-associated circulatory overload, Transfusion-related acute lung injury Introduction Anemia is a hallmark of critical illness, eliciting the frequent administration of red blood cell (RBC) transfusion to critically ill patients. RBC transfusion in this setting can be beneficial (Table 1). Indeed, as arterial oxygen content (CaO2) is a primary determinant of oxygen delivery (DO2), RBC transfusion can be an effective way to increase DO2 when there is impaired tissue perfusion. A recent review indicated that an increase in DO2 after transfusion was associated with an increase in oxygen consumption ( VO2) [1]. This effect may also be helpful in severe hypoxemia, including in patients requiring mechanical ventilation or extracorporeal membrane oxygenation (ECMO) [2]. However, blood transfusions can also have important and even life-threatening complications (Table 1). In some patients, the benefits of RBC *Correspondence: [email protected] 9 Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium Full author information is available at the end of the article
transfusion may outweigh its adverse effects and improve outcomes, but the conundrum is that there are currently no clear methods to determine which patients will benefit from an RBC transfusion and which patients are at risk of harm [3, 4]. Although the indications for transfusion are less liberal than in the past, one in four patients still receives a RBC transfusion during their intensive care unit (ICU) stay [5, 6]. Thus, RBC transfusion remains an important intervention in the ICU. Transfusions are more often administered to the sickest patients [5], whom are also the most likely to be mechanically ventilated. Transfusion and mechanical ventilation can b
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