Neriman Defne ALTINTAŞ, Ekin Yiğit KÖROĞLU

Kritik Hastada Transfüzyon İlkeleri ve Transfüzyon Reaksiyonları

Kan ürünlerinin transfüzyonu kritik hastalarda sıklıkla uygulanan işlemlerdendir. Başlıca eritrosit süspansiyonu, trombosit süspansiyonu ve tazedonmuş plazma transfüzyonları yapılmaktadır. Hastaların sağ kalımına ve iyileşme sürecine olumlu etkileri bulunan bu işlemlerin aynı zamandayan etkiler oluşturarak, morbiditeyi ve mortaliteyi artırabileceği unutulmamalıdır. Bu nedenle, transfüzyon endikasyonlarının doğru belirlenmesi vehasta özelliklerine göre hedef belirlenmesi gerekmektedir. Bu doğrultuda yapılmış olan birçok çalışma bulunmaktadır. Bu çalışmalar sonucunda, bazırehberler oluşturulmuştur. Bu çalışmalar ve bu rehberler aracılığıyla gereksiz transfüzyondan kaçınılması ve transfüzyondan azami fayda sağlanmasıamaçlanmaktadır. Eritrosit süspansiyonu transfüzyonunda, genel popülasyonda, hedef hemoglobin eşiğini yüksek tutmanın, eşiği düşük tutmaya birüstünlüğü gösterilmemiştir. Ayrıca, septik hastalar ve kardiyovasküler ko-morbiditeli hastalarda hedef hemoglobin düzeylerinin bireyselleştirilmesidaha uygun görünmektedir. Trombosit transfüzyonu için hastanın spontan kanama riski veya yapılacak olası işlemler sırasındaki kanama riski gözönünde bulundurularak transfüzyon kararı verilmelidir. Kanama riski düşük olan veya risk olmayan olgularda transfüzyondan kaçınılmalıdır. Tazedonmuş plazma transfüzyonu, doğru endikasyonlarda uygulanmalı ve kanama riskine göre yapılmalıdır. Bütün kan ürünleri transfüzyonları sırasındave sonrasında transfüzyon reaksiyonları gelişebileceği bilinmeli; bunlara karşı uygun önlemler alınmalı ve gerektiğinde uygun tedavi başlanmalıdır.

Transfusion Principles in Critically Ill Patients and Transfusion Reactions

Blood product transfusions are frequently performed during critical illnesses. Primarily; erythrocyte suspension, platelet suspension and fresh frozen plasma transfusions are performed. It should not be forgotten that these procedures, which have positive effects on the survival and healing process of patients, may also cause side effects and increase morbidity and mortality. Therefore, it is necessary to determine the indications of transfusions correctly and determine the goals according to the patient characteristics. There are many studies done in this regard. In light of these studies, several guidelines have been prepared. Through these studies and these guidelines, avoidance of unnecessary transfusions and optimum benefit in transfusions are aimed. Regarding transfusion of erythrocyte suspensions in the general population, higher target hemoglobin levels have not been shown to be superior to lower target levels. In addition, target hemoglobin levels should be individualized in septic patients and the patients with cardiovascular comorbidities. While giving platelet transfusion, the transfusion decision should be made considering the risk of spontaneous bleeding and the risk of bleeding during possible interventions. The transfusion should be avoided in cases of low bleeding risks or non-risk events. Fresh frozen plasma transfusions should be performed with correct indications and the bleeding risk should be taken into account. During and after transfusion of all blood products transfusion reactions may develop; appropriate precautions should be taken and prompt treatment should be given as needed.

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McIntyre L, Tinmouth AT, Fergusson DA. Blood component transfusion in critically ill patients. Curr Opin Crit Care 2013;19:326-333.
Kor DJ, Gajic O. Blood product transfusion in the critical care setting. Curr Opin Crit Care 2010;16:309-316.
Retter A, Wyncoll D, Pearse R, et al. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Br J Haematol 2013;160:445-464.
Vincent JL, Baron JF, Reinhart K, et al. Anemia and Blood Transfusion in Critically ill Patients. JAMA 2002;288:1499-1507.
Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999;340:409-417.
Holst LB, Haase N, Wetterslev J, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 2014;371:1381- 1391.
Rygard SL, Holst LB, Wetterslev J, et al. Long-term outcomes in patients with septic shock transfused at a lower versus a higher haemoglobin threshold: the TRISS randomised, multicentre clinical trial. Intensive Care Med 2016;42:1685-1694.
Rygard SL, Holst LB, Wetterslev J, et al. Higher vs. lower haemoglobin threshold for transfusion in septic shock: subgroup analyses of the TRISS trial. Acta Anaesthesiol Scand 2017;61:166-175.
Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA 2016;316:2025-2035.
Hébert PC, Yetisir E, Martin C, et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med 2001;29:227-234.
Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011;365:2453-2462.
Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA 2010;304:1559- 1567.
Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery. N Engl J Med 2017;377:2133-2144.
Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017;43:304-377.
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368- 1377.
Thachil J, Warkentin TE. How do we approach thrombocytopenia in critically ill patients? Br J Haematol 2017;177:27-38.
Stanworth SJ, Estcourt LJ, Powter G, et al. A no-prophylaxis platelettransfusion strategy for hematologic cancers. N Engl J Med 2013;368:1771- 1780.
Zeidler K, Arn K, Senn O, et al. Optimal preprocedural platelet transfusion threshold for central venous catheter insertions in patients with thrombocytopenia. Transfusion 2011;51:2269-2276.
Walsh TS, Stanworth SJ, Prescott RJ, et al. Prevalence, management, and outcomes of critically ill patients with prothrombin time prolongation in United Kingdom intensive care units. Crit Care Med 2010;38:1939-1946.
Holland LL, Brooks JP. Toward rational fresh frozen plasma transfusion: the effect of plasma transfusion on coagulation test results. Am J Clin Pathol 2006;126:133-139.
Watson GA, Sperry JL, Rosengart MR, et al. Fresh frozen plasma is independently associated with a higher risk of multiple organ failure and acute respiratory distress syndrome. J Trauma 2009;67:221-227.
Segal JB, Dzik WH; Transfusion Medicine/Hemostasis Clinical Trials Network. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Transfusion 2005;45:1413-1425.
Veelo DP, Vlaar AP, Dongelmans DA, et al. Correction of subclinical coagulation disorders before percutaneous dilatational tracheotomy. Blood Transfus 2012;10:213-220.
Yildirim F, Tuncer B, Ozbakkaloglu A, et al. Thromboelastogram reduces blood use by inspecting coagulation in heart surgery. Asian Cardiovasc Thorac Ann 2016;24:441-444.
Stanworth SJ, Walsh TS, Prescott RJ, et al. A national study of plasma use in critical care: clinical indications, dose and effect on prothrombin time. Crit Care 2011;15:108.
Sezik S, Aksay E, Kılıç TY. The effect of fresh frozen plasma transfusion on international normalized ratio in emergency department patients. J Emerg Med 2014;47:596-600.
Nascimento B, Goodnough LT, Levy JH. Cryoprecipitate therapy. Br J Anaesth 2014;113:922-934.
Pantanowitz L, Kruskall MS, Uhl L. Cryoprecipitate. Patterns of use. Am J Clin Pathol 2003;119:874-881.
Delaney M, Wendel S, Bercovitz RS, et al. Transfusion reactions: prevention, diagnosis, and treatment. Lancet 2016;388:2825-2836.
Weinstock C, Möhle R, Dorn C, et al. Successful use of eculizumab for treatment of an acute hemolytic reaction after ABO-incompatible red blood cell transfusion. Transfusion 2015;55:605-610.
Fredlund H, Berséus O, Björsell-Ostlilng E, et al. A retrospective study of acute plasma exchange in severe intravascular hemolysis. Eur J Haematol 1989;43:259-261.
Kohan AI, Niborski RC, Rey JA, et al. High-dose intravenous immunoglobulin in non-ABO transfusion incompatibility. Vox Sang 1994;67:195-198.
Agbaht K, Altintas ND, Topeli A, et al. Transfusion-associated graft-versushost disease in immunocompetent patients: case series and review of the literature. Transfusion 2007;47:1405-1411.