Anemia in the Long-term Ventilator-Dependent Patient With Respiratory Failure

doi:10.1378/chest.128.5_suppl_2.568S

Chest

Volume 128, Issue 5, Supplement 2, November 2005, Pages 568S-575S

https://doi.org/10.1378/chest.128.5_suppl_2.568S Get rights and content

Anemia occurs in virtually all critically ill patients receiving long-term mechanical ventilation and has been associated with increased mortality and poor outcomes. Allogeneic RBC transfusions are routinely administered to critically ill anemic patients, especially during lengthy stays in ICUs or in long-term acute care facilities. Although RBC transfusions are a physiologically rational approach to raising hemoglobin levels, they may increase the risk of complications and have been associated with higher mortality in critically ill patients. Treatment with epoetin alfa, an erythropoiesis-stimulating agent, as a means of reducing transfusion requirements has been studied in the critically ill and in patients receiving long-term mechanical ventilation. Promising results have been reported, including a potential survival benefit, although larger and more definitive studies are needed in order to establish whether raising hemoglobin levels affects clinical outcomes in patients receiving mechanical ventilation.

Learning Objectives

1. To understand the risks and benefits of managing, with RBC transfusions, the increased oxygen requirements of anemic patients receiving mechanical ventilation. 2. To review data regarding epoetin alfa as a potential transfusion alternative in long-term acute care patients. 3. To discuss predictive variables for the possibility of weaning and time to wean from long-term mechanical ventilation.

Section snippets

Anemia and Transfusion Practice in the ICU

Anemia is a common comorbid condition in the ICU. In virtually all critically ill patients, hemoglobin levels are either below normal at the time of admission or decline during the course of an ICU stay.1, 2, 3, 4 In studies1, 3 of anemia and transfusion practices in the critically ill, patients with lower hemoglobin levels were more likely to receive RBC transfusions; had a higher incidence of hemodynamic instability, sepsis, GI bleeding, and complication rates; and had a higher risk of

Infection

Patients who receive allogeneic blood experience increased morbidity and longer and more costly hospital stays.¹⁸ Among the risks associated with allogeneic RBC transfusions are viral infections (most commonly hepatitis)19, 20, 21, 22 and bacterial infections.23, 24 Fortunately, the risk of acquiring an infection directly from a blood transfusion is now lower than in the past.¹² The lowered risk has resulted from the implementation of more comprehensive testing, increasingly stringent donor

Do RBC Transfusions Improve Outcomes in Some Critically Ill Patients?

Specifically designed to investigate transfusion outcomes in ICU patients, the Transfusion Requirements in Critical Care trial conducted by Hebert and colleagues² randomly assigned patients to receive RBC transfusions based on a restrictive strategy (transfusion initiated at hemoglobin level of 7.0 g/dL and maintained between 7.0 g/dL and 9.0 g/dL) or a liberal strategy (transfusion initiated at hemoglobin level of 10.0 g/dL and maintained between 10.0 g/dL and 12.0 g/dL). Overall, 30-day

Treatment of Anemia With Epoetin Alfa in Patients Receiving Long-term Acute Care

In light of the evidence that the benefits of transfusions may not outweigh their risks, treatment of anemia with an erythropoietic agent may be an alternative strategy in critically ill patients. To investigate this concept, a randomized, double-blind, placebo-controlled, two-center trial⁵⁴ was conducted in patients who had been transferred to long-term acute care (LTAC) facilities. The study was designed primarily to evaluate the cumulative number of RBC units transfused in epoetin

Does Treating Anemia Affect Weaning From Mechanical Ventilation?

Maintaining critically ill patients on long-term mechanical ventilation has economic implications, and thus an understanding of the key predictive variables for the possibility of weaning and the time to wean is of considerable interest. We therefore undertook a study to examine the electronic medical records from 3,001 consecutive patients receiving mechanical ventilation from five LTAC facilities.⁶⁶ This data set comprises the largest patient population utilized for this type of statistical

Conclusion

Anemia is common in critically ill patients receiving long-term mechanical ventilation. Although it is possible that treatment of anemia may have a positive impact on outcomes, further study is required. The traditional approach to managing critically ill patients with low hemoglobin levels has been to administer RBC transfusions. Evidence has emerged that RBC transfusions pose a variety of risks, including an increased risk of pulmonary complications in patients receiving mechanical

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Cited by (19)

Ventilator-dependent survivors of catastrophic illness transferred to 23 long-term care hospitals for weaning from prolonged mechanical ventilation
2007, Chest
Citation Excerpt :
The etiology of hypoalbuminemia on LTCH admission is most likely multifactorial, with the catabolic effects of the inflammatory response, difficulties with provision of nutrition in the ICU, and fluid balance (overload) playing roles in most patients. Anemia, as evidenced by low mean hematocrit, is a common comorbid condition in the ICU, and is found in virtually all critically ill patients.20 Sustained severe illness, abnormal gastric emptying, as well as debility and altered sensorium, account for the high rate of percutaneous feeding.
Study objectives:This multicenter study was undertaken to characterize the population of ventilator-dependent patients admitted to long-term care hospitals (LTCHs) for weaning from mechanical ventilation.
Design:Observational study with concurrent data collection. Characteristics of the LTCHs were also surveyed.
Setting:Twenty-three LTCHs in the United States.
Patients:Consecutive ventilator-dependent patients admitted over a 1-year period: March 1, 2002, to February 28, 2003.
Results:A total of 1,419 patients were enrolled in the Ventilation Outcomes Study. Median age of the patients was 71.8 years old (range, 18 to 97.7 years), with an equal gender distribution. The premorbid domicile was home or assisted living in 86.5%; “good” premorbid functional status (Zubrod score 0–2) was assessed in 77%. There was a history of smoking in 59% (mean, 57 ± 42 pack-years [± SD]); premorbid diagnoses averaged 2.6 per patient. Patients came to the LTCH after mean of 33.8 ± 29 days at the transferring hospital; mean time to tracheotomy was 15.0 ± 10 days. A medical illness led to ventilator dependency in 60.8% of patients; a surgical procedure led to ventilatory dependency in 39.2%. On admission to the LTCH, the median acute physiology score of APACHE (acute physiology and chronic health evaluation) III was 35 (range, 4 to 115); > 90% of patients had at least three penetrating indwelling tubes/catheters; 42% of patients had stage 2 or higher pressure ulceration.
Conclusions:This is the first multicenter study to characterize ventilator-dependent survivors of catastrophic illness admitted to the post-ICU venue of LTCHs for weaning from prolonged mechanical ventilation (PMV). Overall, our findings suggest that ventilator-dependent patients admitted to LTCHs for weaning will continue to require considerable medical interventions and treatments, owing to the burden of acute-on-chronic diseases resulting in PMV.
Pharmaceutical industry sponsorship of journal supplements [1]
2006, Chest
S2k-Guideline Published by the german respiratory society
2019, Pneumologie
Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care
2009, Critical Care Medicine
To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care.
Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members.
This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM.
Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion.
Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.
Effect of Hemoglobin Levels on the Success of Weaning and Extubation Processes in Critical Patients with Mechanical Ventilation: a systematic review
2023, Bali Journal of Anesthesiology
Personalizing Medication Recommendation with a Graph-Based Approach
2022, ACM Transactions on Information Systems

View all citing articles on Scopus

The following authors have indicated to the ACCP that no significant relationships exist with any company/organization whose products or services may be discussed in their article: Michael R. Silver, MD, FCCP.

The following authors have disclosed that he or she may be discussing information about a product/procedure/technique that is considered research and is not yet approved for any purpose: Michael R. Silver, MD, FCCP: Use of erythropoeitin in chronically critically ill patients.

This publication was supported by an educational grant from Ortho Biotech Products, L.P.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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Chest

Anemia in the Long-term Ventilator-Dependent Patient With Respiratory Failure

Learning Objectives

Section snippets

Anemia and Transfusion Practice in the ICU

Infection

Do RBC Transfusions Improve Outcomes in Some Critically Ill Patients?

Treatment of Anemia With Epoetin Alfa in Patients Receiving Long-term Acute Care

Does Treating Anemia Affect Weaning From Mechanical Ventilation?

Conclusion

Lancet

Chest

Chest

Transfus Sci

Am J Surg

Hum Immunol

Blood

Blood Rev

Am J Med

Chest

J Crit Care

Eur J Intern Med

Chest

Does transfusion practice affect mortality in critically ill patients?

Am J Respir Crit Care Med

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

The CRIT study: anemia and blood transfusion in the critically ill; current clinical practice in the United States

Crit Care Med

Anemia in the intensive care unit

Can J Anaesth

Perioperative determinants of morbidity and mortality in elderly patients undergoing cardiac surgery

Crit Care Med

A practice guideline and decision aid for blood transfusion

Immunohematology

Anemia and blood transfusion in critically ill patients

JAMA

Transfusion and surgery

Curr Probl Surg

Transfusion medicine: first of two parts; blood transfusion

N Engl J Med

Effects of transfusion on immune function: cancer recurrence and infection

Arch Pathol Lab Med

Blood transfusion-induced immunomodulation

Anesth Analg

The immunosuppressive aspects of blood transfusion

J Intensive Care Med

Effect of stored-blood transfusion on oxygen delivery in patients with sepsis

JAMA

Allogeneic blood transfusion, hospital charges, and length of hospitalization: a study of 487 consecutive patients undergoing colorectal cancer resection

Arch Pathol Lab Med

Basic and clinical immunology

Estimated risk of transmission of the human immunodeficiency virus by screened blood in the United States

N Engl J Med

The risk of transfusion-transmitted viral infections: the Retrovirus Epidemiology Donor Study

N Engl J Med

Transfusion-transmitted infections: update

Semin Hematol

A prospective microbiologic surveillance program to detect and prevent the transfusion of bacterially contaminated platelets

Transfusion

Risk of bacterial infection associated with allogeneic blood transfusion among patients undergoing hip fracture repair

Transfusion

NAT and blood safety: what is the paradigm?

Transfusion