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Research Article | Volume 15 Issue 1 (Jan - Feb, 2025) | Pages 372 - 376
A Cross-Sectional Study on Utilization of Blood Components Among Adult Patients Admitted Under the Intensive Care Unit of a Tertiary Care Center
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1
Senior Resident, MD Pathology, Department of Pathology, Gouri Devi Medical College, Durgapur, West Bengal 713212.
2
DM Resident Cardiology, MD Medicine, Department of Cardiology, Rajendra Institute of Medical Sciences, Ranchi Jharkhand 834009
3
Proffessor and HOD, MP Pathology, Department of Pathology, IQ City Medical College Hospital, Durgapur, West Bengal 713206
4
Professor KHOD, DM Cardiology, Department of Cardiology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand 834009
Under a Creative Commons license
Open Access
Received
Dec. 29, 2024
Revised
Jan. 3, 2025
Accepted
Jan. 20, 2025
Published
Jan. 30, 2025
Abstract

Introduction: Critically sick patients admitted to the Intensive Care Unit (ICU) frequently suffer from anemia. Anemia is defined by the World Health Organization (WHO) as hemoglobin (Hb) < 13g/dl in men and < 12g/dl in women. Aims: To evaluate the morbidity and mortality of adult transfused patients and to establish transfusion protocols for all components—PC, FFP, and PLTC—among critically sick patients. Materials & Methods: The present study was a hospital based observational descriptive study. This Study was conducted from eighteen months after ethical clearance from March 2021 to September 2022 at ICU, IQ CITY Medical College and Hospital, Durgapur. Total 218 patients were included in this study. Result: Out of 44 (80.0%) patients who died had received PRBC transfusion, 1 (1.8%) who died patient had received PRBC+FFP transfusion, 1 (1.8%) patient who died patient had CRBC+FFP+PC transfusion, 8 (14.5%) patients who died had FFP transfusion, and 1 (1.8%) patient who died had PC transfusion. Association of BLOOD COMPONENT with Mortality was not statistically significant (p=0.0634) as shown in table 25 and figure 22. Conclusion: We came to the conclusion that, even if blood transfusions are essential in intensive care units, it is crucial to use blood components with caution, evidence, and individualization. This would guarantee that blood products are utilized safely and effectively in critically ill patients, minimize possible dangers, and improve patient care.

Keywords
INTRODUCTION

Critically sick patients admitted to the Intensive Care Unit (ICU) frequently suffer from anemia. Anemia is defined by the World Health Organization (WHO) as hemoglobin (Hb) < 13g/dl in men and < 12g/dl in women [1]. Red blood cell transfusion is often administered to improve oxygen content and hence restore adequate oxygen reserve [2]. Additionally, RBC transfusion is linked to acute lung injury, transfusion-related immunomodulation, alloimmunization, and microcirculatory dysfunction, all of which increase mortality, lengthen hospital stays, and cause sepsis organ failure [2]. Numerous studies have attested to risks outweighing the benefits of such transfusion. Few studies document that increase in anaemia was assosciated with increase in mortality rates in patients with ischaemic heart desease(Carson , Herbert ) .

 

Much controversy exists on fresh frozen plasma transfusion. Widely regarded as an unfailing measure to correct prolonged coagulation tests, transfusion of fresh frozen plasma as been shown to be of little help to rectify mild increments of INR [3]. The main indications of FFP transfusion is heavy bleeding and to control bleeding in planned invasive procedure.

 

Common risks assosciated with FFP include transfusion associated acute injury, transfusion assosciated circulatory overload, allergic or anaphylactic reactions, transmission of infections and others though most of the adverse reactions are not lethal (suchitra pandey et al2012)[4].

 

Thrombocytopenia is common in ICU. Patients admitted to ICU have a 35-45% incidence of developing thrombocytopenia and 15-30%may be administered the platelet component. Platelet content are transfused to alleviate the risk of bleeding in complex coagulation defects, anticipated surgery in patients taking antiplatelet agents or with renal insufficiency. Platelet concenterates are subject to stress injury and modulation during collection, preparation and storage Potential side effects include alloimmunisation, thrombosis, sepsis, transfusion related acute lung injury. There remain limited studies examining the clinical impacts of platelet concentrate transfusion in critically ill patients [5].

 

To define transfusion practices regarding all components viz PC, FFP and PLTC among critically ill patients and to assess morbidity and mortality among adult transfused patients.

MATERIALS AND METHODS

Type of study: The study was Hospital based observational descriptive study.

 

Study design: The study was longitudinal in design.

 

Place of study: The study was done conducted in ICU, IQ CITY Medical College and Hospital, Durgapur.

 

Period of study: The study was done for eighteen months after ethical clearance from March 2021 to September 2022.

 

Study population: The study was done on patients admitted in ICU of IQ CITY Medical College & Hospital, Durgapur and receiving one or more blood components i.e PRBC, FFP, PC.

 

Study setting: The study was conducted in ICU at IQ CITY Medical College and Hospital, Durgapur. IQ City Medical College and Narayana Multispecialty Hospital is a private medical college located in Durgapur. The number of beds in ICU is ten.

 

Sample size: Total 250 patients of more than 18 years age admitted in ICU and receiving blood component transfusion were selected as cases.

 

Inclusion criteria

  1. Age 18 years and above, either sex.
  2. Minimum 24 hours admission in ICU.
  3. Patient receiving any component transfusion (PRBC, PC and FFP).

Exclusion criteria

  1. Transfusion outside the ICU setting
  2. Cases of thalassemia or other morbidities who are obligatory dependent on transfusion of components.
  3. Pregnancy
  4. H/o platelet disorder (e.g. idiopathic thrombocytopenic purpura, congenital thrombocytopenia).
  5. Hematological malignancy.
  6. Use of chemotherapy (in last 30 days prior to admission).
  7. Alcohol abuse.
  8. Hepatic cirrhosis.
  9. Hypersplenism

 

Statistical Analysis:

For statistical analysis, data were initially entered into a Microsoft Excel spreadsheet and then analyzed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism (version 5). Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests, which compare the means of independent or unpaired samples, were used to assess differences between groups. Paired t-tests, which account for the correlation between paired observations, offer greater power than unpaired tests. Chi-square tests (χ² tests) were employed to evaluate hypotheses where the sampling distribution of the test statistic follows a chi-squared distribution under the null hypothesis; Pearson's chi-squared test is often referred to simply as the chi-squared test. For comparisons of unpaired proportions, either the chi-square test or Fisher’s exact test was used, depending on the context. To perform t-tests, the relevant formulae for test statistics, which either exactly follow or closely approximate a t-distribution under the null hypothesis, were applied, with specific degrees of freedom indicated for each test. P-values were determined from Student's t-distribution tables. A p-value ≤ 0.05 was considered statistically significant, leading to the rejection of the null hypothesis in favour of the alternative hypothesis.

RESULTS

Table 1: Association between Blood component: Mortality

MORTALITY

BLOOD COMPONENT

No

YES

TOTAL

PRBC

167

44

211

Row %

79.1

20.9

100

Col %

85.6

80

84.4

PRBC+FFP

3

1

4

Row %

75

25

100

Col %

1.5

1.8

1.6

PRBC+FFP+PC

0

1

1

Row %

0

100

100

Col %

0

1.8

0.4

PRBC+PC

5

0

5

Row %

100

0

100

Col %

2.6

0

2

FFP

11

8

19

Row %

57.9

42.1

100

Col %

5.6

14.5

7.6

PC

9

1

10

Row %

90

10

100

Col %

4.6

1.8

4

TOTAL

195

55

250

Row %

78

22

100

Col %

100

100

100

 

Table 2: Distribution of Hb Group

Hb Group

Frequency

Percent

<7

76

34.90%

>7

142

65.10%

Total

218

100.00%

 

Table 3: Distribution of INR Group

INR Group

Frequency

Percent

≥1.5

25

92.60%

<1.5

2

7.40%

Total

27

100.00%

 

Figure 1: Distribution of MORTALITY

 

Out of 44 (80.0%) patients who died had received PRBC transfusion, 1 (1.8%) who died patient had received PRBC+FFP transfusion, 1 (1.8%) patient who died patient had CRBC+FFP+PC transfusion, 8 (14.5%) patients who died had FFP transfusion, and 1 (1.8%) patient who died had PC transfusion.

 

Association of BLOOD COMPONENT with Mortality was not statistically significant (p=0.0634) as shown in table 25 and figure 22.

 

In our study, 76 (34.9%) patients had ≤7 g/dl Hb and is assigned group 1 that is restrictive group and 142 (65.1%) patients had >7 g/dl Hb and were assigned group 2 that is liberal group as shown in table 8 and figure 6 .

In our study, 25 (92.6%) patients had ≥1.5 INR and were in restrictive Group and (7.4%) patients had <1.5 INR Group and were in liberal group as shown in table 11 and figure 9.

In our study, 55 (22.0%) patients died.

DISCUSSION

In the present study, the total number of patients was similar to studies done by mahambrey at al [6] and vlaar et al.[7] The mean age of patients was consistent with that of similar studies done.

 

The studies had included critically ill patients admitted to ICU. In the study done by Mahambrey et al [6] and Kasotakis et al [8] trauma patients admitted to ICU were included. Karam et al [9] included pediatric patients. In our study we included all critically patients admitted to ICU irrespective of diagnosis.

 

Our study was near to the study made by Zubrow et al [10] in terms of number of blood component transfused.

In study made by Makroo et al , [11] Herbert et al [12] more patients were in liberal group than restrictive group as seen in present study. In study made by Holst et al more patients were in restrictive group. So in our study guidelines for PRBC transfusion were followed in 35% patients.

 

The study made by Sanne de Buin was near to our study and considered 7g/dl as Hb threshold for PRBC transfusion. The study made by Estcourt et al [13] considered 7-9g/dl as Hb level for PRBC transfusion. The study made by Walsh et al and Holst et al randomized patients into two groups, restrictive group had haemoglobin threshold of 7g/l and liberal group had Hb level of 9g/dl while divided patients into restrictive group with Hb level of 7-9g/dl and liberal group with Hb level of 9-12 g/dl.

 

The study made by lauzier et al [14], considered INR level of 1.5 as threshold for FFP transfusion and was near to our study. In our study 25 patients were in restrictive group as compared to 2 people in liberal group. In study made 118 patients were in restrictive group as compared to 103 patients in liberal group. So guidelines for FFP transfusion were followed in more patients.

 

Our study was near to study by Lauralyn A Mcinttyre et al [15], holst et al [16]. Study by & there was not much difference in mortality among restrictive and liberal group. In our study mortality was more in restrictive group.

 

In study made by Lauralyn A Mcinttyre et al [15], Walsh et al [17] it was shown that there was no significant difference between average length of stay in restrictive and liberal group which is contradictory to our study. Our study was similar to study by Estcourt et al.[18] In our study there was significant difference between average length of stay in restrictive and liberal groups (0.0003).

CONCLUSION

We concluded that, while blood transfusions are indispensable in the ICU setting, the careful, evidence-based, and individualized approach to blood component utilization is vital. This will help optimize patient care, reduce potential risks, and ensure that blood products are used effectively and safely in critically ill patients. Further research and continuous monitoring of transfusion practices are essential to improve outcomes and reduce transfusion-related complications.                           

REFERENCES
  1. WHO | Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity [Internet]. WHO. World Health Organization; [cited 2021 Jan 18]. Available from: http://www.who.int/vmnis/indicators/haemoglobin/en/
  2. Akbaş T. Long length of stay in the ICU associates with a high erythrocyte transfusion rate in critically ill patients. J Int Med Res. 2019 May;47(5):1948–57.
  3. Effect of plasma component transfusion on conventional coagulation screening tests Raturi M, Shastry S, Murugesan M, Baliga PB, Chakravarthy K - Asian J Transfus Sci [Internet]. [cited 2021 Jan 8]. Available from: https://www.ajts.org/article.asp?issn=0973- 6247;year=2018;volume=12;issue=1;spage=57;epage=61;aulast=Raturi
  4. Pandey S, Vyas GN. Adverse effects of plasma transfusion. Transfusion (Paris). 2012 May;52 Suppl 1:65S-79S.
  5. Warner MA, Chandran A, Jenkins G, Kor DJ. Prophylactic Plasma Transfusion Is Not Associated With Decreased Red Blood Cell Requirements in Critically Ill Patients. Anesth Analg. 2017;124(5):1636–43.
  6. Mahambrey TD, Fowler RA, Pinto R, Smith TS, Callum JL, Pisani NS, et al. Early massive transfusion in trauma patients: Canadian single-centre retrospective cohort study. Can J Anaesth J Can Anesth. 2009 Oct;56(10):740–50.
  7. Vlaar APJ, in der Maur AL, Binnekade JM, Schultz MJ, Juffermans NP. A survey of physicians’ reasons to transfuse plasma and platelets in the critically ill: a prospective single-centre cohort study. Transfus Med Oxf Engl. 2009 Aug;19(4):207–12.
  8. Kasotakis G, Starr N, Nelson E, Sarkar B, Burke PA, Remick DG, et al. Platelet transfusion increases risk for acute respiratory distress syndrome in non-massively transfused blunt trauma patients. Eur J Trauma Emerg Surg Off Publ Eur Trauma Soc. 2019 Aug;45(4):671– 9.
  9. Karam O, Demaret P, Duhamel A, Shefler A, Spinella PC, Tucci M, et al. Factors influencing plasma transfusion practices in paediatric intensive care units around the world. Vox Sang. 2017 Feb;112(2):140–9.
  10. Zubrow ME, Thomas NJ, Friedman DF, Yehya N. RBC Transfusions Are Associated With Prolonged Mechanical Ventilation in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc. 2018 Feb;19(2):e88–96.
  11. Makroo RN, Mani RK, Vimarsh R, Kansal S, Pushkar K, Tyagi S. Use of blood components in critically ill patients in the medical intensive care unit of a tertiary care hospital. Asian J Transfus Sci. 2009 Jul;3(2):82.
  12. Hébert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, 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 Feb 11;340(6):409–17.
  13. Estcourt LJ, Malouf R, Trivella M, Fergusson DA, Hopewell S, Murphy MF. Restrictive versus liberal red blood cell transfusion strategies for people with haematological malignancies treated with intensive chemotherapy or radiotherapy, or both, with or without haematopoietic stem cell support. Cochrane Database Syst Rev. 2017 Jan 27;1:CD011305.
  14. Fan YX, Liu FF, Jia M, Yang JJ, Shen JC, Zhu GM, et al. Comparison of restrictive and liberal transfusion strategy on postoperative delirium in aged patients following total hip replacement: a preliminary study. Arch Gerontol Geriatr. 2014 Aug;59(1):181–5.
  15. McIntyre LA, Fergusson DA, Hutchison JS, Pagliarello G, Marshall JC, Yetisir E, et al. Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury. Neurocrit Care. 2006;5(1):4–9.
  16. Holst LB, Haase N, Wetterslev J, Wernerman J, Guttormsen AB, Karlsson S, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med. 2014 Oct 9;371(15):1381–91.
  17. Walsh TS, Boyd JA, Watson D, Hope D, Lewis S, Krishan A, et al. Restrictive versus liberal transfusion strategies for older mechanically ventilated critically ill patients: a randomized pilot trial. Crit Care Med. 2013 Oct;41(10):2354–63.
  18. Estcourt LJ, Birchall J, Mumford AD, Stanworth SJ, Tinegate H. Guidelines for the Use of Platelet Transfusions A British Society for Haematology Guideline. :81.
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