Blood products play key roles in the ICU, but determining which products are most appropriate to transfuse into which critically ill patients can be an unclear decision hedged by unknowns and controversies. Anemia and coagulopathy both present daily challenges that might be managed using a variety of red cells, platelets, and coagulation factors.
“With coagulation factors in particular, there is controversy regarding who needs to be transfused prophylactically prior to a procedure,” said Ashley Marie Scott, MD, pulmonary and critical care medicine fellow at the University of Arizona College of Medicine. “For example, guidelines from the interventional radiology and GI societies conflict. With so many of our ICU patients having some degree of coagulopathy, it is a very practical, everyday problem.”
Dr. Scott will discuss the current evidence for and against the administration of different coagulation factors prior to ICU procedures as part of a panel discussion on the Use of Blood Products in the ICU on Wednesday, October 19, from 8:00 am – 9:00 am CT in Room 102AB. Session Chair Daniel Ouellette, MD, MS, FCCP, associate director of medical critical care at Henry Ford Hospital, will explore the role of red blood cell transfusions in critically ill patients with cardiac disease.
Patrick Bradley, MD, pulmonary and critical care specialist at Henry Ford Hospital, will discuss the latest evidence for platelet transfusions in the ICU. Mary Jane Reed, MD, FCCP, critical care specialist, Geisinger Medical Center, will explore approaches to managing massive red blood cell transfusion protocols in the ICU.
Patient factors play important roles in all of these decisions, Dr. Scott said. Many patients are receiving some sort of anticoagulation before being admitted to the ICU. Some have subtherapeutic levels, others supratherapeutic. Additionally, coagulation status can be influenced by the presence of cirrhosis, immune disorders, nutrition, and other individual factors.
“The reality is that some patients really do need prophylactic blood products to make ICU procedures safer,” Dr. Scott said. “But on the flip side, there is growing evidence suggesting that, for example, INRs in patients with cirrhosis are not reflective of their true coagulopathy.”
Some studies and society guidelines suggest that paracentesis in a cirrhotic patient is safe without the use of prophylactic coagulation factors, even if the INR is elevated, she noted, while other guidelines recommend prophylactic coagulation factors for an INR of 1.5 or greater.
“Those with cirrhosis and most critically ill patients in general are vulnerable to volume overload and prone to hyperinflammatory responses, so there is a potential for harm caused by unnecessary blood product administration,” Dr. Scott explained. “But, you also want to be sure to not miss those patients who could benefit. Clinical practice varies dramatically; some institutions focus more on hepatology guidelines, others on interventional radiology guidelines. Some pay attention to INR, though not as stringently as the IR guidelines suggest.
“This session pertains to our daily practice. With conflicting guidelines, clinicians are making this up as they go along. We are here to help our colleagues more judiciously figure out who should receive blood products.”