Australian and New Zealand Intensive Care Society
Recommendations from the College of Intensive Care Medicine & the Australian and New Zealand Intensive Care Society on end-of-life care, invasive devices, anaemia, sedation & antibiotics. The Australian and New Zealand Intensive Care Society is the leading advocate on all intensive care related matters. ANZICS leads the world in intensive care research through its Clinical Trials Group and patient databases, including the Adult Patient Database, the Paediatric Intensive Care Registry and Critical Care Resources.
Transfuse red cells for anaemia only if the haemoglobin concentration is less than 70gm/L or if the patient is haemodynamically unstable or has significant cardiovascular or respiratory comorbidity.
Numerous studies have highlighted the adverse outcomes that may be associated with blood transfusion. Randomised and other trials have indicated that transfusion of red blood cells for the treatment of anaemia in otherwise haemodynamically stable patients is either of no benefit or even harmful. There appears to be little or no proven benefit of transfusing beyond a threshold haemoglobin level of 70gm/L though the precise threshold for any given patient is unknown. Patients with active cardio-respiratory disease or neurological injury may warrant a higher threshold although harm associated with liberal transfusion in this group has also been reported.
- Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. New England Journal of Medicine 2011;365(26):2453-62.
- Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999;340:409-417 [Erratum, N Engl J Med 1999;340:1056].
- Hajjar LA, Vincent JL, Galas FR, Nakamura RE, Silva CM, Santos MH, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA 2010;304 1559-67.
- Chatterjee S, Wetterslev J, Sharma A, Lichstein E, Mukherjee D. Association of blood transfusion with increased mortality in myocardial infarction: a meta-analysis and diversity-adjusted study sequential analysis. JAMA Intern Med 2013;173:132-9.
- Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C. Transfusion strategies for acute upper gastrointestinal bleeding. New England Journal of Medicine 2013;368(1):11-21.
- Holst LB, Haase N, Wetterslev J, Wernerman J, Guttormsen AB, Karlsson S, Johansson PI, Åneman A, Vang ML, Winding R, Nebrich L. Lower versus higher hemoglobin threshold for transfusion in septic shock. New England Journal of Medicine 2014;371(15):1381-91.
- Boutin A, Chassé M, Shemilt M, Lauzier F, Moore L, Zarychanski R, Griesdale D, Desjardins P, Lacroix J, Fergusson D, Turgeon AF. Red blood cell transfusion in patients with traumatic brain injury: a systematic review and meta-analysis. Transfusion Medicine Reviews 2016;30(1):15-24.
- Griesdale DE, Sekhon MS, Menon DK, Lavinio A, Donnelly J, Robba C, Sekhon IS, Taylor A, Henderson WR, Turgeon AF, Gupta AK. Hemoglobin area and time index above 90 g/L are associated with improved 6-month functional outcomes in patients with severe traumatic brain injury. Neurocritical Care 2015;23(1):78-84.
- National Blood Authority Australia: Patient Blood Management Guidelines 2012 Module 4- Critical Care http://www.blood.gov.au/system/files/documents/pbm-module-4.pdf
- National Blood Authority Australia The Patient Blood Management Guidelines Companion Restrictive Transfusion Strategy http://www.blood.gov.au/system/files/documents/companion-24-pbm-guidelines.pdf
A working group of interested parties from both CICM and ANZICS was formed to develop a list of 12 items that they believe should be focused on to reduce the number of unnecessary tests and interventions performed in intensive care. All CICM Fellows and ANZICS members were surveyed to develop a consensus view of a final list of five items. There were 6 items clearly favoured and two of these were combined by the working group to develop the final 5 recommendations.
For patients with limited life expectancy (such as advanced cardiac, renal or respiratory failure, metastatic malignancy, third line chemotherapy) ensure patients have a ‘goals of care’ discussion at or prior to admission to ICU and for patients in ICU who are at high risk for death or severely impaired functional recovery, ensure that alternative care focused predominantly on comfort and dignity is offered to patients and their families.
- 2 Remove all invasive devices, such as intravascular lines and urinary catheters, as soon as possible.
- 3 Transfuse red cells for anaemia only if the haemoglobin concentration is less than 70gm/L or if the patient is haemodynamically unstable or has significant cardiovascular or respiratory comorbidity.
- 4 Undertake daily attempts to lighten sedation in ventilated patients unless specifically contraindicated and deeply sedate mechanically ventilated patients only if there is a specific indication.
- 5 Consider antibiotic de-escalation daily.