Understanding Blood Transfusion Strategies in Critical Care

On Episode 48 of Inside the Studio, Dr. Sri Kartik Valluri sits down with Dr. Jeffrey L. Carson following Grand Rounds at The Texas Heart Institute to discuss new insights on transfusion practices in cardiovascular care.

Highlights:

• Review of the MINT trial and other key studies
• Shift from restrictive to more liberal transfusion strategies
• Importance of individualized treatment for patients with AMI and post-cardiotomy status
• The role of clinical judgment in applying evolving evidence
• Future research directions in patients with cardiovascular disease

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Transcript

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Hello

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Everyone. Welcome to another

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episode of Inside the Studio.

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My name is Sri Kartik Uri.

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I am a cardiovascular critical care, uh,

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physician here at Baylor St.

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Luke's, THI.

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And I will be speaking with Dr. Carson, uh,

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who has given us grand rounds today

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regarding blood components

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and how low the threshold can go in

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the aftermath of your talk.

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What I've got from it was pretty much

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multiple trials have been conducted

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regarding blood transfusion thresholds

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or multiple recommendations.

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Uh, and there's a lot more data

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that we still need in specific,

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in specific subgroups when it comes

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to cardiovascular critical care.

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Um, I have patients who have acute mis,

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which I know is significant with the mint trial,

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and I have patients who are post cardiotomy,

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whichever cabbages or whatever, uh,

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which might require more.

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And one of the things that you said at the,

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in the mid middle part of your thing,

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and you said it's the most important slide,

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is the clinical context.

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Can you explain that to me in a little bit more detail?

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So look, these trials were designed

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with two thresholds usually, and,

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and, you know, are those numbers the perfect numbers?

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I don't know, but that's what the trials were designed

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to evaluate.

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It's likely that your individual patient has unique

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physiology, unique under com, underlying comorbidity,

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maybe doesn't want blood or,

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or would be happy to take blood.

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So individualizing your treatment makes

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clinical common sense.

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And uh, and, and, and,

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and that's why we always emphasize that.

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Having said that, I don't have evidence

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to tell you exactly how to do that.

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You know, should you weigh the blood pressure?

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Should you weigh the pulse, you know, in, in, in the,

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in acute MI patients.

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What about the, you know, the, the cath results

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and what's vascularized and what's un vascularized?

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I mean, those are all variables

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that you would clinically make common.

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It would be common sense

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that you would consider in your decision making.

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I don't know exactly how to weigh those things,

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but I think in the end, so much of what we do in,

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in clinical practices,

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we don't have perfect data or for sure.

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And that you try to take the average effects

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that you see in these trials

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and then apply to your individual patient and, and,

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and adjust what you do based on, on, on, on

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that patient's unique situation.

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Great, thank you. But you know, since training,

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since residency, not myself in general, the culture is

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that restricted.

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Keep it you only when we hit the seven mark do you give it,

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but today's talk was that you see there's more

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of a shift more toward a liberal aspect to, uh,

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these transfusion thresholds.

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Can you explain for a confused clinic?

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Well, there's new data, what Do we

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Do? There's new

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data, so, you know, like all the data up

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to this point said less is fine.

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Okay. And now there's new data in acute MI

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and there's new data in neurocritical care patients as well.

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There's three big trials, two in New England, one in jama,

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and, and they trend towards more blood liberal

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being helpful in that group.

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So, you know, research advances our knowledge

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and we, we need to keep our best, we need to try as hard

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as we can to keep up with the latest information

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and then adjust what we're doing.

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And I think in your unit

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where you have cardiac surgery patients

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and you have acute MI patients, it means you have

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to look at your individual cases,

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what their underlying diseases and the,

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and the data that applies to each of that subgroup

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of patients is different.

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And, um, so, you know, it's not always easy

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to have just one number.

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I'm afraid that, that, uh, in, in this particular field,

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as we accumulate a lot of trial evidence that, you know,

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that we have to refine our, our approaches.

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And, um, so it it's challenging.

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It's challenging, you know, I'm interested in this,

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you're interested in this,

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but clinicians who have no special interest to

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to know these nuances is hard.

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And, and it's, for us, it's up to us

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to try to teach 'em about it. Okay.

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But we live in a world

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where it's everything's protocol, protocol, protocol, right?

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We're, we're pushed, uh, from a, um, more of an,

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a national standpoint for the, from the corporations

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and the hospital systems to limit our transfusion rate.

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But you said the difference between, uh,

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liberal strategy and restrictive strategy.

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What's the non-inferiority aspect of it?

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Why don't we just stick to the restrictive?

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Well, at least in acute MI patients live longer

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and have less recurrent mis That's a good reason.

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Look, you know, all our, all our communities,

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all our hospital systems, um, you know, uh, we're trying

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to do this most efficiently.

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We're trying to keep our expenses down and uh,

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but improving our patient's outcome is always

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first and paramount.

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And, and in the end, um, you know, the extra blood

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that would be used in, in, if you were

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to adopt a more liberal approach in acute MI is a pretty

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small amount of extra expenses

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for an institution of this size.

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Um, it, it, it won't be that impactful.

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Um, and I think what matters most is

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that these patients do better clinically,

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and when patients do better clinically, they almost cost,

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they almost always cost less money because they're more

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or less likely to, to come back.

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They're, you know, into the hospital

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and have other complications.

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So that's always a secondary consideration.

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Um, just do what's best for our patients.

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Alright. Um, and then finally, uh, when I ask you, uh,

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you are an actively practicing clinician as well, right?

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Um, what is your approach

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to seeing the variations in your patients?

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Do you follow strictly the study that you've, uh, authored

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or do you go off of it?

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What, what, where do you, uh, sort

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of modulate your clinical practice based on data?

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Yeah, so, so what I,

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the way I think about this is the trial data gives us an

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average effect in a population.

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And I take that data as my starting point.

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And then I look at the patients and I'm,

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and I'm looking at them individually,

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just like I emphasized a moment ago.

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You know, how are they feeling?

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What are their si, what are their symptoms?

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You know, what's their blood pressure look like?

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What's their pulse look like?

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You know, what's their underlying co comorbidity?

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What's their, you know, their personal preferences?

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And, and then I factor all into that, uh, as to what I do.

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It's a subjective way of, uh, you know, there's a,

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there's some subjectiveness to this, no doubt.

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So, you know, we call clinical judgment, right?

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Right, right. Yeah. We call it clinical judgment

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and, you know, we all try to do the very best

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for our patients, but I, I start with the trial data

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and then I refine

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what I do in an individual patient based

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upon their circumstances. So

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That would be the advice I would give someone else

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who asked me and if they're in a conundrum

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regarding the situation.

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Yeah. Uh, what's next?

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We have another grant from the NIH, um, in which we're,

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we're, we're looking at patients

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with preexisting cardiovascular disease.

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So the way I characterize these patients is one is

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patients with acute mi, the second group is patients

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undergoing cardiac surgery.

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And then probably the largest group are patients in the

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middle who have some evidence

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for preexisting cardiovascular disease.

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And the question is, you know,

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how should you transfuse those patients?

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The cardiac surgery ones, you can let 'em go low, right?

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To seven and a half in the trials in the MI setting.

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I think the trial data suggests

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that you should keep them higher.

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Now what about this other group?

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So we're gonna be doing an individual patient data

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meta-analysis in which we're, we're, we're,

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we're getting all the trials, well, as many trials

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as we're able to get that enrolled.

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Patients in the transfusion thresholds

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comparing liberal and restrictive.

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And we're gonna look at those patients who have, uh,

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underlying cardiovascular disease

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and compare them to patients without cardiovascular disease

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and see whether liberal or restrictive transfusion strategy

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influences their outcome.

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Awesome. So that's our, that's our next project

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and we're hard at work on that.

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And, uh, hopefully we'll have some

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results for you in a couple years.

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And that will apply to my field. Yes.

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Clinically Yes, for

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Sure. Looking forward to it.

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Thank you very much, sir.

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Yeah, you're welcome. Alright.