Chapter 27 - Blood and blood treatments

Effects of Preoperative Intravenous Erythropoietin Plus Iron on Outcome in Anemic Patients After Cardiac Valve Replacement

Forward This document aims to summarize the current literature guiding the use of red cell transfusion in critically ill patients and provides recommendations to support clinicians in their day-to-day practice. Critically ill patients differ in their age, diagnosis, co-morbidities, and severity of illness. These factors influence their tolerance of anaemia and alter the risk to benefit ratio of transfusion. The optimal management for an individual may not fall clearly within our recommendations and each decision requires a synthesis of the available evidence and the clinical judgment of the treating physician. This guideline relates to the use of red cells to manage anaemia during critical illness when major haemorrhage is not present. A previous British Committee for Standards in Haematology (BCSH) guideline has been published on massive haemorrhage (Stainsby et al, 2006), but this is a rapidly changing field. We recommend readers consult recent guidelines specifically addressing the management of major haemorrhage for evidence-based guidance. A subsequent BCSH guideline will specifically cover the use of plasma components in critically ill patients.

Is minimized extracorporeal circulation effective to reduce the need for red blood cell transfusion in coronary artery bypass grafting? Meta-analysis of randomized controlled trials

See article on page 1093–1101, in this issue

Leukocyte-reduced blood transfusions: perioperative indications, adverse effects, and cost analysis.

Extended Rhesus and Kell Phenotype-Matched Red Blood Cell (RBC) Transfusions Reduce RBC Alloimmunization and RBC Transfusion Burden in Patients with Myeloid Neoplasm

Update in Critical Care for the Nephrologist: Transfusion in Nonhemorrhaging Critically Ill Patients

First oncolytic virus vaccine for advanced melanoma

Aprotinin is useful as a hemostatic agent in cardiopulmonary surgery: yes.

Acute Kidney Injury after Cardiac Surgery Is Associated with Increased Iron Deficiency Anemia Risk

Background: Hemodilution anemia, due to the use of crystalloid liquids during the preparation of cardiopulmonary bypass (CPB) circuits, results in the increased number of RBC, which may lead to hemolysis, acute pulmonary injury, allergic reactions, metabolic and coagulative abnormalities, volume overload, alloimmunization, immunosuppression, graft versus host reaction, and a remarkable increase in hospitalization costs. Objectives: The present study aimed to evaluate the effects of shortened cardiopulmonary bypass circuits on the blood salvage process in patients undergoing cardiac surgery with cardiopulmonary bypass and determine the cutoff BSA value for effectiveness. Methods: A retrospective cohort study was performed in a private hospital, Ankara, Turkey, between January 2011 and November 2015 to assess 235 patients having a CPB with shortened circuits. The control group comprised 240 patients who underwent cardiac surgery utilizing a standard extracorporeal circulation circuit at our institution. In the case group, to achieve a low-priming volume, the CPB circuit was shortened and CPB console was positioned as close as possible to the operative field. The arterial line (3/8”) and the venous line (1/2) were 80 cm and 90 cm, respectively, shorter in the case group than in the control group. Patient data were collected by retrospective medical chart review. Results: Intraoperative red blood cell (RBC) transfusion amount was 465 ± 141.5 mL in the case group and 722.5 ± 285.4 mL in the control group (P < 0.001). Postoperative RBC transfusion was 418.7 ± 198.1 mL in the case group and 628.7 ± 452.3 mL in the control group (P < 0.001). The total amount of RBC transfusion was 742.4 ± 228.7 mL in the case group and 1012.3 ± 625.5 mL in the control group (P < 0.001). ROC analysis showed that shortening the CPB circuits was effective in patients with a BSA of < 1.67 (AUC = 0.84; P < 0.001) Conclusions: Shortening of the CPB circuit could be helpful to avoid severe hemodilution and to reduce RBC use in small adult patients (with BSA < 1.67) undergoing cardiac surgery with cardiopulmonary bypass.

Are current interventions for preventing silent cerebral infarcts in people with sickle cell disease effective and safe? A Cochrane Review summary with commentary.

Clinical improvement after red blood cell (RBC) transfusions in preterm infants remains debated. This study aims to investigate the effect of RBC transfusion on the occurrence of desaturations and hypoxia, and other cardiorespiratory outcomes in preterm infants. In this longitudinal observational study, prospectively stored cardiorespiratory parameters of preterm infants who received at least one RBC transfusion between July 2016 and June 2017 were retrospectively analyzed. Sixty infants with 112 RBC transfusions, median GA of 26.7 weeks, were included. The number of desaturations and area < 80% SpO2 limit, as a measure of the hypoxic burden, were calculated in 24 h before and after RBC transfusion. A mixed effects model was used to account for repeated measurements. Overall, the mean (SE) number of desaturations per hour decreased from 3.28 (0.55) to 2.25 (0.38; p < 0.001), and area < 80% SpO2 limit decreased from 0.14 (0.04) to 0.08 (0.02) %/s (p = 0.02). These outcomes were stratified for the number of desaturations in 24 h prior to RBC transfusion. The largest effect was observed in the group with the highest mean number of desaturations (≥ 6) prior to RBC transfusion, with a decrease from 7.50 (0.66) to 4.26 (0.38) (p < 0.001) in the number of desaturations and 0.46 (0.13) to 0.20 (0.06) in the area < 80% SpO2. Perfusion index increased significantly after RBC transfusion (p < 0.001). No other significant effects of RBC transfusion on cardiorespiratory data were observed.Conclusions: RBC transfusions in preterm newborns could help decrease the incidence of desaturations and the area < 80% SpO2 as a measure of the hypoxic burden. The higher the number of desaturations prior to the RBC transfusion, the larger the effect observed.What is Known:•Red blood cell transfusions potentially prevent hypoxia in anemic preterm infants by increasing the circulatory hemoglobin concentration and improving tissue oxygenation.•There is not a predefined hemoglobin concentration cut-off for the occurrence of symptomatic anemia in preterm infants.What is New:•Oxygen desaturations and hypoxia in anemic preterm infants can be improved by RBC transfusions, especially if more desaturations have occurred before transfusion.•Cardiorespiratory monitor data may help identify infants who will benefit most from red blood cell transfusions.

Literature review

Blood transfusion rates in coronary artery bypass grafting (CABG) surgery using cardiopulmonary bypass (CPB) are typically higher compared with off-pump CABG (OPCAB). However, few studies have specifically examined intraoperative hemodilution as a contributing factor. The aim of this retrospective review was to compare the effect of using CPB or OPCAB on red blood cell (RBC) transfusion and postoperative bleeding. The lowest intraoperative hematocrit (Hct) was used as marker of intraoperative hemodilution. We reviewed the perioperative data of all isolated CABG patients at a metropolitan hospital from January 2003 to June 2005. Stepwise regression analyses were performed to determine whether CPB was an independent predictor of RBC transfusion, reoperation for bleeding, or postoperative chest drainage. Of a total of 1043 patients, there were 433 CPB and 610 off-pump cases. CPB use was not significantly related to increased RBC transfusions (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.63–1.52;p= .921) and was associated with a lower incidence of reoperations for bleeding (OR, 0.4; 95% CI, 0.2–0.8;p= .009). There was less chest drainage over the first 12 hours in patients undergoing CPB (p&lt; .0001); however, total postoperative chest drainage was not significantly related to operative procedure (p= .122). The lowest documented intraoperative Hct was a significant factor in RBC transfusions (OR, 0.89;p&lt; .0001), an increased reoperation rate for bleeding (OR, 0.9;p= .001) and more postoperative chest drainage (log10-transformed: at 12 hours, b = −0.009,p&lt; .0001; total, b = −0.006,p&lt; .0001). CPB is not an independent risk factor in the incidence of RBC transfusions and is not associated with increased postoperative bleeding for isolated CABG. However, intraoperative hemodilution is an independent risk factor, with a lower intraoperative Hct associated with more RBC transfusions, increased reoperations for bleeding, and increased postoperative chest drainage. Addressing intraoperative hemodilution is important in minimizing CPB-associated morbidities.