Over-Transfusion and Unnecessary Transfusion Following Post-Partum Haemorrhage at Te Toka Tumai Auckland Hospital.

Objective To analyze the reasons and therapeutic effect of blood transfusion therapy in postpartum hemorrhage (PPH) patients, and provide references for making blood transfusion strategies for PPH patients. Methods The clinical data of a total of 185 cases of PPH patients who delivered and received blood transfusion therapy (erythrocyte suspension transfusion volume ≥ 4 U) because of PPH in Department of Obstetrics of First Affiliated Hospital of Third Military Medical University (Southwest Hospital) from January 2008 to December 2012 were analyzed by retrospective analysis method. The age, gravidity, parity, delivery method, macrosomia, number of fetus, pregnancy complications, bleeding volume, transfusion volume and blood transfusion therapy effects and so on of all the patients were collected. The reasons of blood transfusion therapy of all PPH patients with blood transfusion, the blood transfusion volume of blood transfusion PPH patients with different clinical characters, the general clinical data and therapy measures of PPH patients with massive transfusion were analyzed by statistical methods. The study protocol was approved by the Ethical Review Board of Investigation in the First Affiliated Hospital of Third Military Medical University (Southwest Hospital). Results ①The main reasons of blood transfusion therapy among the 185 cases of PPH patients with blood transfusion in this study included: placenta previa (61 cases, 33.0%), placenta conglutination, implanted placenta, or residual placenta (15 cases, 8.1%), uterine inertia (40 cases, 21.6%), coagulation dysfunction (30 cases, 16.2%), anemia (33 cases, 17.8%) and other factors (6 cases, 3.2%). ②The median blood transfusion volume of PPH patients with parity times ≥ 2 times was 1 250 mL which was statistically higher than that of patients with parity times 0.05). ③With manual massage of the uterus, using contractions promote drugs, using balloon to oppress the uterus, blood transfusion and other conventional treatments or surgical treatments, all the 185 cases of PPH patients with blood transfusion in this study were effectively controlled and no one was died for PPH. ④Among the 185 cases of PPH patients with blood transfusion in this study, 8 cases received massive transfusion therapy (erythrocyte suspension transfusion volume ≥ 18 U within 24 hours), of which 7 cases were with placenta previa or placental implantation, the average bleeding volume and average volume of blood transfusion were (4 800.0±680.7) mL and (3 685.7±157.4) mL, respectively, and 1 case was with uterine atony. All the 8 cases of PPH patients with massive transfusion received fresh frozen plasma (FFP) transfusion after they were transfused with 3~5 U of red blood cell suspension, and the transfusion volume ratio of FFP and red blood cell was about 1∶1. Conclusions We should recognize the risk factors of blood transfusion therapy in PPH patients as soon as possible, such as placenta previa, placental abruption, placenta conglutination, implanted placenta, residual placenta, uterine inertia and coagulation dysfunction and so on, and evaluate the risk of postpartum hemorrhage in time, and then provide timely and effective treatment and give active treatment of anemia during pregnancy. When the PPH patients should receive massive transfusion therapy, FFP and blood platelets should be transfused early to reduce the incidence of coagulation disorders and maternal mortality rate. Key words: Postpartum hemorrhage; Placenta previa; Obstetrics blood transfusion therapy; Massive transfusion

To compare outcomes of 2 cohorts of patients who underwent total knee arthroplasty (TKA) before and after the introduction of a blood management protocol. Records of 97 and 96 consecutive patients who underwent unilateral TKA before and after introduction of the blood management protocol, respectively, were reviewed. Before introduction of the protocol, patients were cross-matched for blood before surgery. Transfusion after surgery was at the discretion of the surgeons or the on-call doctors. After introduction of the protocol, only patients with a preoperative haemoglobin level of <110 g/l underwent 'type and screening' of blood group. 2 units of blood were cross-matched preoperatively when multiple red-cell antibodies were identified or postoperatively when blood transfusion was required. Only patients with a postoperative haemoglobin level of <80 g/l or being symptomatic received blood transfusion until the haemoglobin level reached >100 g/l. Those with a postoperative haemoglobin level of 80 to 100 g/l were given iron sulphate 300 mg twice daily for a month. The 2 groups did not differ significantly in age, sex ratio, pre- and post-operative haemoglobin levels, and drain output. Comparing outcome before and after introduction of the protocol, the transfusion rate (10.3% vs. 3.1%, p=0.046), crossmatch rate (100% vs. 3.1%, p<0.001), and crossmatch to transfusion ratio (9.7:1 vs. 1:1, p<0.001) decreased. Among transfused patients, the decreased postoperative haemoglobin level indicated a lower transfusion trigger point (100 g/l vs. 75 g/l, p<0.006) No patient developed infection, cardiovascular or cerebrovascular complications within 30 days. The blood management protocol for TKA is effective in reducing unnecessary allogeneic blood transfusions and wastage of unused blood, without an increase in postoperative complications.

Objectives To observe the clinical significance and application value of autologous blood transfusion in neurosurgery of primary hospital. Methods Four hundred and fourteen patients who underwent the neurosurgery operation and were subjected to intraoperative blood transfusion were selected, among whom 97 patients were subjected to autologous blood transfusion (observation group), and 317 patients were subjected to heterogenous blood transfusion (control group). The condition of intraoperative blood transfusion, changes of hemoglobin and hematocrit, blood transfusion related cost were compared between 2 groups. Results There were no statistical differences in operation time, infusion volume, rate of transfusion related complications and postoperation hemoglobin, hematocrit between observation group and control group (P > 0.05). The patients in control group were infused with 189 000 ml, and the transfusion liquid volume proportion of total blood transfusion was 79.22% (189 000/238 580); 13 patients in observation group were used the heterogenous blood transfusion with 5 400 ml, and the transfusion liquid volume proportion of total blood transfusion was 10.30% (5 400/52 430). Eighty- six patients (88.66%, 86/97) in observation group performed autologous blood collection and transfusion, the volume of autologous collection was 80 650 ml, and the volume of transfusion was 47 020 ml. Eleven patients in observation group did not perform autologous blood transfusion, among whom 6 patients was because of operational and mechanical reasons, and 5 patients performed collection but did not transfuse. The cost of heterogenous concentrated suspension red blood cell over 6 U was significantly higher than the cost of disposable material and injection of autologous blood: (2 287.06 ± 243.52) yuan vs. (1 595.08 ± 133.95) yuan, and there was statistical difference (P < 0.05). The rate of heterogenous concentrated suspension red blood cell 6 U in control group was 14.83% (47/317), and the rate of over 6 U was 6.62% (21/317). Conclusions The autologous blood transfusion is safe and effective, and it is worth popularizing in neurosurgery of primary hospital. But in the process of its application, it is necessary to strengthen the user′s operating skills and ensure the quality of autologous blood transfusion. Key words: Blood transfusion, autologous; Neurosurgical procedures; Retrospective studies; Primary hospital

Introduction: Total hip replacement is an intervention with a high transfusion rate. In our center since 2010, it has been widespread the use of perioperative cell salvage devices. The main objectives of this study were to evaluate whether the autologous blood transfusion by using cell saver decreased allogenic blood transfusion rate and compare the direct costs associated with both techniques in our clinical practice.Material and Methods: Retrospective study of 669 patients who underwent primary unilateral total hip replacement: cell saver autotransfusion group with 357 patients in which cell salvage system was used and allogeneic blood transfusion group with 312 patients, in which not. Allogeneic transfusion rates of both groups were evaluated and a comparative analysis of direct costs attributable to both transfusion techniques was performed.Results: Allogenic transfusion rate in the allogeneic blood transfusion group was 21.47% while in the cell saver autotransfusion group was 16.25% (p = 0.084). However, the number of allogenic blood units per transfused patient in allogeneic blood transfusion group was lower (p = 0.020). The relative risk of allogenic transfusion with the use of the cell saver system was 0.76 (95% CI: 0.55-1.04) and the number of patients to be treated to prevent it in this group was 19. The direct costs to avoid allogenic transfusion was 3888,73 euros.Conclusion: In our center the use of cell saver was not effective in reducing allogenic blood transfusion after primary unilateral total hip arthroplasty, increasing costs over 25 times the cost of a donated blood unit.

Blood Conservation

INTRODUCTION: The American Red Cross recently declared a national blood crisis. We aimed to evaluate the effect of a single-unit transfusion guideline on the transfusion rate. METHODS: An interdisciplinary quality improvement initiative to reduce blood transfusion for postpartum hemorrhage (PPH) was conducted in a tertiary obstetric hospital with approximately 5,000 births annually. Opportunities for improvement were prioritized including antepartum anemia treatment, early recognition and treatment of PPH, and blood stewardship. The baseline period was January 2019 to December 2020. The intervention period was July 2021 to April 2022. We recommended transfusions begin with an order for a single unit of blood (“Start with One”). Plan-do-check-act cycles were initiated. The clinical outcome was units of blood transfused per 1,000 deliveries. Relative risks, t tests, and control charts were used for analysis. The quality improvement project was IRB exempt (HUM00213652). RESULTS: Incidence of PPH decreased between baseline and intervention periods (relative risk 0.83, 95% CI 0.77–0.90). The baseline transfusion rate was 79.3 units of blood per 1,000 births. During the intervention period, this decreased by 32.8% to 53.2 units per 1,000 births (P=.004). Special cause variation was found after introduction of the “Start with One” campaign: 8 consecutive months in the intervention period have been above the mean proportion for single-unit transfusions. CONCLUSION: A single-unit transfusion guideline, as part of a multimodal strategy to reduce PPH, was associated with a significant decrease in red cell transfusion. The current national blood shortage should be a call to action for all obstetric providers to safely reduce the volume of blood transfusions.

In this study, the total blood loss, transfusion rate and number of transfused blood units in patients with different indications for shoulder arthroplasty: primary, fracture and secondary were compared. Risk factors for bleeding and transfusion were analysed. Medical records and the database of the institution's blood bank from 527 patients that received shoulder arthroplasty were analysed retrospectively. This study included 419 patients that were divided in three different groups: primary (n = 278), fracture (n = 110) and secondary (following prior osteosynthesis; n = 31) shoulder arthroplasty. The demographic and clinical data were collected. The total blood loss (TBL) was calculated and transfusions recorded. The transfusion rate and mean amount of transfused blood units (BU) were higher in fracture (32.7% and 0.69BU, p < 0.01) and secondary arthroplasty (35.5% and 0.97BU, p < 0.01) than in primary arthroplasty (12.6% and 0.28BU). The overall transfusion rate was 19.6% at a mean TBL of 370ml. However, patients with primary arthroplasty experienced significantly higher total blood loss than those after fracture arthroplasty (p < 0.01). Longer surgery time and male sex are significant risk factors for elevated blood loss. The pre-operative use of vitamin K antagonist, cemented arthroplasty, high BMI, coronary heart disease and ASA score > 2 are relevant risk factors for blood transfusion. The most important susceptible factor that affects the TBL is the surgery time. Transfusion rates are higher in patients with fracture arthroplasty than after primary arthroplasty.

Objective: The diagnosis of disseminated intravascular coagulation (DIC) in obstetrics is complicated owing to physiological changes, particularly during late pregnancy and the postpartum period. Therefore, a pregnancy-modified DIC score that includes only three components of the International Society on Thrombosis and Hemostasis (ISTH) DIC score has been constructed. Our aim was to determine how many blood-transfused postpartum women actually had the diagnosis of overt DIC according to the modified ISTH score and had the correct indications for blood transfusion.Methods: We retrospectively analyzed 279 women who had received transfusion of at least two units of blood for postpartum hemorrhage. We used the modified ISTH score for DIC, which is based on platelet count, fibrinogen concentration, and prothrombin time (PT) differences. A total score of 26 points or higher indicated overt DIC, whereas a score lower than 26 points represented nonovert DIC.Results: According to the modified ISTH score, 100 of the 279 patients (35.8%) had overt DIC, with a median DIC score of 37.0. Thirty-five percent of patients in the overt DIC group and 25.7% in the nonovert DIC group had received more than four units of blood. The levels of PT and activated partial thromboplastin time were higher, and the fibrinogen level was lower in patients with overt DIC.Conclusions: According to the modified ISTH score, we found that blood transfusion was unnecessary in 179 of the 279 postpartum women (64.1%). If this scoring system is used to determine which patients should be transfused, unnecessary transfusions and their related risks and complications will be prevented.

Objective To summarize the nursing cooperation in 28 cases of placenta praevia or dangerous cesarean section delivery in which acute normovolemic hemodilution (ANH) in combination with autologous blood transfusion were applied. Methods Before the surgery, autologous blood were collected from 28 cases with smooth anesthesia of ASA class Ⅰ-Ⅱ parturients post general anesthesia, accompanying rapid intravenous infusion of the equivalent colloid solution.The vital sighs and fetal heart of parturients were comprehensive monitored during the collection procedure. When the blood loss reached to 400-600 ml or the hemoglobin (Hb) were below 80 g/L during the late phase of surgery, autologous blood was transfused to parturients. Results All 28 cases safely wentthrough the operative period with the mean operation time (69.00±18.81) min, mean blood loss (988.00±382.65) ml and mean autologous blood transfusion (387.00±122.07) ml, respectively. Meanwhile, there were no adverse reactions of parturients during the process of collection and transfusion of autologous blood. Furthermore, the mean 1, 5 min Apgar score of newborn children ranged from 7 to 10. Conclusions ANH in combination with autologous blood transfusion, serving as an effective measure for blood conservation, plays a important role in dealing with postpartum hemorrhage and was not harmful to parturients or fetuses.ANH in combination with autologous blood transfusion, as a safe and efficient blood transfusion mode, attenuated the current shortage of blood for clinical use to a great extent. Key words: Cesarean section delivery; Operation Room nursing; Acute normovolemic hemodilution; Autologous blood transfusion

Background: The average requirement of blood and it’s products for a particular elective orthopedic procedure is usually based on subjective anticipation of blood loss rather than an evidence-based estimate. Currently, there is no specific evidence based guidelines for the appropriate amount of blood products to be ordered for specific procedures. Therefore this study aimed to fill the knowledge gap in the effectiveness of blood utilization practice. It is expected to add information on formulating a practical institution based protocol for proper optimizing the use of blood components. Methodology: A hospital based descriptive study was done at Muhimbili Orthopedic Institute from July 2018 to April 2019 in which patients scheduled for elective orthopaedic surgeries for whom blood was requested were include. Demographic data and blood utilization data was collected which was analyzed using SPSS version 20 . Blood utilization was calculated by the following indices: (i) Crossmatch to transfusion ratio (C/T), (ii) Transfusion probability (T %), (iii) Transfusion index (TI), (iv) Maximum surgical blood ordering schedule (MSBOS). Results: A total of 286 patients undergoing 27 different types of elective orthopedic surgeries were included in this study. Five hundred and twenty seven units of blood were cross-matched, of which only 224 units (42.5%) of blood were transfused to 146(51%) patients. The overall crossmatch to transfusion ratio(C/T) calculated was 2.4, transfusion index (TI) was 0.8 and transfusion probability (T %) was 51.0%. All these figures were found to be within the optimal range Conclusion: This study revealed an adequate overall ratio of C/T, T%, and TI blood utilization considerable to significant, except for a few surgeries that showed transfusion above or below-accepted levels. Male patients and patients above 60 years of age had more transfusion rate. The highest proportion of blood transfusion was observed in lower limb surgeries. Knee arthroscopy showed the lowest blood transfusion rate while pelvic and acetabular surgeries showed the highest transfusion rate. Recommendations: There is a need for formulating and practicing institution-based blood ordering policy to guide clinician regarding blood usage

Blood Management

(Acta Obstet Gynecol Scand. 2019;98:382–389) For parturients with a previous cesarean delivery, counseling and decision-making needs to be made regarding whether to attempt a vaginal birth after cesarean (VBAC) or undergo elective repeat cesarean section (ERCS). Many factors should be considered during the decision-making process including the likelihood of requiring blood transfusion due to postpartum hemorrhage (PPH). This is an important factor because blood transfusions after PPH have been associated with longer hospital stay, and increased risk of infection, morbidity, and mortality. This study was undertaken to ascertain blood transfusion and PPH rates related to chosen delivery method (VBAC or ERCS) for women with a prior cesarean delivery, as well as to determine the effect of the number of prior cesarean deliveries on transfusion rates.

Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. At present, there are no reliable clinical or laboratory indicators to identify which patients might require blood transfusions during a PPH. Serum lactate has long been used as an early biomarker of tissue hypoperfusion in trauma settings. The aim of this study is to understand serum lactate's role in the management of obstetric hemorrhage. A retrospective chart review was performed of women who delivered between 2016 and 2019 at our institution and experienced a PPH. The patients were divided into two groups: those with a normal serum lactate level, defined as ≤2 mmol/L, and those with an abnormal serum lactate level, defined as >2 mmol/L. Need for packed red blood cell transfusion, as part of the resuscitation, was assessed for both groups. During the study period, 938 women experienced PPH. Of these, 108 (11.5%) had a normal serum lactate, ≤2 mmol/L, and 830 (88.5%) had an abnormal lactate, >2 mmol/L. Women with elevated lactate levels were more likely to receive a blood transfusion versus those with a normal lactate level (57.0 vs. 46.3%, p = 0.035, respectively). Additionally, the average number of blood transfusions administered was significantly higher in the abnormal lactate group versus in the normal lactate group (1.34 vs. 0.97, respectively, p = 0.004). In a multivariable linear regression model, increasing serum lactate levels were found to be predictive of requiring more than 1 unit of blood (p < 0.001). Women with elevated serum lactate levels were more likely to require blood transfusions during a PPH versus those with a normal serum lactate level. Thus, serum lactate levels are useful as an early indicator of requirement for blood transfusion in the management of obstetric hemorrhage. · Lactate is a biomarker for blood transfusion in trauma.. · Lactate's role in PPH is unknown.. · Elevated lactate predicts receiving more blood transfusions..

Cranial vault remodeling (CVR) for craniosynostosis is a procedure with the potential for significant blood loss. Aminocaproic acid (ACA) has been used at our institution during CVR for its antifibrinolytic effects. The purpose of this study was to investigate the effect of ACA on blood loss and transfusion rates during primary CVR. Three hundred eighty-three patients with craniosynostosis underwent primary CVR at a single institution by a single surgeon over 15 years. Patients were included if they received either ACA or no antifibrinolytic. The estimated blood loss (EBL) and volume of blood transfused was recorded. Thrombotic-related complications were identified. Comparisons were made between subgroups using independent Student t test and Fisher exact test. Among the study population, 148 patients met inclusion criteria. ACA was given to 30 patients, while 118 patients received no antifibrinolytic. There was no difference in the average intraoperative EBL between the ACA (322 mL) and control groups (327 mL, P > 0.05). Additionally, the incidence of transfusion was not significantly different between subgroups (97% vs. 86%, respectively, P > 0.05). Patients treated with ACA, however, received lower average perioperative transfusion volumes (25.5 mL/kg) compared to control patients (53.3 mL/kg, P < 0.0001). Furthermore, patients in the ACA subgroup were less likely to require a second unit of blood (21% vs. 43%, P < 0.0001) and therefore had fewer exposures to donor blood antigens (ARR = 22%, NNT = 4.6). The use of intraoperative ACA minimizes blood transfusion volumes and donor exposures in children who undergo primary CVR for craniosynostosis. Antifibrinolytics should be considered for routine use in pediatric craniofacial surgery.

To salvage (routinely) or not to salvage: that is the question.