Allogeneic Red Blood Cell Transfusion Research Articles

Current concepts in the use of cell salvage in obstetrics.

The worldwide leading cause of maternal death is severe maternal hemorrhage. Maternal hemorrhage can be profound leading to an entire loss of blood volume. In the past two decades, Patient Blood Management has evolved to improve patient's care and safety. In surgeries with increased blood loss exceeding 500 ml, the use of cell salvage is strongly recommended in order to preserve the patient's own blood volume and to minimize the need for allogeneic red blood cell (RBC) transfusion. In this review, recent evidence and controversies of the use of cell salvage in obstetrics are discussed. Numerous medical societies as well as national and international guidelines recommend the use of cell salvage during maternal hemorrhage. Intraoperative cell salvage is a strategy to maintain the patient's own blood volume and decrease the need for allogeneic RBC transfusion. Historically, cell salvage has been avoided in the obstetric population due to concerns of iatrogenic amniotic fluid embolism (AFE) or induction of maternal alloimmunization. However, no definite case of AFE has been reported so far. Cell salvage is strongly recommended and cost-effective in patients with predictably high rates of blood loss and RBC transfusion, such as women with placenta accreta spectrum disorder. However, in order to ensure sufficient practical experience in a multiprofessional obstetric setting, liberal use of cell salvage appears advisable.

Efficacy of intraoperative blood salvage and autotransfusion in living-donor liver transplantation: a retrospective propensity matched case-control study.

Liver transplantation (LT) may be associated with massive blood loss and the need for allogeneic blood transfusion. Intraoperative blood salvage autotransfusion (IBSA) can reduce the need for allogeneic blood transfusion. This study aimed to investigate the effectiveness of blood salvage in LT. Among 355 adult patients who underwent elective living-donor LT between January 1, 2019, and December 31, 2022, 59 recipients without advanced hepatocellular carcinoma received IBSA using Cell Saver (CS group). Based on sex, age, model for end-stage liver disease (MELD) score, preoperative laboratory results, and other factors, 118 of the 296 recipients who did not undergo IBSA were matched using propensity score (non-CS group). The primary outcome was the amount of intraoperative allogenic red blood cell (RBC) transfusion. Comparisons were made between the two groups regarding the amount of other blood components transfused and postoperative laboratory findings. The transfused allogeneic RBC for the CS group was significantly lower than that of the non-CS group (1,506.0 ml vs. 1,957.5 ml, P = 0.026). No significant differences in the transfused total fresh frozen plasma (FFP), platelets, cryoprecipitate, and estimated blood loss were observed between the two groups. The postoperative allogeneic RBC transfusion was significantly lower in the CS group than in the non-CS group (1,500.0 ml vs. 2,100.0 ml, P = 0.039). No significant differences in postoperative laboratory findings were observed at postoperative day 1 (POD1) and discharge. Using IBSA during LT can effectively reduce the need for perioperative allogeneic blood transfusions without causing subsequent coagulopathy.

Obstetric blood transfusion in placenta previa patients with prenatal anemia: a retrospective study

BackgroundThe appropriate use of obstetric blood transfusion is crucial for patients with placenta previa and prenatal anemia. This retrospective study aims to explore the correlation between prenatal anemia and blood transfusion-related parameters in this population.MethodsWe retrieved the medical records of consecutive participants who were diagnosed with placenta previa and underwent cesarean section in our hospital. We compared the baseline demographics and clinical characteristics of patients with and without anemia. The correlation between prenatal anemia and obstetric blood transfusion-related parameters was evaluated using multivariate regression analysis.ResultsA total of 749 patients were enrolled, with a mean prenatal hemoglobin level of 10.87 ± 1.37 g/dL. Among them, 54.87% (391/749) were diagnosed with anemia. The rate of obstetric blood transfusion was significantly higher in the anemia group (79.54%) compared to the normal group (44.41%). The median allogeneic red blood cell transfusion volume in the anemia group was 4.00 U (IQR 2.00–6.00), while in the normal group, it was 0.00 U (IQR 0.00–4.00). The prenatal hemoglobin levels had a non-linear relationship with intraoperative allogeneic blood transfusion rate, massive blood transfusion rate, red blood cell transfusion units, and fresh plasma transfusion volume in patients with placenta previa, with a threshold of 12 g/dL.ConclusionsOur findings suggest that prenatal anemia is associated with a higher rate of blood transfusion-related parameters in women with placenta previa when the hemoglobin level is < 12 g/dL. These results highlight the importance of promoting prenatal care in placenta previa patients with a high requirement for blood transfusion.

Associations Between Nonanemic Iron Deficiency and Postoperative Outcomes in Cardiac Surgery: A Systematic Review and Meta-Analysis.

Preoperative screening for iron deficiency is a part of patient blood management protocols. This systematic review, meta-analysis, and meta-regression reviews the association between nonanemic iron deficiency and postoperative outcomes in patients undergoing cardiac surgery. We aimed to determine whether preoperative screening for nonanemic iron deficiency should be recommended in patients undergoing cardiac surgery. Electronic databases MEDLINE (Ovid), Embase (Ovid), and Scopus were searched from inception until December 9, 2022. Studies were considered for inclusion if they (1) used an observational study design; (2) enrolled adult patients undergoing cardiac surgery; and (3) included an iron-deficient and iron-replete group, defined using serum ferritin and/or transferrin saturation. The primary outcome was the length of acute hospital stay. Secondary outcomes included length of intensive care unit stay, requirement for allogeneic red blood cell transfusion, number of red blood cell units transfused, days alive and at home at postoperative days 30 and 90, all-cause postoperative complications, postoperative infection, mortality, and hospital readmission. Meta-regression was performed to assess the effects of study and patient-level factors on the associations between nonanemic iron deficiency and specific outcomes. Individual study quality was assessed using the Risk of Bias in Non-Randomized Studies of Exposures (ROBINS-E) tool. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used to determine the quality of evidence for each outcome. Eight studies (2683 patients) were included. No significant association was observed between nonanemic iron deficiency and any of the primary or secondary outcomes except for an increased requirement for allogeneic red blood cell transfusion (odds ratio [OR], 1.39 [95% confidence interval, CI, 1.16-1.68; P < .001; I2 2.8%]). Meta-regression did not identify any potential sources of heterogeneity to explain variation in individual study results. The quality of evidence was rated as "low" or "very low" for all outcomes. Few high-quality studies are available to assess associations between nonanemic iron deficiency and outcomes after cardiac surgery. Acknowledging these limitations, the presence of preoperative nonanemic iron deficiency was not associated with a change in the primary outcome of length of hospital stay, or any patient-centered secondary outcome compared to those without iron deficiency. There was an association with increased requirement for allogeneic red blood cell transfusion, but this did not impact the reported patient-centered outcomes.

Correlation Between 6 Characteristics of Perioperative Hypothermia and Allogeneic Red Blood Cell Transfusion in Abdominal Surgery Patients

To explore the correlation between six characteristics of perioperative hypothermia and allogeneic red blood cell (RBC) transfusions in patients who underwent abdominal surgeries. Patients who underwent abdominal surgeries at West China Hospital, Sichuan University between October 2019 and July 2021 were retrospectively enrolled. A wearable wireless temperature sensor was used to continuously monitor the core body temperature of patients throughout the perioperative period. The perioperative temperature nadir, maximum temperature loss, percentage of time with hypothermia, time-weighted average temperature, area under the curve (AUC) at 36 ℃, and AUC at 37 ℃ were calculated for the period from entering the operation room to 24 hours after the end of anesthesia. The restricted cubic spline (RCS) and multiple logistic regression models were used to explore the correlation between these temperature characteristics and perioperative allogeneic RBC transfusions. A total of 3119 patients were included in the study, with an allogeneic RBC transfusion rate of 2.8%. The RCS model showed that allogeneic RBC transfusion was associated with the perioperative temperature nadir (Poverall=0.048) and AUC at 36 ℃ (Poverall=0.026) and no statistical significance was found in the nonlinear test. The association between allogeneic RBC transfusions and other temperature characteristics was not statistically significant. According to the RCS model results, cut-off points were taken to form groups based on the body temperature characteristics. Multivariate logistic regression showed that the perioperative temperature nadir<35.5 ℃ (odds ratio [OR]=2.47, 95% confidence interval [CI]: 1.21-5.03) and AUC at 36 ℃≥100 ℃·min (OR=2.24, 95% CI:1.09-4.58) were associated with increased demand for allogeneic RBC transfusion. Hypothermia is associated with an increased need for perioperative allogeneic RBC transfusions and has a cumulative effect over time. For patients at high risk of bleeding, attention should be paid to the prevention of perioperative hypothermia and reduction in the cumulative exposure to hypothermia, thereby reducing the need for blood transfusion.

Association between Storage Time of Transfused Red Blood Cells and Infection after Clean-contaminated Surgery

Objective: The aim of this study was to investigate the association between storage time of transfused red blood cells and risks of infections after clean-contaminated surgery. Summary Background Data: Storage lesions of red blood cells can aggravate transfusion-related immunomodulation. Very few randomized controlled trials have investigated the impacts of storage time on postoperative outcomes in non-cardiac patients. Methods: We included adult patients who had undergone clean-contaminated surgery from 2014 to 2018 and received allogeneic red blood cell transfusion. In transfusion episode-level analysis, the exposure was the storage time of each transfusion episode. In patient-level analysis, the exposures were the mean, weighted mean, maximum storage time, and Scalar Age of Blood Index of red blood cells transfused into each patient. The primary outcome was infections that developed after transfusions within postoperative Day 30. Results: The 4046 included patients received 11604 transfusion episodes. Of these, 1025 (25.3%) patients developed postoperative infections. An increased storage time of transfused red blood cells was not associated with increased odds of postoperative infections in either transfusion episode-level analysis [odds ratio (OR) 1.03 per five days, 95% confidence interval (CI) 0.95 to 1.11] or patient-level analysis (mean: OR 1.02, 95% CI 0.95 to 1.10; weighted mean: OR 1.02, 95% CI 0.95 to 1.10; maximum: OR 1.06, 95% CI 0.98 to 1.14; Scalar Age of Blood Index: OR 0.99, 95% CI 0.96 to 1.03), after adjusting 17 confounders. Conclusions: Prolonged storage time of transfused red blood cells was not associated with increased risks of infections after clean-contaminated surgery.

Low-Volume Acute Normovolemic Hemodilution Does Not Reduce Allogeneic Red Blood Cell Transfusion in Cardiac Surgery in the Modern Era of Patient Blood Management: A Propensity Score-Matched Cohort Study

Patients undergoing cardiac surgery often require blood transfusions, which are associated with increased morbidity and mortality. Patient blood management (PBM) strategies, including acute normovolemic hemodilution (ANH), have been implemented to minimize allogeneic transfusion requirements. Older studies suggested that ANH is associated with reduced transfusions; however, its effectiveness in the modern era of PBM remains unclear. This was a retrospective cohort study. The study was held at a single university hospital. 542 patients who underwent elective cardiac surgery with cardiopulmonary bypass (CPB) using low-priming-volume circuits between January 2017 and March 2022. Patients who received ANH were matched with those who did not receive ANH, using propensity scores. The primary outcome was the proportion of patients who received perioperative red blood cell (RBC) transfusion. Of the 542 eligible patients, 49 ANH cases were propensity-score matched to 97 controls. The median ANH volume was 450 mL (IQR, 400-800 mL). There was no significant difference in perioperative RBC transfusion rates between the 2 groups (24.5% in the ANH group vs 30.9% in the control group, p=0.42). The odds ratio for perioperative RBC transfusion in the ANH group versus the control group was 0.72 (95% CI, 0.32-1.55, p=0.42). Low-volume ANH was not associated with a significant reduction in perioperative allogeneic RBC transfusion during cardiac surgery with CPB using low-priming-volume circuits. The benefits of low-volume ANH in reducing the requirement for RBC transfusion in the modern era of PBM may be smaller than reported previously.

Trends, complications, and readmission of allogeneic red blood cell transfusion in primary total hip arthroplasty in china: a national retrospective cohort study.

Decrease in allogenic red blood cell (RBC) transfusion rates following total hip arthroplasty (THA) has been reported in the United States, but whether other countries share the same trend remains unclear. Additionally, the relation of allogenic RBC transfusion to the risk of complications in THA remains controversial. Using the Chinese national inpatient database, the current study aimed to examine trends, complications, charges, and readmission patterns of allogeneic RBC transfusion in THA. Patients undergoing primary THA between 2013 and 2019 were included, and then stratified into the transfusion and the non-transfusion group based on the database transfusion records. A generalized estimating equation model was used to investigate trends in transfusion rates. After propensity-score matching, a logistic regression model was used to compare the complications, rates and causes of 30-day readmission between two groups. A total of 10,270 patients with transfusion and 123,476 patients without transfusion were included. Transfusion rates decreased from 19.11% in 2013 to 9.94% in 2019 (P for trend < 0.001). After matching, no significant differences in the risk of of in-hospital death (odds ratio [OR], 4.00; 95% confidence interval [CI] 0.85-18.83), wound infection (OR 0.72; 95%CI 0.45-1.17), myocardial infarction (OR 1.17; 95%CI 0.62-2.19), deep vein thrombosis (OR 1.25; 95%CI 0.88-1.78), pulmonary embolism (OR 2.25; 95%CI 0.98-5.17), readmission rates (OR 1.07; 95%CI 0.88-1.30) and readmission causes were observed between two groups. However, the transfusion group had higher hospitalization charges than the non-transfusion group (72,239.89 vs 65,649.57 Chinese yuan [CNY], P < 0.001). This study found that allogeneic RBC transfusion in THA was not associated with the increased risk of complications and any-cause readmission. However, the currently restrictive transfusion policy should be continued because excessive blood transfusion may increase the socioeconomic burden.

952 The Use of Cell-Salvage in Periprosthetic Femur Fractures: A Cheaper and Safer Alternative?

Abstract Aim Periprosthetic femur fractures (PFF) are becoming increasingly frequent due to an ageing population and growing number of arthroplasties. PFF revision surgery is associated with significant peri-operative blood loss and higher transfusion requirements. There are few strategies to reduce rates of transfusion. One of which is the use of cell-salvage. The aim of this study was to determine whether cell salvage should be routinely implemented during PFF revision surgeries. Method All admission with PFF were retrospectively reviewed over a period of 18 months. Data points including patient demographics, admission/operation dates, fracture site, anticoagulation status, pre/post-op Hb and number of transfusions were collected. Results There were a total of 38 PFF. Average age was 83.4 years with admission Hb 11.65g/dl. Mean time for operation was 2.9 days. 56% of total hip replacement PFF received a blood transfusion post-operatively with an average of 2.6 units per patient. 100% of total knee replacement PFF received a post-operative transfusion with an average of 1.6 units per patient. Of note there was no increased transfusion requirements for patient on anticoagulation (Warfarin/DOAC). Conclusions We identified that &amp;gt;50% of PFF required a post-op transfusion. The cost of 1 unit of RBC locally was found to be £145.99. The average cost of a cell salvage filter is £100 per patient. Considering the above and the well-known risk of allogenic red blood cell transfusion, it was concluded that the routine use of cell salvage could be a cheaper and safer alternative to allogenic red blood cell transfusion.

Establishment of a national quality improvement process on oxygen delivery index during cardiopulmonary bypass.

Targeted oxygen delivery during cardiopulmonary bypass (CPB) has received significant attention due to its influence on patient outcomes, especially in mitigating acute kidney injury. While it has gained popularity in select institutions, there remains a gap in establishing it globally across multiple centers. The purpose of this investigation was to describe the development of a quality improvement process of targeted oxygen delivery during CPB across hospitals throughout the United States. A systematic approach to utilize oxygen delivery index (DO2i) as a key performance indicator within hospitals serviced by a national provider of perfusion services. The process included a review of the current literature on DO2i, which yielded a target nadir value (272mL/min/m2) and an area under the curve (DO2i272AUC) cut off of 632. All data is displayed on a dashboard with results categorized across multiple levels from system-wide to individual clinician performance. From January 2020 through December 2022, DO2i data from 91 hospitals and 11,165 coronary artery bypass graft procedures were collected. During this period the monthly proportion of DO2i measurements above the target nadir DO2i272 ranged from 60.5% to 78.4% with a mean+/-SD of 70.8 +/- 4.2%. Binary logistic regression for the first 7months following monthly DO2i performance reporting has shown a statistically significant positive linear trend in the probability of achieving the target DO2i272 (p < .001), with a crude increase of approximately 7.8% for DO2i272AUC, and a 73.8% success rate (p < .001). A survey was sent to all individuals measuring oxygen delivery during CPB to assess why a target DO2i272 could not be reached. The two most common responses were an 'inability to improve CPB flow rates' and 'restrictive allogeneic red blood cell transfusion policies'. This study demonstrates that targeting a minimum level of oxygen delivery can serve as a key performance indicator during CPB using a structured quality improvement process.

A cost-effectiveness analysis of intraoperative autologous transfusion in adolescent idiopathic scoliosis surgery: a single-centre retrospective study

BackgroundIntraoperative autologous transfusion (IAT) has been used in scoliosis surgery for decades; however, its cost-effectiveness remains debatable. This study aimed to evaluate the cost-effectiveness of IAT in adolescent idiopathic scoliosis (AIS) surgery and identify risk factors of massive intraoperative blood during this surgery.MethodsThe medical records of 402 patients who underwent AIS surgery were reviewed. The patients were divided into different groups according to the intraoperative blood loss volume (group A: ≥500 to < 1000 mL, B: ≥1,000 to < 1,500 mL, and C: ≥1,500 mL) and whether IAT was used (i.e., IAT and no-IAT groups). The volume of blood loss, volume of transfused allogeneic red blood cells (RBC), and RBC transfusion costs were analysed. Univariate and multivariate logistic regression analyses were used to identify the independent risk factors of massive intraoperative blood loss (≥ 1,000 mL and ≥ 1,500 mL). A receiver operating characteristic (ROC) curve was used to analyse the cut-off values of the factors contributing to massive intraoperative blood loss.ResultsIn group A, no significant difference was observed in the volume of allogeneic RBC transfused during and after procedure between the IAT and no-IAT groups; however, total RBC transfusion costs was significantly higher in the IAT group. In groups B and C, the patients in the IAT group compared with those in the no-IAT group had a lower volume of allogeneic RBC transfused during the operation and on the first day after the operation. However, in group B, the total RBC transfusion cost in the patients who used IAT was significantly higher. In group C, total RBC transfusion cost in the patients who used IAT was significantly lower. The number of fused vertebral levels and Ponte osteotomy were found to be independent risk factors for massive intraoperative blood loss. ROC analysis showed that more than eight and 10 fused vertebral levels predicted ≥ 1,000 mL and ≥ 1,500 mL intraoperative blood loss, respectively.ConclusionThe cost-effectiveness of IAT in AIS was related to the volume of blood loss, and when the blood loss volume was ≥ 1,500 mL, IAT was cost-effective, drastically reducing the demand for allogeneic RBC and total RBC transfusion cost. The number of fused vertebral levels and Ponte osteotomy were independent risk factors for massive intraoperative blood loss.

High Cell Saver Autotransfusion is Associated With Perioperative Medical Complications in Adult Spinal Deformity Patients.

A retrospective, propensity-matched observational study. To assess the impact of cell saver (CS) homologous transfusion on perioperative medical complications in adult patients undergoing spinal deformity surgery. Despite many endorsing its use, many analyses still refute the efficacy of CS on decreasing total perioperative allogenic red blood cell transfusions, cost efficiency, and its effect on perioperative complications. Adult patients who underwent spinal deformity surgery at a single center between 2015 and 2021 were retrospectively reviewed. Patient-specific, operative, radiographic, and 30-day complications/readmission data were collected for further analysis. Two methods were utilized to test our hypothesis: (1) absolute threshold model: two cohorts created among patients who received ≥550mL of CS intraoperatively and those who received less; (2) adjusted ratio model: two cohorts created dependent on the ratio of CS to estimated blood loss (EBL). Propensity-score matching and various statistical tests were utilized to test the association between CS and perioperative medical complications. Two hundred seventy-eight patients were included in this analysis with a mean age of 61.3±15.7yrs and 67.6% being female. Using the first method, 73 patients received ≥550mL of CS, and 205 received less. Propensity-score matching resulted in 28 pairs of patients. 39.3% of patients with ≥550mL CS required readmission within 30 days compared with 3.57% of patients in the <550mL cohort ( P =0.016), despite a nearly identical proportion of patients requiring intraoperative blood transfusions ( P >0.9999). Using the second method, 155 patients had CS/EBL<0.33 and 123 with CS/EBL ≥0.33. 5.16% and 21.9% among patients with CS/EBL<0.33 and CS/EBL≥0.33, respectively, were readmitted by the 30-day marker ( P <0.0001). Our findings indicate that greater CS volumes transfused are associated with higher rates of 30-day readmissions. Thus, surgeons should consider limiting CS volume intraoperatively to 550mL and when greater volumes are required or preferred, ensuring that the ratio of CS:EBL remains under 0.33.

The use of intraoperative cell salvage in total hip arthroplasty with subtrochanteric shortening osteotomy for the treatment of high hip dislocation: a retrospective cohort study

BackgroundIntraoperative cell salvage (ICS) is an important component of blood management in patients undergoing orthopedic surgery. However, the role of ICS is less well defined in total hip arthroplasty (THA) with subtrochanteric shortening osteotomy (SSO) which is a common surgical technique to manage high hip dislocation. This study aimed to determine the effect of ICS during THA with SSO and to identify factors associated with the ability to salvage sufficient collection for reinfusion in patients with high hip dislocation.MethodsWe identified 178 patients who underwent THA with SSO for high hip dislocation between November 2010 and April 2021. The consecutive cohort was analyzed by logistic regression to determine the effect of ICS on postoperative allogeneic blood transfusion (ABT) and to explore the associations between patient demographics, clinical and radiographic characteristics, preoperative laboratory examination, and surgical variables with the ability to generate adequate blood salvage to reinfuse.ResultsIn the consecutive cohort of 178 patients, cell salvage was reinfused in 107 patients (60.1%) and postoperative allogeneic red blood cell (RBC) transfusion within 3 days of implantation was administrated in 40 patients (22.5%). In multivariate analysis, the reinfusion of ICS (OR (95%CI) 0.17 (0.07–0.47)), center of rotation (COR) height ≥ 60 mm (OR (95%CI) 3.30 (1.21–9.01)), the length of SSO ≥ 30 mm (OR (95%CI) 2.75 (1.05–7.22)) and the use of drainage (OR (95%CI) 2.28 (1.04–5.03)) were identified as independent factors of postoperative allogeneic RBC transfusion. In addition, the following variables were identified as independent factors associated with the ability to generate sufficient blood salvage volume for reinfusion: COR height ≥ 60 mm (OR (95%CI) 3.47 (1.58–7.61)), limb-length discrepancy (LLD) ≥ 25 mm (OR (95%CI) 2.55 (1.15–5.65)) and length of SSO ≥ 30 mm (OR (95%CI) 2.75 (1.33–5.69)).ConclusionsICS was efficacious in reducing the exposure rate of postoperative RBC transfusion for high hip dislocation during THA with SSO. In addition, patients with greater COR height, larger LLD, and longer length of SSO were predisposed to generate sufficient collection for reinfusion in THA with SSO.

Clinical efficacy of intraoperative Cell Saver autologous blood salvage in emergency surgery for massive hemothorax.

The objective of this study was to investigate the efficacy of intraoperative Cell Saver blood salvage during emergency surgery for massive hemothorax on minimizing perioperative allogeneic red blood cell (RBC) transfusion. Fourteen consecutive patients of massive hemothorax with more than 800cc of intrathoracic bleeding estimated by chest X-ray and/or chest computed tomography (CT) scan at presentation between 2009 and 2021 were retrospectively reviewed. Intraoperative Cell Saver blood salvage was performed in 11 patients (Cell Saver group) with a median volume of 820cc (range, 421-1700cc). The amount of perioperative allogeneic RBC transfusion in the Cell Saver group (median, 4 units) was significantly smaller than that in the non-Cell Saver group (median, 10 units) (P = 0.009). The volume of Cell Saver autologous transfusion in 6 patients without preoperative chest tube drainage (median, 1114cc) was significantly larger than that in 5 patients who had preoperative drainage (median, 660cc) (P = 0.0173). In conclusion, the utilization of intraoperative blood salvage in emergency surgery for massive hemothorax along with limiting the amount of preoperative chest tube drainage is an efficient strategy to minimize perioperative allogeneic RBC transfusion.

Appropriateness of Allogeneic Red Blood Cell Transfusions in Non-Bleeding Patients in a Large Teaching Hospital: A Retrospective Study.

In hemodynamically stable patients, both anemia and red blood cell (RBC) transfusion may be detrimental to patients; hence, a decision regarding RBC transfusion should be based on thorough risk-benefit assessment. According to hematology and transfusion medicine organizations, RBC transfusion is indicated when recommended hemoglobin (Hb) triggers are met, and symptoms of anemia are present. The aim of our study was to examine the appropriateness of RBC transfusions in non-bleeding patients at our institution. We performed a retrospective analysis of all RBC transfusions performed between January 2022 and July 2022. The appropriateness of RBC transfusion was based on the most recent Association for the Advancement of Blood and Biotherapies (AABB) guidelines and some additional criteria. The overall incidence of RBC transfusions at our institution was 10.2 per 1000 patient-days. There were 216 (26.1%) RBC units appropriately transfused and 612 (73.9%) RBC units that were transfused with no clear indications. The incidence of appropriate and inappropriate RBC transfusions were 2.6 and 7.5 per 1000 patient-days, respectively. The most frequent clinical situations when RBC transfusion was classified as appropriate were: Hb < 70 g/L plus cognitive problems/headache/dizziness (10.1%), Hb < 60 g/L (5.4%), and Hb < 70 g/L plus dyspnea despite oxygen therapy (4.3%). The most frequent causes of inappropriate RBC transfusions were: no Hb determination pre-RBC transfusion (n = 317) and, among these, RBC transfused as a second unit in a single-transfusion episode (n = 260); absence of anemia sings/symptoms pre-transfusion (n = 179); and Hb concentration ≥80 g/L (n = 80). Although the incidence of RBC transfusions in non-bleeding inpatients in our study was generally low, the majority of RBC transfusions were performed outside recommended indications. Red blood cell transfusions were evaluated as inappropriate mainly due to multiple-unit transfusion episodes, absence of anemia signs and/or symptoms pre- transfusion, and liberal transfusion triggers. There is still the need to educate physicians on appropriate indications for RBC transfusion in non-bleeding patients.

Contribution of Salvaged Blood Red Blood Cell Transfusion During Living Donor Liver Transplantation.

Transfusion of allogeneic blood products can have adverse effects and profoundly influence postoperative liver transplantation outcomes, including graft survival. To minimize allogeneic red blood cell (RBC) transfusion, salvaged blood can be used during liver transplantation. The aim of this study was to determine the contribution of salvaged blood to allogeneic RBC transfusion in living donor liver transplantation (LDLT) recipients. Data of 311 adult-to-adult LDLT recipients between January 2015 and April 2019 were analyzed. The primary outcome was a change in requirement for allogeneic RBCs due to the use of salvaged blood. Additionally, predictors of intraoperative allogeneic RBC transfusion were investigated. One hundred fifty-three (49.2%) recipients required allogeneic RBC transfusion. If recipients did not receive salvaged blood, 253 (81.4%) recipients would have needed allogeneic RBC transfusion. The total volume of salvaged blood transfused into recipients during surgery was 269,165mL, which corresponded to 993 units of allogeneic RBCs and accounted for 76.1% of total RBC transfusion volume. Multivariate analysis showed that male recipients, model for end-stage liver disease score, preoperative hemoglobin level, and volume of salvaged blood used during surgery were independent predictors of the need for intraoperative allogenic RBC transfusion. Intraoperative use of salvaged blood significantly reduced allogeneic RBC transfusion in LDLT recipients. It can help transplant teams manage transfusion of allogeneic RBCs during liver transplantation.

Phlebotomy resulting in controlled hypovolemia to prevent blood loss in major hepatic resections (PRICE-2): study protocol for a phase 3 randomized controlled trial

IntroductionBlood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection.MethodsThis study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment.DiscussionThe results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs.Trial registrationClinicalTrials.gov NCT03651154. Registered on August 29 2018.

Assessment of the need for routine intraoperative cell salvage in liver transplantation.

This study aimed to assess the necessity of routine intraoperative cell salvage in liver transplantations. A total of 327 liver transplants performed between 2014 and 2016 was included in the analysis. Patient data, including pre-transplant examinations, intraoperative red blood cell transfusions, and procedural information, were collected. The median age of the patients was 54 years old, with 67% (219) being male. The most prevalent ABO blood type was O, accounting for 48% (155) of cases. The leading causes of liver disease were hepatitis C (113 cases, 34.6%) and alcohol-related liver disease (97 cases, 29.7%). Out of the 327 liver transplants, allogeneic red blood cell transfusions were administered in 110 cases (34%) with a median of two units of red blood cells per case. Cell salvage was employed in 237 transplants (73%), and successful blood recovery was achieved in 221 cases (93%). Among the group that recovered more than 200 mL of blood, the median volume of recovered blood was 417 mL, with no transfusion of allogeneic blood required. A total of 90 transplants was performed without utilizing cell salvage, and, among these cases, 19 required blood transfusions, with a median of zero units transfused. This study suggests that routine cell salvage is unnecessary for all liver transplantations. The most suitable indication for its use is in patients presenting with portal vein thrombosis and abnormal creatinine levels.

Medicare and Medicaid insurance status is associated with increased allogeneic red blood cell transfusion in cardiac surgery patients: 2007-2018.

Allogeneic red blood cell (RBC) transfusion and health insurance status are independently associated with perioperative morbidity. The aim of this study was to evaluate the effect of insurance status on allogeneic and autologous transfusion risk in cardiac surgery patients. We conducted a retrospective observational study of data spanning 2007-2018 from six states from the State Inpatient Databases. Patients were cohorted by medical insurance type. Rates and risk-adjusted odds ratios (aOR) were calculated for allogenic and autologous RBC transfusions. Interactions between insurance and race/ethnicity were assessed. A total of 710,296 cardiac surgery patients were included. Allogeneic infusions occurred in 34.7% of Medicare patients, 31.9% of Medicaid patients, 24.7% of privately insured patients, and 26.1% of uninsured patients. Autologous rates were 2.3%, 2.5%, 3.4%, and 2.6% for Medicare, Medicaid, privately insured, and uninsured patients, respectively. Medicare and Medicaid patients were more likely to receive allogeneic RBC than privately insured patients (Medicare: aOR: 1.42, 99% confidence interval [CI]: 1.40-1.44, p < .001, Medicaid: aOR: 1.18, 99% CI: 1.14-1.21, p < .001). Nonwhite Medicare patients showed higher odds of allogeneic transfusion compared with White patients with private insurance (Black Medicare: aOR 1.74, 99% CI: 1.65-1.83, p < .001, Hispanic Medicare: aOR 1.92, 99% CI: 1.84-2.00, p < .001). Cardiac surgery patients with Medicare and Medicaid insurance demonstrate increased risk of allogeneic RBC transfusion; nonwhite patient groups are particularly vulnerable. Further research is needed to understand the causes and implications of these disparities, and to help ensure equitable care across patient groups.

Perioperative Outcomes of Patients Treated in an Anemia Clinic before Spine Surgery

BACKGROUND: Patients with preoperative anemia are at increased risk of postoperative blood transfusion, as well as other adverse outcomes, including infection, prolonged length of stay (LOS), and death. Requirement of intraoperative transfusions may be an independent risk factor for mortality among patients undergoing noncardiac surgery. As such, efforts have emerged internationally to establish clinical decision support tools, dedicated preoperative anemia clinics, and clinical trials studying the effects of preoperative treatment of patients to improve outcomes after surgery. While studies to date have shown mixed results, some suggest that treatment with intravenous (IV) iron improves anemia and decreases transfusion requirements. Treatment with erythropoietin-stimulating agents (ESA) has also been associated with fewer transfusions in patients undergoing orthopedic surgery. METHODS: We established a preoperative clinic in 2019 with a pilot for patients undergoing spine surgery. Patients who were found to have a hemoglobin (Hgb) < 13.0 g/dL on preadmission testing were automatically referred, and when possible, had iron studies reflexively added on to their samples. Patients were offered an appointment with a nurse practitioner or physician in Hematology and treated with IV iron or a combination of IV iron and ESA at the discretion of the provider. Importantly, if time did not allow for a visit or the patient declined an appointment or preoperative treatment, surgeries were not cancelled or delayed. This retrospective study included patients undergoing elective spine surgeries between August 1, 2019 and June 1, 2021 at Thomas Jefferson University Hospital and Jefferson Hospital for Neuroscience. Patients were eligible if they were automatically referred to the preoperative anemia clinic based on preadmission testing results. The primary outcome was postoperative allogeneic red blood cell (RBC) transfusion during the index admission. Secondary outcomes included decrease in Hgb postoperatively, LOS, and 30-day readmission rate. RESULTS: The study included 108 patients (53.7% female) who underwent a total of 112 distinct elective spine surgeries. The median age at the time of surgery was 65 years. The most common surgery was decompression and fusion (73.2%), followed by decompression (17.0%) and fusion (9.8%). 16.1% of surgeries were revisions of a prior surgery. The median preoperative Hgb was 11.6 g/dL. Prior to the 112 surgeries, 45 (40.2%) patients were seen by a Hematology provider and 37 (33.0%) received preoperative treatment for anemia, including 28 (25.0%) who got IV iron plus ESA, 8 (7.1%) IV iron alone, and 1 (0.9%) ESA alone. The final treatment was given a median of 5 days before surgery (IQR 3-9.5 days). There was a nonsignificant trend toward lower mean preoperative Hgb in patients who were treated before surgery and those who were not (mean 11.2 vs 11.6 g/dL, p=.162) and greater mean estimated blood loss during surgery when reported (392 vs 315 mL, p=.462). Compared to untreated patients, those who were treated before surgery were significantly more likely to be iron deficient (ferritin < 30 ng/mL or iron saturation < 15%) (45.9% vs 26.7%, p=.041). The primary outcome of allogeneic RBC transfusion occurred in 18.9% of patients who received pre-treatment and 9.3% of those who did not (p=.149). The degree of initial Hgb drop postoperatively from last pre-op value was significantly lesser in pre-treated patients (-0.93 vs -1.56 g/dL, p=.015), and a nonsignificant improvement was observed in the change from baseline to nadir Hgb during the index admission (-1.54 vs -2.15 g/dL, p=.074). A trend toward shorter LOS was observed in pre-treated patients (3.30 vs 3.47 days, p=.739), though that group also experienced more 30-day inpatient readmissions (18.9 vs 12.0%, p=.325). No deaths were observed during the study period. CONCLUSION: In this preoperative anemia clinic pilot, treatment with IV iron and/or ESA before major spine surgery was not associated with a reduction in allogeneic RBC transfusions or hospital readmission. However, those who received pre-treatment had significantly lesser declines in Hgb after surgery and a trend toward shorter LOS. Patients who received treatment were significantly more likely to be iron deficient before surgery and had lower mean Hgb levels, which confounds the results. Larger prospective studies of preoperative anemia therapy are needed. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal