Blood Cell Transfusion In Patients Research Articles

Restrictive versus liberal blood transfusion strategies in patients with myocardial infarction and anemia: individual patient data meta-analysis of randomized trials

Abstract Background There are insufficient data to guide the appropriate use of red blood cell transfusion in patients with anemia and acute myocardial infarction (MI). Purpose To combine individual patient data from randomized clinical trials evaluating restrictive versus liberal transfusion strategies in patients with acute MI and anemia to generate precise estimates of treatment effects. Methods We searched all major databases to identify trials comparing restrictive versus liberal transfusion strategies in patients with acute MI and anemia (Hgb < 10 g/dl). We included studies that allocated participants to a liberal transfusion strategy that maintained hemoglobin greater than 10 g/dL or a restrictive transfusion strategy in which transfusion was administered if hemoglobin concentration was less than 8 g/dL. The primary outcome was a composite of 30-day death or MI. Secondary outcomes included 30-day death, 30-day cardiac death, and 6-month death. One-stage individual patient data meta-analyses were performed using a multilevel generalized linear model accounting for the clustering of patients within trials. Results We included 4311 participants from four trials. The primary outcome occurred in 334 patients (15.4%) in the restrictive and 296 patients (13.8%) in the liberal strategy (relative risk (RR) 1.13, 95% confidence interval (CI), 0.97 to 1.30) (figure 1). Death at 30-days occurred in 201 patients (9.3%) in the restrictive and 174 patients (8.1%) in the liberal strategy (RR 1.15; 95% CI, 0.95 to 1.39). Cardiac death at 30 days occurred in 5.5% in the restrictive strategy compared to 3.7% in the liberal strategy (RR 1.47; 95% CI, 1.11 to 1.94). Heart failure and thromboembolism occurred slightly more frequently in the liberal transfusion strategy group. Death at six months was higher in the restrictive (20.5%) compared to the liberal strategy (19.1%) (hazard ratio (HR) 1.08; 95% CI 1.05 to 1.11) (figure 2). The HR for cardiac death at 6 months was higher with a restrictive than liberal strategy (HR 1.38; 95% CI 1.08 to 1.76). In contrast, the HR for non-cardiac death at 6 months was lower with a restrictive than a liberal transfusion strategy (HR 0.89; 95% CI 0.84 to 0.94). Adjustment for baseline characteristics minimally changed the relative risk. Results for subgroups were similar except in patients without a history of renal failure whose risk of death or MI was increased with a restrictive strategy (RR 1.19; 95% CI, 1.01 to 1.39). Conclusions Pooled data from randomized trials found no significant differences for the primary outcome 30-day death or MI, but risk of cardiac death at 30 days and all cause death at 6 months was higher with a restrictive transfusion strategy. Given most outcomes favored liberal transfusion, and the risks from liberal transfusion were low, it may be prudent to use a liberal transfusion strategy in patients with acute MI and anemia.

Red Blood Cell Transfusions in Patients with Advanced Cancer Receiving Home Palliative Care.

Background: Red blood cell (RBC) transfusion is the standard treatment for anemia in advanced cancer. Nevertheless, guidelines for managing this condition are still not exhaustive. Objective: To investigate frequency, timing, and clinical characteristics associated with RBC transfusions in patients with advanced cancer assisted by at-home oncological care service and to evaluate the association between parameters at the entry and the possibility of receiving RBC transfusions during homecare. Design: Retrospective observational study without medication. Setting/Subjects: Patients with advanced cancer entered in homecare during 2021 living in Bologna (Italy). Measurements: Gender, tumor primary site, oncological therapy, and symptoms at the entry were considered as possible factors in a binary logistic regression for the possibility of receiving at least one RBC transfusion during assistance. Data about transfusions were analyzed, and the transfusion history for each patient from the entry to death was traced. Results: Among the 1108 patients admitted, 179 (16.2%) were given at least one RBC transfusion during homecare. Genitourinary, hematological malignancies, and being still in therapy for advanced cancer are associated with a higher probability of receiving RBC transfusion during assistance (p = 0.017, p < 0.001, and p = 0.032, respectively). Half of the patients (52%) underwent RBC transfusions less than a month before death. Duration of the assistance was correlated with the period from last transfusion to death (p < 0.001). Conclusion: Hematological and genitourinary cancer and being in simultaneous care at the entry were associated with transfusion. Although the appropriateness of this treatment remains to be defined in this population, transfused patients frequently received "late in life" transfusions.

Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury

Blood transfusions are commonly administered to patients with acute brain injury. The optimal hemoglobin transfusion threshold is uncertain in this patient population. To assess the impact on neurological outcome of 2 different hemoglobin thresholds to guide red blood cell transfusions in patients with acute brain injury. Multicenter, phase 3, parallel-group, investigator-initiated, pragmatic, open-label randomized clinical trial conducted in 72 intensive care units across 22 countries. Eligible patients had traumatic brain injury, aneurysmal subarachnoid hemorrhage, or intracerebral hemorrhage; hemoglobin values below 9 g/dL within the first 10 days after injury; and an expected intensive care unit stay of at least 72 hours. Enrollment occurred between September 1, 2017, and December 31, 2022. The last day of follow-up was June 30, 2023. Eight hundred fifty patients were randomly assigned to undergo a liberal (transfusion triggered by hemoglobin <9 g/dL; n = 408) or a restrictive (transfusion triggered by hemoglobin <7 g/dL; n = 442) transfusion strategy over a 28-day period. The primary outcome was occurrence of an unfavorable neurological outcome, defined as a Glasgow Outcome Scale Extended score between 1 and 5, at 180 days following randomization. There were 14 prespecified serious adverse events, including occurrence of cerebral ischemia after randomization. Among 820 patients who completed the trial (mean age, 51 years; 376 [45.9%] women), 806 had available data on the primary outcome, 393 in the liberal strategy group and 413 in the restrictive strategy group. The liberal strategy group received a median of 2 (IQR, 1-3) units of blood, and the restrictive strategy group received a median of 0 (IQR, 0-1) units of blood, with an absolute mean difference of 1.0 unit (95% CI, 0.87-1.12 units). At 180 days after randomization, 246 patients (62.6%) in the liberal strategy group had an unfavorable neurological outcome compared with 300 patients (72.6%) in the restrictive strategy group (absolute difference, -10.0% [95% CI, -16.5% to -3.6%]; adjusted relative risk, 0.86 [95% CI, 0.79-0.94]; P = .002). The effect of the transfusion thresholds on neurological outcome at 180 days was consistent across prespecified subgroups. In the liberal strategy group, 35 (8.8%) of 397 patients had at least 1 cerebral ischemic event compared with 57 (13.5%) of 423 in the restrictive strategy group (relative risk, 0.65 [95% CI, 0.44-0.97]). Patients with acute brain injury and anemia randomized to a liberal transfusion strategy were less likely to have an unfavorable neurological outcome than those randomized to a restrictive strategy. ClinicalTrials.gov Identifier: NCT02968654.

Acquired Low Factor XIII Activity Is Associated with an Increased Need for Blood Transfusions in Patients with Gastrointestinal Bleedings

BackgroundFactor XIII plays a key role within the coagulation cascade.ObjectiveWe aimed to investigate the relevance of factor XIII activity on the outcome of patients with gastrointestinal bleedings.MethodsIn this retrospective, single-center study patients with gastrointestinal bleeding and measurement of factor XIII activity were included. The primary endpoint was the number of red blood cell transfusions in patients with reduced factor XIII activity (< 70%) compared to patients with normal activity. Additionally, the influence of factor XIII substitution was assessed.ResultsNinety-seven patients (median age: 64 [IQR 55, 77] years, 31 (32%) females) were included in the analysis. Fifty-six (58%) patients suffered from an upper gastrointestinal bleeding. 66 (68%) patients had a factor XIII activity < 70% and 24 (36%) of those received factor XIII substitution. Patients with reduced FXIII activity needed significantly more red blood cell transfusions than patients with normal activity (9 [5, 12] vs. 4 [1, 8], p < 0.001). Patients receiving factor XIII substitution showed a trend toward a decreased need for transfusions after substitution (0 [0, 5] vs. 3 [1, 6], p = 0.066). Factor XIII activity correlated negatively with the INR (rs = -0.24, p = 0.018) and positively with hemoglobin levels (rs = 0.28, p = 0.006) and with thrombocyte counts (rs = 0.30, p = 0.003).ConclusionThe present study shows an association of factor XIII activity with the requirement of blood transfusions in patients with gastrointestinal bleedings and indicates a potential benefit of factor XIII substitution. Factor XIII activity seems to be dependent from the amount of blood loss and the global coagulation parameters.

Immune cell kinetics after allogeneic red blood cell transfusion in patients undergoing cardiovascular surgery

Background and ObjectivesRecent reports have highlighted that allogeneic blood transfusions decrease immune responses and affect patient outcomes. However, the effects of allogeneic red blood cell transfusions on the composition of immune cells are unclear. We aimed to clarify the alterations in host immune cells in patients who received allogeneic red blood cell transfusions during the perioperative period of cardiovascular surgery. Materials and MethodsEight non-transfused, 22 intraoperative autotransfusions, and 36 allogeneic red blood cell-transfused patients undergoing surgery were grouped, and lymphocyte subsets were analyzed using flow cytometry. Blood samples collected before surgery, approximately 1-week, and 1-month after surgery were used for analysis. Surgical parameters, operation time, blood loss, and length of hospital stay were also assessed. ResultsThe group receiving transfusions showed statistical significance compared to non-transfused in the above-mentioned surgical parameters. When comparing the autologous and allogeneic transfusion groups, only the allogeneic red blood transfusion group had a longer hospital stay. In comparing preoperative and 1-week and 1-month postoperative samples, there were almost no differences in CD4, CD20, or NK counts between the autotransfusions and the allogenic red blood cell transfusion groups. In contrast, a significant decrease in lymphocyte count was observed in the allogenic red blood cell transfused group 1-week postoperatively compared to preoperatively. Moreover, the number of CD8 + cells was statistically lowest in the allogeneic transfusion group 1 week after the operation. ConclusionOur results suggest that allogeneic red blood cell transfusion could alter immune cell composition especially CD8 + cells, potentially impacting immune function.

Development of a machine learning approach for prediction of red blood cell transfusion in patients undergoing Cesarean section at a single institution

Despite recent advances in surgical techniques and perinatal management in obstetrics for reducing intraoperative bleeding, blood transfusion may occur during a cesarean section (CS). This study aims to identify machine learning models with an optimal diagnostic performance for intraoperative transfusion prediction in parturients undergoing a CS. Additionally, to address model performance degradation due to data imbalance, this study further investigated the variation in predictive model performance depending on the ratio of event to non-event data (1:1, 1:2, 1:3, and 1:4 model datasets and raw data).The area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC) were evaluated to compare the predictive accuracy of different machine learning algorithms, including XGBoost, K-nearest neighbor, decision tree, support vector machine, multilayer perceptron, logistic regression, random forest, and deep neural network. We compared the predictive performance of eight prediction algorithms that were applied to five types of datasets. The intraoperative transfusion in maternal CS was 7.2% (1020/14,254). XGBoost showed the highest AUROC (0.8257) and AUPRC (0.4825) among the models. The most significant predictors for transfusion in maternal CS as per machine learning models were placenta previa totalis, haemoglobin, placenta previa partialis, and platelets. In all eight prediction algorithms, the change in predictive performance based on the AUROC and AUPRC according to the resampling ratio was insignificant. The XGBoost algorithm exhibited optimal performance for predicting intraoperative transfusion. Data balancing techniques employed to alter the event data composition ratio of the training data failed to improve the performance of the prediction model.

Utility of hemoglobin electrophoresis to distinguish between severe delayed hemolytic transfusion reaction versus hyperhemolysis syndrome

Delayed hemolytic transfusion reaction (DHTR) and hyperhemolysis syndrome (HHS) are both complications of red blood cell transfusions in patients with sickle cell disease.Clinically, both present with hemolysis and can be difficult to differentiate. Hemoglobin electrophoresis may aid in the diagnosis. Herein we describe a case in which a patient with hemoglobin SC disease presented with features of severe hemolysis several days after initiation of red blood cell exchange. Increase in reticulocyte count and complete absence of hemoglobin A on electrophoresis during this event supported the diagnosis of severe DHTR, indicating a rapid and selective destruction of the transfused red blood cells. Ability to interpret the hemoglobin electrophoresis can help clinicians distinguish between these two severe transfusion complications in patients living with sickle cell disease. It is important to identify the presence or absence of concomitant HHS, as patients with HHS tend to have a worse prognosis and there is a higher rate of recurrence of HHS with subsequent transfusions. Accurate diagnosis can lead to prompt management and decrease morbidity and mortality.

Challenging the dogma: Red blood cell-directed autoimmunity as risk factor for red blood cell alloimmunisation after blood transfusion.

Red blood cell autoimmunity and alloimmunity are potentially linked. Quantification of this association can tailor extensively matched red blood cell transfusions in patients with autoimmunity. Using an incident new-user cohort comprising 47 285 previously non-transfused, non-alloimmunised patients, we compared transfusion-induced red blood cell alloimmunisation incidences in direct antiglobulin test (DAT)-positive and control patients. Additionally, we performed case-control analyses to handle potential confounding by clinical immunomodulators. Among (IgG and/or C3d) DAT-positive patients (N = 380), cumulative red blood cell alloimmunisation incidences after 10 units transfused reached 4.5% (95% confidence interval [CI] 2.5-8.2) versus 4.2% (CI 3.9-4.5, p = 0.88) in controls. In case-control analyses, alloimmunisation relative risks among DAT-positive patients increased to 1.7 (CI 1.1-2.8). Additional adjustments for pre-DAT transfusion exposure or the extent of Rh/K mismatching did not impact results. In conclusion, while patients with DAT positivity show an intrinsically increased alloimmune red blood cell response, their absolute risk is comparable to control patients due to counteracting co-existing immunosuppressive conditions. Consequently, isolated DAT positivity in patients lacking overt haemolysis or complicated alloantibody testing does not seem to warrant extended matching strategies.

Red blood cell transfusion in patients undergoing elective primary glioblastoma resection.

Red blood cell (RBC) transfusion in patients undergoing major elective cranial surgery is associated with increased postoperative morbidity and mortality. This study aims to identify the clinical outcome of transfused glioblastoma patients undergoing primary surgical tumor resection and identify risk factors for RBC transfusion. Between 2009 and 2019, 406 patients underwent elective primary glioblastoma resection. For multivariate analysis to assess risk factors for RBC transfusion, logistic regression was conducted. The impact of RBC transfusion on overall survival was assessed using Kaplan-Meier analysis. In total, 36 (8.9%) patients received RBC transfusion. Preoperative anemia rate was significantly higher in transfused patients compared to patients without RBC transfusion (33.3 vs 6.5%; p<0.0001). Postoperative complications as well as hospital length of stay (LOS) (p<0.0001) were significantly increased in transfused patients compared to non-transfused patients. After multivariate analysis, risk factors for RBC transfusion were preoperative anemia (p<0.0001), intraoperative blood loss (p<0.0001), female gender (p=0.0056) and radiation (p=0.0064). Kaplan-Meier curves revealed that RBC transfusion and being elderly (age ≥75 years) were relevant for overall survival. RBC transfusion is associated with increased postoperative morbidity and mortality in patients undergoing elective primary glioblastoma resection. Preoperative anemia and intraoperative blood loss are major risk factors for RBC transfusion. Preoperative anemia management and blood conservation strategies are crucial in patients undergoing elective primary glioblastoma resection.

Intravenous iron administration before cardiac surgery reduces red blood cell transfusion in patients without anaemia

BackgroundReducing the need for blood transfusion among patients undergoing cardiac surgery FLA reduce postoperative complications and mortality. Our study aimed to assess the effects of administering preoperative i.v. ferric carboxymaltose on postoperative red cell transfusion requirements in patients without anaemia undergoing on-pump cardiac surgery. MethodsThis double-blind, randomised, placebo-controlled trial was conducted between October 2016 and November 2019, with a follow-up period of up to 6 weeks after surgery. Patients without anaemia who underwent on-pump cardiac surgery were included as participants and administered i.v. iron in the form of ferric carboxymaltose or placebo once, 24–72 h before surgery. The primary outcome was the number of red cell units transfused during the first four postoperative days, and the secondary outcome measures were blood haemoglobin concentrations at 4 days and 6 weeks after surgery. ResultsThe 200 patients included were randomly assigned to the ferric carboxymaltose (n=102) and placebo (n=98) groups. By postoperative Day 4, a significantly lower mean number of red cell units were transfused in the ferric carboxymaltose than in the placebo group, 0.3 (0.8) vs 1.6 (4.4), respectively; P=0.007. The mean haemoglobin concentrations on postoperative Day 4 were 9.7 (1) g dl−1 and 9.3 (1) g dl−1, respectively (P=0.03). Corresponding values at 6 weeks after surgery were 12.6 (1.4) g dl−1 and 11.8 (1.5) g dl−1, respectively (P=0.012). ConclusionsIn patients without anaemia undergoing on-pump cardiac surgery, treatment with a single dose of 1000 mg ferric carboxymaltose i.v. 1–3 days before surgery significantly reduced the need for red cell transfusions and increased the postoperative haemoglobin concentration. Clinical trial registrationNCT02939794.

Safety of Tigecycline in Patients on Antithrombotic Therapy: A Single-Center Retrospective Study

Introduction: The aims of the study were to investigate the risk factors of tigecycline-induced hypofibrinogenemia and to evaluate the safety of tigecycline with concomitant antithrombotic drugs. Methods: We performed a retrospective analysis of patients who received tigecycline for more than 3 days between January 2015 and June 2019. Clinical and laboratory data were collected including fibrinogen concertation, tigecycline dose, duration of treatment, disease severity, complete blood count, indicators of infection, liver and renal function. Risk factors of hypofibrinogenemia were analyzed by univariate and multivariate analysis. To evaluate the safety of tigecycline and concomitant antithrombotic drugs, bleeding events were assessed by comparing the decline in hemoglobin and the amount of red blood cell transfusion in patients with antithrombotic drugs and those without. Results: This study included a total of 68 cases, 20 of which experienced hypofibrinogenemia while receiving tigecycline treatment. Duration of treatment, cefoperazone/sulbactam combination therapy, and fibrinogen levels prior to initiation of tigecycline were risk factors associated with tigecycline-induced hypofibrinogenemia. There were 26 recorded bleeding incidents, 25 of which happened before the start of tigecycline. Antithrombotic and non-antithrombotic patients did not differ in their hemoglobin decline or need for red blood cell transfusions while taking tigecycline. Conclusion: A longer treatment duration, cefoperazone/sulbactam combination therapy, and a lower level of fibrinogen before tigecycline were associated with an increased risk of tigecycline-induced hypofibrinogenemia. A combination of antithrombotic drugs and tigecycline did not aggravate the bleeding events during tigecycline treatment.

Iron Load Toxicity in Medicine: From Molecular and Cellular Aspects to Clinical Implications.

Iron is essential for all organisms and cells. Diseases of iron imbalance affect billions of patients, including those with iron overload and other forms of iron toxicity. Excess iron load is an adverse prognostic factor for all diseases and can cause serious organ damage and fatalities following chronic red blood cell transfusions in patients of many conditions, including hemoglobinopathies, myelodyspasia, and hematopoietic stem cell transplantation. Similar toxicity of excess body iron load but at a slower rate of disease progression is found in idiopathic haemochromatosis patients. Excess iron deposition in different regions of the brain with suspected toxicity has been identified by MRI T2* and similar methods in many neurodegenerative diseases, including Alzheimer's disease and Parkinson's disease. Based on its role as the major biological catalyst of free radical reactions and the Fenton reaction, iron has also been implicated in all diseases associated with free radical pathology and tissue damage. Furthermore, the recent discovery of ferroptosis, which is a cell death program based on free radical generation by iron and cell membrane lipid oxidation, sparked thousands of investigations and the association of iron with cardiac, kidney, liver, and many other diseases, including cancer and infections. The toxicity implications of iron in a labile, non-protein bound form and its complexes with dietary molecules such as vitamin C and drugs such as doxorubicin and other xenobiotic molecules in relation to carcinogenesis and other forms of toxicity are also discussed. In each case and form of iron toxicity, the mechanistic insights, diagnostic criteria, and molecular interactions are essential for the design of new and effective therapeutic interventions and of future targeted therapeutic strategies. In particular, this approach has been successful for the treatment of most iron loading conditions and especially for the transition of thalassemia from a fatal to a chronic disease due to new therapeutic protocols resulting in the complete elimination of iron overload and of iron toxicity.

Research on hemoglobin thresholds for red blood cell transfusion in patients with major oncologic surgery is needed!

Research on hemoglobin thresholds for red blood cell transfusion in patients with major oncologic surgery is needed!

A novel predictive model of perioperative blood transfusion requirement in tuberculous spondylitis patientsundergoing posterior decompression and instrumentation.

Retrospective study. The aim of this study was to develop apredictive model for determining perioperative blood transfusion in tuberculous spondylitis patients undergoingposterior decompression and instrumentation. Tuberculous spondylitis is a common infection found in the spine. This condition may result in the need of surgical treatment, especially when there is a delay in diagnosis with inadequate antituberculosis drug treatment. The procedure results in high amount of bleeding on many occasions, leading to the higher rate of intraoperative transfusion.We develop a predictive model that can be used to determine blood transfusion requirement in spinal tuberculosis surgery. We reviewed the medical records of 83 tuberculous spondylitis patients who underwent posterior decompression and instrumentation. The clinical characteristics of the patients were analyzed using bivariate and multivariate regression test. The impact and strength of these variables was assessed to predict the probability of intraoperative red blood cell transfusion presence based on unstandardized beta, standard error, receiver operating characteristic, and confluence of sensitivity and specificity curve analyses. Furthermore, validation of this newly proposed predictive scoring system was performed using a set of 45 patients. The factors that significantly affect the need of blood transfusion during posterior spondylitis tuberculosis surgery were BMI (p = 0.005), pre-operative Hb (p < 0.001), number of affected segments (p = 0.042), and duration of surgery (p = 0.003). Our predictive model showed good sensitivity and specificity values based on a large area under the curve (0.913) and strong Pearson's r testing (correlation coefficient of 0.752). Validation set also resulted a large area under the curve (0.905) and strong correlation coefficient of 0.713. BMI, pre-operative Hb, number of affected segments, and duration of surgery became the significant factors which correlated to the presence of red blood cell transfusion in patients undergoing posterior spondylitis tuberculosis surgery. This predictive scoring system can be used to further adjust blood matching and inventory, determine intraoperative blood management, and ensure the safety of surgery in a comprehensive manner.

The burden of red blood cell transfusions in patients with lower-risk myelodysplastic syndromes and ring sideroblasts: an analysis of the prospective MDS-CAN registry

Many patients with lower-risk myelodysplastic syndromes (LR MDS) require long-term red blood cell (RBC) transfusions to manage anemia. The consequences of RBC transfusions in LR MDS with ring sideroblasts (LR MDS-RS) are not well known. We estimated the association between cumulative RBC dose density and clinical and patient-reported outcomes using data from the MDS-CAN registry for patients enrolled between January 2008 and December 2018. Outcomes included overall survival, hospitalization, and health-related quality of life (HRQoL). A total of 145 enrolled patients with LR MDS and RS ≥5% had a median follow-up time of 27.1 months; 45 had no transfusions during follow-up, 51 had <1 transfusion per month, and 49 had ≥1 transfusion per month. The cumulative density of RBC transfusions was associated with significantly greater mortality, hospitalization, and inferior HRQoL, suggesting that exposure to RBC transfusion may constitute a significant treatment burden in patients with LR MDS-RS.

TRansfusion strategies in Acute brain INjured patients (TRAIN): a prospective multicenter randomized interventional trial protocol

BackgroundAlthough blood transfusions can be lifesaving in severe hemorrhage, they can also have potential complications. As anemia has also been associated with poor outcomes in critically ill patients, determining an optimal transfusion trigger is a real challenge for clinicians. This is even more important in patients with acute brain injury who were not specifically evaluated in previous large randomized clinical trials. Neurological patients may be particularly sensitive to anemic brain hypoxia because of the exhausted cerebrovascular reserve, which adjusts cerebral blood flow to tissue oxygen demand.MethodsWe described herein the methodology of a prospective, multicenter, randomized, pragmatic trial comparing two different strategies for red blood cell transfusion in patients with acute brain injury: a “liberal” strategy in which the aim is to maintain hemoglobin (Hb) concentrations greater than 9 g/dL and a “restrictive” approach in which the aim is to maintain Hb concentrations greater than 7 g/dL. The target population is patients suffering from traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH). The primary outcome is the unfavorable neurological outcome, evaluated using the extended Glasgow Outcome Scale (eGOS) of 1–5 at 180 days after the initial injury. Secondary outcomes include, among others, 28-day survival, intensive care unit (ICU) and hospital lengths of stay, the occurrence of extra-cerebral organ dysfunction/failure, and the development of any infection or thromboembolic events. The estimated sample size is 794 patients to demonstrate a reduction in the primary outcome from 50 to 39% between groups (397 patients in each arm). The study was initiated in 2016 in several ICUs and will be completed in December 2022.DiscussionThis trial will assess the impact of a liberal versus conservative strategy of blood transfusion in a large cohort of critically ill patients with a primary acute brain injury. The results of this trial will help to improve blood product and transfusion use in this specific patient population and will provide additional data in some subgroups of patients at high risk of brain ischemia, such as those with intracranial hypertension or cerebral vasospasm.Trial registrationClinicalTrials.gov NCT02968654.

Delayed haemolytic transfusion reaction in paediatric patients with sickle cell disease: A retrospective study in a French national reference centre.

Delayed haemolytic transfusion reaction (DHTR) is a life-threatening haemolytic anaemia following red blood cell transfusion in patients with sickle cell disease, with only scarce data in children. We retrospectively analysed 41 cases of DHTR in children treated between 2006 and 2020 in a French university hospital. DHTR manifested at a median age of 10.5 years, symptoms occurred a median of 8 days after transfusion performed for an acute event (63%), before surgery (20%) or in a chronic transfusion programme (17%). In all, 93% of patients had painful crisis. Profound anaemia (median 49 g/L), low reticulocyte count (median 140 ×109 /L) and increased lactate dehydrogenase (median 2239 IU/L) were observed. Antibody screening was positive in 51% of patients, and more frequent when there was a history of alloimmunisation. Although no deaths were reported, significant complications occurred in 51% of patients: acute chest syndrome (12 patients), cholestasis (five patients), stroke (two patients) and kidney failure (two patients). A further transfusion was required in 23 patients and corticosteroids were used in 21 to reduce the risk of additional haemolysis. In all, 13 patients subsequently received further transfusions with recurrence of DHTR in only two. The study affords a better overview of DHTR and highlights the need to establish guidelines for its management in children.

Haemoglobin transfusion threshold in traumatic brain injury optimisation (HEMOTION): a multicentre, randomised, clinical trial protocol

IntroductionTraumatic brain injury (TBI) is the leading cause of mortality and long-term disability in young adults. Despite the high prevalence of anaemia and red blood cell transfusion in patients with...

A value-based approach to optimize red blood cell transfusion in patients receiving extracorporeal membrane oxygenation.

The risk, cost, and adverse outcomes associated with packed red blood cell (RBC) transfusions in patients with cardiopulmonary failure requiring extracorporeal membrane oxygenation (ECMO) have raised concerns regarding the overutilization of RBC products. It is, therefore, necessary to establish optimal transfusion criteria and protocols for patients supported with ECMO. The goal of this study was to establish specific criteria for RBC transfusions in patients undergoing ECMO. This was a retrospective cohort study conducted at Stanford University Hospital. Data on RBC utilization during the entire hospital stay were obtained, which included patients aged ≥18years who received ECMO support between 1 January 2017, and 30 June 2020 (n = 281). The primary outcome was in-hospital mortality. Hemoglobin (HGB) levels >10g/dL before transfusion did not improve in-hospital survival. Therefore, we revised the HGB threshold to ≤10g/dL to guide transfusion in patients undergoing ECMO. To validate this intervention, we prospectively compared the pre- and post-intervention cohorts for in-hospital mortality. Post-intervention analyses found 100% compliance for all eligible records and a decrease in the requirement for RBC transfusion by 1.2 units per patient without affecting the mortality. As an institution-driven value-based approach to guide transfusion in patients undergoing ECMO, we lowered the threshold HGB level. Validation of this revised intervention demonstrated excellent compliance and reduced the need for RBC transfusion while maintaining the clinical outcome. Our findings can help reform value-based healthcare in this cohort while maintaining the outcome.

Adverse events of red blood cell transfusions in patients with sickle cell disease

Blood transfusion is a common medical intervention for patients with sickle cell disease (SCD) and disease related complications. While patients with SCD are at risk for all transfusion related adverse events defined by the National Healthcare Safety Network (NHSN) Biovigilance Component Hemovigilance Module Surveillance Protocol, they are uniquely susceptible to certain adverse events. This review discusses risk factors, mitigation strategies, and management recommendations for alloimmunization, hemolytic transfusion reactions, hyperviscosity and transfusion-associated iron overload in the context of SCD.