Consumption Of Blood Products Research Articles

The carbon footprint and energy consumption of liver transplantation.

There is growing interest in the environmental impact of surgical procedures, yet more information is needed specifically regarding liver transplantation. This study aims to quantify the total greenhouse gas emissions, or carbon footprint, associated with adult whole-size liver transplantation from donors after brain death, including the relevant back-table graft preparation. The carbon footprint was calculated retrospectively using a bottom-up approach. This approach sums the volumes of energy consumption (kWh), volatile anesthetics (ml), solid waste (kg), and units of blood products transfused for each transplant. These consumption values were converted using validated conversion factors to the equivalent mass of carbon dioxide released into the environment (kg CO2e). A total of 147 patients with a mean age of 55 years (male, 78.9%) who underwent liver transplants between 2021 and 2022 were analyzed, resulting in 45.5 tons CO2e. The mean (SD) carbon footprint for each procedure was 309.8 (33.2) kg CO2e [95% CI: 304.4; 315.3]. Total energy power consumption was 96.5 MW, contributing 65.4% of greenhouse emissions (29.8 tons CO2e), while volatile anesthetics, solid waste, and blood product transfusions contributed 8.0% (3.64 tons CO2e), 5.9% (2.7 tons CO2e), and 20.6% (9.4 tons CO2e), respectively. The duration of surgery (t = 29.0; p < 0.001), transfused red blood cells (t = 13.1; p < 0.001), fresh frozen plasma (t = 11.1; p < 0.001), platelets (t = 8.9; p < 0.001), and the use of an extracorporeal pump machine (t = 3.6; p < 0.001) had the greatest effects on greenhouse gas emissions. Liver transplantation requires significant energy and is associated with considerable greenhouse gas emissions, particularly during longer procedures. Transplant clinicians, hospital administrators, policymakers, and patients should be aware of the environmental impact of liver transplantation and collaborate to adopt sustainable energy practices.

The Effect of Hemoperfusion on Bleeding after CABG in Patients on Preoperative Plavix: A Pilot Study

Background: Bleeding management during and after urgent heart surgery is always challenging in patients who are taken anticoagulants especially antiplatelet ones. The present study was conducted with the aim of investigating the role of intraoperative hemoperfusion in the active removal of Plavix in patients undergoing on-pump CABG surgery. Methods: The present study recruited patients on Plavix who underwent urgent CABG surgery. All patients have discontinued consuming Plavix less than 36 hours before surgery. During cardiopulmonary bypass, hemoperfusion set was added to the circuit and the surgery was done according to the standard open heart surgery protocols. The patients were transferred to the intensive care unit at the end of surgery and amount of bleeding was recorded in the ICU sheet hourly and calculated after 24 hours. Results: In our study, the average age of participating patients was 73,625 years. 5 patients out of 8 (62.5%) were male and 3 (37.5%) were female. Hypertension and blood type O were the most prevalent among the patients. The average amount of bleeding was 425 in the first day after surgery and the average units of transfused blood for patients was 0.125, which is acceptable and less than the values reported in other studies that do not use the hemoperfusion. Conclusion: The use of hemoperfusion during urgent CABG surgery, can reduce the postoperative bleeding and blood products consumption in patients on preoperative Plavix.

Coronary Artery Bypass Grafting Plus Mitral Valve Plasty May Not Provide More Advantage in Patients with Coronary Heart Disease and Moderate Ischemic Mitral Regurgitation: An Inverse Probability of Treatment Weighting Retrospective Cohort Study.

To compare the efficacy of isolated off-pump coronary artery bypass grafting (OPCABG) and of coronary artery bypass grafting (CABG) plus mitral valve plasty (MVP) in treating coronary heart disease with moderate ischemic mitral regurgitation to find a better surgical method. Clinical data of 822 patients diagnosed with coronary heart disease and moderate ischemic mitral regurgitation were analyzed retrospectively. Patients were divided into the OPCABG and CABG+MVP groups according to surgical methods. Baseline data of both groups were corrected, and clinical efficacy of the two surgical methods was analyzed and compared using the propensity score inverse probability of treatment weighting (IPTW) method. There were no significant differences in the use of mammary artery grafts, number of grafts, and blood product consumption between the two groups (P>0.05) after IPTW. However, the CABG+MVP group had a significantly longer operation time than the OPCABG group (4.13 ± 0.85 hours vs. 5.65 ± 1.02 hours, P<0.001). No statistically significant differences in postoperative major adverse cardiac and cerebrovascular events were observed between the two groups. However, the intra-aortic balloon pump rate was higher in the CABG+MVP group than in the OPCABG group (12.3% vs. 25.0%, P=0.012). Although CABG+MVP can improve ischemic mitral regurgitation significantly (95.4% vs. 81.2%, P<0.001), there were no significant differences in the cumulative survival rate and the incidence of major adverse cardiac and cerebrovascular events between the groups (P>0.05) after IPTW. CABG+MVP may not provide more advantage in patients with coronary heart disease and moderate ischemic mitral regurgitation.

Influence of vascular graft type for ascending aorta replacement on the early postoperative outcome.

Aim of this study was to find out if the type of vascular prosthesis used, especially collagen impregnated polyester versus gelatin impregnated woven fabric graft, has any impact on the early postoperative bleeding rate, blood product consumption and re-thoracotomy rate in isolated ascending aortic surgery. n = 46 consecutive patients who received a supra-commissural replacement of the ascending aorta between 01/2016 - 01/ 2021 were included in this retrospective single-center study. The underlying pathology was an aortic aneurysm in 36 (81 %) and/or an acute type A aortic dissection (ATAAD) limited to the ascending aorta in 7 (15 %) and/or a penetrating aortic ulcer (PAU) with intramural hematoma in 6 (13 %) patients. According to the type of vascular graft used, the cohort was divided as follows: 25 patients (54%) received a double velour woven, collagen impregnated polyester graft (Hemashield, Getinge; CI-Group) whereas in 21 patients (46 %) a gelatin impregnated woven fabric graft was used (Gelweave, Vascutek / Terumo; GI-group). As primary endpoints class 3 bleeding according to the Valve Academic Research Consortium (VARC3) criteria and freedom from re-intervention were assessed. As secondary endpoints, 30-day mortality and stroke were defined. Preoperative risk assessment (EuroSCORE II), gender-, BMI-stratification and NYHA-classification as well as mean CPB-times (114 ± 44min vs 110 ± 48min) and aortic cross-clamp times (71 ± 28min vs 66 ± 30min) were similar in both groups. Bleeding, measured by drainage volume output within the first postoperative 24h (480 ± 426mL vs 389 ± 169mL), erythrocytes concentrate consumption (2,4 vs 2,3) and similar re-thoracotomy rates (4 vs 4.7 %) showed no difference between groups. 30- day mortality (12 vs 5 %; p = 0.614) and stroke rates (4 vs 9.5; p = 0,4) showed no differences between groups. Regarding postoperative bleeding no difference were seen between the two graft types. Long-term follow-up and larger prospective randomized studies are requested to prove these findings.

The Association of Calcium Derangements With 24-Hour Outcomes in the Deployed Combat Setting.

Calcium derangements remain poorly characterized in the combat trauma population. We describe the incidence of emergency department (ED) calcium derangements, associated physiologic derangements, and 24-hour mortality from the deployed combat setting. We analyzed adult casualties from 2007 to 2023 from the DoD Trauma Registry for U.S. military, U.S. contractor, and coalition casualties that had at least 1 ionized calcium value documented in the ED at a Role 2 or Role 3 military treatment facility. We constructed a series of multivariable logistic regression models to test for the association of hypocalcemia and hypercalcemia with physiological derangements, blood product consumption, and survival. Vital signs and other laboratory studies were based on the concurrent ED encounter. There were 941 casualties that met inclusion for this analysis with 26% (245) having at least 1 calcium derangement. Among those, 22% (211) had at least 1 episode of hypocalcemia and 5% (43) had at least 1 episode of hypercalcemia in the ED. The vast majority (97%, 917) received calcium at least once. Median composite injury severity scores were lower among those with no calcium derangement (8 versus 17, P < .001). Survival was higher during the total hospitalization (98% versus 93%) among those with calcium derangements but similar at 24 hours (99% versus 98%, P = .059). After adjusting for confounder, any hypocalcemic measurement was associated with an elevated international normalized ratio (odds ratio 1.94, 95% CI 1.19-3.16), acidosis (1.66, 1.17-2.37), tachycardia (2.11, 1.42-3.15), hypotension (1.92, 1.09-3.38), depressed Glasgow coma scale (3.20, 2.13-4.81), elevated shock index (2.19, 1.45-3.31), submassive transfusion (3.97, 2.60-6.05), massive transfusion (4.22, 2.66-6.70), supermassive transfusion (3.65, 2.07-6.43), and all hospital stay mortality (2.30, 1.00-5.29). Comparatively, any hypercalcemic measurement was associated with acidosis (2.96, 1.39-6.32), depressed Glasgow coma scale (4.28, 1.81-10.13), submassive transfusion (3.40, 1.37-8.43), massive transfusion (6.25, 2.63-14.83), and supermassive transfusion (13.00, 5.47-30.85). Both hypocalcemia and hypercalcemia in the ED were associated with physiological derangements and blood product use, with a greater extent observed in those with hypocalcemia compared to those with hypercalcemia. Prospective studies are underway to better explain and validate these findings.

Evaluation of the consumption of blood products after the patient blood management implementation in a tertiary referral hospital within five consecutive years

Abstract: BACKGROUND AND AIMS: Patient blood management (PBM) is a multimodal scheme with several principles in the perioperative period which improves the outcome for patients. We prospectively evaluated the blood consumption situation during and after the years of implementation of PBM. METHODS: A 5 years’ prospective cross-sectional study was conducted between May 2016 and May 2020 in a tertiary referral hospital (Shahid Lavasani Hospital, Tehran, Iran). The outcome includes utilization rate of blood and its components (red blood cell [RBC], plasma and platelet [PLT]), transfused units per active hospital and intensive care unit (ICU) bed, the cross-match to transfusion ratio, transfusion index (TI), were evaluated before and after PBM implementation. The data were analyzed by the SPSS version 21. One-way repeated measures ANOVA and Friedman test were used. RESULTS: During 5 consecutive years, 6290 patients needed blood transfusions and entered to PBM protocol after their consent. Consumption of whole blood ceased in the initial year following PBM establishment. In 2017, RBC product usage (including whole blood and RBCs) decreased by 14.1% compared to 2016. This trend continued with further declines in 2018 (71.22%), 2019 (65.2%), and 2020 (59.10%) compared to 2016 (P &lt; 0.001). The reduction in the number of plasma transfused over time was statistically significant (P &lt; 0.001), as was the decrease in PLT transfusions (P &lt; 0.001). RBC usage per active hospital bed per year declined from 22.83 to 3.61, and the TI showed a significant decrease. The highest RBC usage was observed in surgical departments during this period. RBC utilization per bed in the ICU was 57.7 in 2017, 25 in 2018, 22.7 in 2019, and 11.3 in 2020. CONCLUSION: With the implementation of the PBM program, the consumption of blood products in the hospital gradually decreased. The initial reductions in blood product consumption were observed in whole blood, plasma, and then RBCs.

Long-term prediction of Iranian blood product supply using LSTM: a 5-year forecast

BackgroundThis study aims to predict the trend of procurement and storage of various blood products, as well as planning and monitoring the consumption of blood products in different centers across Iran based on artificial intelligence until the year 2027.MethodsThis research constitutes a time-series investigation within the realm of longitudinal studies. In this study, information on the number of packed red blood cells (RBC), leukoreduced red blood cells (LR-RBC), and platelets (PLT), PLT-Apheresis, and fresh frozen plasma (FFP) was requested from all blood transfusion centers in the country and extracted using a unified protocol. After the initial examination of the information and addressing data issues and inconsistencies, the corrected data were analyzed. Both conventional and artificial intelligence approaches were used to predict each product in this study. The best model was selected based on goodness-of-fit indicators RMSE and MAPE.ResultsBased on the obtained results, the FFP product will follow a relatively consistent process similar to previous years in the next five years. The PLT product is predicted to have a growing trend over the next 5 years, which applies to both the demand and supply of the product. The PLT-Apheresis product also shows a similar upward trend, albeit with a lower growth rate. The RBC product will have a constant trend over a 5-year period (long-term) according to both models, taking into account short-term changes. Similarly, there is a similar trend in LR-RBC, with the expectation that short-term pattern repetition will continue over a 5-year period (long-term). Comparing the goodness-of-fit results, the LSTM model proved to be better for predicting the dominant blood products.ConclusionsThe growth of the elderly population and diseases related to old age, and on the other hand, the trend of increasing the consumption of the product with a short lifespan (PLT) requires the activation of the management of the patient’s blood, especially in relation to this product in medical centers. The trend for other products in the next five years is similar to previous years, and no growth in demand is observed. The LSTM method, considering periodic and cyclical events, has performed the prediction.

Comparison of the benefits and risks of hemihepatic inflow occlusion: a systematic review and meta-analysis.

Application of hemihepatic inflow occlusion (HIO) and total hepatic inflow occlusion (TIO) are two common approaches for hepatectomy. However, their efficacy and safety remain controversial. Randomized control trials (RCTs) published before 15t January 2023 were included by a systematic literature search, which compared the clinical outcomes between HIO and TIO. The primary outcome was the estimated blood loss (EBL). Three independent authors screened and extracted the data and resolved disagreements by consensus. The ROB2.0 tool was used for evaluating the risk of bias. A total of 1026 patients (511 TIO and 515 HIO) from 9 studies were analyzed in the meta-analyses. The EBL between TIO and HIO group was similar, while HIO was associated with a lower proportion of patients required transfusion (P=0.002), less units of blood transferred (P<0.001) and a lower overall complication rate (P=0.008). There were no significant differences between TIO and HIO in mortality (P=0.37), length of stay (P=0.97), bile leak rate (P=0.58), liver failure rate (P=0.96), reoperation rate (P=0.48), postoperative haemorrhage rate (P=0.93) and incidence of postoperative ascites (P=0.96). The operative time of HIO was usually no more than 15 min longer than that of TIO (P<0.001). Comparing with the TIO, HIO increased the operative time and failed to further reduce the EBL in patients with liver surgery. However, despite the complexity of the operation, HIO was recommended due to the similar effect on the consumption of blood products and the postoperative complications.

Effect of blood conservation protocol on the utilisation of blood and outcome of patients undergoing open heart surgery.

Cardiac surgery is fraught with increased consumption of blood and blood products. Various strategies for blood conservation have been described. Our aim was to study the impact of a structured blood conservation protocol (BCP) on the utilization of blood and patient outcome. Retrospective analysis of prospectively collected data comparing adult patients undergoing open heart surgery with BCP with those undergoing surgery without BCP. The primary objective was to compare the amount of blood utilized and the hematocrit at discharge. The secondary objective was to compare the parameters of patient outcomes. The level of significance was set at 0.05. The proportion of patients requiring transfusion (19.1% [9/47] vs 58.9% [33/56]; p < 0.001) and the quantity of blood transfused (12 units vs 45 units; p 0.003) in the BCP group was significantly lower. Interestingly, the hematocrit level at discharge was comparable between the groups (30.9 (4.8) versus 31.8 (2.4), p-0.671). The average cost incurred for transfusing blood in the BCP group was ₹ 370.2 as compared to ₹1165.1 in the other (p < 0.001). BCP reduced the odds of overall blood transfusion by 79.8% (OR 0.202 (0.084-0.485); p < 0.001) and intraoperative blood transfusion by 95.3% (OR 0.047 (0.010-0.213); p < 0.001). The morbidity and mortality were comparable between the groups. Implementing a structured blood conservation protocol in patients undergoing open heart surgery significantly reduces the need for blood transfusion. It also has a promising impact on patient recovery after surgery and significant positive cost implications.

Blood consumption in the Role 2 setting: A Department of Defense Trauma Registry analysis.

The Role 2 setting represents the most far-forward military treatment facility with limited surgical and holding capabilities. There are limited data to guide recommendations on blood product utilization at the Role 2. We describe the consumption of blood products in this setting. We analyzed data from 2007 to 2023 from the Department of Defense Trauma Registry (DODTR) that received care at a Role 2. We used descriptive and inferential statistics to characterize the volumes of blood products consumed in this setting. We also performed a secondary analysis of US military, Coalition, and US contractor personnel. Within our initial cohort analysis of 15,581 encounters, 17% (2636) received at least one unit of PRBCs or whole blood, of which 11% received a submassive transfusion, 4% received a massive transfusion, and 1% received a supermassive transfusion. There were 6402 encounters that met inclusion for our secondary analysis. With this group, 5% received a submassive transfusion, 2% received a massive transfusion, and 1% received a supermassive transfusion. We described volumes of blood products consumed at the Role 2 during recent conflicts. The maximum number of units consumed among survivors exceeds currently recommended available blood supply. Our findings suggest that rapid resupply and cold-stored chain demands may be higher than anticipated in future conflicts.

Evaluation of the blood and blood products reservation and consumption status and factors related to non-injection and their wastage in Imam Reza Hospital, Kermanshah

Evaluation of the blood and blood products reservation and consumption status and factors related to non-injection and their wastage in Imam Reza Hospital, Kermanshah

Forecasting demand for blood products: Towards inventory management of a perishable product.

Forecasting consumption of blood products can reduce their order frequency by 60% and inventory level by 40%. This also prevents shortage by balancing demand and supply. The study aimed to establish a "Simple Average with Mean Annual Increment" (SAMAI) method of time series forecasting and to compare its results with those of ARIMA, ratio to trend, and simple average to forecast demand of blood products. Monthly demand data of blood component from January 2017 to December 2022 (data set I) was used for creating a forecasting model. To avoid the effect of COVID19 pandemic instead of actual data of year 2020 and 2021, average monthly values of previous three years were used (data set II). The data from January to July 2023 were used as testing data set. To assess the fitness of model MAPE (Mean Absolute Percentage Error) was used. By SAMAI method MAPE were 18.82%, 13.392%, 14.516% and 27.637% respectively for of blood donation, blood issue, RDP issue and FFP issue for data set I. By Simple Average method MAPE were 20.05%, 12.09%, 29.06% and 34.85%, respectably. By Ratio-to-Trend method MAPE were 21.08%, 21.65%, 25.62% and 39.95% respectively. By SARIMA method MAPE were 12.99%, 19.59%, 37.15% and 31.94% respectively. The average MAPE was lower in data set II by all tested method and overall MAPE was lower by SAMAI method. The SAMAI method is simple and easy to perform. It can be used in the forecasting of blood components demand in medical institution without knowledge of advanced statistics.

Abstract 12573: Differences in Blood Product Consumption Between Ventricular Assist Device and Extracorporeal Membrane Oxygenation During Postoperative Period

Introduction: Mechanical circulatory supports such as veno-arterial extracorporeal membrane oxygenation (ECMO) and left ventricular assist device (LVAD) are used in advanced heart failure patients. Due to their thrombogenic surfaces, these devices can lead to disseminated thrombosis. The need for anticoagulation also predisposes to hemorrhage, in addition to hemolysis from shear stress. As a result, transfusion of blood components is usually warranted following implantation. Hypothesis: To evaluate the differences in the need for transfusion of blood products between these devices during immediate postoperative period up to day 3. Methods: Fifty-four patients with advanced heart failure patients admitted at our facility between January 2016-2019 were included. All patients were anticoagulated with continuous heparin infusion. We analyzed the need for packed red blood cells (pRBC), fresh frozen plasma (FFP), and platelet transfusion. Lactate dehydrogenase (LDH), CBC, aPTT, and PT were also measured. The study was approved by Institutional Review Board (#L19-093). Results: A total of 54 patients (25 patients received ECMO and 29 patients received LVAD) were included. The median age was 56 years [47-62]. Thirty-eight patients (70.4%) were male. The means daily substitution of pRBC were significantly lower in the LVAD group on day 2 (0.35 vs 2.64 units/day, p=0.002) and day 3 (0.58 vs 1.64 units/day, p=0.028). The means daily substitution of platelets were comparable between the ECMO and LVAD groups. A trend toward the lower mean daily substitution of FFP in the LVAD group on day 2 (0 vs 0.44 units/day, p=0.069) was seen. There was a significantly lower serum LDH in the LVAD group on day 3 (391 ± 345 vs 599 ± 268, p=0.003). Conclusions: Data from this retrospective study showed that, compared to ECMO, LVAD was associated with lower rates of hemolysis and pRBC transfusion.

Angioembolisation for arterial haemorrhage related to pelvic ring injury.

Haemorrhage related to pelvic fractures has been associated with mortality rates of up to 50%. Angioembolisation for the management of pelvic haemorrhage was performed as early as 1972; however, there remains uncertainty over its exact use, timing and priority as a component of modern pelvic management protocols. We retrospectively analysed cases of angioembolisation for arterial haemorrhage related to pelvic ring fractures at a level 1 trauma centre. Patient demographics were assessed as well as the time taken to reach the interventional radiology (IR) suite from the time of trauma and also arriving at the emergency room (ER). Other factors analysed included the volume of blood products consumed and fracture pattern. Fifty-four patients received pelvic angiography for pelvic ring injuries between 2006 and 2021. The average age was 45.1 (20.5) years, with the male to female ratio 2.4:1. Forty (74.1%) of these patients had embolisation to actively bleeding pelvic arterial vessels. Median time to the IR was 4.4 [IQR 3.1-8.1] hours from time of trauma and 2.5 [IQR 2.1-4.2] hours from arrival to ER. The overall mortality rate was 18.5% and the median amount of blood transfused was 4584 mL [IQR 1643.5-8026.5]. In the subset of embolised patients (n = 40), mortality rate was 10% and there was an inverse association between time from ER to IR and volume of blood product consumption (P = 0.024). Angioembolisation is a life-saving intervention in very severely injured patients and is growing in popularity as a component of modern pelvic trauma management protocols.

Implementation of a Bleeding Management Algorithm in Liver Transplantation: A Pilot Study

Objectives: The aims of the study were to compare the consumption of blood products before and after the implementation of a bleeding management algorithm in patients undergoing liver transplantation and to determine the feasibility of a multicentre, randomized study. Background: Liver transplantation remains the only curative therapy for patients with end-stage liver disease, but it carries a high risk of surgical bleeding. Materials and Methods: Retrospective study of patients treated before (group 1) and after (group 2) implementation of a haemostatic algorithm guided by viscoelastic testing, including use of lyophilized coagulation factor concentrates (prothrombin complex and fibrinogen concentrates). Primary outcome was the number of units of blood products transfused in 24 h after surgery. Secondary outcomes included hospital stay, mortality, and cost. Results: Data from 30 consecutive patients was analysed; 14 in group 1 and 16 in group 2. Baseline data were similar between groups. Median total blood product consumption 24 h after surgery was 33 U (IQR: 11–57) in group 1 and 1.5 (0–23.5) in group 2 (p = 0.028). Significantly fewer units of red blood cells, fresh frozen plasma, and cryoprecipitate were transfused in group 2 versus group 1. There was no significant difference in complications, hospital stay, or in-hospital mortality between groups. The cost of haemostatic therapy was non-significantly lower in group 2 versus group 1 (7,400 vs. 15,500 USD; p = 0.454). Conclusion: The haemostatic management algorithm was associated with a significant reduction in blood product use during 24 h after liver transplantation. This study demonstrated the feasibility and provided a sample size calculation for a larger, randomized study.

Cost-Effectiveness of Hydroxyurea for Sickle Cell Anemia in a Low-Income African Setting: A Model-Based Evaluation of Two Dosing Regimens.

The disease burden of sickle cell anemia (SCA) in sub-Saharan African (SSA) countries is substantial, with many children dying without an established diagnosis or proper treatment. The global burden of SCA is increasing each year, making therapeutic intervention a high priority. Hydroxyurea is the only disease-modifying therapy with proven feasibility and efficacy suitable for SSA; however, no one has quantified the health economic implications of its use. Therefore, from the perspective of the health care provider, we estimated the incremental cost-effectiveness of hydroxyurea as a fixed-dose regimen or maximumtolerated dose (MTD) regimen, versus SCA care without hydroxyurea. We estimated the cost of providing outpatient treatment at a pediatric sickle cell clinic in Kampala, Uganda. These estimates were used in a discrete-event simulation model to project mean costs (2021 US$), disability-adjusted life years (DALYs), and consumption of blood products per patient (450mL units), for patients between 9months and 18years of age. We calculated cost-effectiveness as the ratio of incremental costs over incremental DALYs averted, discounted at 3% annually. To test the robustness of our findings, and the impact of uncertainty, we conducted probabilistic and one-way sensitivity analyses, scenario analysis, and price threshold analyses. Hydroxyurea treatment averted an expected 1.37 DALYs and saved US$ 191 per patient if administered at the MTD, compared with SCA care without hydroxyurea. In comparison, hydroxyurea at a fixed dose averted 0.80 DALYs per patient at an incremental cost of US$ 2. The MTD strategy saved 11.2 (95% CI 11.1-11.4) units of blood per patient, compared with 9.1 (95% CI 9.0-9.2) units of blood per patient at the fixed-dose alternative. Hydroxyurea at MTD is likely to improve quality of life and reduce the consumption of blood products for children with SCA living in Uganda. Compared with a fixed dose regimen, treatment dosing at MTD is likely to be a cost-effective treatment for SCA, using realistic ranges of hydroxyurea costs that are relevant across SSA. Compared with no use of the drug, hydroxyurea could lead to substantial net savings per patient, while reducing the disease morbidity and mortality and increasing quality of life.

Massive transfusion protocol.

The management of severe traumatic bleeding includes damage control resuscitation procedures including, in addition to surgical bleeding control, the application of the massive transfusion protocol. The aim of this paper is to present the massive transfusion protocol and selected scoring systems for an early detection of patients with severe post-traumatic bleeding. The use of a standardized protocol to activate the massive transfusion protocol reduces lethality due to severe traumatic bleeding and the consumption of blood products in trauma centers.

Early Re-Exploration versus Conservative Management for Postoperative Bleeding in Stable Patients after Coronary Artery Bypass Grafting: A Propensity Matched Study.

Postoperative bleeding requiring re-exploration in cardiac surgery has been associated with complications impacting short-term outcomes and perioperative survival. Many aspects of decision-making for re-exploration still remain controversial, especially in hemodynamically stable patients with significant but not acutely cumulating chest drain output. We investigated the impact of re-exploratory surgery on short-term outcomes in a "borderline population" of CABG patients who experienced significant non-acute bleeding, but that were not in critically hemodynamic unstable conditions. A prospectively collected database of 8287 patients undergoing primary isolated elective CABG was retrospectively interrogated. A population of hemodynamically stable patients experiencing significant non-acute or rapidly cumulating bleeding (>1000 mL of blood loss in 12 h, <200 mL per hour in the first 5 h) with normal platelet and coagulation tests was identified (N = 1642). Patients belonging to this group were re-explored (N = 252) or treated conservatively (N = 1390) based on the decision of the consultant surgeon. Clinical outcomes according to the decision-making strategy were compared using a propensity score matching (PSM) approach. After PSM, reoperated patients exhibited significantly higher overall blood product consumption (88.4% vs. 52.6% for red packed cells, p = 0.001). The reoperated group experienced higher rates of respiratory complications (odds ratio 5.8 [4.29-7.86] with p = 0.001 for prolonged ventilation), prolonged stay in intensive care unit (coefficient 1.66 [0.64-2.67] with p = 0.001) and overall length of stay in hospital (coefficient 2.16 [0.42-3.91] with p = 0.015) when compared to conservative management. Reoperated patients had significantly increased risk of multiorgan failure (odds ratio 4.59 [1.37-15.42] with p = 0.014) and a trend towards increased perioperative mortality (odds ratio 3.12 [1.08-8.99] with p = 0.035). Conservative management in hemodynamically stable patients experiencing significant but non-critical or emergency bleeding might be a safe and viable option and might be advantageous in terms of reduction of postoperative morbidities and hospital stay.

Hemodynamic monitoring in liver Transplantation patients in the third millennium

In patients undergoing orthotopic liver transplantation (OLTx) surgery, the intraoperative hemodynamic monitoring technique that is most utilized is still the pulmonary artery catheter (PAC). The popularity of transesophageal echocardiography (TEE) is increasing, so today's updated issue is the following: should the use of PAC and/or volumetric monitoring with transpulmonary thermodilution and/or advanced volumetric PAC be limited in clinical practice, only for some high risk patients? Could we use the TEE, if necessary, in less critical ill patients undergoing OLTx surgery? We can integrate all of the aforementioned monitoring techniques in an increasing modular step wise monitoring concept. But in an uncertain hemodynamic situation, transthoracic and/or transoesophageal echocardiographic evaluation represents a cornerstone. The use of echocardiography during OLTx is more and more common with several benefits demonstrated particularly by the TEE in this patient population. To achieve and maintain adequate tissue perfusion becomes difficult in case of major bleeding, an event quite possible to occur during OLTx, affecting the immediate and the late outcome. All the clinicians agree that bleeding interfere with the choice of hemodynamic monitoring and or vice versa. A reasonable compromise is to find a balance between the need to extend monitoring in high-risk surgical patients and the average consumption of blood products that characterizes each individual transplant center. This is also in line with what is shown in literature in terms of Maximum Surgical Blood Ordering Schedule (MSBOS).

Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion

Optimal transfusion strategies in traumatic hemorrhage are unknown. Reports suggest a beneficial effect of 4-factor prothrombin complex concentrate (4F-PCC) on blood product consumption. To investigate the efficacy and safety of 4F-PCC administration in patients at risk of massive transfusion. Double-blind, randomized, placebo-controlled superiority trial in 12 French designated level I trauma centers from December 29, 2017, to August 31, 2021, involving consecutive patients with trauma at risk of massive transfusion. Follow-up was completed on August 31, 2021. Intravenous administration of 1 mL/kg of 4F-PCC (25 IU of factor IX/kg) vs 1 mL/kg of saline solution (placebo). Patients, investigators, and data analysts were blinded to treatment assignment. All patients received early ratio-based transfusion (packed red blood cells:fresh frozen plasma ratio of 1:1 to 2:1) and were treated according to European traumatic hemorrhage guidelines. The primary outcome was 24-hour all blood product consumption (efficacy); arterial or venous thromboembolic events were a secondary outcome (safety). Of 4313 patients with the highest trauma level activation, 350 were eligible for emergency inclusion, 327 were randomized, and 324 were analyzed (164 in the 4F-PCC group and 160 in the placebo group). The median (IQR) age of participants was 39 (27-56) years, Injury Severity Score was 36 (26-50 [major trauma]), and admission blood lactate level was 4.6 (2.8-7.4) mmol/L; prehospital arterial systolic blood pressure was less than 90 mm Hg in 179 of 324 patients (59%), 233 patients (73%) were men, and 226 (69%) required expedient hemorrhage control. There was no statistically or clinically significant between-group difference in median (IQR) total 24-hour blood product consumption (12 [5-19] U in the 4F-PCC group vs 11 [6-19] U in the placebo group; absolute difference, 0.2 U [95% CI, -2.99 to 3.33]; P = .72). In the 4F-PCC group, 56 patients (35%) presented with at least 1 thromboembolic event vs 37 patients (24%) in the placebo group (absolute difference, 11% [95% CI, 1%-21%]; relative risk, 1.48 [95% CI, 1.04-2.10]; P = .03). Among patients with trauma at risk of massive transfusion, there was no significant reduction of 24-hour blood product consumption after administration of 4F-PCC, but thromboembolic events were more common. These findings do not support systematic use of 4F-PCC in patients at risk of massive transfusion. ClinicalTrials.gov Identifier: NCT03218722.