Blood Product Utilization Research Articles

Aortic Neck IFU Violations During EVAR for Ruptured Infrarenal Aortic Aneurysms are Associated with Increased In-Hospital Mortality

Vascular surgeons treating patients with ruptured abdominal aortic aneurysm must make rapid treatment decisions and sometimes lack immediate access to endovascular devices meeting the anatomic specifications of the patient at hand. We hypothesized that endovascular treatment of ruptured abdominal aortic aneurysm (rEVAR) outside manufacturer instructions-for-use (IFU) guidelines would have similar in-hospital mortality compared to patients treated on-IFU or with an infrarenal clamp during open repair (ruptured open aortic aneurysm repair [rOAR]). Vascular Quality Initiative datasets for endovascular and open aortic repair were queried for patients presenting with ruptured infrarenal AAA between 2013-2018. Graft-specific IFU criteria were correlated with case-specific proximal neck dimension data to classify rEVAR cases as on- or off-IFU. Univariate comparisons between the on- and off-IFU groups were performed for demographic, operative and in-hospital outcome variables. To investigate mortality differences between rEVAR and rOAR approaches, coarsened exact matching was used to match patients receiving off-IFU rEVAR with those receiving complex rEVAR (requiring at least one visceral stent or scallop) or rOAR with infrarenal, suprarenal or supraceliac clamps. A multivariable logistic regression was used to identify factors independently associated with in-hospital mortality. 621 patients were treated with rEVAR, with 65% classified as on-IFU and 35% off-IFU. The off-IFU group was more frequently female (25% vs. 18%, P = 0.05) and had larger aneurysms (76 vs. 72 mm, P= 0.01) but otherwise was not statistically different from the on-IFU cohort. In-hospital mortality was significantly higher in patients treated off-IFU vs. on-IFU (22% vs. 14%, P= 0.02). Off-IFU rEVAR was associated with longer operative times (135 min vs. 120 min, P= 0.004) and increased intraoperative blood product utilization (2 units vs. 1 unit, P= 0.002). When off-IFU patients were matched to complex rEVAR and rOAR patients, no baseline differences were found between the groups. Overall in-hospital complications associated with off-IFU were reduced compared to more complex strategies (43% vs. 60-81%, P< 0.001) and in-hospital mortality was significantly lower for off-IFU rEVAR patients compared to the supraceliac clamp group (18% vs. 38%, P= 0.006). However, there was no significantly increased mortality associated with complex rEVAR, infrarenal rOAR or suprarenal rOAR compared to off-IFU rEVAR (all P> 0.05). This finding persisted in a multivariate logistic regression. Off-IFU rEVAR yields inferior in-hospital survival compared to on-IFU rEVAR but remains associated with reduced in-hospital complications when compared with more complex repair strategies. When compared with matched patients undergoing rOAR with an infrarenal or suprarenal clamp, survival was no different from off-IFU rEVAR. Taken together with the growing available evidence suggesting reduced long-term durability of off-IFU EVAR, these data suggest that a patient's comorbidity burden should be key in making the decision to pursue off-IFU rEVAR over a more complex repair when proximal neck violations are anticipated preoperatively.

Living donor liver transplantation in septuagenarians: Better late than never.

The coupling of increased life expectancy and improvements in both quality and access to chronic liver disease care, is culminating in an expanding population of septuagenarians (≥70years) in need of liver transplantation (LT). The objective of this study is to partially alleviate this knowledge deficit and to add clarity to the current status and role of LDLT in this recipient population. Of 295 adult patients underwent LDLT between January 1, 2011 and December 31, 2016. Twelve (4%) of these patients were septuagenarians and this group was compared to younger cohort (n=283). Comorbidity profiles between the two groups were similar and no statistically significant differences were noted in warm/cold ischemia times, operative duration, or blood product utilization. ICU and total hospital stays were comparable. Septuagenarian 1-and 5-year graft and patient survivals were identical at 91.7%. Their younger counterparts had 1-and 5-year patient survivals of 91.1% and 84.0 % accompanied by 1-and 5-year graft survivals of 89.8% and 82.7%, respectively. Our study highlights a recognition that LDLT can afford highly-selected elderly patients to access to transplant with equivalent outcomes to those realized by younger recipients.

Minimally invasive versus conventional continuous-flow left ventricular assist device implantation for heart failure: a meta-analysis

Many studies have reported various minimally invasive techniques for continuous-flow left ventricular assist device implantation. There is no consensus on whether minimally invasive techniques can bring more benefits for patients compared with the conventional technique, due to the limited number of patients and diverse results in current studies. Our meta-analysis mainly discussed the comparison of minimally invasive and conventional techniques. We searched controlled trials from PubMed, Cochrane Library, and Embase databases until Dec 11, 2020. Perioperative and postoperative outcomes were analyzed among 10 included studies. The protocol has been registered with PROSPERO (CRD42020221532). There were no statistical differences in the 30-day mortality (OR 0.57; 95% CI 0.29 to 1.14), 6-month mortality (OR 0.66; 95% CI 0.41 to 1.05), neurological dysfunction (OR 1.10; 95% CI 0.69 to 1.76), major infection (OR 0.68; 95% CI 0.36 to 1.28), and pump thrombus (OR 1.49; 95% CI 0.63 to 3.52) among the cohorts. Minimally invasive techniques were associated with lower incidences of major bleeding (OR 0.39; 95% CI 0.22 to 0.68), severe right heart failure (OR 0.43; 95% CI 0.23 to 0.81), and less blood-product utilization (SMD -0.44). Sensitivity analysis suggested that minimally invasive techniques were associated with a lower incidence of respiratory failure (OR 0.50; 95% CI 0.26 to 0.96) and shorter mechanical ventilation time (SMD -0.53). Subgroup analysis demonstrated that patients, implanted with a centrifugal pump by minimally invasive techniques, were associated with a shorter length of intensive care unit (ICU) stay (SMD -0.27) and hospital stay (SMD -0.42), and less blood-product utilization (SMD -0.26). In conclusion, minimally invasive techniques can reduce the risks of major bleeding, severe right heart failure, and blood-product utilization, as well as have positive impacts on reducing mechanical ventilation time and the risk of respiratory failure. Minimally invasive centrifugal pump implantation can reduce the length of ICU and hospital stay.

Safety and efficacy of thromboelastography guidance of antifibrinolytic therapy in trauma patients: An observational cohort analysis.

Background:Tranexamic acid (TXA) is an antifibrinolytic therapy intended to decrease blood loss and improve hemostasis in traumatic hemorrhage. Viscoelastic assays, such as thromboelastography (TEG), allow for the identification of a patient's specific hemostasis. The purpose of this research study was to explore the safety and efficacy of TEG-guided antifibrinolytic therapy in trauma patients.Methods:This study was a retrospective review of trauma patients meeting institution-specific inclusion criteria for TXA. Patients were assigned to fibrinolytic groups per TEG LY30 data. Safety outcomes (24-h mortality, overall in-hospital mortality, and thromboembolic events) were compared between patients who did or did not receive TXA and within fibrinolytic groups. Mortality outcomes were adjusted for baseline Injury Severity Score (ISS). Secondary aims included blood product utilization, length of hospital, and intensive care unit stay.Results:Hypofibrinolysis was the most common fibrinolytic phenotype. Adjusting for ISS, there were no significant differences in mortality. A 30.7% thromboembolism incidence was identified in the TXA group compared to 16.6% not receiving TXA (P = 0.26), with 72.7% of these patients experiencing fibrinolytic shutdown.Conclusions:There were no differences in 24-h mortality, all-cause mortality, or secondary outcomes. The difference in thromboembolic rates between patients receiving TXA and those who did not, while not statistically significant, poses clinical concern.

The Use of Antifactor Xa Assays in a Comprehensive Pediatric Extracorporeal Membrane Oxygenation Anticoagulation Protocol is Associated with Increased Survival and Significant Blood Product Cost-Savings.

We augmented our standard extracorporeal membrane oxygenation laboratory protocol to include antifactor Xa assays, thromboelastography, and antithrombin measurements. We performed a retrospective chart review to determine outcomes for patients placed on extracorporeal membrane oxygenation (ECMO) prior to and after the initiation of our anticoagulation laboratory protocol. A total of 663 consecutive ECMO runs were evaluated from January 1, 2007 to June 30, 2018. Of these patients, 252 were on ECMO prior to initiation of the anticoagulation laboratory protocol on September 1, 2011, and 411 patients were on ECMO after initiation of the protocol. There were no major changes to our extracorporeal membrane oxygenation circuit or changes to our transfusion threshold during this continuous study period. Transfusion utilization data revealed statistically significant decreases in almost all blood components, and a savings in blood component inflation-adjusted acquisition costs of 31% bringing total blood product cost-savings to $309,905 per year. In addition, there was an increase in survival to hospital discharge from 45 to 56% associated with the initiation of the protocol ( p = 0.004). Our data indicate that implementation of a standardized ECMO anticoagulation protocol, which titrates unfractionated heparin infusions based on antifactor Xa assays, is associated with reduced blood product utilization, significant blood product cost savings, and increased patient survival. Future prospective evaluation is needed to establish an antifactor Xa assay-driven ECMO anticoagulation strategy as both clinically superior and cost-effective.

Vitamin K and ECMO for neonatal hypoxic respiratory failure.

The objectives of this retrospective cohort study were to examine the effect of vitamin K administration on hemorrhagic and thrombotic complications, blood product utilization, and outcomes in neonatal extracorporeal membrane oxygenation (ECMO). In the pilot study, complications, blood product use, and outcome data for neonates who received (n = 21) or did not receive (n = 18) a single dose of vitamin K (5 mg) immediately after initiation of ECMO for respiratory failure between 2006 and 2010 were compared. In the validation cohort, complications and outcomes were compared for 74 consecutive neonates supported with ECMO for respiratory failure who received (n = 45) or did not receive (n = 29) additional vitamin K once daily for prothrombin time (PT) ⩾14 seconds during ECMO from 2014 to 2019. In the pilot study, vitamin K at ECMO initiation was associated with fewer thrombotic complications and similar hemorrhagic complications. The volume of fresh frozen plasma was higher in neonates who received vitamin K, but total blood product and other component volume did not differ between groups. ECMO run time, survival off ECMO, survival to discharge, and length of stay did not differ between cohorts. In the validation cohort, neonates who received additional vitamin K during ECMO had longer ECMO run time and length of stay, but no difference in mortality was observed. Further, thrombotic and hemorrhagic complications as well as blood product exposure were similar between cohorts. These data suggest that routine vitamin K administration may have limited or no benefit during neonatal ECMO.

Comprehensive Analysis of Long-Term Outcomes after HeartMate 3 LVAD Implantation Depending on Surgical Access

Purpose The goal of this project is to assess the safety, possibility and effectiveness of minimally invasive HeartMate 3 LVAD implantation. Methods Our retrospective, single-center study included patients implanted with the HM3 LVAD between November 2016 and May 2020. The patients were divided into two groups depending on the surgical access: minimall invasive (MI) or full sternotomy (FS). The primary outcomes was heart regeneration, heart transplantation or death. We compared 30, 60, 180 days, 1 and 2 years survival. Secondary outcomes included peri- and postoperative complications, right heart-, respiratory-, renal- or liver failure, blood product utilization, ICU-, total hospital stay, bleeding and infection events. Results Of 73 patients implanted with the HM3 LVAD, 26 (35,61%) were implanted via MI and 47 (64,38%) via FS access. A previous heart surgery was more likely in MI group 54% vs. 12%; p Conclusion MI technique may be safe, possible and effective for HeartMate 3 LVAD implantation, even as redo cardiac surgery.

Central venoarterial extracorporeal life support in pediatric refractory septic shock: a single center experience.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is recognized as a potential support therapy for pediatric patients with refractory septic shock (RSS). This review aims to report our experience with central VA cannulation in pediatric patients with RSS, and to compare this with peripheral VA ECMO cannulations for this condition at our institution. Retrospective case series. Pediatric and cardiac intensive care units in an academic pediatric hospital. All patients 0-18 years old meeting criteria of RSS placed on VA ECMO between January 2011 and December 2018. None. Demographics, relevant clinical variables, ECMO run details, and outcomes were collected. Between 2011 and 2018, 14 children were placed on VA ECMO for RSS. Nine were cannulated centrally, with the rest placed on peripheral VA ECMO. Overall survival to hospital discharge was 57.1% (8/14), with 66.7% of the central cannulation cohort surviving versus 40% in the peripheral cannulation (p = 0.34). Median ECMO duration was 147.1 hours (IQR: 91.9-178.6 hours), with survivors having a median length of 147.1 (IQR: 138.5-185.7) versus non survivors 114.7 hours (IQR: 63.7-163.5), p = 0.48. Overall median ICU length of stay (LOS) was 19 days (IQR: 10.5-42.2). The median % maximum flow achieved on VA ECMO was higher in the central cannulation group at 179.6% (IQR: 154.4-188.1) versus the peripheral with 133.5% (98.1-149.1), p = 0.01. Functional status scale (FSS) was used to capture morbidity. All survivors had a mean increase in their FSS from baseline. In the centrally cannulated group, 50% (4/8) received mediastinal exploration, but none developed mediastinitis. In terms of blood product utilization, the central cannulation received more platelets compared to the peripherally cannulated group (median 15.6 vs 3.3 mL/kg/day, p = 0.03). A central approach to VA ECMO cannulation is feasible and has potential for good patient outcomes in selected patients.

Preemptive VAE-An Important Tool for Managing Blood Loss in MVT Candidates With PMT.

Background.Explantation of native viscera in multivisceral transplant candidates, particularly in those with extensive portomesenteric thrombosis (PMT), carries considerable morbidity due to extensive vascularized adhesions. Preemptive visceral angioembolization has been previously described as a technique to minimize excessive blood loss during mobilization of the native viscera but is not well described specifically in patients with extensive PMT.Methods.In a series of 5 patients who underwent mutivisceral transplant for PMT from June 2015 to November 2018, we performed preoperative superior mesenteric, splenic, and hepatic artery embolization to reduce blood loss during explanation and evaluated the blood loss and blood product utilization, as well as 30-day rates of infectious complications.Results.Following preemptive embolization, median total blood loss was 6000 mL (range 800–7000 mL). The median transfusion requirements were as follows: 16 units packed red blood cells (range 2–47), 14 units fresh frozen plasma (range 0–29), 2 units cryoprecipitate (range 1–14), 4 units platelets (range 2–10), and 500 mL cell saver autotransfusion (range 0–1817). In the first 30 postoperative days, 2 out of 5 patients developed positive blood cultures and 3 out of 5 developed complex intra-abdominal infections. Two patients developed severe graft pancreatitis resulting in mycotic aneurysm of the aortic conduit; bleeding from the aneurysm led to 1 patient mortality.Conclusions.Preoperative embolization is an effective modality to mitigate exsanguinating blood loss during multivisceral transplant in patients with portomesenteric thrombosis; however, it is unclear if the resultant native organ ischemia during explant carries clinically relevant consequences.

Institution of prothrombin complex concentrate protocols is associated with a reduction in plasma administration at a Tertiary Care Hospital

Study objectiveExplore how the introduction of 4-factor prothrombin complex concentrates (4F-PCC) protocols for reversing anticoagulation and the treatment of critical bleeding influenced blood product utilization. DesignA retrospective analysis of the utilization rate of plasma and 4F-PCC from September 2012 through December 2018. SettingBlood bank and pharmacy records of a single large tertiary care medical center. PatientsAdmitted patients except obstetric during the study period (n = 283,319). InterventionFive institutional protocols providing guidelines for 4F-PCC administration were deployed over a 3-year period. MeasurementsThe utilization rate of plasma and 4F-PCC was the primary outcome and analyzed using an interrupted time series analysis. Utilization of platelets and cryoprecipitate as well as the impact of the intervention on the service prescribing the blood products were evaluated as secondary outcomes. Data were evaluated using a segmented time series regression. ResultsWhen adjusted for seasonality, the monthly rate of plasma administration was 24.7 ± 2.0 units per 100 admissions in the 6-month period prior to the 1st intervention (May–October 2013) and decreased to 9.9 ± 2.2 units per 100 admissions in the same six-month period following the 5th intervention (May–October 2018), median difference − 14.5, 95% CI -16.0 to −13.2, P < 0.001. During the 6-month period prior to the 1st intervention (May–October 2013) the monthly rate of 4-F PCC use was 1.2 ± 0.8 doses per 1000 admissions and increased to 2.8 ± 1.0 doses per 1000 admissions 6-months following the 5th intervention (May–October 2018), median difference 1.6, 95% CI 0.3 to 1.9, P = 0.014. The monthly utilization of platelets was decreased and cryoprecipitate slightly increased following the implementation of the PCC protocols. Conclusions and relevanceOur findings demonstrate that establishing institutional protocols for the use of 4F-PCC to reverse the effects of anticoagulation and to treat critical bleeding with associated coagulopathy was associated with reduced plasma utilization.

A high transfusion burden following an ambulatory-allogeneic hematopoietic cell transplantation using reduced-intensity conditioning is associated with adverse outcomes

ObjectivesAmbulatory allogeneic hematopoietic cell transplantation (allo-HCT) after reduced-intensity conditioning (RIC) is a cost-effective option for hematology patients. Data on the impact of transfusion burden in this setting are scarce; we analyzed this retrospectively. MethodsA study of 177 HLA-identical and haploidentical allo-HCT recipients on an outpatient basis was conducted between 2013 and 2019. Packed red blood cell (PRBC) and platelet transfusions were documented from days 0–100 after HCT. ResultsA total of 121 patients (68.4%) required transfusion while 56 (31.6%) did not. In the multivariate analysis, a lower disease-free (DFS) and overall survival (OS) were documented for patients that received ≥9 total blood products (p = 0.018) (p = 0.014), those who required hospitalization (p = 0.001) (p < 0.001), had acute graft-versus-host disease (p = 0.016) (p = 0.004), and a high/very high Disease-Risk-Index (p = 0.002; p = 0.004), respectively. Transfusion of ≥5 PRBC units was associated with a lower OS (p = 0.027). The cumulative incidence of transplant-related mortality at two years for an HLA-identical transplant was 9.5% and for haploidentical, it was 27.1% (p = 0.027); this last group had significantly more transfusion demands than HLA-identical recipients (p = 0.029). ConclusionIncreased blood product utilization is an independent predictor of decreased survival in ambulatory RIC allo-HCT recipients. Further evidence leading to individualized guidelines to transfuse in this complex scenario is needed.

Liberal Versus Restrictive Hemoglobin Levels as Thresholds for Blood Transfusions.

Blood transfusion is a common treatment of anemia due to chronic disease or acute blood loss. However, there continues to be uncertainty concerning the appropriate threshold for transfusion. A restrictive protocol could decrease blood administered, transmissible infections, transfusion reactions, volume overload, and utilization of a limited commodity. However, anemia may result in decreased oxygen delivery which could lead to metabolic dysfunction an increased cell death. Determining an appropriate transfusion threshold is thus an important objective. A previous Cochrane review found the use of restrictive thresholds decreased transfusions compared to liberal thresholds. No difference in secondary outcomes, including 30-day mortality, hospital length of stay, cardiac events, and myocardial infarction, was noted.

Patterns of Blood Products Utilization at a Tertiary Care Center in the Southern Region of Saudi Arabia

MATERIALS AND METHODS: A total of 457 blood transfusion requests for 244 patients were received over a 3-month period. Registered demographic characteristics (age, sex, and nationality), ward, type of blood, and hemoglobin concentration before transfusion for all the patients were collected. RESULTS: A total of 1328 blood products were requested, while 780 (59%) units were transfused. The cross-matched packed red cells/transfusion ratio was 1.8, while request/transfusion was 1.7 for the fresh frozen plasma and 1.23 for platelets. Packed red blood cells were the main blood product used in blood transfusion (BT). General surgery/orthopedics and intensive care unit were reported with a greater number of requests. The main indications noted for blood requisition were surgery and anemia. CONCLUSIONS: Current guidelines appear to be respected within services regarding BT decision criteria. However, about half of the requested blood is not transfused which suggest further improvement. Adherence to established guidelines seems variables among different departments. Elective transfusion medicine rotations for all trainees and specialized dedicated sessions for doctors may help in further betterment of utilization of blood bank services.

Intraoperative Anti-A/B Immunoadsorption Is Associated With Significantly Reduced Blood Product Utilisation With Similar Outcomes in Paediatric ABO-Incompatible Heart Transplantation

Background: Intraoperative anti-A/B immunoadsorption (ABO-IA) was recently introduced for ABO-incompatible heart transplantation. Here we report the first case series of patients transplanted with ABO-IA, and compare outcomes with those undergoing plasma exchange facilitated ABO-incompatible heart transplantation (ABO-PE). Methods: Data were retrospectively analysed on all ABO-incompatible heart transplants undertaken at a single centre between 1st January 2000 and 1st June 2020. Data included all routine laboratory tests, demographics and pre-operative characteristics, intraoperative details and post-operative outcomes. Primary outcome measures were maximum post-transplant isohaemagglutinin titres, graft survival, occurrence of rejection and volume of blood product transfusions. Secondary outcome measures were length of intensive care and hospital stay. Demographic and survival data were also obtained for ABO-compatible transplants during the same time period for comparison. Results: Thirty-seven patients underwent ABO-incompatible heart transplants, with 27 (73%) using ABO-PE and 10 (27%) using ABO-IA. ABO-IA patients were significantly older than ABO-PE patients (p <0.001) and the total volume of blood products transfused during the hospital admission was significantly lower (164 [126 - 212] ml/kg vs. 323 [268 - 379] ml/kg, p <0.001). No significant differences were noted between methods in either pre or post-transplant maximum isohaemagglutinin titres, incidence of rejection, length of intensive care or total hospital stay. Survival comparison showed no significant difference between antibody reduction methods, or indeed ABO-compatible transplants (p = 0.47). Conclusions: This novel technique allows a significantly older population than typical to undergo ABO-incompatible heart transplantation, as well as significantly reducing blood product utilisation. Furthermore, intraoperative anti-A/B immunoadsorption does not demonstrate increased post-transplant isohaemagglutinin rebound or rates of rejection compared to ABO-PE. Survival is equivalent between ABO-IA, ABO-PE and ABO-compatible heart transplantation. Funding Statement: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: British Heart Foundation Research Fellowship to RI (FS/19/52/34563). Declaration of Interests: The authors declare no conflicts of interests. Ethics Approval Statement: Fulfilling the ethical guidelines of the Helsinki Declaration and approved by the Institutional Review Board as part of a wider study on Antibody Immunoadsorption for Transplantation (19HL02). Individual consent was not required since only routinely collected deidentified hospital data was evaluated within the secure digital research environment as part of an existing research database approval (17/LO/0008).

Audit of blood product utilization in the care of injured children.

Blood product utilization in injured children is poorly characterized; the decision to prepare products or transfuse patients can be difficult due to a lack of reliable evidence of transfusion needs across pediatric age-groups and injury types. We conducted an audit of transfusion practices in pediatric trauma based on age, injuries, and mechanism of injury. We reviewed and cross-referenced blood product transfusion practice data from the trauma registry and the anesthesia transfusion record database at a level 1 pediatric trauma center over a 10-year period. Demographic data, injury severity scores, and survival statistics were obtained from the trauma registry. Transfusion rates are reported separately for hospital admission and for intraoperative transfusions for procedures performed during the first two hospital days. Descriptive statistical analysis was used to compare specific groups based on age, injury type, and mechanism of injury. We report 14569 trauma admissions of 14606 patients. The transfusion rate during the admission was 1.56% (227/14569). 4591 (30.9%) admissions had surgical interventions in first two days of hospitalization with an intraoperative transfusion rate of 2.98%. Patients younger than one year had the highest transfusion rate during admission (2.8%), and the highest transfusion rate during surgical procedures performed in the first two days of the admission (18.87%). Admissions due to vascular injuries had the highest transfusion rates in infancy followed by hollow visceral injuries in adolescents (71.4% and 25%, respectively). Vascular injuries in most age-groups also had high transfusion rates ranging from 11% in 5- to 9-year age-group to 71% in infants. Mechanisms with the highest transfusion rates were firearm wounds in patients older than one year and vehicular accidents for patients younger than one year. The overall blood product needs in the pediatric trauma population are low (1.56%). Selected populations requiring higher rates of need include infants younger than one year, and children with thoracic and vascular injuries. Understanding transfusion patterns is important to optimize resource allocation.

Blood component utilization in COVID-19 patients in New York City: Transfusions do not follow the curve.

BackgroundBlood suppliers and transfusion services have worked diligently to maintain an adequate blood supply during the COVID‐19 pandemic. Our experience has shown that some COVID‐19 inpatients require transfusion support; understanding this need is critical to blood product inventory management.Study Design and MethodsHospital‐wide and COVID‐19 specific inpatient blood product utilization data were collected retrospectively for our networkʼs two tertiary academic medical centers over a 9‐week period (March 1, 2020‐May 2, 2020), when most inpatients had COVID‐19. Utilization data were merged with a COVID‐19 patient database to investigate clinical demographic characteristics of transfused COVID‐19 inpatients relative to non‐transfused ones.ResultsOverall, 11 041 COVID‐19 patients were admitted and 364 received blood product transfusions for an overall transfusion rate of 3.3%. COVID‐19 patients received 1746 blood components in total, the majority of which were red blood cells. COVID‐19 patientsʼ weekly transfusion rate increased as the pandemic progressed, possibly reflecting their increased severity of illness. Transfusion was significantly associated with several indicators of severe disease, including mortality, intubation, thrombosis, longer hospital admission, lower hemoglobin and platelet nadirs, and longer prothrombin and activated partial thromboplastin times. As the pandemic progressed, institutional adherence to transfusion guidelines improved for RBC transfusions compared to prior year trends but did not improve for platelets or plasma.ConclusionThere is a need to closely monitor the blood product inventory and demand throughout the COVID‐19 pandemic as patientsʼ transfusion needs may increase over time. Daily or weekly trending of patientsʼ clinical status and laboratory values may assist blood banks in inventory management.

Returning the Blood and Saving the Supply, the Veteran Affairs Medical Center (VAMC) Experience

Abstract Introduction/Objective Blood conservation techniques such as perioperative autologous cell salvage (PACS) can reduce patient usage and exposure to allogeneic blood products during surgery. As all blood transfusions carry risk and cost, the avoidance of transfusion through PACS represents an opportunity to reduce risk of allogeneic transfusion related reactions or complications and reduce costs from blood product utilization. Although the benefits of PACS has been documented in the literature, quality assurance demonstrations of the blood volume returned to veteran patients undergoing surgeries with a high likelihood of significant blood loss are sparse; thus, we present the quality assurance study of PACS usage in a VAMC. Methods Quality assurance documentation from the American Red Cross (ARC) that provides autologous cell salvage services at the VAMC were examined from February 2017 to August 2018, for a total of 17 months examined. The procedure, estimated blood loss, and volume returned was documented as part of a quality assurance/improvement project. The volume returned was compared to the typical RBC volume (~250 mL) within a packed red blood cell volume (~350 mL). Results A total of 44 procedures took place corresponding usage of PACS. Of these 44 procedures, 15 had no estimated blood loss, and an additional 10 had too little estimated blood loss (&amp;lt;250 mL) for blood volume to be returned. Among the procedures with blood loss, an average of 864 mL of blood was lost (1230 mL when the low blood loss cases are excluded) with an average volume returned of 511 mL or the approximate equivalent of 2 units of RBCs when utilized. Two cases with significant estimated blood loss (5400 mL and 4850 mL) had 2250 mL and 2125 mL or about the equivalent of 9 RBC units each. The total volume returned to all patients was 9700 mL, or the equivalent RBC volume of 38-39 RBC units. Conclusion PACS is a procedure that can rapidly provide large quantities of autologous blood in surgeries with significant risk of bleeding. Blood salvage avoids or reduces the risks of allogeneic blood transfusion and reduces cost to the transfusion service as the autologous blood loss would not need to be replaced with allogeneic blood transfusions. PACS in the VAMC returned significant blood volumes to patients undergoing procedures with high risk of blood loss, therefore reducing allogeneic blood transfusion requirements in the veteran population.

Management and outcomes of severe pelvic fractures in level I and II ACS verified trauma centers

BackgroundThe aim of this study was to evaluate the management strategies and outcomes of isolated severe pelvic fractures in level I and II ACS verified trauma centers. MethodsACS-TQIP database study, including patients with blunt, isolated severe pelvic facture (AIS 3–5). Results2629 level I and 1277 level II patients were included. Early blood product transfusion was significantly higher, pharmacological VTE prophylaxis significantly lower and ICU length of stay significantly longer in level II centers (p < 0.001). On multivariate analysis, treatment at level II centers was independently associated with increased overall complications, specifically ARDS, but not mortality. ConclusionsIn isolated severe pelvic fractures there was a significantly higher use of early blood products, less VTE pharmacological prophylaxis, longer ICU length of stay and higher overall complications and ARDS in level II centers. Blood product utilization and pharmacological VTE prophylaxis are potential areas of quality improvement in level II centers.

Utilisation of blood products at a centre in Pakistan. Is donating better than wasting?

The study was designed to investigate the quantity and reasons of wastage of blood products. This was an observational study conducted from February 2018 to February 2019 at the National Institute of Blood Disease and Bone Marrow Transplantation (NIBD and BMT), PECHS campus. The study was approved by the institutional review board. Wastage and reasons of wastage for all the blood products were evaluated. Frequencies were calculated by using SPSS version 23.0. A total of 2,880 bags of blood products were available, including 960 each of platelets, packed red cells and fresh frozen plasma. The overall wastage rate was 3.5%. Packed red cells and platelets were fully consumed, yet shortage of supply was observed. However, highest wastage was observed in fresh frozen plasma i.e. 102 bags. Expiry of unused products 60 (59%) followed by broken bags 30 (29%) were two common modes of wastage. Wastage of blood products is a genuine issue in a hospital setup, strategies and plan of action should be discussed and implemented to ensure that they are available when and where they are needed most.

Bivalirudin May Reduce the Need for Red Blood Cell Transfusion in Pediatric Cardiac Patients on Extracorporeal Membrane Oxygenation.

We retrospectively compared anticoagulation with heparin and bivalirudin for 32 consecutive children under 18 years old during extracorporeal membrane oxygenation (ECMO) in our pediatric cardiac intensive care unit (PCICU). Between September 2015 and January 2018, 14 patients received heparin, 13 venoarterial (VA), and 1 venovenous (VV). From February 2018 to September 2019, 18 received bivalirudin (all VA). The mean (standard deviation [SD]) percentage of time with therapeutic activated partial thromboplastin time and activated clotting time was bivalirudin 54 (14%) and heparin 57 (11%), p = 0.4647, and percentage of time supratherapeutic was bivalirudin 18 (10%) and heparin 27 (12%), p = 0.0238. Phlebotomy-associated blood loss per hour of ECMO was double in the heparin compared with bivalirudin group 1.08 ml/h (0.20 ml/h), compared with 0.51 ml/h (0.07 ml/h), p = 0.0003, as well as interventions to control bleeding. Packed red blood cell (PRBC) transfusions significantly correlated with higher blood loss in the heparin group (Pearson correlation coefficient = 0.49, p = 0.0047). Overall amount of blood product utilization was not different between the groups. Survival to ECMO decannulation was 89% for bivalirudin and 57% for heparin, p = 0.0396, although 6 month survival was not significantly different (67% versus 57%, p = 0.5809). Heparin may increase the need for PRBC transfusions and strategies to attenuate bleeding when compared with bivalirudin for children receiving ECMO in PCICU.