Blood Transfusion Strategies Research Articles

Diverse Phenotypes of Cis-AB Blood Group and Transfusion Strategy

Diverse Phenotypes of Cis-AB Blood Group and Transfusion Strategy

Blood Transfusion and the Risk of Acute Kidney Injury Among Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Acute kidney injury (AKI) complicating percutaneous coronary intervention (PCI) is associated with adverse clinical outcomes. To date, no studies have evaluated the association of blood transfusion with AKI in patients undergoing PCI. We used a retrospective cohort study of all patients with acute coronary syndrome undergoing PCI from CathPCI Registry (n=1 756 864). The primary outcome was AKI defined as the rise in serum creatinine post procedure ≥0.5 mg/dL or ≥25% above baseline values. AKI developed in 9.0% of study sample. Patients with AKI were older, more often women, and had high prevalence of comorbidities, including diabetes mellitus, hypertension, and advanced stages of chronic kidney disease at baseline. Blood transfusion was utilized in 2.2% of patients. In the overall sample, AKI developed in 35.1% of patients who received transfusion versus 8.4% of patients without transfusion (adjusted odds ratio, 4.87 [4.71-5.04]). In the subgroup of patients who sustained bleeding event and received transfusion, the rate of AKI was significantly increased across all preprocedure hemoglobin levels versus no blood transfusion. Similar findings were seen in the subgroup of patients with no bleeding event. Blood transfusion is strongly associated with AKI in patients with acute coronary syndrome undergoing PCI. Further investigation is needed to determine whether a restrictive blood transfusion strategy might improve PCI outcomes by reducing the risk of AKI.

Blood transfusion strategy and risk of postoperative delirium in nursing homes residents with hip fracture. A post hoc analysis based on the TRIFE randomized controlled trial.

To investigate whether a liberal blood transfusion strategy [Hb levels ≥11.3g/dL (7mmol/L)] reduces the risk of postoperative delirium (POD) on day 10, among nursing home residents with hip fracture, compared to a restrictive transfusion strategy [Hb levels ≥9.7g/dL (6mmol/L)]. Furthermore, to investigate whether POD influences mortality within 90days after hip surgery. This is a post hoc analysis based on The TRIFE - a randomized controlled trial. Frail anemic patients from the Orthopedic Surgical Ward at Aarhus University Hospital were enrolled consecutively between January 18, 2010 and June 6, 2013. These patients (aged ≥65 years) had been admitted from nursing homes for unilateral hip fracture surgery. After surgery, 179 patients were included in this study. On the first day of hospitalization, all enrolled patients were examined for cognitive impairment (assessed by MMSE) and delirium (assessed by CAM). Delirium was also assessed on the tenth postoperative day. The prevalence of delirium was 10% in patients allocated to a liberal blood transfusion strategy (LB) and 21% in the group with a restrictive blood transfusion strategy (RB). LB prevents development of delirium on day 10, compared to RB, odds ratio 0.41 (95% CI 0.17-0.96), p=0.04. Development of POD on day 10 increased the risk of 90-day death, hazard ratio 3.14 (95% CI 1.72-5.78), p<0.001. In nursing home residents undergoing surgery for hip fracture, maintaining hemoglobin level above 11.3g/dL reduces the rate of POD on day 10 compared to a RB. Development of POD is associated with increased mortality.

Massive Transfusion in Children.

Massive transfusions occur frequently in pediatric trauma patients, among some children undergoing surgery, or in children with critical illness. Over the last years, many authors have studied different aspects of massive transfusions, starting with an operative definition. Some information is available on transfusion strategies and adjunctive treatments. Areas that require additional investigation include: studies to assess which children benefit from transfusion protocols based on fixed ratios of blood components vs transfusion strategies based on biophysical parameters and laboratory tests; whether goal-directed therapies that are personalized to the recipient will improve outcomes; or which laboratory tests best define the risk of bleeding and what clinical indicators should prompt the start and stop of massive transfusion protocols. In addition, critical issues that require further study include transfusion support with whole blood vs reconstituted whole blood prepared from packed red blood cells, plasma, and platelets; and the generation of high quality evidence that would lead to treatments which decrease adverse consequences of transfusion and improve outcomes.

Effect of restrictive versus liberal transfusion strategies on outcomes in patients with cardiovascular disease in a non-cardiac surgery setting: systematic review and meta-analysis

Objective To compare patient outcomes of restrictive versus liberal blood transfusion strategies in patients with cardiovascular disease not undergoing cardiac surgery. Design Systematic review and meta-analysis. Data sources Randomised controlled...

Reduction of red blood cell transfusions by implementation of a concise pretransfusion checklist.

This study assesses the effect of the implementation of a concise pretransfusion checklist as a means for restrictive blood transfusion strategy. To achieve an optimal use of red blood cells and to prevent overdosing of transfusion by implementation of a decision support algorithm. To ensure adequate use of red blood cells, physicians were obliged to complete the checklist with pretransfusion patient information before transfusion was approved. Laboratory employees checked the information and provided approval or refused to process the request. The red blood cell transfusion events, length of stay and mortality were analysed during a pre- and post-implementation period of 1 year. Transfusion requests decreased by 17·0%. The proportion of 1-unit and 2-unit transfusions decreased by 5·6% and 29·2%, respectively, corresponding with a total red blood cell units reduction of 22·6% and a yearly direct local cost reduction of 190·000 €. The median length of stay of transfused patients on wards decreased by 1·07 days (P < 0·05). Average pre- and post-transfusion haemoglobin levels before and after implementation of the checklist decreased by 0·32-0·35 g L(-1) (P < 0·05) for one unit red blood cell transfusions and 0·72-0·87 g L(-1) (P < 0·05) for two units of red blood cell transfusions. Decision support for transfusion necessity, in the form of a concise checklist as part of the transfusion request, is an example of a successful restricted blood transfusion strategy. The checklist can be applied in other hospitals as well.

Restrictive versus Liberal Blood Transfusion Strategies in Egyptian Patients with Esophageal Variceal Bleeding

Background and Study Aim: Esophageal variceal bleeding is a major medical emergency and one of the most important indications for hospital admission and for blood transfusion. However, the safest and the effective blood transfusion strategy is controversial. Here, we studied the safety and the effectiveness of the restrictive versus liberal transfusion strategies in patients with esophageal variceal bleeding. Patients and Methods: The study included 342 patients with esophageal variceal bleeding. Patients were divided into 2 groups: group I (Restrictive strategy) transfusion when the hemoglobin level is ≤7 g/dl and group II (Liberal strategy): transfusion when the hemoglobin level is ≤9 g/dl. All patients were subjected to complete blood counts, liver and kidney profiles, coagulation profile, pelvi-abdominal ultrasonography and upper GI endoscopy. Clinical outcome measures include rebleeding, infection, allergic transfusion reactions thromboembolic events, and mortality. Results: Of all patients admitted to hospital with esophageal variceal bleeding, the number of transfused RBCs units and hospital stay were more in the liberal transfusion strategy. Also, the overall rate of complications was higher in the liberal transfusion strategy (49.7% versus 38.5% in the restrictive transfusion strategy). The most common complications were rebleeding (26.9%) and infection (21.6%). As regard the death rate, 13 cases (7.6%) died in the restrictive transfusion strategy versus 25 cases (14.6%) in the liberal transfusion one. Conclusions: For esophageal variceal bleeding, restrictive transfusion strategy is better than the liberal one as regard cost-effectiveness, risk of complications and hospital stay with no harm and less mortality as compared to liberal strategy.

Abstract 12873: Blood Transfusion and the Risk of Contrast-Induced Nephropathy Among Acute Coronary Syndrome Patients Undergoing Percutaneous Coronary Intervention

Introduction: Emerging scientific and clinical evidence suggests that blood transfusion might be risk factor for acute kidney injury. Hypothesis: Blood transfusion is independently associated with contrast-induced nephropathy (CIN) in acute coronary syndrome (ACS) patients undergoing PCI. Methods: Retrospective cohort study from the NCDR CathPCI Registry (2009-2014) (n=1,756,864). Primary outcome was CIN defined as rise in serum creatinine peak post-procedure ≥ 0.5 mg/dl or ≥ 25% above baseline. Results: CIN developed in 9.0% of the cohort; these patients were older (66.0 vs. 64.0 years; P&lt;0.01), more often female (43.2% vs. 31.9%; P&lt;0.01), and had more baseline comorbidities including DM (46.1%), hypertension (85.1%), and lower baseline GFR. Blood transfusion was utilized in 38,626 (2.2%) of patients. The adjusted OR for the risk of CIN with transfusion in the overall sample, patients with major bleeding, and patients with no bleeding were 4.87 (4.71-5.04), 2.21 (2.12-2.31), and 4.80 (4.40 - 5.24) respectively (Table). Association of CIN with transfusion was significantly increased across all pre-procedure hemoglobin (Hgb) levels and in stepwise fashion with increasing Hgb levels and regardless of post-procedure bleeding (Hgb &amp;lt=10: adjusted OR (95%CI) 2.90 (2.75-3.05); Hgb &amp;gt10 to &amp;lt=13: 5.26 (5.06-5.48); Hgb &amp;gt13 to &amp;lt=15: 6.37 (5.99-6.78); Hgb &amp;gt15 g/dl: 7.03 (6.43-7.67); Ptrend &lt;0.01). Conclusions: Blood transfusion is strongly associated with CIN in ACS patients undergoing PCI. Whether a restrictive blood transfusion strategy lowers the risk of contrast nephropathy should be investigated.

P-170: Blood transfusion strategy and risk of postoperative delirium in nursing homes residents with hip fracture

P-170: Blood transfusion strategy and risk of postoperative delirium in nursing homes residents with hip fracture

Blood Transfusion Strategies in Patients Supported by Extracorporeal Membrane Oxygenation

Since red blood cell (RBC) transfusion was first performed by English obstetrician James Blundell 200 years ago,[1] it has become one of the most commonly used lifesaving therapies. Historically, RBC transfusion have been viewed as a safe and effective means of treating anemia and improving oxygen delivery to tissues. However, in the early 1980s, transfusion practice began to come under systematic scrutiny.[2,3] The early concern about the safety of blood transfusion revolved around transfusion-related infection. However, the concern about risks of blood transfusion have become diverse and complicated over the last three decades, according to research findings. In the recent literature, blood transfusion has been confirmed as an independent risk factor for mortality, perioperative infection, postinjury multiple organ failure, systemic inflammatory response syndrome, and admission to the intensive care unit(ICU).[4-7] Problems about blood transfusion are particularly important in the critically ill patients. Many data suggest that critically ill patients can tolerate hemoglobin levels as low as 7 g/dL and that a “liberal” RBC transfusion strategy may in fact lead to worse clinical outcomes.[8] Actually, RBC transfusion impairs physiologic control of regional vascular tone, induces coagulopathy and negatively impacts immune function and antioxidant system.[9] The 2012 Cochrane analysis reported that restrictive transfusion strategies were more effective than liberal transfusion strategies in reducing hospital mortality significantly among 6,264 patients from 1986 to 2011.[10,11] As such, newer “restrictive” hematocrit threshold for transfusion (e.g., 21%) are now appreciated to be at least noninferior to more “liberal” hematocrit thresholds (e.g., 30%) for broad array of conditions.[9] The efficacy of transfusion in critically ill pediatric patients has been also questioned as is still uncertain for adult critically ill patients. Lacroix et al. suggested, based on their TRIPICU study, that there was no difference in outcomes of stable critically ill children between restrictive (hemoglobin threshold of 7 g/dL) and liberal (hemoglobin threshold of 9.5 g/dL) transfusion strategies.[12] Subgroup analysis of postsurgical and postcardiac surgical patients from the TRIPICU study revealed similar findings. Among pediatric cardiac surgical patients, greater RBC transfusion volumes are associated with prolonged duration of mechanical ventilation, an increase in nosocomial infection rates and duration of hospitalization.[13,14]

Restrictive blood transfusion strategies and associated infection in orthopedic patients: a meta-analysis of 8 randomized controlled trials.

This study sought to evaluate whether restrictive blood transfusion strategies are associated with a risk of infection in orthopedic patients by conducting a meta-analysis of randomized controlled trials (RCTs). RCTs with restrictive versus liberal red blood cell (RBC) transfusion strategies were identified by searching Medline, Embase, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews from their inception to December 2014. Eight RCTs with infections as outcomes were included in the final analysis. According to the Jadad scale, all studies were considered to be of high quality. The pooled risk ratio [RR] for the association between transfusion strategy and infection was 0.65 (95% CI, 0.47–0.91; p = 0.012), and the number of patients needed to treat to avoid an infection using a restrictive transfusion strategy was 62. No heterogeneity was observed. The sensitivity analysis indicated unstable results, and no significant publication bias was observed. This meta-analysis of RCTs demonstrates that restrictive transfusion strategies in orthopedic patients result in a significant reduction in infections compared with more liberal strategies.

Effect of blood transfusion strategy on mortality in cardiac surgery: a meta-analysis of randomized controlled trials

Effect of blood transfusion strategy on mortality in cardiac surgery: a meta-analysis of randomized controlled trials

Improving clinical practice through the use of clinical practice guidelines

Clinical practice guidelines are a valued resource for clinicians looking for expert recommendations to direct clinical decision‐making. However, the reliability and trustworthiness of many clinical practice guidelines were subpar as many guidelines were fraught with expert opinion, conflicts of interest and bias. The Institute of Medicine thus created a set of standards for the development of clinical practice guidelines. These standards emphasize transparency, avoidance of conflicts of interest and a foundation in high‐quality peer‐reviewed evidence. The AABB adhered to the IOM standards in generating guidelines on red blood cell transfusion in 2012. A varied, multidisciplinary panel was convened to perform a rigorous evaluation of all available research. Clear rationale was given to every recommendation, including a discussion on the lack of available evidence when the panel was unable to make a strong recommendation. Both the quality of evidence used to make recommendations and the strength of the recommendations themselves were rated. The end result was a set of recommendations expounding a restrictive blood transfusion strategy that clinicians should feel comfortable relying on to influence their practice. Overall, all future guidelines should strive to follow in the footsteps of the AABB guidelines by meeting the IOM standards.

Postoperative blood transfusion strategy in frail, anemic elderly patients with hip fracture

Background and purpose — Hip fracture (HF) in frail elderly patients is associated with poor physical recovery and death. There is often postoperative blood loss and the hemoglobin (Hb) threshold for red blood cell (RBC) transfusions in these patients is unknown. We investigated whether RBC transfusion strategies were associated with the degree of physical recovery or with reduced mortality after HF surgery.Patients and methods — We enrolled 284 consecutive post-surgical HF patients (aged ≥ 65 years) with Hb levels < 11.3 g/dL (7 mmol/L) who had been admitted from nursing homes or sheltered housing. Allocation was stratified by residence. The patients were randomly assigned to either restrictive (Hb < 9.7 g/dL; < 6 mmol/L) or liberal (Hb < 11.3 g/dL; < 7 mmol/L) RBC transfusions given within the first 30 days postoperatively. Follow-up was at 90 days.Results — No statistically significant differences were found in repeated measures of daily living activities or in 90-day mortality rate between the restrictive group (where 27% died) and the liberal group (where 21% died). Per-protocol 30-day mortality was higher with the restrictive strategy (hazard ratio (HR) = 2.4, 95% CI: 1.1–5.2; p = 0.03). The 90-day mortality rate was higher for nursing home residents in the restrictive transfusion group (36%) than for those in the liberal group (20%) (HR = 2.0, 95% CI: 1.1–3.6; p = 0.01).Interpretation — According to our Hb thresholds, recovery from physical disabilities in frail elderly hip fracture patients was similar after a restrictive RBC transfusion strategy and after a liberal strategy. Implementation of a liberal RBC transfusion strategy in nursing home residents has the potential to increase survival.

Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial

Blood transfusion might affect long-term mortality by changing immune function and thus potentially increasing the risk of subsequent infections and cancer recurrence. Compared with a restrictive transfusion strategy, a more liberal strategy could reduce cardiac complications by lowering myocardial damage, thereby reducing future deaths from cardiovascular disease. We aimed to establish the effect of a liberal transfusion strategy on long-term survival compared with a restrictive transfusion strategy. In the randomised controlled FOCUS trial, adult patients aged 50 years and older, with a history of or risk factors for cardiovascular disease, and with postoperative haemoglobin concentrations lower than 100 g/L within 3 days of surgery to repair a hip fracture, were eligible for enrolment. Patients were recruited from 47 participating hospitals in the USA and Canada, and eligible participants were randomly allocated in a 1:1 ratio by a central telephone system to either liberal transfusion in which they received blood transfusion to maintain haemoglobin level at 100 g/L or higher, or restrictive transfusion in which they received blood transfusion when haemoglobin level was lower than 80 g/L or if they had symptoms of anaemia. In this study, we analysed the long-term mortality of patients assigned to the two transfusion strategies, which was a secondary outcome of the FOCUS trial. Long-term mortality was established by linking the study participants to national death registries in the USA and Canada. Treatment assignment was not masked, but investigators who ascertained mortality and cause of death were masked to group assignment. Analyses were by intention to treat. The FOCUS trial is registered with ClinicalTrials.gov, number NCT00071032. Between July 19, 2004, and Feb 28, 2009, 2016 patients were enrolled and randomly assigned to the two treatment groups: 1007 to the liberal transfusion strategy and 1009 to the restrictive transfusion strategy. The median duration of follow-up was 3·1 years (IQR 2·4-4·1 years), during which 841 (42%) patients died. Long-term mortality did not differ significantly between the liberal transfusion strategy (432 deaths) and the restrictive transfusion strategy (409 deaths) (hazard ratio 1·09 [95% CI 0·95-1·25]; p=0·21). Liberal blood transfusion did not affect mortality compared with a restrictive transfusion strategy in a high-risk group of elderly patients with underlying cardiovascular disease or risk factors. The underlying causes of death did not differ between the trial groups. These findings do not support hypotheses that blood transfusion leads to long-term immunosuppression that is severe enough to affect long-term mortality rate by more than 20-25% or cause of death. National Heart, Lung, and Blood Institute.

Blood Transfusion Strategy in Gastrointestinal Tract Bleeding: Liberal or Restrictive

Gastrointestinal tract bleeding is an emergency problem, which is frequently found. The manifestations of gastrointestinal tract bleeding vary, ranging from massive bleeding which is life threatening until occult bleeding that is not sensed by the patient. One of the main objectives in the management of gastrointestinal tract bleeding is stabilizing patient’s hemodynamic, either by using infusion of crystalloid, colloid, or even with the administration of blood transfusion. In massive gastrointestinal tract bleeding, administration of red blood cells transfusion may be life saving. However, in cases where bleeding is not profuse, the safest and most effective blood transfusion strategy is still controversial. Until now, there is no trial that gives information regarding safety and effectiveness of liberal or restrictive transfusion strategy in lower gastrointestinal tract bleeding. However, for most patients with gastrointestinal bleeding, with or without portal hypertension, it is better to postpone blood transfusion until the hemoglobin level decrease to less than 7 g/dL.Keywords: gastrointestinal tract bleeding, blood transfusion, liberal, restrictive

P463: Blood transfusion strategies in recovery from physical disability and overall quality of life in frail elderly with hip fracture

P463: Blood transfusion strategies in recovery from physical disability and overall quality of life in frail elderly with hip fracture

Evaluation of the blood transfusion strategy in Baghdad Teaching Hospital

Background: Guidelines for blood products transfusion are needed to avoid unnecessary blood transfusion in acute and chronic anaemias to minimize complications.Objective: To evaluate the practice of blood transfusion in Baghdad Teaching Hospital.Patients and methods: One hundred and sixty adults Iraqi patients, who had blood transfusion, were selected randomly from different wards of Baghdad Teaching Hospital including General Medicine (GM), General Surgery (GS), Gynecology/Obstetrics (G/O), forty patients from each ward, from October 2011 to October 2012. Collected data included age, gender, type of ward, indication for transfusion, pre-transfusion packed cell volume (PCV) and hemoglobin (Hb), type (whole blood or red blood cells (RBCs)) and number of units transfused.Results: Pre-transfusion PCV was &gt;30% (Hb &gt;10gm/dl) in 23.1% of the patients, and were highest in G/O (47.5%) and GS (37.5%) wards. Whole blood was given instead of RBCs to 60% of patients (100% in G/O and GS).Single unit blood was given to 22.5% of patients (37.5% in G/O and 35% 1n GS.Conclusion: There is general unawareness of the risks of blood transfusion in Baghdad Teaching Hospital as shown by the use of whole blood instead of RBCs and single unit transfusion, so a more restrictive strategy is needed by following the international guidelines.

Evaluation of the blood transfusion strategy in Baghdad Teaching Hospital

Background: Guidelines for blood products transfusion are needed to avoid unnecessary blood transfusion in acute and chronic anaemias to minimize complications.Objective: To evaluate the practice of blood transfusion in Baghdad Teaching Hospital.Patients and methods: One hundred and sixty adults Iraqi patients, who had blood transfusion, were selected randomly from different wards of Baghdad Teaching Hospital including General Medicine (GM), General Surgery (GS), Gynecology/Obstetrics (G/O), forty patients from each ward, from October 2011 to October 2012. Collected data included age, gender, type of ward, indication for transfusion, pre-transfusion packed cell volume (PCV) and hemoglobin (Hb), type (whole blood or red blood cells (RBCs)) and number of units transfused.Results: Pre-transfusion PCV was &gt;30% (Hb &gt;10gm/dl) in 23.1% of the patients, and were highest in G/O (47.5%) and GS (37.5%) wards. Whole blood was given instead of RBCs to 60% of patients (100% in G/O and GS).Single unit blood was given to 22.5% of patients (37.5% in G/O and 35% 1n GS.Conclusion: There is general unawareness of the risks of blood transfusion in Baghdad Teaching Hospital as shown by the use of whole blood instead of RBCs and single unit transfusion, so a more restrictive strategy is needed by following the international guidelines

Selected epidemiological aspects of fresh whole blood application in the Polish Field Hospital in Afghanistan

Minimisation of blood transmitted diseases is a basic element of all blood transfusion strategies. Civilian health service standards used in peacetime may be difficult to implement in a battlefield. The risk of blood-borne diseases depends on the applied donor qualification procedures and the epidemiological situation in the areas of military operations. The authors discuss various epidemiological aspects considered when selecting potential donors of fresh whole blood for a Walking Blood Bank at the Polish Field Hospital in Afghanistan.