Blood Transfusion Utilization Research Articles

Pharmacokinetic-Guided Hydroxyurea to Reduce Transfusions in Ugandan Children with Sickle Cell Anemia: Study Design of the Alternative Dosing And Prevention of Transfusions Trial.

People with sickle cell anemia (SCA) may require frequent blood transfusions to treat acute and chronic complications. Hydroxyurea is a life-saving treatment for SCA that could also decrease the need for blood transfusions. Inadequate medication access and challenges in dose optimization limit the widespread use of hydroxyurea in Africa. If feasible, pharmacokinetic (PK) dosing might improve dose determination to minimize toxicities and maximize clinical benefits. The Alternative Dosing And Prevention of Transfusions (ADAPT, NCT05662098) trial will analyze the impact of hydroxyurea on transfusion rate and serve as a pilot study to evaluate the feasibility of PK-guided hydroxyurea dosing in Uganda. Herein we describe the rationale and design of ADAPT, a prospective cohort study of ∼100 children with SCA in Jinja, Uganda. The primary hypothesis is that hydroxyurea will decrease blood transfusion use by ≥ 50%, comparing the transfusion incidence rate ratio between a 3-month pretreatment and a 12-month treatment period. A key secondary hypothesis is that our PK-dosing approach will generate a suitable hydroxyurea dose for ≥80% of participants. Every ADAPT participant will undergo hydroxyurea PK testing, and if a dose is generated within 15-35 mg/kg/day, participants will start on their individualized dose. If not, they will start on a default dose of 20 mg/kg/day. Hydroxyurea dose optimization will occur with periodic dose adjustments. Overall, demonstrating the reduction in blood transfusion utilization with hydroxyurea treatment would provide leverage to increase hydroxyurea access, and PK-guided hydroxyurea dosing should optimize the safe and effective treatment of SCA across sub-Saharan Africa.

Spontaneous Coronary Artery Dissection with Cardiogenic Shock in the United States.

Spontaneous coronary artery dissection (SCAD) is defined as a non-traumatic separation of the epicardial coronary artery walls that creates a false lumen. SCAD poses a difficult challenge in management, as decisions regarding revascularization and medical management seem to be tailored to the individual patient. We evaluated and compared outcomes based on cardiogenic shock in patients with SCAD utilizing Nationwide Readmissions Database (NRD) between January 1, 2016, to December 30, 2020. We utilized the NRD 2016-2019 to carry out this study. We evaluated demographics (e.g., age, gender), conventional risk factors, comorbidities present on the index admission, and in-hospital outcomes using their specific ICD-10-CM codes. The primary outcomes were In-hospital mortality and 30-day readmission, and the secondary outcome was to compare the complications in SCAD patient with cardiogenic shock (CS) compared to those without CS. We analyzed 2473 individuals with SCAD, 2199 of these individuals did not have cardiogenic shock whereas 274 of these individuals did have cardiogenic shock. When comparing SCAD with cardiogenic shock to SCAD without cardiogenic shock, there was a statistically significant increased odds ratio (OR) for death (propensity matched OR 24.93 (7.49-83.05), use of mechanical circulatory support (propensity matched OR 15.30 (6.87-34.04), ventricular tachycardia (propensity matched OR 4.45 (1.92-10.34), utilization of blood transfusions (propensity matched OR 3.82 (1.86-7.87), acute kidney injury (propensity matched OR 4.02 (1.45-11.13), need for mechanical ventilation (propensity matched OR 8.87 (3.53-22.31), and respiratory failure (propensity matched OR 4.95 (1.83-13.41)))))))). There was no statistically significant difference in 30-day readmission rates between the two groups. SCAD is a unique condition that can lead to many complications. In our analysis, we showed that SCAD associated with cardiogenic shock compared to SCAD not associated with cardiogenic shock results in greater odds of complications including death, use of mechanical circulatory support, need for blood transfusions, ventricular tachycardia, acute kidney injury, use of mechanical ventilation, and respiratory failure. SCAD with cardiogenic shock represents a significantly critical clinical scenario that requires a multi-disciplinary approach to prevent the many potential complications associated with this disease process.

Retrospective Study of Blood Transfusion Utilization in Surgical Patients in a Quebec, Canada Health Region: Do We Overestimate the Surgical Risk

Introduction Blood transfusions were initially developed in the 20 th century to support emergency surgery on injured soldiers. Their access and use have since revolutionized our ability to perform elective surgeries. However, there is a misconception that surgical procedures continue to be a primary user of blood transfusions, such that many surgeons have become reliant on blood units being reserved for their patients. A high-risk surgery is currently defined as a 48-hour risk of requiring a transfusion in at least 2-4% of cases ( Blood 2012,120:2954-2963). Patients meeting that risk category must have a blood group determination and cross-match before elective surgeries. While data from the ACS-NSQIP US database reported a decrease from 5.5% to 4% in transfusion rate for general surgery procedures between 2012 and 2018, rates remain elevated, included a risk of 6.6% for hemorrhoid ligation ( Transfusion 2021,61:3119-3128). The present study sought to evaluate the rates of use of transfusions during and immediately following surgery in a Canadian setting. Given improvement in surgical techniques, the regulated training of surgeons, and a universal healthcare access favoring the concentration of more complex surgical cases to regional centers, it was suspected that the need for blood products may be overestimated. Study design We conducted a retrospective study of the use of pRBC transfusions in all surgeries performed during a 24-month period in a single Quebec health region. Region 12 has a mix of urban and rural communities with a total population of almost half a million inhabitants. All types of surgeries are performed, with the exception of cardiac surgery, neurosurgery, and transplantation. The region includes 5 operating theaters, a larger regional center with 8 operating rooms and 4 smaller centers with 2-5 rooms. The current recommendation is for all patients undergoing surgery to have a group determination and cross-match before all major surgeries. Results Between January 2018 to December 2019, a total of 34 934 elective and emergency surgeries were performed. 172 patients received a total of 546 pRBC units (0.49% of surgeries). 395 units were transfused either during surgery or during the first 24 hours post-operatively. During the same period, a total of 10 982 blood units were transfused in the health region for all indications. Only 4.9% were given to surgical patients. Table 1 demonstrates transfusion rates by surgical specialty in Health Region 12. Major surgeries such as thoracic and vascular surgery, and urologic and ENT oncology are centralized to the urban regional center. 9% of vascular surgeries required blood transfusions (half being elective procedures), followed by thoracic surgery with 2.8% of surgeries (half also being elective procedures). All other types of surgeries had a < 1% utilization of blood transfusion, independent of hospital. 34 cases (0.1%) required 3 or more blood units during surgery. Only 3 of 9 patients who received more than 5 blood units during the first 24 hours of surgery survived 30 days post-operatively. Of the 172 patients who were transfused, alloantibodies were found in only 7 patients, of which 4 were significant. All four were already known in the national database, even though two were not detected during the pre-operative cross-match. Conclusions The 48-hour surgical blood transfusion risk in our region is significantly lower than that reported in recent data. Surgical sub-specialization and the concentration of more complex cases in higher volume centers may explain the reduced operative blood transfusion risk. In the present study, only vascular and thoracic surgeries qualified as high-risk, representing only 1.4% of all surgeries performed in the region. Therefore, pre-operative complete cross-matching could be avoided in more than 98% of surgeries, resulting in significant savings in specialized technical time, which is of particular importance at a time of personnel shortages.

Postpartum Hemorrhage Prevention Quality Improvement Initiatives and Blood Transfusion Utilization [ID: 1378079

INTRODUCTION: The universal implementation of active management of the third stage of labor, quantitative assessment of blood loss, and hemorrhage risk assessment on admission is recommended to reduce the incidence and morbidity of postpartum hemorrhage. We evaluated the effect of these quality improvement (QI) initiatives, in addition to an active management protocol for iron deficiency anemia antepartum, on the use of blood transfusion during delivery hospitalization. METHODS: We obtained blood transfusion data for the obstetric service at a tertiary care university hospital from January 1, 2017 to July 13, 2022, as well as data for every delivery during that time period (N=11,101). Institutional review board approval was obtained for the study. Patients whose transfusions were administered for nonobstetric indications were excluded. We compared the frequency of blood transfusions and number of units transfused per patient before and after the implementation of QI initiatives. RESULTS: There was a significant downward trend in the frequency of blood transfusions (P=.003) and the number of units transfused per patient (P=.000006) during the study period. The transfusion rate was 3.3% in the year prior to any intervention and 1.78% after implementation of all QI initiatives. No differences were observed in the characteristics of the patient population relevant to hemorrhage risk during the study period. CONCLUSION: This study provides evidence that in addition to reducing postpartum hemorrhage and its morbidity, these QI initiatives also help reduce blood transfusion utilization.

Modernizing transfusion medicine education

Blood transfusion is one of the most common medical procedures [1]. Even though blood transfusion could be life-saving in some circumstances, it also carries significant risks [2]. Inappropriate utilization of blood transfusion is well documented [3] and may stem from poor transfusion knowledge amongst medical professionals. Numerous studies have shown that medical trainees receive limited education in transfusion; furthermore, its content is not always relevant. Not surprisingly, medical trainees score poorly on knowledge assessments in transfusion.

O-01: HYDROXYUREA REDUCES THE TRANSFUSION BURDEN IN CHILDREN WITH SICKLE CELL ANEMIA IN SUB-SAHARAN AFRICA: THE REACH EXPERIENCE

Purpose: Many children with sickle cell anemia (SCA) require blood transfusions, which carry risks and utilize a scarce resource globally, particularly in Africa. Realizing Effectiveness Across Continents with Hydroxyurea (REACH, NCT01966731) has documented the safety, feasibility, and benefits of hydroxyurea for children with SCA living in sub-Saharan Africa. In REACH, hydroxyurea escalated to maximum tolerated dose (MTD) significantly decreased vaso-occlusive events, malaria, and death; transfusions were decreased by ~70% over 30 months of treatment when compared to the 2-month screening period. Characterizing and investigating how hydroxyurea reduces transfusion needs in REACH could contribute to improved clinical understanding, better outcomes, a decreased transfusion burden, and preservation of the blood supply in these limited-resource settings. Materials and methods: Transfusions were recorded prospectively in the REACH REDCap database. Transfusion rates and indications were compared during screening and treatment. Risk factors for receiving a transfusion were identified using time-varying predictors and landmark analysis. Univariate relationships were assessed using the Anderson-Gill model, plus multiple regression to estimate Hazard Ratios (HR) with 95% confidence intervals (CI). Results: A total of 635 children with HbSS from Angola, Democratic Republic of Congo, Kenya, and Uganda enrolled, and 606 started hydroxyurea treatment. During screening, 48 transfusions were administered to 43 children, and during the treatment phase 405 transfusions were administered to 214 children over a mean treatment time of 5.2 ± 1.3 years. The transfusion rate was 43.3 per 100 patient-years during screening, which decreased to 22.0 per 100 patient-years during the initial fixed dose treatment period (IRR = 0.50; 95%CI = 0.35-0.74, p<0.001 compared to screening) and then decreased further to 12.1 per 100 patient-years during the dose escalation period (IRR = 0.28; 95%CI = 0.21-0.39, p<0.001 compared to screening; IRR = 0.54; 95%CI = 0.43-0.73, p<0.001 compared to fixed-dose). For every 100 children treated for one year with hydroxyurea dose escalation, there were 31.4 fewer transfusions compared to the untreated screening period (number needed to treat = 3.2). Children with palpable splenomegaly at enrollment had a higher likelihood of receiving a transfusion during the trial (HR 1.98, 95% CI 1.59 to 2.47, p<0.0001). Age, gender, alpha thalassemia trait, and G6PD deficiency were not associated with differences in transfusion rates. Conclusion: Hydroxyurea significantly reduces blood transfusion administration in children with SCA in sub-Saharan Africa, especially when escalated to MTD. Overall, this demonstrates that treating children with SCA may not only improve individual patient outcomes through reduction in anemia, transfusion burden, and transfusion-associated complications including infections, but may also to help preserve the scarce blood supply for the benefit of the larger population. For example, applying similar outcomes to the population of Uganda predicts that about 30,000 transfusions per year are administered to patients with SCA and that with universal screening and treatment that 21,600 (72%) of these could be preventable, representing ~20% of all annual transfusions administered. The fact that treating SCA patients can benefit the entire population through reducing blood transfusion utilization reframes the importance of treating this population from an individual health decision to a public health strategy. R. WARE, MD, PHD declares a conflict of interest: Consultancy, Expert: DSMB Member for Novartis and Editas clinical trials; Medical Advisor for Nova Laboratories Research support/Scientific studies: Hydroxyurea donations from Bristol Myers Squibb and Addmedica; equipment donation from Hemex Health

Temporal trends, predictors of blood transfusion and in-hospital outcomes among patients with severe burn injury in the United States-A national database-based analysis.

Severe burn can be accompanied by life-threatening bleeding on some occasions, thus, blood transfusion is often required in these patients during their hospitalization. Therefore, we aimed to examine temporal trends, predictors, and in-hospital outcomes of blood transfusion in these patients in the United States. The National Inpatient Sample wasused to identify severe burn patients between January 2010 and September 2017 in the United States. Trends in the utilization of blood transfusion were analyzed using the Cochran-Armitage trend test. Moreover, propensity score matching (PSM) was employed, and then in-hospital outcomes were compared between these two groups in the matched cohort. Multivariable logistic regressions were further used to validate the results of PSM. Among 27,260 severe burn patients identified during the study period, 2120 patients (7.18%) received blood transfusion. Blood transfusion rates decreased significantly from 9.52% in 2010 to 5.02% in 2017 (p for trend <.001). In the propensity-matched cohort (2120 pairs with and without transfusion), patients transfused were at increased risk of in-hospital mortality (13.3% vs 8.77%, p < .001), overall postoperative complications (88.3% vs 72.59%, p < .001), longer hospital stays (defined as > median hospital stays=5d) (73.8% vs 50.6%, p< .001) and increased overall cost (defined as > median overall costs=30,746) (81.6% vs 57.3%, p< .001). This was also the case for the multivariable analysis. Blood transfusion following severe burn injury may be associated with worse clinical outcomes. The utility for blood transfusion in burn patients warrants further prospective exploration.

Assessment of Blood Transfusion Utilization and Patient Outcomes at Yekatit-12 Hospital, Addis Ababa, Ethiopia.

BackgroundThe goal of blood transfusion is to provide a safe, sufficient, and timely supply of blood components to the recipients by ensuring that donation is safe and no harm to the recipient. So the current study was aimed to assess blood transfusion utilization and its outcome in patients at Yekatit-12 Hospital, Addis Ababa, Ethiopia.MethodsA cross-sectional study was conducted from May 01 to July 30, 2021, on 616 individuals who have requested blood transfusion at Yekatit-12 Hospital, Addis Ababa, Ethiopia. Information on blood and blood component utilization was collected by using a checklist. Finally, data were analyzed using SPSS version 21.0, and those variables in which P-value is less than 0.05 were considered statistically clinically significant.ResultsA total of 1540 cross-match units were requested for 616 (53.2% male) patients with a mean age of 43 years. Out of 1540 cross-matched blood units, 1498 units of blood were transfused for 615 individuals with a mean of 2.43 units. The most widely used blood component was whole blood 694 (46.3%) and 1252 (83.6%) of the blood unit were “RH” positive. From a total of 68 (11.1%) none improved reported cases, 48 (10.5%) were those transfused with whole blood transfusion. The proportion of improvement after transfusion according to the service ranged from 83.3.0% to 100% and no post-transfusion reactions were reported. A significant improvement was seen in the hematological profile (hemoglobin, red blood cells, hematocrit, platelets, and white blood cells) findings of the transfused individuals after blood unit transfusion (P < 0.05).ConclusionThe overall utilization rate and improvement status after transfusion were high even if the utilization rate has some limitations. The overall ratios of cross-match to transfusion ratio, transfusion probability, and transfusion index were 1.03, 99.8%, and 0.97, respectively.

Blood transfusions in gunshot-wound-related emergency department visits and hospitalizations in the United States.

The United States (US) leads all high-income countries in gunshot wound (GSW) deaths. However, previous US studies have not evaluated the national blood transfusion utilization patterns in hospitalized GSW patients. Data from 2016 to 2017 were analyzed from the Nationwide Emergency Department Sample (NEDS) and Nationwide Inpatient Sample (NIS), the largest all-payer emergency department (ED) and inpatient databases, respectively. Using stratified probability sampling, weights were applied to generate nationally representative estimates. Multivariable Poisson-regression models were used to estimate prevalence ratios (PR) of blood transfusion. There were 168,315 ED visits and 58,815 hospitalizations (age=18-90 years) following a GSW. The majority of hospitalizations were men (88.5%), age 18-24 years (31.8%), and assault-related GSW (51.3%). Blacks had the largest proportion (48.7%) overall of all GSW hospitalizations; Whites accounted for the highest proportion of intentional self-harm injuries (72.4%). Blood transfusions occurred in 12.7% of hospitalizations (12.0% red blood cell [RBC], 4.9% plasma, and 2.5% platelet transfusions). Only 1.9% of cases were associated with transfusion of all three blood components. Hospitalizations with major/extreme severity of illness had significantly higher prevalence of transfusion versus those with mild/moderate severity [crude PR=4.79 (95%CI:4.15-5.33, p< .001)]. Overall, 8.2% of hospitalizations with GSW died, of whom 26.8% required blood transfusions, which was significantly higher than survivors [crude PR=2.34 (95%CI:2.10-2.61, p< .001)]. The vast majority (95%) of the transfusions among those who died were within 48 h since admission. Gun-related violence is a public health emergency in the US, and GSWs are a source of significant mortality, blood utilization, and health care costs.

Assessment of recipients' characteristics, transfusion appropriateness, and utilization pattern of blood and blood products in Jimma Medical Center, Jimma, Ethiopia.

BackgroundAs blood transfusion remains life-saving and is being frequently prescribed, a greater number of its practice is unnecessary or inappropriate. This important clinical intervention is reported as one of the five overused medical treatments, with gross over-ordering and whole blood transfusions as the sole component being common in developing countries. Study of recipient’s demographics, clinical conditions, appropriate blood utilization, and continuous clinical audits for quality assurance and service improvement plan are important factors to this practice. This study was designed to assess the recipient’s characteristics, blood type distributions, appropriateness of blood transfusion, and utilization practice of the big medical center.MethodsInstitution based cross-sectional study was conducted from February 1 to June 30, 2018. Data were collected using a structured data collection format prepared for this study. All transfusion prescriptions were followed from requisition up to completion. Patient’s age, sex, requesting departments, hemodynamics, number and component of units requested and issued, and units transfused were collected. Transfusion appropriateness was assessed by a criterion-based method while blood utilization was calculated.ResultsA total of 545 units of blood for 425 patients were cross-matched of the 809 units of total blood prescribed. The mean and median age of transfused individuals was found to be 27.47 ±15.28 years and 26 years respectively, and 65.4% females most in reproductive age groups. O and A Rhesus-positive blood types were the two major blood groups observed. Overall 82.1% of transfusions were appropriate; while only 27.8% of patients received appropriate components as 96.5% of individuals received a whole blood transfusion. Significant blood utilization was recorded with a C/T ratio of 1.05, TP% of 100%, and TI of 1.23.ConclusionMuch of the transfusion recipients were relatively young aged and females, most in the reproductive age group. Although whole blood was used as a sole component, significant blood transfusion utilization and appropriateness were recorded; while appropriate component transfusion was recorded to be significantly low. Local transfusion guidelines and appropriate component preparation and utilization are required to improve the sub-optimal blood component transfusion practice.

Significant Variation in Blood Transfusion Practice Persists Following Adolescent Idiopathic Scoliosis Surgery.

Retrospective case control study. To review current transfusion practise following Adolescent Idiopathic Scoliosis (AIS) surgery and assess risks of complication from transfusion in this cohort. No study to date has investigated variation in blood transfusion practices across surgeons and hospitals following AIS surgery. Data were extracted from the Statewide Planning and Research Cooperative System. Using International Classification of Diseases (ICD-9) all patients with (ICD-9) code for AIS (737.30) ("idiopathic scoliosis") and underwent spinal fusion between 2000 and 2015 were included. Bivariate and mixed-effects logistic regression analyses were performed to assess patient, surgeon, and hospital factors associated with perioperative allogeneic red blood cell transfusion. Additional multivariable analyses examined the association between transfusion and infectious complications. Of the 7689 patients who underwent AIS surgery, 21.1% received a perioperative blood transfusion. After controlling for patient factors, wide variation in risk-adjusted transfusion rates was present with a 10-fold difference in transfusion rates observed across surgeons (4.4%-46.1%) and hospitals (5.1%-50%). Patient factors did not explain any of the surgeon or hospital variation. Use of autologous blood transfusion, higher surgeon procedure volume, and greater surgeon years in practice were independently associated with lower odds of allogeneic blood transfusion (P < 0.001), and surgeon and hospital characteristics explained 45% of surgeon variation but only 2.4% of hospital variation. Allogeneic blood transfusion was independently associated with postoperative wound infection (OR = 1.87, 95% CI = 1.20-2.93), pneumonia (OR = 1.68, 95% CI = 1.26-2.44), and sepsis (OR = 2.42, 95% CI = 1.11-5.83). Significant variation exists across both surgeons and hospitals in perioperative blood transfusion utilization following AIS surgery. Use of autologous blood transfusion and implementing institutional transfusion protocols may reduce unwarranted variation and potentially decrease infectious complication rates.Level of Evidence: 3.

Blood transfusion utilization in hospitalized COVID-19 patients.

BackgroundThe acute respiratory illness designated coronavirus disease 2019 (COVID‐19) was first reported in Wuhan, China, in December 2019 and caused a worldwide pandemic. Concerns arose about the impact of the COVID‐19 pandemic on blood donations and potential significant blood transfusion needs in severely ill COVID‐19 patients. Data on blood usage in hospitalized COVID‐19 patients are scarce.Study Design and MethodsWe performed a retrospective observational study of blood component transfusions in the first 4 weeks of COVID‐19 ward admissions. The study period began 14 days before the first COVID‐19 cohort wards opened in our hospital in March 2020 and ended 28 days afterward. The number of patients and blood components transfused in the COVID‐19 wards was tabulated. Transfusion rates of each blood component were compared in COVID‐19 wards versus all other inpatient wards.ResultsCOVID‐19 wards opened with seven suspected patients and after 4 weeks had 305 cumulative COVID‐19 admissions. Forty‐one of 305 hospitalized COVID‐19 patients (13.4%) received transfusions with 11.1% receiving red blood cells (RBCs), 1.6% platelets (PLTs), 1.0% plasma, and 1.0% cryoprecipitate (cryo). COVID‐19 wards had significantly lower transfusion rates compared to non‐COVID wards for RBCs (0.03 vs 0.08 units/patient‐day), PLTs (0.003 vs 0.033), and plasma (0.002 vs 0.018; all p < 0.0001). Cryo rates were similar (0.008 vs 0.009, p = 0.6).ConclusionsHospitalized COVID‐19 patients required many fewer blood transfusions than other hospitalized patients. COVID‐19 transfusion data will inform planning and preparation of blood resource utilization during the pandemic.

Integrated Fragility Hip Fracture Program: A Model for High Quality Care.

Hip fractures are a significant cause of morbidity and mortality among elderly patients. Coordinated multidisciplinary care is required to optimize medical outcomes. To determine the effect of the implementation of standardized, evidence-based protocols on clinical outcomes and mortality in patients with fragility hip fractures. A multidisciplinary group was convened to define best practices in fragility hip fracture care and implement a fragility hip fracture clinical protocol at Yale-New Haven Hospital. Clinical outcomes in 2015, prior to program initiation, were compared with 2018, after the program was well established. Measured outcomes included 30-day mortality, blood transfusion utilization, adverse effects of drugs, venous thromboembolic complications, sepsis, myocardial infarction, mechanical surgical fixation complications during the index admission, length of stay, 30-day readmission, unexpected return to the operating room (OR) and time to the OR. The implementation of the Integrated Fragility Hip Fracture Program was associated with significant reductions in 30-day mortality from 8.0% in 2015 to 2.8% in 2018 (P = .001). Significant reductions were also seen in use of blood transfusions (46.6% to 28.1%; P < .001), adverse effects of drugs (4.0% to 0%; P < .001), length of stay (5.12 to 4.47 days; P = .004), unexpected return to the OR (5.1% to 0%; P < .001), and time to the OR <24 hours (41.8% to 55.0%, P = .001). An Integrated Fragility Hip Fracture Program using multidisciplinary care, physician and nursing engagement, evidence-based protocols, data tracking with feedback, and accountability can reduce mortality and improve clinical outcomes in patients with hip fractures.

Multidisciplinary Implementation of an Iron Deficiency Anemia in Pregnancy Treatment Protocol

Background: Anemia in pregnancy increases the need for blood transfusion during and after delivery and is associated with an increased risk of maternal and fetal mortality, therefore preventing maternal anemia may improve outcomes. Iron deficiency is the most common pathologic cause of anemia in pregnancy and is estimated to affect about 30% of pregnant women in the third trimester in the US. The baseline peripartum blood transfusion rate at our institution is 3.2%. Historically, patients who may have benefited from intravenous (IV) iron were continued on oral iron and subsequently delivered with persistent iron deficiency anemia. If identified to need IV iron, these patients were usually referred to a hematologist. However, in the absence of a structured protocol, referral was provider-dependent. Objective: We formed a multidisciplinary work group consisting of members from the departments of Hematology, Obstetrics, Pharmacy, Nursing, and Blood Bank to reduce peripartum blood transfusions by developing a process to manage pregnant patients with iron deficiency anemia. The treatment algorithm utilized at our institution was adapted from "How I treat anemia in pregnancy: iron, cobalamin, and folate" (Achebe &amp; Gafter-Gvili, 2017), which recommends IV iron for hemoglobin less than 11 g/dL and ferritin less than 30 µg/dL in the third trimester and for hemoglobin less than 10.5 g/dL and ferritin less than 30 µg/dL in the second trimester along with recommendations for iron repletion in the first trimester. The primary endpoint was the utilization of blood transfusion. Secondary endpoints included an increase in maternal hemoglobin after treatment and evaluating the safety of IV ferric carboxymaltose as measured by side effects and frequency of hypophosphatemia. Five months after initiation of the IV iron recommendations, we performed an audit to assess its use. Methods: A retrospective IRB-approved chart review of anemic, iron-deficient pregnant women who received IV ferric carboxymaltose from 1/30/19 - 6/30/19 was performed. Thirty-six patients were identified and their charts were reviewed to determine the hemoglobin and ferritin levels prior to IV iron, the number of IV iron infusions received with any side effects, phosphorus levels on days of IV iron, hemoglobin level after IV iron, and need for peripartum blood transfusion. Results: Of the 36 patients who received IV iron for anemia in pregnancy, post-IV iron hemoglobin and blood transfusion information was only available for 26 patients. The remaining 10 patients had not delivered as yet or had delivered at another institution so data were not available. Of these 26 patients, the median age was 26.0 years and all received IV iron during their third trimester. No patients required a blood transfusion peripartum. The average hemoglobin prior to IV iron was 9.3 g/dL and the average hemoglobin after 1-2 IV iron infusions was 11.3 g/dL, an increase of 2.0 g/dL across the total group (Figure 1) (p&lt;0.0001). Of these 26 patients, 7 patients received 1 dose of IV iron and 2 patients experienced heartburn or nausea during or soon after the IV iron infusion. Phosphorus levels were checked in 24 patients and 6 experienced hypophosphatemia with no attributable side effects. No patient experienced a serious adverse effect or reaction requiring discontinuation of IV iron therapy. Conclusion: Results from the first 5 months of this project suggest using a standardized iron deficiency anemia treatment protocol including IV iron to reduce the need for peripartum blood transfusion and increase hemoglobin levels. Additionally, our data suggest IV ferric carboxymaltose is well-tolerated in these patients. These results also support using multi-professional teams to improve the quality of healthcare delivery to pregnant patients with iron deficiency anemia. We have created an IRB-approved database to study more patient-centered postpartum outcomes such as quality of life among IV iron recipients as well as lactation rates and fetal outcomes. We plan to expand this strategy to other patients who have a predictable and likely preventable need for intermittent blood transfusion, such as patients with chronic gynecologic blood loss. Reference: Achebe, M. M., &amp; Gafter-Gvili, A. (2017). How I treat anemia in pregnancy: iron, cobalamin, and folate. Blood, 129(8), 940-949. https://doi.org/10.1182/blood-2016-08-672246. Disclosures Davidson: ABIM: Other: American Board of Internal Medicine.

Percutaneous Kidney Biopsy and the Utilization of Blood Transfusion and Renal Angiography Among Hospitalized Adults

IntroductionData on percutaneous kidney biopsy (KBx) incidence and frequencies of hemorrhagic complications among inpatients are limited.MethodsUsing nationally representative US hospitalization discharge data, we report temporal trends in inpatient KBx rates from 2007 to 2014 and estimate frequencies of, and risk factors for, utilization of packed red blood cell (pRBC) transfusion and renal angiography.ResultsFrom 2007 to 2014, rates of native KBx among adult inpatients increased from 8.2 to 10.0 per 100,000, while transplant KBx rates declined from 3.6 to 3.1 per 100,000. We studied 35,183 and 14,266 discharge records with native and transplant KBx. We found that 5.7% (95% confidence interval [CI]: 5.3%–6.0%) of inpatients undergoing native KBx and 4.9% (4.2%–5.5%) of those undergoing transplant KBx received a pRBC transfusion within 2 days of biopsy. Similarly, 0.6% (0.5%–0.7%) of inpatients undergoing native KBx and 0.4% (0.2%–0.5%) undergoing transplant KBx received a renal angiogram within 2 days of KBx. For inpatient native KBx, female sex, older age, higher chronic kidney disease stage, acute renal failure, lupus, vasculitis, cirrhosis, multiple myeloma/paraproteinemia, and anemia of chronic disease were independently associated with increased odds of pRBC transfusion; cirrhosis and end-stage renal disease (ESRD) were associated with increased odds, and nephrotic syndrome was associated with decreased odds, of renal angiography.ConclusionsIn this large population-based study of inpatient KBx practices, we demonstrate increasing rates of inpatient native KBx among US adults and provide accurate estimates of the frequencies of, and risk factors for, pRBC transfusion and renal angiography following inpatient KBx.

Role of Restrictive Transfusion Strategy on Post-Operative Complication and Prosperity of Thai Patients upon Total Knee Replacement

Introduction: Blood transfusions have been reported to cause post-operative complications. Despite the protocols being conducted to minimize the utilization of blood transfusion and improve the standard of care in blood transfusion strategy, there is no consensus on transfusion indication threshold.Objectives: This study assessed the effect and complication using a new restrictive blood transfusion strategy threshold in patients undergoing total knee replacement.Materials and methods: This study performed observational evaluation on the proportion of patients to be transfused with the new restrictive blood transfusion strategy (Hb level below 8 g/dL and/or presence of symptoms of anemia) and compared post-operative symptoms of transfused patients to un-transfused patients, who underwent total knee surgery at Police General Hospital. A total of 120 patients were studied. Patients’ demographics, peri-operative parameter, and post-operative symptoms in conjunction with length of hospitalization were compared between groups. Statistics was determined for each parameter and analyzed using Student’s t-test, Pearson’s chi-square test, Fisher’s exact test, and odd ratio at 95% confidence level.Results: Of 120 patients, 12 patients (10%) were transfused. The post-operative complications including cardiovascular, respiratory, gastrointestinal, infection, and other symptoms did not differ significantly between transfused and un-transfused patients (p>0.05), except that there was more neuropsychiatric symptom in the un-transfused group than the transfused group (in 16.3% vs. 1.6% of patients; 95% CI 1.43-101.97), whereas the length of hospital stay was not different between groups (p>0.05). Blood utilization reduction with the new transfusion strategy was 74 units.Conclusion: Among patients undergoing total knee replacement, most patients with hemoglobin level 8-10 g/dL were tolerant to the new transfusion strategy (90.24%). Further, post-operative symptoms were not significantly higher between transfused and un-transfused patients. Also, as in the aforementioned study, the new transfusion strategy is considered relatively safe and can be effective as a blood conservative algorithm.

Incidence and Risk Factors for Blood Transfusion in Total Joint Arthroplasty: Analysis of a Statewide Database

BackgroundSignificant attempts have been made to adopt practices to minimize blood transfusion after total joint arthroplasty (TJA) because of transfusion cost and potential negative clinical consequences including allergic reactions, transfusion-related lung injuries, and immunomodulatory effects. We aimed to evaluate risk factors for blood transfusion in a large cohort of TJA patients. MethodsWe used the all-payer California Healthcare Cost and Utilization Project data from 2006 to 2011 to examine the trends in utilization of blood transfusion among arthroplasty patients (n = 320,746). We performed descriptive analyses and multivariate logistic regression clustered by hospital, controlling for Deyo-Charlson comorbidity index, age, insurance type (Medicaid vs others), gender, procedure year, and race/ethnicity. ResultsEighteen percent (n = 59,038) of TJA patients underwent blood transfusion during their surgery, from 15% with single knee to 45% for bilateral hip arthroplasty. Multivariate analysis indicated that compared with the referent category of single knee arthroplasty, single hip had a significantly higher odds of blood transfusion (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.68-1.83), as did bilateral knee (OR, 3.57; 95% CI, 3.20-3.98) and bilateral hip arthroplasty (OR, 6.17; 95% CI, 4.85-7.85). Increasing age (eg, age ≥80 years; OR, 2.99; 95% CI, 2.82-3.17), Medicaid insurance (OR, 1.36; 95% CI, 1.27-1.45), higher comorbidity index (eg, score of ≥3; OR, 2.33; 95% CI, 2.22-2.45), and females (OR, 1.75; 95% CI, 1.70-1.80) all had significantly higher odds of blood transfusion after TJA. ConclusionPrimary hip arthroplasties have significantly greater risk of transfusion than knee arthroplasties, and bilateral procedures have even greater risk, especially for hips. These factors should be considered when evaluating the risk for blood transfusions.

Abstract P34: Variation in Transfusion Practice and Associated Postoperative Complications in Abdominally-Based Autologous Breast Reconstruction Surgery

PURPOSE: Blood transfusion is the most frequently performed procedure in US hospitals. Despite its life-saving potential when clinically indicated, evidence shows that transfusion in some cases does not provide a significant clinical benefit to patients and thus does not justify its associated costs and risks. Increasing emphasis has been placed on reducing these potentially unnecessary transfusions, demonstrated by recently published guidelines from the American Association of Blood Banks (AABB) recommending restrictive hemoglobin thresholds for transfusion (≤7 g/dL). In plastic and reconstructive surgery, free flap procedures are associated with high utilization of blood transfusion, reported in the literature to be as high as 42%. The high volume of flap-based breast reconstructions makes this procedure an ideal target for quality improvement interventions related to blood transfusion practices. In this study, we assessed variation in transfusion practice and its associated clinical outcomes in a large cohort of breast reconstruction patients to identify potential targets for quality improvement. METHODS: After obtaining IRB approval, we extracted perioperative blood utilization data and hemoglobin transfusion triggers from two prospectively-collected anesthesia and blood management databases (Metavision and IMPACT Online) for all patients who underwent abdominally-based autologous breast reconstruction at the Johns Hopkins Hospital between 2009 and 2015. We defined hemoglobin transfusion triggers as the lowest measured hemoglobin level preceding a blood transfusion. We used ANOVA, Chi-squared, and linear regression to examine patient-level and surgeon-level variation in the use of overall blood transfusions, potentially unnecessary blood transfusions, and hemoglobin transfusion triggers. RESULTS: Of 653 patients, 65 (10%) received perioperative blood transfusions. Risk factors for increased blood utilization were higher ASA class (OR: 2.4; p=0.015) and younger age (OR: 1.2 for every 5-year decrease in age; p=0.008), with a trend for the presence of rheumatic comorbidities (OR: 3.7; p=0.098). Use of perioperative blood transfusions varied by surgeon (range: 5% to 24%; p=0.001), suggesting the presence of variation in transfusion practices. Mean hemoglobin trigger was 6.6 g/dL (±0.83 g/dL; range 3.4–8.2 g/dL). Hemoglobin triggers varied by surgeon (range: 6 g/dL to 7.5 g/dL; p<0.001) and patient age (p=0.031), with a trend for Charlson comorbidity index (p=0.093). Of the 65 patients that received blood transfusions, 16 patients (25%) had potentially unnecessary transfusions (hemoglobin triggers ≥7g/dL). Potentially unnecessary utilization of blood transfusion did not vary by surgeon (range: 1% to 4%; p=0.142), but was higher in TRAM flap reconstructions (OR: 9; p=0.001) and showed a trend for higher ASA class (OR: 3; p=0.076). Patients who received blood transfusions experienced worse clinical outcomes in terms of postoperative infections (p=0.006), Clostridium difficile infection (p=0.003), sepsis (p<0.001), and 30-day readmission (p<0.001). CONCLUSION: Use of perioperative blood transfusion varied among surgeons. However, there was no evidence for surgeon-level variation in potentially unnecessary perioperative transfusion. Transfusions were significantly associated with higher risk of perioperative infections and postoperative readmissions. These findings emphasize the importance of standardizing transfusion practices with the goal of minimizing unnecessary transfusions and their potential negative consequences.

Significant Variation in Blood Transfusion Practice Persists following Upper GI Cancer Resection

PurposePerioperative blood transfusions are costly and linked to adverse clinical outcomes. We investigated the factors associated with variation in blood transfusion utilization following upper gastrointestinal cancer resection and its association with infectious complications. MethodsThe Statewide Planning and Research Cooperative System was queried for elective esophagectomy, gastrectomy, and pancreatectomy for malignancy in NY State from 2001 to 2013. Bivariate and hierarchical logistic regression analyses were performed to assess the factors associated with receiving a perioperative allogeneic red blood cell transfusion. Additional multivariable analysis examined the relationship between transfusion and infectious complications. ResultsAmong 14,875 patients who underwent upper GI cancer resection, 32 % of patients received a perioperative blood transfusion. After controlling for patient, surgeon, and hospital-level factors, significant variation in transfusion rates was present across both surgeons (p < 0.0001) and hospitals (p < 0.0001). Receipt of a blood transfusion was also independently associated with wound infection (OR = 1.68, 95% CI = 1.47 and 1.91), pneumonia (OR = 1.98, 95% CI = 1.74 and 2.26), and sepsis (OR = 2.49, 95% CI = 2.11 and 2.94). ConclusionSignificant variation in perioperative blood transfusion utilization is present at both the surgeon and hospital level. These findings are unexplained by patient-level factors and other known hospital characteristics, suggesting that variation is due to provider preferences and/or lack of standardized transfusion protocols. Implementing institutional transfusion guidelines is necessary to limit unwarranted variation and reduce infectious complication rates.

Mo1652b The Need for Perioperative Transfusion Guidelines: Significant Surgeon and Hospital Variation in Blood Transfusion Utilization Following Upper Gastrointestinal Cancer Resection

Mo1652b The Need for Perioperative Transfusion Guidelines: Significant Surgeon and Hospital Variation in Blood Transfusion Utilization Following Upper Gastrointestinal Cancer Resection