Hgb Drop Research Articles

Bloodless Total Hip Arthroplasty in Jehovah’s Witness Patients: Contemporary Strategies and Outcomes

BackgroundReported blood transfusion rates in total hip arthroplasty (THA) range between 3 and 22%. Jehovah’s Witnesses (JW) do not accept blood transfusions and make conscience decisions to accept blood derivatives. This study reports on strategies and outcomes for bloodless THA. MethodsAll JW patients undergoing primary THA at our institution between 2011 and 2022 were included in this study (94 of 110 THA). The indications for THA were osteoarthritis (92%), femoral neck fracture (6%), rheumatoid arthritis (1%), and failed open reduction and internal fixation (1%). Strategies used to optimize outcomes included erythropoietin, tranexamic acid, cell savers, intrailiac artery tourniquets, and minimizing phlebotomy. ResultsThe mean estimated blood loss was 201.2 ± 122.2 mL. Preoperative hemoglobin (Hgb) levels were 13.4 ± 1.4 g/dL, which decreased to 11.0 ± 1.3 g/dL on postoperative day 1 (POD1, P < 0.001), 10.3 ± 1.5 g/dL on POD2 (P = 0.001), and 9.8 ± 1.1 g/dL on POD3 (P = 0.171). The use of tranexamic acid significantly decreased Hgb drop on POD1 (P = 0.04). Subgroup analysis showed that preoperatively anemic patients (closed circuit, Hgb < 12 g/dL) had significantly less Hgb drop postoperatively (P = 0.003). No patients met the recommended transfusion threshold (Hgb < 7 g/dL). There were two 90-day readmissions due to falls. There was zero 90-day mortality. ConclusionsA THA can be safely performed on JW patients. Preoperatively anemic patients had a decreased Hgb drop postoperatively. JW patients make a conscious decision to accept blood derivatives, which may be present in medications including erythropoietin. We recommend maintaining an Hgb above 11 g/dL prior to surgery, as a Hgb drop of 3.1 g/dL can be expected. These findings highlight the efficacy of a multimodal approach to optimizing bloodless primary THAs.

Impact of Significant Hemoglobin Drop Without Bleeding in Patients Undergoing Transcatheter Aortic Valve Replacement.

Hemoglobin (Hgb) drop without bleeding is common among patients undergoing transcatheter aortic valve replacement; however, the clinical implications of significant Hgb drop have not been fully evaluated. Consecutive patients undergoing transcatheter aortic valve replacement at our institution from 2011 to 2021 were retrospectively reviewed. Three groups were assessed: no Hgb drop and no bleed (NoD-NoB [reference group]), Hgb drop with bleed, and Hgb drop and no bleed (D-NoB). Hgb drop was defined as ≥3 g/dL decrease from pre- to post-transcatheter aortic valve replacement. Outcomes of interest were in-hospital death and 1-year all-cause mortality. A total of 1851 cases with complete Hgb data were included: NoD-NoB: n=1579 (85.3%); D-NoB: n=49 (2.6%); Hgb drop with bleed: n=223 (12.6%). Compared with NoD-NoB, the D-NoB group was older (81.1 versus 78.9 years of age) with higher preprocedure Hgb (12.9 versus 11.7 g/dL). In-hospital death rate was higher among patients with D-NoB versus NoD-NoB (4.5% versus 0.8%, P<0.001) and similar to Hgb drop with bleed (4.5% versus 4.1%, P=0.999). Predictors of in-hospital death were D-NoB (odds ratio [OR], 3.45 [95% CI, 1.32-8.69]) and transfusion (OR, 10.6 [95% CI, 4.25-28.2]). Landmark survival analysis found that D-NoB experienced 1-year mortality rate comparable to NoD-NoB, whereas Hgb drop with bleed had higher midterm mortality (hazard ratio [HR], 3.2 [95% CI, 1.83-5.73]), and transfusion continued to impact mortality (HR, 2.5 [95% CI, 1.79-3.63]). Hgb drop without bleeding is common among patients undergoing transcatheter aortic valve replacement and may represent a higher risk of periprocedural death. Blood transfusion increases short- and midterm mortality risk in patients with and without bleeding, supporting a restrictive transfusion strategy.

Splenic Sequestration in Febrile Pediatric Sickle Cell Disease Patients

Introduction: Acute splenic sequestration is a rare complication of pediatric sickle cell disease (SCD). Acute splenic sequestration crisis (ASSC) is characterized by an acute decrease in hemoglobin and is associated with an increased risk for hypovolemic shock, often requiring blood transfusion during acute episodes and splenectomy to prevent recurrent episodes. Recent studies have also shown that chronic splenomegaly and resultant anemia (described as chronic or subacute sequestration) with potential benefit of splenectomy. However, non-life-threatening splenic sequestration in febrile, hospitalized children with SCD is a frequent occurrence that has not been well-described in current literature. Aim: To estimate the change in WBC, Hemoglobin, platelet count from inpatient and outpatient baseline to lowest recorded value (LRV) for each febrile hospitalization in sickle-cell disease patients while controlling for hydroxyurea use and patient age. Methods: A retrospective chart review was performed on febrile, hospitalized children with a diagnosis of SCD who presented to a tertiary care hospital from 2018-2021. Data including the magnitude of fever, presence of splenomegaly and trends in laboratory parameters such as complete blood count, and chemistries were recorded. Demographics, hydroxyurea use, transfusions and sickle cell phenotype were also recorded. For our primary outcome we estimated the change in Hgb, platelets, and WBC count from inpatient (first day of hospitalization) and outpatient (most recent outpatient values) baselines to the lowest recorded value (LRV) for each hospital encounter. We employed mixed models to account for within-subject correlation and adjusted for hydroxyurea use and categorized patient age. The beta coefficient and corresponding 95% confidence interval (CI) were reported for the model intercept and predictors. Results: Sixty-six unique patients (ages 0-17) accounted for a total of 117 hospital encounters. There was a statistically significant drop in WBC per microliter (-5.40, 95% CI: -6.89 - [-3.91]) , Hgb g/dL (-0.95, 95% CI : -1.25 - [-0.66]), and platelets per microliter (-60.95, 95% CI : -83.18 - [-38.71]) from the inpatient baseline to the LRV. There was a statistically significant drop in estimated Hgb g/dL (-1.83, 95% CI : -2.23 - [-1.42]) and platelets per microliter (-130.50, CI: -169.59 - [-91.41]) from outpatient baseline to the LRV. Hospital encounters with hydroxyurea had a significantly greater drop in estimated platelets per microliter from inpatient baseline to LRV (-54.43 CI : -93.64 - [-15.22]) but significantly greater increase in estimated Hgb g/dL from inpatient baseline to the LRV (1.11 CI : 0.45 - 1.78) compared to hospital encounters without hydroxyurea. Hospital encounters over the age of 8 were associated with a significantly greater decrease in HGB g/dL (-0.59 CI : -1.04 - [-0.14]) from inpatient baseline to the LRV compared to hospital encounters under the age of 8. Conclusion: Our study demonstrated features consistent with acute, non-life-threatening splenic sequestration in febrile pediatric SCD patients, as evidenced by a statistically significant drop in platelets, Hgb, and WBC count from the inpatient baseline. The largest acute drop was observed in platelets, which presents the strongest argument for sequestration, as drops in Hgb may be explained by rehydration or hyperhemolysis, and changes in WBC count may be related to infection. Hydroxyurea use may delay auto-infarction of the spleen, thus predisposing to splenic sequestration at an age later than classically associated with sequestration. The preservation of splenic function probably explains greater decrease in platelet count for patients on hydroxyurea. Our study has treatment implications: children with SCD experiencing non-life-threatening acute splenic sequestration recover spontaneously without the need for blood transfusion in many cases, thus avoiding long-term complications such as RBC alloimmunization or iron overload. Also, as the drop in WBC, hemoglobin, and platelets are not due to myelosuppression, they should not lead to modification of hydroxyurea therapy. Splenectomy should be reserved for the most severe and life-threatening episodes of sequestration. Further research may assist in correlating sickle cell phenotype and history of blood transfusion with the magnitude of sequestration in this population.

Post-Embolization Hemoglobin Changes: When to Consider Re-intervention.

Decline in hemoglobin (Hgb) levels is common post-embolization, but there is no consensus on the classification of patients based on risk for re-bleeding or re-intervention. The current study evaluated post-embolization Hgb level trends with the goal of understanding the factors predictive of re-bleeding and re-intervention. All patients who underwent embolization for gastrointestinal (GI), genitourinary, peripheral, or thoracic arterial hemorrhage from 01/2017 to 01/2022 were reviewed. Data included demographics, periprocedural pRBC transfusion (TF) or pressor requirements, and outcome. Lab data consisted of Hgb values pre-embolization, immediately post-embolization, and daily values on days 1-10 after embolization. Hgb trends were compared between patients across TF and re-bleeding outcomes. Regression model was used to examine factors predictive of re-bleeding and magnitude of Hgb reduction post-embolization. A total of 199 patients were embolized for active arterial hemorrhage. Perioperative Hgb level trends were similar for all sites and between TF + and TF- patients, showing a decline reaching a nadir within 6days post-embolization followed by an upward trend. Maximum Hgb drift was predicted by GI embolization (p = 0.018), TF before embolization (p = 0.001), and use of vasopressor (p = 0.000). Patients with Hgb drop > 15% within the first two days post-embolization had a higher chance of having a re-bleeding episode (p = 0.04). Perioperative Hgb trends showed a consistent downward drift followed by an upward shift, irrespective of TF requirement status or site of embolization. Using a cut-off value of 15% Hgb reduction within the first two days post-embolization may be helpful to assess re-bleeding risk.

Perioperative Outcomes of Patients Treated in an Anemia Clinic before Spine Surgery

BACKGROUND: Patients with preoperative anemia are at increased risk of postoperative blood transfusion, as well as other adverse outcomes, including infection, prolonged length of stay (LOS), and death. Requirement of intraoperative transfusions may be an independent risk factor for mortality among patients undergoing noncardiac surgery. As such, efforts have emerged internationally to establish clinical decision support tools, dedicated preoperative anemia clinics, and clinical trials studying the effects of preoperative treatment of patients to improve outcomes after surgery. While studies to date have shown mixed results, some suggest that treatment with intravenous (IV) iron improves anemia and decreases transfusion requirements. Treatment with erythropoietin-stimulating agents (ESA) has also been associated with fewer transfusions in patients undergoing orthopedic surgery. METHODS: We established a preoperative clinic in 2019 with a pilot for patients undergoing spine surgery. Patients who were found to have a hemoglobin (Hgb) < 13.0 g/dL on preadmission testing were automatically referred, and when possible, had iron studies reflexively added on to their samples. Patients were offered an appointment with a nurse practitioner or physician in Hematology and treated with IV iron or a combination of IV iron and ESA at the discretion of the provider. Importantly, if time did not allow for a visit or the patient declined an appointment or preoperative treatment, surgeries were not cancelled or delayed. This retrospective study included patients undergoing elective spine surgeries between August 1, 2019 and June 1, 2021 at Thomas Jefferson University Hospital and Jefferson Hospital for Neuroscience. Patients were eligible if they were automatically referred to the preoperative anemia clinic based on preadmission testing results. The primary outcome was postoperative allogeneic red blood cell (RBC) transfusion during the index admission. Secondary outcomes included decrease in Hgb postoperatively, LOS, and 30-day readmission rate. RESULTS: The study included 108 patients (53.7% female) who underwent a total of 112 distinct elective spine surgeries. The median age at the time of surgery was 65 years. The most common surgery was decompression and fusion (73.2%), followed by decompression (17.0%) and fusion (9.8%). 16.1% of surgeries were revisions of a prior surgery. The median preoperative Hgb was 11.6 g/dL. Prior to the 112 surgeries, 45 (40.2%) patients were seen by a Hematology provider and 37 (33.0%) received preoperative treatment for anemia, including 28 (25.0%) who got IV iron plus ESA, 8 (7.1%) IV iron alone, and 1 (0.9%) ESA alone. The final treatment was given a median of 5 days before surgery (IQR 3-9.5 days). There was a nonsignificant trend toward lower mean preoperative Hgb in patients who were treated before surgery and those who were not (mean 11.2 vs 11.6 g/dL, p=.162) and greater mean estimated blood loss during surgery when reported (392 vs 315 mL, p=.462). Compared to untreated patients, those who were treated before surgery were significantly more likely to be iron deficient (ferritin < 30 ng/mL or iron saturation < 15%) (45.9% vs 26.7%, p=.041). The primary outcome of allogeneic RBC transfusion occurred in 18.9% of patients who received pre-treatment and 9.3% of those who did not (p=.149). The degree of initial Hgb drop postoperatively from last pre-op value was significantly lesser in pre-treated patients (-0.93 vs -1.56 g/dL, p=.015), and a nonsignificant improvement was observed in the change from baseline to nadir Hgb during the index admission (-1.54 vs -2.15 g/dL, p=.074). A trend toward shorter LOS was observed in pre-treated patients (3.30 vs 3.47 days, p=.739), though that group also experienced more 30-day inpatient readmissions (18.9 vs 12.0%, p=.325). No deaths were observed during the study period. CONCLUSION: In this preoperative anemia clinic pilot, treatment with IV iron and/or ESA before major spine surgery was not associated with a reduction in allogeneic RBC transfusions or hospital readmission. However, those who received pre-treatment had significantly lesser declines in Hgb after surgery and a trend toward shorter LOS. Patients who received treatment were significantly more likely to be iron deficient before surgery and had lower mean Hgb levels, which confounds the results. Larger prospective studies of preoperative anemia therapy are needed. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Analysis of Bicarbonate-Based Purge Solution in Patients With Cardiogenic Shock Supported Via Impella Ventricular Assist Device.

The Impella device is a continuous axial flow pump which provides hemodynamic support by expelling blood into the aorta. The manufacturer recommends using dextrose-based heparin containing solutions as the default purge. As an alternative to anticoagulant solutions, a bicarbonate-based purge solution has been proposed with limited data substantiating adequate protection and durability. To assess the impact of a bicarbonate-based purge solution on Impella pump thrombosis and bleeding outcomes. Single-center, retrospective study of cardiogenic shock patients who received an Impella between December 2020 through September 2021. Patients were evaluated based on whether they received bicarbonate-based purge solutions or remained on heparin-based purge solutions. The primary outcome was the rate of Impella pump thrombosis, defined as multiple purge pressures greater than 800 mm Hg. Secondary outcomes included incidence of bleeding defined as a drop in Hgb of at least 2 g/dL along with use of blood products and supratherapeutic anticoagulation defined as an aPTT of greater than 70 seconds. Forty-three patients received bicarbonate-based purge solutions and 49 controls received heparin. The incidence of purge thrombosis by purge pressure threshold was similar between the two groups (16.3% vs 12.2%, P = 0.58). The rate of bleeding was lower with bicarbonate-based purge (27.9% vs 65.3%, P < 0.05) driven by a drop in Hgb of more than 2 g/dL. The rate of supratherapeutic anticoagulation was higher in the heparin arm (65.3% vs 27.9%, P < 0.05). Nonanticoagulant purge alternatives offer the potential to reduce bleeding complications and laboratory monitoring burden while maintaining durability.

Efficacy and safety of minimally invasive percutaneous nephrolithotomy in patients with lower pole kidney stones 1-2 cm in diameter

Introduction: Anatomical features of the lower pole calyces plays an important role in the treatment of urolithiasis. The optimal treatment options for lower pole stones with a diameter below 2 cm are controversially discussed. Extracorporeal shock wave lithotripsy (SWL) is non-invasive, but is hampered by low stone-free rates and a significant retreatment rate in patients with unfavourable factors for lithotripsy. Retrograde intrarenal surgery (RIRS) has been demonstrated to have high stone-free rates since the development of modern flexible endoscopes. But the long operative time in the case of a large stone burden, unfavourable anatomy and considerable costs for consumables represent limiting factors for this technique. With the miniaturization of percutaneous approach and decreasing the morbidity, minimally invasive percutaneous nephrolithotomy (miniPCNL) is a promising method for treatment of lower pole stones in one stage procedure. The objective of this study is to investigate the efficacy and safety of mini-PCNL for the treatment of lower pole stones 1-2 cm. Material and methods: The medical records of 54 patients with lower pole kidney stones 1-2 cm, treated at the Clinic of Endurology and SWL, Military Medical Academy, Sofia between January 2020 to January 2022, were retrospectively reviewed. All patients underwent mini-PCNL under spinal anesthesia in prone position with fluoroscopic guidance through 18 Fr sheath using semirigid nephroscope and Ho:YAG laser for lithotripsy. Stone-free rate was defined as absence of residual fragments ≥2 mm. Data on patients’ preoperative characterstics, stone-free rates, operating times, intra- and postoperative complications were analyzed. Results: Patients mean age was 54,68±11,99 years. Mean stone surface was 169,02±57,40mm2 and mean CT stone density was 1112,26±250,47 HU. Stone-free rate after single procedure was 96,3 % (52 patients). 14,8% of patients had preoperative urinary tract infection. Mean operative time was 27,46±12,40 min and mean hospital stay - 2,5±1,17 days. The mean Hgb drop was 11.9±15.6 g/l. Lower pole puncture was performed in all patients. Two tracts were required in 1 (1,9 %) patient. One patient had intraoperative haemorrhage at the end of the procedure. Postoperative complications were observed in 2 (3,8 %) patients: postoperative fever t &gt;38.5o C in 1 patient (1,9%) and postoperative AV-fistula in 1 (1,9%) patient, who needed hemotransfusion and selective embolization. 2 patients required auxiliary procedures: 1 patient needed stent JJ and 1 underwent ureteroscopy for fragments in ureter. Conclusion: Various factors are important for management of lower pole kidney stones and should be taken into consideration, when choosing the optimal treatment modality. The results from this study suggest that mini-PCNL is an effective and safe procedure with high stone free rates and low complication rates in patients with lower pole kidney stones unfavourable for SWL and RIRS. Key words: minimally invasive nephrolithotomy, lower pole kidney, urolithiasis

Hip resurfacing and posterior approach total hip arthroplasty have equivalent blood loss when tranexamic acid is used: a propensity score matched cohort analysis.

Hip resurfacing (HR) requires a larger approach and soft tissue dissection and might therefore be associated with increased blood loss compared to total hip arthroplasty (THA). However, the effect of the adoption of tranexamic acid (TXA) in this setting is unknown. Therefore, the current study compares the blood loss and transfusion requirements between HR and posterior THA in patients receiving TXA. This retrospective cohort study included patients undergoing primary, unilateral THA or HR using a posterior approach between February 2016 and 2020 in which TXA was administered. THA and HR patients were propensity score matched using nearest neighbor greedy matching accounting for demographic, health and surgical variables. Postoperative hemoglobin (Hgb) levels and Hgb drop from preoperative to post-operative day (POD) 1 were compared using t-tests and associated risk factors were assessed using linear mixed modelling. After matching, each cohort consisted of 1395 patients. Cohorts were similar regarding age, sex, BMI, and Charlson Comorbidity Index. No significant differences were found for Hgb levels on POD 1 (12.3g/dl; p = 0.90) or Hgb drop (2.3g/dl; p = 0.87). Duration of surgery was significantly longer for HR patients (82 vs 77min; p < 0.01). Transfusion rate was 0.1% in both cohorts (p = 1.00). Hospital stay was significantly shorter for HR patients (1 vs 2days; p < 0.01). HR using a standard TXA regimen is not associated with greater perioperative blood loss than posterior THA and does not result in increased transfusion requirements. Both surgical procedures can be considered equally safe in terms of perioperative blood management when TXA is used.

Effect of Tranexamic Acid on Bleeding Outcomes After Percutaneous Nephrolithotomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Purpose: We performed a systematic review and meta-analysis of the literature to evaluate the efficacy of the routine use of tranexamic acid (TXA) during percutaneous nephrolithotomy (PCNL). Methods: This systematic review was conducted following the updated reporting guidelines from PRISMA 2020. Results: In total, 275 titles and abstracts were reviewed, of which 20 were screened to be eligible for full text review. Of these 20 articles, 11 were selected for inclusion after full article evaluations. Seven of these 11 studies were seen as having a low risk of bias with a Jadad score of ≥3. These studies were included for data extraction. Once data were extracted, 964 patients were included. The primary outcome, blood transfusion rate, showed significant reduction with a ratio for transfusion rate of 0.34 [95% confidence interval (CI) (0.19 to 0.61), z = 3.61, p = 0.0003]. Mean hemoglobin (Hgb) drop and operative time were both shown to be reduced with the use of TXA. The mean difference for Hgb drop was -0.86 [95% CI (-1.26 to -0.46), z = 4.23, p < 0.0001]. Reduction in operative time showed a mean difference of -8.45 minutes [95% CI (-15.04 to -1.86), z = 2.51, p = 0.01]. Stone clearance was not shown to differ significantly between experimental and control groups, with a risk ratio of 1.28 [95% CI (0.89 to 1.84), z = 1.31, p = 0.19]. Conclusions: This meta-analysis revealed that the routine use of TXA at time of PCNL reduces the rates of blood transfusion, mean Hgb drop, and operative time. With the low cost of TXA and strong safety profile, stronger consideration should be given to the routine use of TXA during PCNL by endoscopic surgeons.

Hyperhemolysis Syndrome in SCD Patient: Reminder of a Rare but Life-Threatening Complication of Blood Transfusion

Background: Sickle cell disease (SCD) patients are at risk of developing multiple complications from transfusions, including alloimmunization to red blood cell (RBC) antigens, delayed hemolytic transfusion reactions, and hyperhemolysis syndrome (HS). HS is a serious complication of transfusion characterized by the destruction of both transfused and autologous RBCs with resulting severe anemia and post transfusion hemoglobin lower than pretransfusion levels. We report the case of a middle age female patient with known SCD who developed severe HS following a blood transfusion. We aim to remind physicians of the importance of conservative blood transfusions in SCD patients in order to avoid serious transfusion-related complications.Case report: A 57-year-old African American patient, with known history of SCD who was doing well with a baseline hemoglobin (Hgb) of 6-7 g/dl. Transfusion history included 4 units of Packed Red Blood Cell (PRBC) during the 5 years prior to this presentation, all of which for mild, non-resolving vaso-occlusive pain crisis. Her most recent transfusion was 7 days prior to her presentation, she received 1 unit of PRBC for a Hgb level of 6.3 g/dl, associated with mild musculoskeletal pain and fatigue. She presented to the Emergency Department 4 days later with worsening fatigue, decreased oral intake and dark urine. On presentation, she was normotensive, afebrile and mildly tachycardic. She had increasing oxygen requirements to maintain O2 saturation above 94%. Her blood work showed a Hgb of 2.8 g/dl (12-15 g/dL), hematocrit 8.3 % (36-46 %), RBC count 0.87 M/uL (4.15-5.55 M/uL), Mean Corpuscular Volume 95.5 fl (80-100 fl), elevated White Cell Count at 28.4 K/uL (3.8-10.6 K/uL), and platelet count 125 K/uL (150-450 K/uL). Hemolysis labs showed low haptoglobin of < 30 mg/dl (30-200 mg/dl), elevated Lactate Dehydrogenase at 3420 IU/L (< 250 IU/L), total bilirubin 2.7 mg/dl (< 1.2 mg/dl), direct bilirubin 0.6 mg/dl (0-0.3 mg/dl), and reticulocyte count 3.5% (0.5-1.5 %; reticulocytopenia relative to degree of anemia). A disseminated intravascular coagulation (DIC) panel showed fibrinogen of 263 mg/dL (200-450 mg/dL), D-dimer greater than 20 ug/mL (< 0.50 ug/ml), prothrombin time of 19.8 seconds (s) (11.5-14.5 s), and partial thromboplastin time of 32 s (22-36 s). High sensitivity troponin was elevated at 650 ng/L (< 19 ng/L). Antibody screen and direct antiglobulin test (DAT) were negative. Peripheral blood smear showed severe anemia with marked anisopoikilocytosis including numerous blister cells, occasional sickle cells and numerous nucleated red blood cells. The recent history of blood transfusion and the current laboratory workup were consistent with HS.Patient was admitted to the intensive care unit (ICU) for management; she initially received 1g intravenous iron dextran and intravenous immunoglobulin (IVIG) 0.4 g/kg for 5 days. She was also started on erythropoietin, folic acid, and vitamin B12. Her reticulocyte count improved to 19%. Given no improvement in Hgb levels, systemic steroids were started after ruling out infectious etiologies. She initially received methylprednisolone 125mg daily for 2 days, followed by oral prednisone 60mg daily for 7 days. Patient had increased oxygen requirements during admission, had an elevated lactate to 4 mmol/L, and had a drop in Hgb to 2.1 g/dL. She was still managed conservatively with oxygen supplementation and intravenous crystalloid fluids. The decision was to avoid transfusions unless they were life-saving. Patient remained in the ICU unit for 5 days, then was transferred to the hematology floor where she remained hospitalized for 7 days. Oxygen requirements and patient's symptoms steadily improved, hemolysis labs trended down, and reticulocyte count improved. Hgb levels improved gradually to highest of 5.7 g/dl prior to discharge. Patient was then discharged to follow up with her hematologist in the outpatient setting.Conclusion: This case aims to highlight the importance of early recognition of HS to avoid wrong management with RBC transfusion. Our patient had severe anemia and was managed with transfusion-free approach with good outcome. This case is also meant to remind physicians of the importance of conservative blood transfusions in SCD patients in order to avoid serious and life-threatening transfusion-related complications. DisclosuresNo relevant conflicts of interest to declare.

The Utility of Serial Hemoglobin Monitoring in Non-Operative Management of Blunt Splenic Injury.

The Eastern Association for the Surgery of Trauma (EAST) states there is not enough evidence to recommend a particular frequency of measuring Hgb values for non-operative management (NOM) of blunt splenic injury (BSI). This study was performed to compare the utility of serial Hgb (SHgb) to daily Hgb (DHgb) in this population. We conducted a retrospective chart review of patients with BSI between 2013 and 2019. Demographics, comorbidities, lab values, clinical decisions, and outcomes were gathered through a trauma database. A total of 562 patients arrive in the trauma bay with BSI. In the NOM group, 297 were successful and 37 failed NOM. Of those that failed NOM, 8 (21.6%) changed to OM due to a drop in Hgb. 5 (62.5%) were hypotensive first, 2 (25%) were no longer receiving SHgb, and 1 (12.5%) had a repeat CT scan and was embolized. DHgb patients were not significantly different from SHgb patients in injury severity, length of stay, the largest drop in Hgb, and incidence of failing NOM. Patients taking aspirin were more likely to fall below 7g/dl at 48 and 72hours into admission. These results suggest that that trending SHgb may not influence clinical decision-making in NOM of BSI. Besides taking aspirin, risk factors for who would benefit from SHgb were not identified. Patients who received DHgb had similar injuries and outcomes than patients who received SHgb. Prospective studies are needed to evaluate the clinical utility of SHgb compared to DHgb.

Admission for Isolated Low-Grade Solid Organ Injury May Not Be Necessary in Pediatric Patients.

Recent publications indicate that blunt solid organ injuries can be safely managed with reduced length of stay using pathways focused on hemodynamics. We hypothesized that pediatric patients with isolated blunt Grade I or II solid organ injuries may be safely discharged after brief observation with appropriate outpatient follow-up. The purpose of this study is to evaluate the need for admission of pediatric trauma patients with isolated low-grade solid organ injury resulting from blunt trauma. We performed a retrospective cohort study of trauma registry data from 2011 to 2018 to identify isolated blunt Grade I or II solid organ injuries among children younger than 19 years. "Complication or intervention" was defined as transfusions, transfer to the intensive care unit, repeat imaging, decrease in Hgb greater than 2 g/dl, fluid bolus after initial resuscitation, operation or interventional radiology procedure, or readmission within 1 week. A total of 51 patients were admitted to the trauma service with isolated Grade I or II blunt solid organ injuries during the 8-year study period. The average age was 11 years. Among isolated Grade I or II injuries, seven (14%) had "complication or intervention" including greater than 2 g/dl drop in Hgb in four patients (8%), follow-up ultrasonography for pain in one patient (2%), readmission for pain in one patient (2%), or a fluid bolus in two patients (4%). None required transfusion or surgery. The most common mechanism of injury was sports related (45%), and the average length of stay was 1 day. Among a cohort of 51 patients with isolated blunt Grade I or II solid organ injuries, none required a significant intervention justifying need for admission. All "complication or intervention" patients observed were of limited clinical significance. We recommend that hemodynamically stable patients with isolated low-grade solid organ injuries may be discharged from the emergency department after a brief observation along with appropriate instructions and pain management.

Use of Hemoglobin Based Oxygen Carrier HBOC-021 (Hemopure) As a Bridge during Emergencies in Patients Unable to Receive Blood Products: Experience at a Tertiary Care Center

IntroductionThere are about 1.1 million Jehovah's witnesses (JW) in the United States who do not accept blood transfusions due to religious beliefs. When these patients present with severe anemia, management is challenging and mortality high. Hemoglobin based Oxygen Carrier HBOC-201 has been available for compassionate use, but its use is limited due to lack of experience. Here we present the experience of a tertiary care center with HBOC-201 to better manage critically ill JW patients with anemia.Case159 y.o. JW female was admitted with diabetic ketoacidosis, right lower extremity gangrene, and sepsis. Labs showed WBC 17.4, Hgb 7.9, and platelets 434. Within hours, the patient went into septic shock requiring vasopressors and mechanical ventilation, AKI requiring dialysis, and transaminitis. Her Hgb dropped to 6.9. She was started on insulin drip and broad-spectrum antibiotics. Her clinical condition improved, vasopressors were discontinued and she was extubated. She subsequently had a below knee amputation. On post-operative day 2, her condition worsened. She developed fevers and vasopressors were restarted. Her Hgb dropped to 5.8. Erythropoietin injections and Iron supplementation were initiated. At this point, the surgical team planned for an above knee amputation for better control of the infection, with a pre-operative goal Hgb of 8. On post-op day 7, the patient's clinical status deteriorated, and she was re-intubated and found to have an embolic stroke. Her Hgb continued to drop to 5.3 and she subsequently received 2 units of HBOC in preparation for urgent surgical intervention for infection control. Her Hgb improved to 6.5 following administration of 2 units of HBOC. Despite the improvement in Hgb, she acutely worsened with increased vasopressor and ventilation requirement, severe acidosis, methemoglobinemia, elevated troponin (0.5), and hypoglycemia. On the next day, she went into cardiac arrest and died.Case249 y.o. JW male was admitted with acute pancreatitis. Labs showed WBC 12.9, Hgb 18.6, transaminitis and lipase >600. The patient's clinical status improved with conservative management but on day 3 developed hematemesis with a drop in Hgb to 9.7. He became lethargic and was subsequently intubated. Esophagogastroduodenoscopy (EGD) showed a gastroesophageal junction clot. Gastrointestinal bleeding persisted over the next 3 days with drop in Hgb to 5. EGD showed an ulcer with visible vessel. Apart from proton pump inhibitor drip, he was also started on Erythropoeitin , B12 and Iron Despite these measures, his Hgb continued to drop with a nadir of 3.3 and worsening clinical status requiring multiple vasopressors. On Day 9, HBOC was approved for compassionate use. The patient was infused 4 units of HBOC. Hgb improved to 5.2, and the patient was weaned off vasopressors. A repeat EGD with injection and cauterization of the bleeding vessel were performed. The patient received one unit of HBOC daily to keep Hgb>5 (figure 1) and the gastroduodenal artery was embolized. The patient developed complications from HBOC, including hypernatremia, alkalosis and methemoglobinemia successfully treated with ascorbic acid and methylene blue. Troponin was normal and EKG was normal. Two days later, he developed lactic acidosis, ventilator associated pneumonia, acute respiratory distress syndrome, shock and multiorgan failure and succumbed to his illness. During this time, his Hgb was stable at 6.1 and there was no further bleeding.ConclusionHBOC-021 (Hemopureâ) is a polymerized bovine hemoglobin. It has been used for management of anemia in JW patients under compassionate-use FDA guidelines with varying success. Our experience with HBOC shows that it can be used successfully in emergencies to hemodynamically stabilize patients. Our first patient showed an improvement in Hgb while our second patient attained a stable Hgb and recovered from his hemorrhagic shock. With clinical improvement, he could get an EGD and embolization done which controlled his bleeding. The side effects of HBOC are easily managed with supportive care and methylene blue. We believe that Intensivists and Hematologists should be aggressively involved in JW patients who urgently need but refuse blood transfusion. An institution based protocol should be available to rapidly obtain HBOC. Efforts should be made to minimize blood loss and the use of erythropoiesis stimulating agents should be maximized. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Sickle Cell Disease and the Adherence to Guidelines for Use of Blood Transfusions

▪Background:An expert panel convened by the NHLBI in 2014 provided guidelines and indications for blood transfusions in patients with sickle cell disease (SCD). These recommendations were to help conserve the use of blood transfusions in SCD in order to reduce the complications of iron overload, transmission of blood-borne pathogens and development of alloantibodies. We retrospectively reviewed the charts of SCD patients who received blood during inpatient admissions and evaluated the indications for transfusions in this population.Methods:The hospital database was screened for admissions of patients with the diagnosis of SCD (HbSS, HbSβ0, HbSβ+, HbSC) who were billed for a blood transfusion between 8/1/2015 to 8/31/2016. All patients were >18 years of age. Each chart was reviewed individually to assess the clinical setting and reasons for transfusion. The following parameters were documented: age, sex, length of hospital stay (LOS), hemoglobin (Hgb) at time of transfusion, baseline Hgb, reticulocyte count, total bilirubin, number of units transfused, documented reason for transfusion, immediate reaction to transfusion, presence of alloantibodies and ferritin level. We defined the infusion of blood as a transfused event which included single or multiple units of blood. We excluded transfusions given for acute bleeding.Results:There were a total of 200 decisions to transfuse blood for 87 patients between 8/1/2015 to 8/31/2016. 72% of the patients had HbSS disease. HbSB0, HbSB+, HbSC, and unknown genotype constituted 14%, 19%, 6% and 7% of the cohort, respectively. Mean age was 30.6 years and 76% were female. A total of 434 units were transfused. The most common reasons for transfusion that deviated from guidelines were uncomplicated pain crises and a fall in Hgb (> 2g/dl, >1.5 g/dl) which accounted for 65.5% (n = 237 units) of the transfusion events (Pain 27%, Hgb drop > 2 gm 20.5% and Hgb drop > 1.5 gm 17.5%). The most common indicated guideline reasons for transfusion were symptomatic anemia and acute chest syndrome and only accounted for 12.5% and 10%, respectively of transfusions in this cohort. The mean Hgb at which patients were transfused was 6.6 g/dl, with a median value of 6.5 g/dl. The mean Hgb of those transfused for drop in hemoglobin and symptomatic anemia were 5.9 g/dl and 5.7 g/dl, respectively. The mean level of ferritin in this cohort was 2483. 15/87(17%) of patients had allo-antibodies. There was a 2% occurrence of immediate allergic blood transfusion reaction. The average LOS for all patients was 9.0 days. The average LOS for patient who received blood for uncomplicated pain or drop in Hgb was 8.9 days.Conclusion:In this group of patients with SCD, the majority of the inpatient transfusions were not indicated by national guidelines. Only 34.5% of transfusion events met expert panel recommendations. There was significant iron overload and development of allo-antibodies noted in our cohort. It is possible that there was a lack of documentation of symptoms due to anemia in those who received blood for a drop in hemoglobin. Regardless, there appears to be a significant number of unnecessary transfusions in SCD patients. We plan to develop and implement an educational program for care providers as to increase adherence to guidelines for transfusions in SCD. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

A retrospective real-world major bleeding (MB) comparison of direct oral anticoagulants (DOAC) and low molecular weight heparin (LMWH) in genitourinary cancer-associated venous thromboembolism (GU-CAVTE) with reported randomized clinical trials (RTC).

410 Background: MB is a serious complication in patients with CAVTE receiving treatment with DOAC or LMWH. The most recent meta-analysis of the four major RCT showed that MB events rate were similar among the DOAC and LMWH group, however, it was noted that MB occurred at GU site 4.9 times more in DOAC than LMWH patients. While GUCA (e.g. bladder and testicular) are considered to be high-risk based on the Khorana Score, they were underrepresented among the RCT ( &lt; 12%). We present a Real-World retrospective cohort study analyzing the MB rates in patients presenting with GU-CAVTE treated either by a DOAC or LMWH compared to those of the RTC. Methods: We performed a retrospective chart review of patients with a diagnosed GUCA and VTE who presented to The University of Arizona Cancer Center (UACC) and were subsequently placed on anticoagulant therapy with either a DOAC or LMWH from 11/2013-4/2020. MB outcome was defined as documented Hgb drop of ≥2 g/dL, ≥2 units of PRBC, MB in a critical site, or contributing to death. MB was extracted and compared from the SELECT D, ADAM VTE, and Caravaggio for DOAC and Hokusai for the LMWH control arm with the GUCA subgroup. Recurrent VTE was collected. In situations where there was insufficient data to categorize individuals, those individuals were excluded from the analysis. The proportion of MB reported in each study were compared using a binomial test. Results: Our review included 56 patients with similar baseline characteristics to the RCT, who were prescribed enoxaparin (n = 13), apixaban (n = 27) and rivaroxaban (n = 16). Our UACC data was compared to the RCT reported MB outcomes with rivaroxaban (12% vs 8%, [p = 0.63]), apixaban (11% vs 6%, [p = 0.40]), and LMWH (both 0 vs 1% [p = 0.67]). No statistical difference among DOAC selection [p = 0.90]. Our UACC rate of MB in patients with GUCA for both DOAC combined versus LWMH were 11.6% (5/43) and 0% [p = 0.1910], compared to the RCT GU subgroup was 5.7% (6/104) [p = 0.02] and 0.6% (1/175) [p = 1.0], respectively. Furthermore, our data found no statistical significance difference among the recurrent VTE rate among DOAC, LMWH, UACC Retrospective or RCT events. Conclusions: In agreement with the four major RCT, our study demonstrated that patients with high-risk GUCA and underlying VTE treated with a DOAC had a non-significant higher incidence of MB compared to those treated with LMWH. Further, our Real-World experience showed that GUCA DOAC had a significantly higher MB event rate compared to the RCT subgroup population. We acknowledge there are inherent biases in all retrospective studies and RCT. These data support the idea that DOAC should be further studied and used with caution in patients with a high risk of bleeding. We recommend LMWH being the safest anticoagulation modality for High-Risk Bleeding GU malignancy.

Low Complication Rates in Patients with Bleeding Disorders Undergoing Major Surgery at an Academic Hemophilia Treatment Center

BACKGROUND: Hemophilia and von Willebrand disease (VWD) are the most common inherited bleeding disorders, and hemostatic management surrounding surgical procedures is complex. Hemophilia Treatment Centers (HTCs) devote significant time and resources to formulating perioperative hemostatic plans to allow these patients to safely undergo necessary procedures. Yet, scant data exists in the literature in the era of routine recombinant and plasma-derived factor concentrate use on outcomes of persons with bleeding disorders undergoing major surgeries. METHODS: We performed a retrospective chart review of surgical outcomes in patients with bleeding disorders at the Cardeza Hemophilia and Thrombosis Center, an HTC at a large academic medical center in Philadelphia, PA. The study included 50 patients, among whom a total of 63 surgeries occurred between 2017-2019. Patients carried a diagnosis of Hemophilia A or B, VWD, or other congenital coagulation factor deficiency. We included planned surgeries requiring general anesthesia for &amp;gt;30 minutes, as well as orthopedic and neurologic surgeries; only procedures occurring at our hospital were included. The primary outcome was postoperative bleeding, assessed according to the ISTH-SSC's 2010 definition. Secondary outcomes included use of unplanned postoperative hemostatic therapy, length of stay, and 30-day readmission rate. To compare outcomes in our population to that of a non-bleeding disorder population, the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database was queried for 2018 (N=251,682). Only patients with a primary surgical CPT code shared with our study population were included, and those with a surgery occurring beyond Day 0 of admission or with a known bleeding disorder were excluded. Not all procedures undergone by our patients are captured by NSQIP, so our comparison study population included 40 procedures among 35 patients. RESULTS: Characteristics of the study population are summarized in Table 1. Among 50 eligible patients in our registry, 21 (42%) were female and mean age at the time of surgery was 50.9 years. The most common diagnosis was VWD (64%), with Type 1 (42%) the most frequent subtype. Most patients (44%) had a mild bleeding disorder. Three (6%) had a severe phenotype, including 1 patient with an inhibitor, and 2 (4%) used chronic outpatient prophylaxis. Outcomes in the 63 surgeries are summarized in Table 2. The most common surgical procedure category was orthopedic (21, 33.3%), including 12 arthroplasties. 62 patients (98.4%) had a preoperative hemostatic plan documented in the chart. 58 (92.1%) patients received preoperative hemostatic therapy, and 34 (54.0%) had planned postoperative therapy. Postoperatively, 59 patients (93.7%) had no documented bleeding complications. One (1.6%) had clinical bleeding not meeting ISTH major bleeding criteria and 3 (4.8%) had major bleeding, including 2 patients with unexpected surgical site bleeding and Hgb drop ≥2 g/dL and 1 who had a Hgb drop and required 5 units of pRBCs. Seven (11.1%) patients required unplanned postoperative hemostatic therapy. The mean length of stay was 1.65 days, and only 4 patients (6.3%) re-presented to the hospital within 30 days related to surgery - 2 for bleeding complications - including 3 ED visits and 1 inpatient admission. To understand how this rate of complications compares to the general population at academic centers, we compared study patients to non-bleeding disorder patients in the 2018 NSQIP database. Characteristics of each group are shown in Table 3. NSQIP defines bleeding only as postoperative transfusion, however all bleeding events in the study patients in this comparison included transfusion. Postoperative bleeding rates were low in both groups (3.0% in study patients vs 1.2% in NSQIP controls, P=.082). There was no difference in unplanned 30-day readmission rates related to surgery. Mean length of stay was longer in study patients (2.25 vs 1.90 days, P=.003). DISCUSSION: This study at a single HTC suggests that, with comprehensive care and preoperative planning, patients with bleeding disorders can safely undergo major surgical procedures with risks of bleeding complications similar to the general population. We observed few bleeding events or readmissions, and length of stay remained relatively short despite most patients being planned for postoperative hemostatic therapy. Disclosures Drelich: Octapharma: Honoraria; Bayer: Honoraria; CSL Behring: Honoraria.

Anti-IH Related Hemolytic Reaction in a Sickle Cell Patient and Further Management While Avoiding Transfusion

Abstract Introduction/Objective H antigen is a precursor for A and B antigens and is mostly converted except for the O blood group, which has the highest amount of H antigen. I is present on all adult RBCs. Anti-IH is usually an IgM antibody active at cold temperatures, and rarely demonstrates a wide thermal amplitude and can cause a significant hemolytic transfusion reaction. Methods Data was collected from patient information and transfusion management systems. Results 38 year old female with sickle cell disease presented to the emergency room with dizziness, tachypnea and Hgb: 5.9 g/dl Hct:19.1%. Upon further review, patient chart showed that she had received an emergency RBC exchange transfusion 21 days prior to this admission for acute chest syndrome. She was B positive. The units for RBC exchange consisted of 5 group B and 1 group O units and an additional 1 group O unit later. All RBC units were matched for her phenotype; Rh, K, Duffy &amp; Kidd, except anti-S which was ruled out. At the time of discharge, Hgb was 9.3 g/dl and Hct was 27.7%. The drop in Hgb between discharge and the present admission prompted a suspicion for delayed hemolytic reaction/hyperhemolysis. The sample sent to the local Reference Laboratory came back as follows: DAT/Coombs Positive, DAT C3 positive; positive for cold auto-anti-IH antibody. A thermal amplitude test indicated that the anti-IH was reactive at 30 C and therefore had the potential to be of clinical significance. Her Hgb continued to drop and 3 days later Hb=3.7 g/dl with instructions not to transfuse unless clinically emergent. With treatment of IVIG and steroids, reducing further blood draws and monitoring the patient for clinical symptoms only, her Hgb/Hct started to rise and the patient was discharged 4 days later with Hgb: 6.4 g/dl, and no symptoms of anemia. Conclusion Our case study is important in two ways: Firstly, it raises awareness of the severity of a cold autoantibody, i.e. anti-IH, with a wide thermal amplitude. Specifically, in this case, our attempt to provide phenotypically similar RBCs resulted in the destruction of all the type O donor cells as well as some of the B donor cells. Secondly, even with Hgb counts as low as 3.7, treating the patient and not the number proved to be better clinical practice. In conclusion, a good monitoring protocol for sickle cell patients is required to transfuse less and avoid serious complications.

S3454 Dieulafoy Lesion Masquerading as Diverticular Bleeding

INTRODUCTION: Dieulafoy lesion (DL) is an aberrant submucosal artery which protrudes from a small mucosal defect presenting with massive painless gastrointestinal bleeding (GIB) in the form of melena, hematemesis or hematochezia (Hcz), depending on its location. DLs are most commonly found in the proximal stomach within 6 cm of the gastro-esophageal junction along the lesser curvature, however, can occur anywhere along the GI tract to a lesser degree. DLs in the small intestine are rare, mostly seen in the jejunum, with DLs in terminal ileum occurring even rarer. CASE DESCRIPTION/METHODS: A 49-year-old woman with hypertension and history of peptic ulcer disease presented to emergency department complaining of maroon colored stools. She denied epigastric pain, nausea, constipation or weight loss. Her last colonoscopy (CF) was at 48 years of age with finding of “benign” polyps. Patient’s family history was significant for colon cancer in her father. Physical exam was positive for maroon colored stool on rectal exam. Laboratory tests revealed hemoglobin (Hgb) of 9.7 mg/dL, blood urea nitrogen (BUN) of 14 mg/dL and creatinine of 1 mg/dL. Endoscopic evaluation was started with esophagogastroduodenoscopy (EGD), which revealed no source of active or stigmata of recent bleeding. During EGD, patient had a large bloody bowel movement and decision was made to proceed with unprepped CF, which revealed small internal hemorrhoids, pan-diverticulosis and maroon colored blood clots in terminal ileum, which were felt to be secondary to incompetent ileocecal valve. Hcz was thought to be secondary to diverticular bleed, however, over the course of the day patient was noted to have a significant drop in Hgb to 5.7 mg/dL and continued to have Hcz. Blood transfusion was initiated and computed tomography (CT) angiography ordered, which was found to be negative for active bleeding. Repeat CF after bowel prep revealed a 0.3 cm ulcer with visible non-bleeding vessel in the terminal ileum, and was treated with epinephrine injections and two endoclips. Patients remained hemodynamically stable and was ultimately discharged home. DISCUSSION: DLs can cause life threatening hemorrhages and account for 1–2% of overt GIBs. They can be difficult to differentiate from other sources of bleeding, such as diverticular bleeds or bleeding due to arterio-venous malformations. Multidisciplinary approach is necessary for quick diagnosis and proper treatment as multiple endoscopies and imaging studies may be necessary to localize the site of bleeding.Figure 1.: Terminal Ileum filled with blood from first colonoscopy.Figure 2.: 0.3 cm ulcer with visible vessel in terminal Ileum.Figure 3.: Status post injection of epinephrine and placement of 2 endoclips.

882: A comparison of quantified versus estimated blood loss at the time of cesarean delivery

To compare the diagnostic accuracy of visual estimation of blood loss (EBL) versus quantified blood loss (QBL) for the targeted outcomes of blood transfusion and hemoglobin (Hgb) drop ≥ 3 gm/dL after cesarean delivery. Comparison of EBL versus QBL in a cohort of women being delivered in a tertiary care facility from July 1, 2017 – July 31, 2018 via scheduled and unscheduled non-emergent cesarean delivery. Maternal/neonatal demographics were collected along with outcome measures to include pre-operative hemoglobin, post-operative hemoglobin, and blood transfusion. EBL versus QBL for identifying postpartum hemorrhage were compared utilizing the area under the ROC curve for the targeted outcomes of blood transfusion and hemoglobin decline of more than 3 grams/dL. From July 1, 2017 – July 31, 2018 there were 994 deliveries with complete data. There were 40 women (4.0%) who received red cell transfusions and 132 (13.3%) who had a post-operative hemoglobin drop of ≥3grams/dL. In the majority of cases (701/995, 70.5%), QBL exceeded EBL. In ROC curve analysis, the area under the curve estimate was 0.67 for QBL vs 0.6 for EBL to predict the need for blood transfusion; this was not statistically significant (difference = 0.074, 95% CI -0.023 - 0.171, p=0.13). The area under the curve estimate was 0.69 for QBL vs 0.646 for EBL to predict post-partum hemoglobin drop of > 3 grams/dL; this was not statistically significant (difference = 0.044, 95% CI -0.011 - 0.100, p=0.12). QBL and EBL perform similarly in scheduled and non-emergent cesarean deliveries for identifying hemorrhage utilizing the target outcomes of blood transfusion and drop in Hgb ≥ 3 gm/dL. Costs and benefits should be considered further before implementing QBL as a standard of care to predict postpartum hemorrhage.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Education Program to Improve the Adherence to Guidelines for Use of Blood Transfusions in Sickle Cell Disease

Background: An expert panel convened by the NHLBI in 2014 provided guidelines and indications for blood transfusions in patients with sickle cell disease (SCD). These recommendations were to help conserve the use of blood transfusions in SCD patients in order to reduce the complications of iron overload, transmission of blood-borne pathogens and development of alloantibodies. In a retrospective review of SCD patients who received blood during inpatient admissions we identified deviations from guideline recommendations including transfusions for pain, and asymptomatic drops in hemoglobin(hgb). A standardized education program was subsequently developed and implemented to improve compliance with NHLBI recommendations for transfusion use in hospitalized patients with SCD. Methods: A standardized education program was developed based on American Society of Hematology (ASH) and NHLBI recommendations. This program included a PowerPoint presentation which was delivered to small groups of hematologists, hospitalists, emergency room and primary care physicians, nurse practioners and medical residents who regularly manage inpatient SCD admissions. A post-test of knowledge was administered and completed by 65 individuals. Additionally, the ASH pocket guide app was placed on physician's smartphones. Following completion of the program, transfusion use and indications were reassessed over the next 6 months. The hospital database was screened for admissions of patients with the diagnosis of SCD (HbSS, HbSβ0, HbSβ+, HbSC) who were billed for a blood transfusion between 8/1/2015 to 8/31/2016. This served as the baseline data. All patients were &gt;18 years of age. Each chart was reviewed individually to assess the clinical setting and reasons for transfusion. The following parameters were documented: age, sex, length of hospital stay (LOS), hgb at time of transfusion, baseline hgb, number of units transfused, documented reason for transfusion, presence of alloantibodies and ferritin level. We defined the infusion of blood as a transfused event which included single or multiple units of blood. We excluded transfusions given for acute bleeding. Following the educational program, this same methodology was used to collect a second cohort of SCD patients admitted to the hospital between 1/2/2019-6/22/2019 wherein the indications and outcomes of blood transfusion were compared with the first, pre-educational cohort. Results: In phase one (pre-education cohort), a total of 87 SCD patients were analyzed and the majority of inpatient transfusions were not indicated by national guidelines with only 34.5% of transfusion events meeting expert panel recommendations. In this phase of our study, we reviewed a second cohort of 53 SCD patients (post-education). A total of 123 units of blood were transfused. 73.5% of patients had HbSS disease, 22.6% had HbSβ0 disease and 3.77% had HbSC disease. The mean age was 32.5 years and 69.8% were female. Compared to management of patients prior to the education program, less blood was administered for the non-guideline indications of acute pain crisis (15% vs 28%) and Hgb drop &gt;2gm (9% vs 21%) (see Figure 1). The mean level of ferritin in the second cohort was 1751 and 7.54% of patients had alloantibodies, compared to the baseline group with ferritin of 2483 and alloantibodies of 17%. The average LOS in the baseline group was 9 days and in the second cohort was 8.4 days with an average LOS for uncomplicated pain or a drop of hemoglobin in the baseline group of 8.9 days and in the second cohort of 6.6 days. The most common indicated guideline reasons for transfusion in both cohorts were for symptomatic anemia and acute chest syndrome. Conclusion: This educational program was able to reduce transfusion use in SCD patients who were hospitalized for vaso-occlusive crises and asymptomatic anemia. There was a trend towards decrease in LOS for patients when they had less transfusions. Face to face education in combination with the use of the readily available ASH pocket app on smartphones are effective tools to increase adherence to national guidelines for transfusion in SCD. Disclosures Cohen: Global Therapeutics: Other: Trial for GBT440.