Fresh Frozen Plasma Transfusion Research Articles

Incidence of Bleeding Complications With Flexible Bronchoscopy in Cancer Patients With Thrombocytopenia.

Bronchoscopy is a safe procedure, but current guidelines recommend transfusion for platelets <20 K/μL. Studies of bronchoscopy in thrombocytopenia are limited. Our objective was to evaluate the incidence of bleeding with flexible bronchoscopy in those with thrombocytopenia especially those <20 K/μL. We performed a retrospective review of all flexible bronchoscopies between June 1, 2008 and December 31, 2010. Biopsies and therapeutic procedures were excluded. The χ, Fisher exact, and Rank-sum test were conducted to evaluate associations of clinically significant bleeding. There were 1711 patients who underwent 2053 flexible bronchoscopies. Cancer diagnosis included hematologic (61.3%) and solid organ malignancy (34.9%). Half of the bronchoscopies had moderate to severe thrombocytopenia (<100 K/μL) with the following ranges: 14.7% with 50 to <100 K/μL, 20.6% with 20 to <50 K/μL, 10.6% with 10 to <20 K/μL, 4.1% with <10 K/μL. Platelet transfusion was given in 90.6% of those with platelets <10 K/μL and 55.5% of those with platelets 10 to <20 K/μL. The nasal route for bronchoscopy was used in 92.4%. Bleeding complication rate however was 1.1% (0.2% major) and not affected by platelets. Bronchoscopy with lavage can be safely performed without platelet transfusion in those with platelets of ≥10 K/μL. In the absence of nasal bleeding, trauma, or deformity, the nasal route can be used for bronchoscopy.

Investigation of factors associated with allergic transfusion reaction due to platelet transfusion and the efficacy of platelets resuspended in BRS-A in adult patients.

Although allergic transfusion reactions (ATRs) resulting from platelet concentrate (PC) are a common adverse reaction, the mechanism underlying ATRs has not been fully elucidated. Plasma-replaced PC suspended in bicarbonate Ringer's solution and anticoagulant citrate dextrose solution A (RPC-B) is effective for preventing ATRs in children in Japan; however, there is not enough evidence in adult populations. We conducted a retrospective analysis focused on factors associated with ATRs developing from PC transfusions in adult patients in a single institution between 2015 and 2018. The clinical efficacy of RPC-B for adult patients was also analyzed. In total, 4,677 untreated regular PC products in plasma were transfused into 914 patients. ATRs developed in 65 patients (7.1%) treated with 92 PC products (2.0%). Multivariate analysis revealed that patients who were elderly, diagnosed with a non-hematological disease, and who received a transfusion of fresh-frozen plasma and red blood cell concentrate products together with PC products had lower frequencies of ATRs. Although 40 patients received 490 RPC-B transfusions, six ATRs (1.2%) were confirmed in five patients (12.5%). The ATR frequency was not significantly lower in the analysis of all patients; however, ATRs in patients with hematological diseases were lower in terms of both the patient and product numbers. Corrected count increments (24 hr) were also within an acceptable range in patients with hematological diseases. Several patient-specific factors may be associated with the development of ATRs from PC transfusion. Because RPC-B appears to efficiently prevent ATRs, even in adult patients, safe and efficient transfusions may be performed by using RPC-B preferentially depending on the patient's risk factors.

Fresh frozen plasma transfusion in patients with cirrhosis and coagulopathy: Effect on conventional coagulation tests and thrombomodulin-modified thrombin generation

The efficacy of fresh frozen plasma (FFP) transfusion in enhancing thrombin generation in patients with cirrhosis and impaired conventional coagulation tests has not been sufficiently explored. Thus, we aimed to assess the effect of FFP transfusion on thrombin generation in these patients. Fifty-three consecutive patients receiving a standard dose of FFP to treat bleeding and/or before invasive procedures - if international normalized ratio (INR)/prothrombin time (PT) ratio were ≥1.5 - were prospectively enrolled. The primary endpoint was the amelioration of endogenous thrombin potential (ETP) with thrombomodulin (ETP-TM) after transfusion, which corresponds to the total amount of generated thrombin. INR/PT ratio and activated partial thromboplastin time (aPTT) were also assessed before and after transfusion. FFP enhanced ETP-TM by 5.7%, from 973 (731-1,258) to 1,028 (885-1,343 nM × min; p = 0.019). Before transfusion, evidence of normal or high ETP-TM was found in 94% of patients, even in those with bacterial infections. Only 1 (1.9%) patient had ETP-TM values reverting to the normal range after transfusion. Notably, no patients with low ETP-TM had bleeding. The median decrease in ETP-TM was 8.3% and the mean was 12.8% in 18 (34%) patients after transfusion (from 1,225 [1,071-1,537] to 1,124 [812-1,370] nM × min; p ≤0.0001). Similar responses to FFP transfusion were observed in patients with compensated and acute decompensated cirrhosis, acute-on-chronic liver failure, infection or shock. FFP significantly ameliorated INR and aPTT values (p <0.0001), but in a minority of patients the values were reduced to less than the cut-off point of 1.5. FFP transfusion enhanced thrombin generation and ameliorated conventional coagulation tests to normal values in a limited number of patients, and slightly decreased thrombin generation in 34% of cases. Transfusion of fresh frozen plasma in patients with cirrhosis only slightly improves coagulation test values in a limited number of patients and even appears to worsen them in a third of cases. Transfusion for the purpose of preventing or treating bleeding events could cause inherent risks and costs without clear benefits.

Low-Dose, Early Fresh Frozen Plasma Transfusion Therapy After Severe Trauma Brain Injury: A Clinical, Prospective, Randomized, Controlled Study

To investigate role of Low-dose, Early Fresh frozen plasma Transfusion (LEFT) therapy in preventing perioperative coagulopathy and improving long-term outcome after severe traumatic brain injury (TBI). A prospective, single-center, parallel-group, randomized trial was designed. Patients with severe TBI were eligible. We used a computer-generated randomization list and closed opaque envelops to randomly allocate patients to treatment with fresh frozen plasma (5 mL/kg body weight; LEFT group) or normal saline (5 mL/kg body weight; NO LEFT group) after admission in the operating room. Between January 1, 2018, and November 31, 2018, 63 patients were included and randomly allocated to LEFT (n= 28) and NO LEFT (n= 35) groups. The final interim analysis included 20 patients in the LEFT group and 32 patients in the NO LEFT group. The study was terminated early for futility and safety reasons because a high proportion of patients (7 of 20; 35.0%) in the LEFT group developed new delayed traumatic intracranial hematoma after surgery compared with the NO LEFT group (3 of 32; 9.4%) (relative risk, 5.205; 95% confidence interval, 1.159-23.384; P= 0.023). Demographic characteristics and indexes of severity of brain injury were similar at baseline. LEFT therapy was associated with a higher incidence of delayed traumatic intracranial hematoma than normal fresh frozen plasma transfusion in patients with severe TBI. A restricted fresh frozen plasma transfusion protocol, in the right clinical setting, may be more appropriate in patients with TBIs.

A Case Report of Mild TRALI and Literature Review

Abstract Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-associated fatalities. The diagnosis of TRALI is challenging due to lack of pathognomonic laboratory tests and the diagnosis is mainly based on clinical and radiographic findings. The criteria for the diagnosis of TRALI include (1) onset: within 6 hours of transfusion; (2) oxygenation: PAO2/FiO2 ≤300 mm Hg regardless of positive end-expiratory pressure level or oxygen saturation of ≤90% on room air; (3) chest x-ray: bilateral infiltrates on frontal chest radiography; and (4) blood pressure: pulmonary artery occlusion pressure ≤18 mm Hg when measured or no evidence of left atrial hypertension. Although the pathogenesis of TRALI is not fully understood, two different hypothetical pathways have been postulated. One of the pathways is an antibody-mediated, one-hit event (immune TRALI, 89% of cases) and mainly related to the antibodies against the human leukocyte antigen (HLA) or human neutrophil antigen (HNA). The other pathway (nonimmune TRALI) is a two-hit event, and the risk depends on certain predisposing factors, such as underlying pulmonary diseases. However, diagnosis of mild TRALI is challenging due to absence of stridor, wheezing, and rales on physical examination and lack of typical chest x-ray features of TRALI. On the other hand, identification of mild TRALI is important in order to initiate appropriate donor investigation and limit the potential for more severe occurrence in other patients. Recently, we diagnosed a rare case of mild TRALI and report it as follows: A 47-year-old African American male was admitted for relapsed acute myeloid leukemia (AML) who developed therapy-related thrombocytopenia requiring platelet transfusion. Within 15 minutes of starting the transfusion, the patient developed acute dyspnea, hypertension, tachycardia, and hypoxemia with PaO2/FiO2 of 78.9 mm Hg and SaO2 of 92.4%. However, the chest x-ray showed no infiltrates. He was treated with IV steroids, antihistamines, and 15 L of oxygen by face mask with improvement of signs and symptoms within 90 minutes of the reaction. The diagnosis of mild TRALI was confirmed by the detection of anti-HLA class I antibodies in the donor’s plasma. We reviewed the literature, and only four cases of mild TRALI were reported. Mild TRALI can be caused by transfusion of fresh-frozen plasma (2/4), RBCs (1/4), and platelets (1/4). The initial symptoms usually include fever (3/4), chills (4/4), dyspnea (4/4), tachycardia (3/4), and blood pressure changes (2/4 increased in both systolic and diastolic BP, 1/4 increased in systolic BP, 1/4 increased in systolic but decreased in diastolic BP, and 1/4 decreased in diastolic BP). On physical examination, no stridor, wheeze, rales, or urticaria were found (4/4). Laboratory test showed a decrease in the WBC (4/4). Chest x-ray did not show obvious bilateral infiltration and therefore was not required. The symptoms improved rapidly in a few minutes (2/4) to several hours (1/4 in 2 hours and 1/4 in 4 hours). HLA testing showed HLA class I (4/4) or class II (2/4) antibodies in the donor’s plasma. In conclusion, identification of mild TRALI is critical but challenging because diagnosis is based principally on the clinical symptoms and there is no specific laboratory test for mild TRALI. We need to have a high index of suspicion for TRALI in any patient who experiences respiratory symptoms related to transfusion in our daily practice.

Fresh Frozen Plasma and Platelet Transfusion Practices in Neonatal Intensive Care Unit of a Tertiary Care Hospital.

Blood transfusion is an indispensable part of modern medical and surgical practices. More than 35% of critically ill patients receive transfusion of blood components during their intensive care unit stay. The aim of study is to obtain an information regarding the relationship of platelet concentrate (PC) and fresh frozen plasma (FFP) transfusion on clinical outcome of neonates admitted in neonatal ICU (NICU). This prospective cohort study was conducted from 1st November 2011 to 30th April 2013. The clinical history, blood component details and laboratory parameters were evaluated with clinical outcome. The neonates requiring PC and FFP transfusion were followed up in blood bank for laboratory parameters. Clinical parameters were noted from case file. During the study period, 291 neonates were admitted in NICU. 2 neonates had congenital malformations and thus, were excluded from the study. Of the remaining 289 neonates, 49 neonates received transfusion of platelets and/or FFP. The combined mean donor exposure for all components was found to be 1.48. The mean volume of PC and FFP transfused was 20ml and 30ml respectively. The mean pre- and post-transfusion platelet count was 34,000µl and 42,000µl respectively. The mean pre- and post-transfusion INR was 2.37 and 1.53 respectively. There was a significant increase in platelet count and decrease in INR in transfused neonates. However, no clinical benefit of PC and FFP transfusion seen on bleeding. Transfusion of PC and FFP has significant effect on laboratory parameters as compared to clinical parameter.

A retrospective study of the effect of fibrinogen levels during fresh frozen plasma transfusion in patients with traumatic brain injury.

The association between traumatic brain injury (TBI) and coagulopathy is well established. While coagulopathy prophylaxis in TBI involves replenishing coagulation factors with fresh frozen plasma (FFP), its effectiveness is controversial. We investigated the relationship between plasma fibrinogen concentration 3h after initiating FFP transfusion and outcomes and evaluated the correlation with D-dimer levels at admission. We retrospectively examined data from 380 patients with severe isolated TBI with blood samples collected a maximum of 1h following injury. Plasma fibrinogen and D-dimer concentrations were obtained at admission, and plasma fibrinogen concentration was again assessed 3-4h following injury. The patients were divided into two groups based on whether or not they received FFP transfusion. Patients were also divided into subgroups according their fibrinogen level: ≥ 150mg/dL (high-fibrinogen subgroup) or < 150mg/dL (low-fibrinogen subgroup) 3h after injury. Demographic, clinical, radiological and laboratory data were compared between these subgroups. Glasgow Outcome Scale (GOS) scores at discharge and 3months after injury were significantly lower in the FFP transfusion group than in the FFP non-transfusion group. Among patients who received FFP, GOS scores at discharge and 3months after injury were significantly higher in the high-fibrinogen subgroup than in the low-fibrinogen subgroup. Elevated admission D-dimer predicted subsequent fibrinogen decrease. In FFP transfusion, fibrinogen level ≥ 150mg/dL 3h after injury was associated with better outcomes in TBI patients. Assessing the admission D-dimer and tracking the fibrinogen are crucial for optimal coagulopathy prophylaxis in TBI patients.

A Case Presenting Massive Umbilical Hemorrhage with Previously Unrecognized Factor XIII Subunit A Mutation (Factor XIII A1 gene; NM_000129.3 c.1817_1817delA (p.H606Pfs*23) (p.His606Profs*23, homozygous)

ABSTRACT Congenital factor XIII deficiency is an autosomal recessive inheritance bleeding disorder. Usually, the cause of this disease is deficiency of factor XIII subunit A protein in plasma. Some symptoms of the disease support that the clinical suspicions related to FXIII deficiency. For example; prolonged umbilical cord bleeding which is started in the newborn period. Diagnose of Factor XIII deficiency is difficult, on the other hand it has important therapeutic implications. When cryoprecipitate or plasma-derived factor XIII concentrate is used prophylactically, the prognosis of the disease will be good. We report here a case related to factor XIII deficiency with presented a massive umbilical cord bleeding as the first manifestation of factor XIII deficiency. The patient was managed successfully with cryoprecipitate, fresh frozen plasma transfusion and supportive treatments.

Impact of cell saver during cardiac surgery on blood transfusion requirements: a systematic review and meta‐analysis

We performed a systematic review and meta-analysis of randomized clinical trials on adult patients undergoing cardiac surgery and compared the rates of red blood cell (RBC), platelet and fresh frozen plasma (FFP) transfusion between the cell saver (CS) and the standard of care groups. MEDLINE ®, The Cochrane Central Register of Controlled Trials (CENTRAL), American Society of Hematology (ASH) and bibliographies of relevant studies were searched. We used random-effect model. Our search strategy returned 624 citations, of which 15 studies were selected. The use of CS did not decrease the rate of RBC transfusion (odds ratio [OR]: 0·69; 95% CI: 0·48-1·00), albeit with a substantial heterogeneity (I2 =60%). The year of publication explained most of the heterogeneity (P for subgroup effect <0·001). Although the rate of platelet transfusion was lower in the CS group, the difference was not statistically significant (OR: 0·83; 95% CI: 0·57-1·2; I2 =0%). The rate of FFP transfusion was numerically higher in the CS group; however, this difference did not reach statistical significance (OR: 1·26; 95% CI: 0·82-1·94; I2 =15%). Only two studies scored five on the Jadad score. There was no indication of a publication bias using the funnel plot and Egger test (P=0·34, 0·87, and 0·62 for RBC, platelet and FFP, respectively). The use of CS during cardiac surgery does not have an impact on the rates of RBC, platelet and FFP transfusion; however, this should be interpreted in the light of the study limitations.

Precision Surgery for Placenta Previa Complicated with Placenta Percreta

Abstract Objectives: To investigate whether a precise circular resection of the uterine tissue at the placental attachment part is effective in cases with placenta previa complicated with placenta percreta (PPWPP). Methods: Patients diagnosed with PPWPP were assessed for pregnancy termination at 34–36 weeks of gestation. During the operation, we performed circular resection of the uterine tissue at the placental attachment part. Then the characteristics of the operation and the follow-ups were recorded. Results: During the operation, the vital signs were stable. The mean intraoperative blood loss, packed red blood cells units transfusion, fresh frozen plasma transfusion, and operation time were 2140 mL, 6 U, 440 mL, and 179.8 minutes, respectively. There was no bowel, ureter, or bladder injury. And there was no patient transferred to the ICU after operation. The mean postoperative blood loss was 458.6 mL. There was no fever, infection, intestinal obstruction, or other complications after operation during the hospitalization. The shape and the blood flow of the uterus were normal. After the patients were discharged, one had developed cesarean scar diverticulum. The mean lochia duration was 30 days. The menstrual cycle and volume were as before. The shape and the blood flow of the uterus and the ovarian were normal. Conclusions: The circular resection following end-to-end anastomosis is an effective precision surgical approach for PPWPP. It can achieve the purpose of hemostasis while maximizing the protection of organ function and reducing surgical trauma.

Analysis of pre- and intraoperative clinical factors for successful operating room extubation after living donor liver transplantation: a retrospective observational cohort study

BackgroundEarly extubation after liver transplantation is safe and accelerates patient recovery. Patients with end-stage liver disease undergo sarcopenic changes, and sarcopenia is associated with postoperative morbidity and mortality. We investigated the impact of core muscle mass on the feasibility of immediate extubation in the operating room (OR) after living donor liver transplantation (LDLT).MethodsA total of 295 male adult LDLT patients were retrospectively reviewed between January 2011 and December 2017. In total, 40 patients were excluded due to emergency surgery or severe encephalopathy. A total of 255 male LDLT patients were analyzed in this study. According to the OR extubation criteria, the study population was classified into immediate and conventional extubation groups (39.6 vs. 60.4%). Psoas muscle area was estimated using abdominal computed tomography and normalized by height squared (psoas muscle index [PMI]).ResultsThere were no significant differences in OR extubation rates among the five attending transplant anesthesiologists. The preoperative PMI correlated with respiratory performance. The preoperative PMI was higher in the immediate extubation group than in the conventional extubation group. Potentially significant perioperative factors in the univariate analysis were entered into a multivariate analysis, in which preoperative PMI and intraoperative factors (i.e., continuous renal replacement therapy, significant post-reperfusion syndrome, and fresh frozen plasma transfusion) were associated with OR extubation. The duration of ventilator support and length of intensive care unit stay were shorter in the immediate extubation group than in the conventional extubation group, and the incidence of pneumonia and early allograft dysfunction were also lower in the immediate extubation group.ConclusionsOur study could improve the accuracy of predictions concerning immediate post-transplant extubation in the OR by introducing preoperative PMI into predictive models for patients who underwent elective LDLT.

Viscoelastic Blood Tests Use in Adult Cardiac Surgery: Meta-Analysis, Meta-Regression, and Trial Sequential Analysis

Postoperative hemorrhage in cardiac surgery is a significant cause of morbidity and mortality. Standard laboratory tests fail as predictors for bleeding in the surgical setting. The use of viscoelastic (VE) hemostatic assays thromboelastography (TEG) and rotational thromboelastometry (ROTEM) could be an advantage in patients undergoing cardiac surgery. The objective of this meta-analysis was to analyze the effects (benefits and harms) of VE-guided transfusion practice in cardiac surgery patients. A meta-analysis of randomized trials. For this study, PubMed, EMBASE, Scopus, and the Cochrane Collaboration database were searched, and only randomized controlled trials were included. A systematic review and meta-analysis were performed in accordance with the standards set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, using a random-effects model. The study comprised adult cardiac surgery patients. VE-hemostatic assays transfusion algorithm compared with transfusion algorithms based on clinicians' discretion. Seven comparative randomized controlled trials were considered, including a total of 1,035 patients (522 patients in whom a TEG- or ROTEM-based transfusion algorithm was used). In patients treated according to VE-guided algorithms, red blood cell (odds ratio 0.61; 95% confidence interval [CI]: 0.37-0.99; p: 0.04; I2: 66%) and fresh frozen plasma transfusions (risk difference 0.22; 95% CI: 0.11-0.33; p < 0.0001; I2: 79%) use was reduced; platelets transfusion was not reduced (odds ratio 0.61; 95% CI: 0.32-1.15; p: 0.12; I2 74%). This study demonstrated that the use of VE assays in cardiac surgical patients is effective in reducing allogenic blood products exposure, postoperative bleeding at 12 and 24 hours after surgery, and the need for redo surgery unrelated to surgical bleeding.

Defining Usage and Clinical Outcomes Following Perioperative Fresh Frozen Plasma and Platelet Administration in Spine Surgery Patients.

This was a retrospective study. The main objectives of this study were to characterize the utilization of fresh frozen plasma (FFP) and platelets in spine surgery and the clinical outcomes following their administration. Blood component transfusion is often a crucial therapy during spine surgery. Little is known about the association between transfusion with FFP and/or platelets and perioperative morbidity in patients undergoing spine surgery. At a single large tertiary medical center, the surgical billing database was retrospectively queried for patients undergoing spinal surgery from 2008 to 2015. A univariate analysis compared patient characteristics for those who received FFP and/or platelets perioperatively and those who did not. To determine independent predictors of FFP and platelet administration and independent predictors of perioperative complications, both univariate and multivariate analyses were used. In total, 6931 patients met inclusion criteria. One thousand seven (14.5%) patients received perioperative FFP transfusion and 432 (6.2%) received platelets. In multivariate analysis, Charlson Comorbidity Index (CCI) ≥4, preoperative hemoglobin <12 g/dL, preoperative international normalized ratio (INR) ≥1.7, higher estimated blood loss, and receipt of packed red blood cell or platelet transfusion were associated with perioperative FFP administration (all P≤0.001). More than half of all patients received FFP with an INR trigger of <1.7. Those who received perioperative FFP were more likely to experience infection, increased length of stay, and ischemic, respiratory, thrombotic, and renal complications (all P<0.0001). Perioperative FFP [odds ratio (OR): 2.43], platelet transfusion (OR: 1.81), American Society of Anesthesiologists (ASA) grade 3 or 4 (OR: 1.84), CCI≥4 (OR: 1.75), and receipt of packed red blood cells (OR: 1.73) were independent predictors of experiencing any complication (all P≤0.008). The majority of patients were given FFP with a liberal INR trigger of >1.7. Perioperative FFP and platelet administration are independent predictors of perioperative complications following spine surgery.

Platelet transfusion as treatment for factor V deficiency in the parturient: a case report

Congenital factor V deficiency, also called parahemophilia, is a rare hematological disorder that can be treated with platelet transfusion. A 27-year-old G2P0100 with factor V deficiency was admitted for induction of labor and requested labor epidural analgesia. Throughout her hospital course, factor V levels were managed per recommendation from her hematologist, which included transfusing fresh frozen plasma (FFP) to maintain a factor V level of 50% before any neuraxial technique and 40% for postpartum hemostasis. The parturient required multiple transfusions of FFP to stay at this level, which eventually resulted in pulmonary edema. Given the request to maintain high levels of factor V, the parturient was transfused with platelets as an alternative source of factor V. The parturient eventually delivered a healthy neonate without signs of postpartum hemorrhage or epidural hematoma. A major learning point from this case is that platelet transfusion is an effective alternative in the management of factor V deficiency. Factor V released by platelets has enhanced procoagulant function, resulting in local factor V concentrations 100 times more than that of plasma, and has a significantly extended half-life. Platelet transfusion should be considered as a therapy in treating parturients with factor V deficiency.

Thromboelastography or rotational thromboelastometry for bleeding management in adults undergoing cardiac surgery: a systematic review with meta-analysis and trial sequential analysis.

Severe bleeding and massive transfusion of blood products may be associated with increased morbidity and mortality of cardiac surgery. A transfusion algorithm incorporating thromboelastography (TEG) or rotational thromboelastometry (ROTEM) can help to determine the appropriate time and target for the use of hemostatic blood products, which may thus reduce the quantity of blood loss as well as blood products transfused. We conducted meta-analysis and trial sequential analysis to evaluate the effects of TEG or ROTEM-guided transfusion algorithms vs. standard treatments for patients undergoing cardiac surgery with cardiac pulmonary bypass. Nineteen studies with a total of 15,320 participants, including 13 randomized controlled trials (RCTs), were included. All-cause mortality was not reduced either in overall studies or in RCTs. Blood loss volume was reduced by 132 mL in overall studies [mean difference (MD): -132.46, 95% CI: -207.49, -57.43; I2 =53%, P<0.01], and by 103 mL in RCTs (MD: -103.50, 95% CI: -156.52, -50.48; I2 =0%, P<0.01). The relative risks (RRs) in RCTs were 0.89 (95% CI: 0.80-0.98; I2 =0%, P=0.02) for red blood cells transfusion, 0.59 (95% CI: 0.42-0.82; I2 =55%, P<0.01) for fresh frozen plasma transfusion, and 0.81 (95% CI: 0.74-0.90; I2 =0%, P<0.01) for platelet transfusion, respectively. Trial sequential analysis of continuous data on blood loss and dichotomous outcomes on transfusion of blood products suggested the benefits of a TEG/ROTEM-guided algorithm. TEG or ROTEM-guided transfusion strategies may reduce blood loss volume and the transfusion rates in adult patients undergoing cardiac surgery.

Trends in transfusion practice over 20years in paediatric liver transplant programme.

We investigated changes to transfusion practices over time in paediatric liver transplant centre and evaluated the effect of transfusion practice to mortality. A pilot retrospective study included two cohorts each with 101 sequential paediatric LT recipients: an Early group (1994-1998) and a Recent group (2009-2013). Demographic characteristics and data on the intraoperative transfusion of red blood cells (RBC), fresh-frozen plasma (FFP), platelets and cryoprecipitate were collected. Postoperative laboratory results were also obtained, together with donor and data regarding 1- and 5-year survival. Appropriate intergroup comparisons, univariate and multivariate analysis were made and P≤0·05 was considered statistically significant. There were no significant group differences in demographic data (except patient height). Despite the fact that median total blood loss did not differ between groups (111ml/kg in both groups), the Early group had greater levels of intraoperative RBC transfusion (75 vs. 59ml/kg, respectively, P=0·04) and less use of FFP (53 vs. 62ml/kg, respectively, P=0·01). Overall we noted a lower 1- and 5-year survival in the Early group (88·2% vs. 96%, P=0·04 and 82·4% vs. 89·1%, P=0·01, respectively). Univariate, but not multivariate regression analyses demonstrated that higher PELD score, RBC and FFP transfusion, and inclusion in the Early group were contributing factors to 1-year higher mortality. This retrospective analysis of blood loss and replacement in paediatric LT patients demonstrates that the majority of our patients suffer major haemorrhage and require large-volume RBC and FFP replacements. In our pilot study, large volume of RBC and FFP replacement did not contribute to mortality. Paediatric LT involves a number of multidisciplinary teams. Thus, all care-related factors and combinations thereof that may contribute to outcome and should be evaluated in the future.

Four-factor prothrombin complex concentrate is associated with improved survival in trauma-related hemorrhage: A nationwide propensity-matched analysis.

Post-traumatic hemorrhage is the most common preventable cause of death in trauma. Numerous small single-center studies have shown the superiority of four-factor prothrombin complex concentrate (4-PCC) along with fresh frozen plasma (FFP) over FFP alone in resuscitation of trauma patients. The aim of our study was to evaluate outcomes of severely injured trauma patients who received 4-PCC + FFP compared to FPP alone. Two-year (2015-2016) analysis of the American College of Surgeons-Trauma Quality Improvement Program database. All adult (age ≥18 years) trauma patients who received 4-PCC + FFP or FFP alone were included. We excluded patients who were on preinjury anticoagulants. Patients were stratified into two groups: 4-PCC + FFP versus FFP alone and were matched in a 1:1 ratio using propensity score matching for demographics, vitals, injury parameters, comorbidities, and level of trauma centers. Outcome measures were packed red blood cells, plasma and platelets transfused, complications, and mortality. A total of 468 patients (4-PCC + FFP, 234; FFP alone, 234) were matched. Mean age was 50 ± 21 years; 70% were males; median injury severity score was 27 [20-36], and 86% had blunt injuries. Four-PCC + FFP was associated with a decreased requirement for packed red blood cells (6 units vs. 10 units; p = 0.02) and FFP (3 units vs. 6 units; p = 0.01) transfusion compared to FFP alone. Patients who received 4-PCC + FFP had a lower mortality (17.5% vs. 27.7%, p = 0.01) and lower rates of acute respiratory distress syndrome (1.3% vs. 4.7%, p = 0.04) and acute kidney injury (2.1% vs. 7.3%, p = 0.01). There was no difference in the rates of deep venous thrombosis (p = 0.11) and pulmonary embolism (p = 0.33), adverse discharge disposition (p = 0.21), and platelets transfusion (p = 0.72) between the two groups. Our study demonstrates that the use of 4-PCC as an adjunct to FFP is associated with improved survival and reduction in transfusion requirements compared to FFP alone in resuscitation of severely injured trauma patients. Further studies are required to evaluate the role of addition of PCC to the massive transfusion protocol. Therapeutic studies, level III.

Rational use of blood components in children with dengue by using WHO and NVBDC guidelines

Background: Dengue fever has become a major public health concern. The disease is now endemic in more than 100 countries with very high case fatality rate and children are the most affected age group worldwide. During explosive outbreaks, there is sudden surge in demands of blood components. Hence the aim of present research was to study the rational use of blood components in children with dengue by using WHO 2012 and NVBDCP 2015 (GOI) guidelines.Methods: Total 219 children of age ˂12 years, who has been diagnosed to have dengue and received blood component therapy during 12 months of study period, were included in the study. The transfusions of blood components [packed red cells (PRC), platelets and fresh frozen plasma (FFP)] were being given to the cases accordance to the WHO and NVBDCP guidelines. The patients’ demographic data, diagnosis, details of blood component therapy used the reason for transfusion was recorded.Results: Out of 219 children, 12(5.4%) children received platelet transfusion, 4(1.8%) children received PRC transfusion and 5(2.2%) children received FFP transfusion. One transfusion (4.7%) out of 12 platelet transfusion was inappropriate and all PRC and FFP transfusions were appropriate according to WHO and National Vector Born Disease Control Programme (GOI) guidelines.Conclusions: The need for platelet transfusion is often overemphasized and the fact is that the platelet count alone is not a predictor of bleeding. Unnecessary and empirical use of platelets should be completely avoided.

Contemporary Reversal of Oral Anticoagulation in Intracerebral Hemorrhage.

Author(s): Bower, Matthew M; Sweidan, Alexander J; Shafie, Mohammad; Atallah, Steven; Groysman, Leonid I; Yu, Wengui

Individual differences of plasma proteins and factors in fresh frozen plasma from Chinese regional blood donors.

Currently, single fresh frozen plasma (FFP) for clinical use is derived from individual blood donors. The objective of this study is to investigate the differences in single FFP units to make related strategies for improving FFP transfusion efficacy. 120 units of single FFP were selected randomly from Chinese PLA Clinical Blood Transfusion Center in Beijing, China. Single FFP samples were thawed in 37°C water bath and were assessed immediately for total protein (TP), albumin (Alb), fibrinogen (Fg), factor V (FV), factor VIII (FVIII), antithrombin-III (AT-III) and protein C (PC). Multiple comparisons were employed to analysis the differences. The quality levels of 120 single FFP units showed wider ranges and presented normal distribution. Fg, FV and PC showed larger fluctuation range but TP, Alb, FVIII and AT-III showed smaller. The mean level of TP was 56.07g/L and FVIII was 0.62IU/mL. There were no significant differences to genders in single FFP units. FFP from younger people with 18-30years old showed a trend towards reduced activity of coagulation factors, especially FV and FVIII. TP and Alb levels in FFP with type O were significantly higher than that in non-O type, but FVIII, AT-III and PC levels were lower in type O than that in non-O type. In a word, the whole quality of single FFP units from Chinese regional donors was acceptable, except FVIII. There were great differences of plasma proteins and factors in single FFP units, age and ABO blood type were main influence factors.