Frozen Plasma Transfusion Research Articles

Comparison of transfusion rates between robotic- and video-assisted lobectomy: a propensity score matching analysis.

The objective is to compare the perioperative blood transfusion rate and postoperative complications between robot-assisted surgery and thoracoscopic surgery in lung cancer patients. This is a single-center retrospective study. Patients underwent lung cancer minimally invasive resection at Fujian Cancer Hospital from April 1, 2022, to April 30, 2023, were enrolled in this study. Patients were divided into robotic-assisted lobectomy (RAL) and video-assisted lobectomy (VAL) groups according to the surgical methods. Data, including demographics, clinic variables, and endpoint outcomes were collected from the electronic medical record. Propensity score matching(PSM) was performed to analyze the baseline data of patients. The RAL group and the VAL group were matched 1:1. Then, the blood transfusion rates and short-term outcomes of the two groups were compared. A logistic regression was performed to analyze the independent risk factors of perioperative blood transfusion. A total of 558 patients were enrolled in this study. 166 of 558 patients were divided into the RAL group, and 392 patients were into the VAL group. A total of 118 patients were selected and analyzed following propensity score matching. After PSM, there was no difference in perioperative transfusion rates, including RBC transfusion and frozen plasma transfusion, between the VAL and RAL groups (P > 0.05). TheRAL group had fewer days of drainage tubes (P = 0.036). There was no difference in other short-term outcomes, including the volume of thoracic drainage, the volume of intraoperative blood loss, the length of hospitalization, and the rate of postoperative pulmonary infection (P > 0.05). Volume of intraoperative blood loss, volume of thoracic drainage, and preoperative hemoglobin were independent risk factors of perioperative red blood cell or frozen plasma transfusion; however, RAL or VAL was not. The study showed that the rates of perioperative blood transfusion were comparable between RAL and VAL. RAL is superior for patient recovery in terms of short-term outcomes.

The Analysis of the Effect of Blood Transfusion on Changes of Blood Platelet Parameters in Patients with Leukemia Treated with Chemotherapy.

Objective To study and analyze the effect of blood transfusion on the change of blood platelet parameters in patients with leukemia treated with chemotherapy. Methods Ninety-eight patients with leukemia treated with chemotherapy in the First Affiliated Hospital of Xi'an Jiaotong University from January 2021 to January 2022 were selected to observe the changes of platelet parameters before and after blood transfusion. Results There was significant difference between pre-transfusion and post-transfusion indexes (platelet count, mean platelet volume, and hematocrit) (P < 0.05). After binary logistic regression analysis, the use of antibiotics (OR = 2.235), blood transfusion history (OR = 3.086), abnormal white blood cell count (OR = 1.134), and frozen plasma transfusion (OR = 3.121) were the main factors of blood platelet parameters after transfusion in leukemia patients (P < 0.05). Conclusion Blood transfusion is beneficial to improve blood platelet parameters and prevent bleeding in patients with leukemia treated with chemotherapy. Attention should be paid to patients with risk factors for poor response to blood platelet transfusion and early intervention.

Value of the controlling nutritional status score and psoas muscle thickness per height in predicting prognosis in liver transplantation.

BACKGROUNDPatients with end-stage liver disease usually have varying degrees of malnutrition, and severe malnutrition may affect the prognosis of patients after liver transplantation (LT). However, there is no recommended standard for the nutrition assessment of patients waiting for LT, and it is unknown whether malnutrition has an impact on the occurrence of postoperative complications.AIMThe study aim was to investigate the value of the controlling nutritional status (CONUT) score and psoas muscle thickness per height (PMTH) in predicting prognosis in LT.METHODSWe retrospectively analyzed the clinical data of 313 patients who underwent classic orthotopic LT from January 2016 to December 2018 in Tianjin First Central Hospital affiliated with Tianjin Medical University. The CONUT score is derived from the preoperative serum albumin and total cholesterol levels, and total lymphocyte count. Patients were divided into low (≤ 4), medium (5–8), and high (9–12) CONUT score groups perioperative characteristics, Clavien-Dindo grade III/IV/V postoperative complications, graft loss and infection, and cumulative postoperative survival in the three groups were compared 3 mo after LT. PMTH was calculated as the ratio of the transverse thickness of the psoas muscle in the umbilical plane to the height of the patient. The cutoff values of receiver operating characteristic curves were determined separately for men and women. The values were 14.1 cm/m2 for women and 17.9 cm/m2 for men. The patients were then divided into low and high PMTH groups by the cutoff values. The comparison of data between the two groups was the same as above.RESULTSPatients with medium and high CONUT scores had lower preoperative serum hemoglobin, more intraoperative red blood cell (RBC) transfusions, longer postoperative intensive care unit stay and hospital stays, higher 7 and 14 preoperative-day serum bilirubin levels, and a higher incidence of postoperative grade III/IV complications and infections than patients with low CONUT scores. Differences in the 3-mo cumulative survival among the three groups were not significant. Patients with a low PMTH had higher preoperative serum urea nitrogen, more intraoperative packed RBC and frozen plasma transfusions, longer times to postoperative ventilator extubation, higher incidence of total postoperative complications, and a lower 3-mo cumulative survival than those with a high PMTH.CONCLUSIONA CONUT score ≥ 5 and a low PMTH were both associated with poor prognosis in LT. The CONUT score had no predictive value for short-term patient survival after LT, but the PMTH was predictive of short-term patient survival after LT.

Variations in Red Blood Cell and Frozen Plasma Transfusion Rates Across 60 Ontario Community Hospitals

Background: A restrictive transfusion strategy has been shown to be equivalent to a liberal transfusion strategy in terms of mortality and morbidity outcomes in major clinical trials.Liberal transfusions have been associated with higher mortality and morbidity, as well as longer lengths of stay in hospital based on observational data. Although patient blood management programs have reduced transfusion rates and improved patient outcomes, these programs have not been universally applied. Recent province wide audits of frozen plasma (FP) use in Ontario showed a high rate of inappropriate transfusions. Similarly, a recent red blood cell (RBC) audit in Ontario showed that approximately 25% of RBC units transfused were inappropriate.Objectives: The primary aim of this study was to compare transfusion rates of RBCs and FP across 60 Ontario community hospitals with more than 50 active treatment beds from 2012-2016. The secondary aims were to identify clinical and hospital factors, which may account for these differences.Methods:This study was a retrospective review of transfusion data from Ontario community hospitals between 2012-2016. RBC and FP transfusion data were acquired through the Canadian Blood Services data warehouse. Acute inpatient bed days and the annual average number of active treatment beds were obtained through the Ministry of Health and Long Term Care of Ontario. Annual transfusion rates were reported as FP and RBC units transfused per 100 acute inpatient days (AIPD), using descriptive statistics. Rates of blood component use were correlated with size of hospital using linear regression to determine whether size of hospital impacted on transfusion practices. Rates of RBC transfusion were correlated with rates of FP transfusion using linear regression. Finally, available data on local transfusion guidelines and pre-existing quality improvement mechanisms, such as pre-printed order sets, the presence of transfusion guidelines at each site were surveyed and reviewed to determine the impact of institutional culture on transfusion practices.Results: From 2012 to 2016, there were decreasing rates of RBC and FP use over time, with a wide range of variation amongst hospitals (Table 1). The average number of FP units transfused was 0.67, 0.62, 0.50, and 0.44 units per 100 AIPD for 2012-2013, 2013-2014, 2014-2015, and 2015-2016 respectively.The average number of RBC units transfused was 6.1, 6.0, 5.5, and 5.4 units per 100 AIPD for 2012-2013, 2013-2014, 2014-2015, and 2015-2016 respectively. Larger hospitals were associated with a significantly higher FP transfusion rate (p<0.05 for all years). However, there was no correlation between RBC transfusion rates and size of hospital. Of the 24 hospitals that responded to the survey, sites with transfusion quality improvement indicators (N=19) had statistically fewer units of FP transfused (p=0.04 for 2014-2015, p<0.01 for 2015-2016), and had a decrease in the units of FPs transfused from year to year. There was a statistically significant association between FP transfusion rates and RBC transfusion rates (p<0.01 for all years).Conclusion and significance: There may be cultural differences at different institutions contributing to the variations in transfusion rates across Ontario community hospitals. Characterization of transfusion practices and understanding of institutional culture surrounding blood component use will hopefully lead to quality improvement (QI) initiatives aimed at creating better guidelines, education, and transfusion order entry systems. These data will serve as a baseline to highlight sites and practices where QI initiatives may be most beneficial and potentially replicated in other provinces and states. [Display omitted] DisclosuresLin:Pfizer: Other: advisory board; Pfizer: Honoraria; Novartis: Research Funding; CSL Behring, Grifols: Other: unrestricted education grant.

Effect of Fresh Frozen Plasma Transfusion on Electrochemical Parameters of Blood Plasma in Patients with Severe Combined Trauma

Purpose: to study the dynamics of blood plasma electrochemical parameters in patients with severe combined trauma before and after fresh frozen plasma (FFP) transfusions.Materials and methods. The open circuit potential (OCP) of platinum electrode and antioxidant activity of blood plasma were studied in 35 patients with severe combined trauma and 35 post-FFP samples with at least 6-month shelf life. The electrochemical parameters of patients’ blood plasma were analyzed before transfusion, and 1 hr. and 24 hrs. after transfusion.Results. OCP measured in FFP was found to be more positive vs. OCP measured in recipients' blood plasma in 34 out of 35 cases (97%). It has been shown that in patients with severe combined trauma, OCP increased from 5.047 [-7.553; 12.976] mV to 12.827 [-1.372; 24.764] mV and antioxidant activity decreased 24 hours after FFP transfusion from 16.979 [11.302; 20.946] µC to 13.551 [9.288; 18.405] µC. After FFP transfusion, there were no significant changes in clinical blood parameters.Conclusion. By measuring electrochemical parameters of blood plasma in patients with severe combined trauma before and after FFP transfusions, it was discovered that in spite of absence of changes in blood parameters by routine methods, there are changes in the condition of the antioxidant system of the body, which manifest in the bias of patients’ blood plasma OCP towards higher positive values and decreased antioxidant activity. Redox imbalance in the body might cause the oxidative stress development.

Frozen Plasma Transfusion Practices in Ontario-an Electronic Audit at Five Tertiary Care Hospitals to Inform a Knowledge Translation Strategy to Reduce Inappropriate Plasma Transfusions

Frozen plasma transfusions are blood components that are frequently transfused to patients who are bleeding or require an invasive procedure and have a deficiency of coagulation factors detected on abnormal coagulation testing as inferred by a prolonged prothrombin time (PT), partial thromboplastin time (PTT), or increased international normalized ratio (INR). Despite published guidelines, supporting optimal plasma use, two recent provincial audits have suggested that 50% of the plasma transfused in the Province of Ontario is inappropriate. Inappropriate utilization of plasma has numerous adverse consequences for the recipient, including transfusion associated lung overload, allergic reactions, and delays necessary procedures while awaiting completion of the transfusion. In addition to the direct risks that inappropriate utilization of plasma has on the patient, it also has adverse consequences for the health care system; Given 98,521 units transfused in Canada in 2017, of which 50% are unnecessary, the annual revenue loss is estimated to be CAN$1.7 million.We will include all adult Inpatients receiving plasma during the time period January 1, 2017 and December 31, 2017. The study population will be subdivided into 5 groups of inappropriate plasma use that include: (1) patients with a normal INR≤1.5 and who were not actively bleeding, as indicated by no RBC transfusion; (2) patients with normal INR≤1.5 with moderate bleeding only; (3) elevated INR>1.5, without active bleeding or procedures; (4) no INR drawn before or after plasma infusion; or, (5) transfused a non-therapeutic dose of plasma, defined by less than or equal to 2 units. RBC transfusion requirement and the quantitative drop in hemoglobin will be used as a surrogate marker for bleeding. We plan to analyze the number and proportion of unnecessary plasma transfusions at five tertiary care centres by patient demographics, by triggering INR, and by the presence or absence of bleeding.As part of preliminary work to facilitate future audits and monitor appropriate plasma utilization in Ontario, there has been an Ontario Blood Utilization Data Strategy (ONBUDS) data extraction project where preliminary data has been extracted from blood transfusion databases, laboratory databases, and the discharge abstract database (DAD) for four institutions. We expect to confirm previous findings that 50% of the plasma transfused in Ontario is transfused inappropriately. Based on the preliminary ONBUDS data, it was found that the majority of inappropriate plasma transfusions were in the areas of cardiac surgery, orthopedic surgery, intensive care and gastroenterology.This study will inform a large quality improvement study aimed at reducing unnecessary plasma transfusion. The long-term goal is to develop an alternative electronic auditing strategy that is more comprehensive, faster, and more cost efficient than the historical annual Provincial audit which requires manual chart reviews by physicians, nurses and technologists. DisclosuresNo relevant conflicts of interest to declare.

Variations in RBC and frozen plasma utilization rates across 62 Ontario community hospitals.

Recent province-wide audits of frozen plasma (FP) and RBC use in Ontario showed a high rate of inappropriate transfusions. This was a retrospective, ecological study to determine variations in RBC and FP utilization rates across Ontario community hospitals between 2012 and 2017. Annual utilization rates were reported using descriptive statistics. Rates of blood component use were correlated with size of hospital, presence of specialized programs, and quality improvement (QI) initiatives, using Poisson regression. RBC and FP utilization rates decreased from 2012 to 2017 (p = 0.03 for FP; p < 0.01 for RBC). There was a 10-fold difference in RBC and FP transfusion rates between the highest and lowest users. Smaller hospitals (p < 0.05) and sites with any QI initiative (p = 0.006) were associated with lower FP utilization rates. Hospitals without cancer programs (p = 0.02) and sites with RBC guidelines (p = 0.05) or with technologists who prospectively screened transfusion orders (p = 0.01) had lower RBC transfusion rates. RBC utilization rates decreased further after the implementation of RBC guidelines (p = 0.02) and order sets (p = 0.005). There was a positive correlation between FP and RBC transfusion rates for each fiscal year (p < 0.005 for all years). RBC and FP utilization showed wide variation across community hospitals in Ontario. Overall, transfusion rates decreased over time. A further decrease was observed at sites with QI initiatives, supporting their implementation in reducing utilization. These data will serve as a baseline to highlight sites and practices where QI initiatives may be most beneficial and replicated in other jurisdictions.

Research advances in pathophysiology, diagnosis and therapy of trauma-induced coagulopathy

Objective Trauma-induced coagulopathy(TIC)is an acute coagulopathy in which coagulation, fibrinolysis, and anticoagulant pathways are activated after trauma due to massive hemorrhage and tissue damage. TIC is caused by hypothermia, acidosis, blood dilution, hyperfusion, tissue injury, etc. To diagnose TIC, we mainly rely on traditional coagulation function analysis and thrombelastogram (TEG). At present, the key to treat TIC is quick hemostasis. The basic treatment procedure includes transfusion of packed red blood cells and fresh frozen plasma by appropriate proportion, and timely infusion of platelets and coagulant material so as to stabilize blood pressure and reconstruct the blood coagulation mechanism. In this paper, we reviewed recent advances in the pathophysiological and treatment of TIC in order to provide references for further research in related fields. Key words: Blood coagulation disorders; Wounds and injuries; Pathology; Physiology; Diagnosis and treatment

Ruptured Abdominal Aortic Aneurysm - Results and Prognostic Factors at a Certified Centre of Vascular Surgery

Introduction: Although the perioperative management has been optimised over the past few decades, there has not been a remarkable improvement in the mortality rates of patients with a ruptured abdominal aortic aneurysm (rAAA). The aim of this retrospective trial was to define pre-, intra- and postoperative parameters which influence the perioperative and long-term outcome of patients and which can be modified by the operating team. Methods: A retrospective database analysis was performed in 49 patients who had undergone an operation of rAAA in our certified centre of vascular surgery between the beginning of 2006 and the end of 2012. The minimal follow-up period was 30 months. The statistical analysis was done univariately using the Kaplan-Meier method and a log-rank-test, and multivariately with the Cox model. Results: Intrahospital mortality was 40.8 %, perioperative mortality (30 postoperative days) was 28.9 %. The survival rate for 1 year was 52.4 %; the survival rate for 5 years was 45.3 %. In the univariate analysis, significant differences in the early postoperative survival rates were found depending on preoperative systolic blood pressure, preoperative haemoglobin (< 10 vs. ≥ 10 g/dl), the intraoperative need of blood and frozen plasma transfusions, type of perforation, type of AAA, the need for further surgical interventions, postoperative MOF, acute kidney failure and postoperative septicaemia. The late survival rates were significantly influenced by the type of perforation and AAA, pre-existing coronary disease and diabetes mellitus in fully identified patients discharged from hospital (n = 27). In the multivariate analysis pursuant to the Cox model, patients with pre-existing coronary disease had a 3.9-fold higher relative risk to die after the operation of rAAA, while patients with a free perforation of the rAA had a 10-fold higher relative risk. Conclusion: The high mortality of rAAA is caused by haemorrhagic shock and its complications, which are mostly non-surgical. Therapeutic efforts should focus on those perioperative parameters which can be modified by the treating teams. Alongside the centralisation of rAAA in high-volume-departments of vascular surgery, the systematic sonographic screening for asymptomatic AAA in the population older than 65 years should be enforced. A possible advantage of EVAR in rAAA has yet to be shown by trials in progress such as IMPROVE, AJAX and RCAR.

A clinical profile of hemophilia patients and assessment of their quality of life in Western Uttar Pradesh, India: An observational study

Objective: To describe the clinical profile of hemophiliac patients and their quality of life (QoL) in Western Uttar Pradesh. Materials and Methods: This was an observational cross-sectional study. Patients of all age groups with hemophilia admitted in the medicine and pediatrics ward for factor/fresh frozen plasma transfusion or having history of such type of transfusion were consecutively enrolled. A detailed clinical history was elicited from the accompanying parent/guardian. The HAEMO-QoL questionnaire was used for the assessment of QoL of the patients. Results: Out of the total 71 hemophilia patients, 66.2% (51/77) were >18 years of age. Type A hemophilia was observed in 88.3% (68/71) patients. Majority of the patients had severe hemophilia (80.5%). The family history and joint involvement were present in 58.4% and 77.9% of the patients, respectively. Knee joint was observed to be as the target joint among 57.1% of the patients. 76.6% of the patients had joint swelling, resulting in compromised joint movement. Bleeding occurred in soft tissues and joints in 62.3% and 15.6% of the patients, respectively. The patients had poor QoL scores. Overall, hepatitis B and C infection were observed in 6.5% and 9.1% of the patients, respectively. Orthophysiotherapy was needed in 22/26 (84.6%) patients. Conclusion: The severe type of haemophilia Type A was more common than mild and moderate types. The study suggests that important determinants for QoL in haemophilia patients are availability of factor concentrate from the clinical perspective and social and psychological support to ensure a holistic care approach.

Evaluation Of The Appropriateness Of Frozen Plasma Usage In The Era Of Prothrombin Complex Concentrates: A Retrospective Study

IntroductionAlthough frozen plasma (FP) transfusion is ubiquitous in clinical practice there is growing evidence that calls into question its administration outside a few selected clinical disorders. Indications for FP have been further reduced by the introduction of prothrombin complex concentrates (PCCs), which are now recommended for reversal of coagulopathies due to vitamin K antagonists (VKA).Audits consistently demonstrate that FP is administered to patients who do not have a specific indication for its use; in some cases “inappropriate” FP use exceeds “appropriate” FP use. This audit sought to determine if the introduction of PCCs has changed patterns of practice and the appropriateness of FP use. MethodsAfter ethics review we performed a quality assurance retrospective chart audit at a single tertiary care hospital of consecutive patients receiving FP over a 3 month period. Baseline characteristics were obtained for each of these patients via chart review. Each episode of FP use over a 24 hour period was adjudicated independently by two Hematology fellows and determined to be appropriate, inconsistent (with guidelines) yet appropriate, or inappropriate in accordance to Canadian and AABB guidelines. Episodes where a consensus could not be reached were adjudicated independently by a consultant hematologist. Specific criteria for “appropriateness” were developed based on the chart review; for example, transfusion of more than 5 units of packed red blood cells in a 2:1 ratio or greater with FP was considered inconsistent yet appropriate. Bleeding was defined as a decrease in hemoglobin of 2 g/dL over 24 hours, a transfusion of 2 units of red blood cells without a rise in hemoglobin, or bleeding in an enclosed space. Reversal of oral VKAs with FP was always deemed inappropriate. FP usage during the study period was also compared to 3-month periods from previous years. ResultsOver the study period, 111 episodes and 466 units of frozen plasma use were recorded. Comparisons to the three month period between January to March of previous years are shown in Figure 1. Interobserver agreement was good between the two Hematology fellows (weighted kappa=0.736) and very good with the fellows to the consensus adjudication (weighted kappa=0.824 and 0.810). After exclusion of FP use for plasmapheresis (always considered appropriate), 33/89 (37.1%), 16/89 (18.0%), and 40/89 (44.9%) episodes were deemed to be appropriate, inconsistent yet appropriate, or inappropriate, respectively. The most common reasons for inappropriate use were the absence of bleeding with an increased INR or VKA reversal. Results are presented in further detail in Table 1. FP transfusion occurred in the ICU 74.8% of the time. ConclusionOur study is the first to audit FP transfusions in the post-PCC era. FP usage remains inappropriately high. FP transfusion to patients who are not bleeding or having procedures despite INR prolongation and the use of FP to reverse VKA are the main reasons for inappropriate FP usage. The majority of FP usage occurred in the ICU. Targeted interventions to reduce FP usage in the future should include both educational and administrative programs, with a focus on the ICU. Clearer evidence on the role of FP in massive transfusions may also reduce FP usage. [Display omitted] Table 1Summary of Results of Consensus Adjudication of FP UseAppropriate (n=55)Inconsistent Yet Appropriate (n=16)Inappropriate (n=40)↑INR + Bleeding↑INR + Major ProcedurePLEX↑INR + Unclear bleeding↑INR + Minor/Recent ProcedureMassive TransfusionNo BleedingNo elevation or slight INR prolongationOAC ReversalNumber24922367161014% of Category43.6%16.4%40%18.8%37.5%43.7%40%25%35%% of Total21.6%8.1%19.8%2.7%5.4%6.3%14.4%9.0%12.7% Disclosures:Crowther:Pfizer: Consultancy, Honoraria, Research Funding; Octapharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Merck: Consultancy; Leo Pharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; CSL Behring: Speakers Bureau; Boehringer Ingelheim: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Baxter: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Asahi Kasai: Membership on an entity's Board of Directors or advisory committees; Sanofi-Aventis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Viropharma: Membership on an entity's Board of Directors or advisory committees.

Utilization of frozen plasma in Ontario: a provincewide audit reveals a high rate of inappropriate transfusions

Frozen plasma (FP) is frequently transfused inappropriately, an intervention that results in risk without benefit for the patient. To better understand current utilization practices in our region, we undertook a provincewide prospective audit to evaluate the clinical indications and appropriateness of FP transfusion. All hospitals in the Canadian province of Ontario with transfusion medicine services were invited to participate in a 5-day audit of FP utilization. FP dose, indication, and clinical patient data were collected for each transfusion request. Indications for FP transfusions were independently adjudicated as appropriate, inappropriate, or indeterminate based on predefined criteria. Seventy-six (49%) of 155 invited hospitals participated in the audit, which included 573 requests for 2012 units of FP. A total of 559 transfusions (1909 units) were administered. Of 573 requests, 164 (28.6%) were deemed inappropriate most often because: 1) they were administered to patients with an international normalized ratio below 1.5 or 2) they were administered in absence of bleeding or emergency surgery. The most frequent indications for FP transfusions were before surgery and warfarin reversal. Overall, patients admitted to the clinical areas of surgery, internal medicine, and the emergency department represented the largest users of FP, but this varied by hospital type (community vs. academic). The most frequently requested doses of FP were 2 and 4 units. This point-prevalence hospital audit revealed that transfusion of FP is frequently inappropriate. Focusing on reducing the two most common reasons for inappropriate FP transfusions could lead to a significant improvement in FP utilization.

Plasma transfusion for bedside, radiologically guided, and operating room invasive procedures

Frozen plasma (FP) is commonly used in an attempt to correct coagulation defects before performing bedside, radiologically guided, or operating room procedures. Use of FP prophylactically is closely linked to results for standard coagulation tests in the laboratory, including prothrombin time, but there is a general lack of evidence supporting the predictive value of abnormalities of these tests for bleeding. Use of FP has little effect on correcting abnormal coagulation tests when mild and moderate results are recorded. There is no support for evidence of effectiveness for the prophylactic use of FP when reviewing the wider randomized controlled trial literature. When the lack of clinical effectiveness is combined with the risks of FP transfusion, such as transfusion-related acute lung injury and transfusion-associated circulatory overload, the need to challenge continued preprocedure prophylactic use of FP becomes pressing. In clinical practice, abnormalities of standard coagulation tests should not be interpreted in isolation, but alongside review of clinical bleeding history and other hemostatic markers such as platelet count. A more appropriate transfusion strategy may be one that emphasizes the therapeutic use of FP.

Is fresh‐frozen plasma clinically effective? An update of a systematic review of randomized controlled trials (CME)

BACKGROUND: The clinical use of frozen plasma (FP) continues to increase, both in prophylactic and in therapeutic settings. In 2004, a systematic review of all published randomized controlled trials (RCTs) revealed a lack of evidence that supported the efficacy of FP use. This is an update that includes all new RCTs published since the original review.STUDY DESIGN AND METHODS: Trials involving transfusion of FP up to July 2011 were identified from searches of MEDLINE, EMBASE, CINAHL, The Cochrane Library, and the UKBTS/SRI Transfusion Evidence Library. Methodologic quality was assessed. The primary outcome measure was the effect of FP on survival.RESULTS: Twenty‐one new trials were eligible for inclusion. These covered prophylactic and therapeutic FP use in liver disease, in cardiac surgery, for warfarin anticoagulation reversal, for thrombotic thrombocytopenic purpura treatment, for plasmapheresis, and in other settings, including burns, shock, and head injury. The largest number of recent RCTs were conducted in cardiac surgery; meta‐analysis showed no significant difference for FP use for the outcome of 24‐hours postoperative blood loss (weighted mean difference, −35.24 mL; 95% confidence interval, −84.16 to 13.68 mL). Overall, there was no significant benefit for FP use across all the clinical conditions. Only two of the 21 trials fulfilled all the criteria for quality assessment.CONCLUSION: Combined with the 2004 review, 80 RCTs have investigated FP with no consistent evidence of significant benefit for prophylactic and therapeutic use across a range of indications evaluated. There has been little improvement in the overall methodologic quality of RCTs conducted in the past few years.

Long-Term Outcome of All-Trans-Retinoic-Acid(ATRA)+Intensive Chemotherapy in Acute Promyelocytic Leukemia(APL),

Abstract 3604 Background:ATRA has improved treatment of APL and particularly made remission induction therapy easier. However, there is no post-remission therapy that can surely cure APL. As ATRA alone is unlikely to cure the disease, a new combination therapy that uses ATRA and can attain a high rate of cure is needed. Objective: To cure APL by a combination of intensive remission induction therapy and post-remission therapy with ATRA. Also, to give supportive therapy under careful monitoring to avoid death due to chemotherapy. Subjects and Methods: Sixty-five consecutive patients with previously untreated APL who visited our hospital between January 2000 and January 2011 were treated. The t (15;17) or PML-RARA translocation was observed respectively in chromosome analysis and genotyping in all patients. The age range was 16 to 79 (median: 51). Nineteen were aged 60 or older. Thirty-four and thirty-one were men and women, respectively. Remission induction therapy was started with ATRA at 45 mg/m2 (P.O.) immediately after diagnosis of APL. Idarubicin (IDR) at 10 mg/m2 (Days 1, 3, 5, and 7) and behenoyl-ara-C (BH-AC) at 350 mg/m2 (Days 1 through 7) were also administered. DIC was treated with continuous infusion of gabexate mesilate, platelet transfusion (to maintain a platelet count of ≥ 50,000/mm3), and frozen plasma transfusion (to maintain fibrinogen ≥ 100 mg/dL). The remission induction therapy was given in a sterile room. After completion of chemotherapy, macrophage colony-stimulating factor (M-CSF) was given for 10 days. Subsequently, granulocyte colony-stimulating factor (G-CSF) was administered until neutrophil recovery. After remission, the post-remission therapy commonly used in AML patients at our hospital (ASH, 2009, abstract, no. 1052) was given for 1 year. ATRA was given at 40 mg/body daily with chemotherapy. Patients received ATRA daily at the same dose for 3 years after completion of the post-remission therapy. The post-remission therapy involved high-dose-cytarabine (2 g/m2 BID for 5 days but 1 g/m2 × BID for 5 days for those aged 60 or older) combined with mitoxantrone (MIT) at 7 mg/m2/day for 3 days (HD-AC + MIT) given immediately after complete remission (CR). Subsequently, a combination of BH-AC at 350 mg/m2 × 4 + aclarubicin at 20 mg/body × 6 and another combination of BH-AC at 350 mg/m2 + IDR at 10 mg/m2 × 1 were given repeatedly in an alternating manner (35 days each). M-CSF (for 7 days) was administered followed by G-CSF after completion of each chemotherapy combination. Each patient was transferred to a sterile room when the WBC count decreased below 1,000. Results: CR was achieved in 63/65(97%). Early deaths (ED) occurred in 2/65 (aged 74 and 79) due to interstitial pneumonia. The follow-ups of patients lasted from 3 to 142 months (median: 74 months). Three patients have experienced a relapse of APL, and relapse of hematological malignancy (myelodysplastic syndrome [MDS]) was seen in 5 patients. A chromosomal aberration not observed at first visit was found at relapse in all 5 patients who developed MDS. Six patients have died from relapsed APL (2), MDS (2), pneumonia following HD-AC + MIT (1), or liver cancer (1). For 63 patients who achieved CR, the overall survival (OS) calculated by the Kaplan-Meier method was 87% at 13 years. The disease-free survival (DFS) was 82% at 13 years. The OS and DFS for patients younger than 60 were respectively 93% and 80%. They were respectively 78% and 87% for patients aged 60 or older, showing no difference between the age groups. The DFS was 83% and 80% for patients treated with HDAC (52) and not treated with HDAC (11), respectively, showing little difference. When analyzed using the risk-based prognostic system of Sanz, et al., the OS was 70, 87, and 100% respectively for patients classified into the low (18), intermediate (27), and high risk (18) groups. The DFS was 72, 81, 94%, respectively. The analysis showed the best results for the high-risk group. Discussion: ATRA + intensive chemotherapy and long-term ATRA can attain a high rate of long-term survival (cure) for patients with APL regardless of age and risk group. Despite the use of intensive chemotherapy, only one patient died due to chemotherapy. This seems to be due to the selection of appropriate supportive therapy. Early diagnosis and bone marrow transplantation in patients with relapse (MDS) may further improve the rate of cure in patients with APL. Disclosures:No relevant conflicts of interest to declare.

A multifaceted strategy to reduce inappropriate use of frozen plasma transfusions in the intensive care unit

Purpose The purpose of this study is to determine the effect of a multifaceted behavior-change strategy on inappropriate use of frozen plasma (FP) transfusions in the intensive care unit (ICU). Materials and Methods A prospective, time-series study was conducted in a 15-bed medical-surgical ICU in 3 phases: (1) baseline observation; (2) educational campaign, audit and feedback to prescribers, and implementation of an FP request form; and (3) FP request form only. Independently, in triplicate and blinded to study phase, appropriateness of each FP request was adjudicated based on published guidelines and clinical context. Results Over the 15-month study period, 626 FP transfusions (210 FP requests) were administered to 88 patients. Inappropriate FP requests decreased slightly from phases I to III (60% vs 46%; P = .09), FP requests that were consistent with the guidelines did not change (23% vs 22%; P = .86), and FP requests that were appropriate for the ICU yet inconsistent with the guidelines increased (17% vs 32%; P = .04). Although uptake of the FP request form decreased in phase III, it was associated with fewer inappropriate transfusions. Conclusions The behavior-change strategy modestly improved appropriate use of FP transfusions in the ICU. Improving FP request form accuracy, completeness, and compliance may be required to achieve maximum effect and ensure sustainability.

Blood-saving effect of tranexamic acid in off-pump coronary artery bypass

Objective To investigate the blood-saving effect of tranexamic acid in off-pump coronary artery bypass (OPCAB). Methods Two hundred and sixty ASA Ⅰ- Ⅲ and NYHA Ⅰ- Ⅲ patients of both sexes,aged 18-64 yr, with body mass index 16-22 kg/m2 , undergoing OPCAB, were randomly divided into 2 groups (n = 130 each): control group (group C) and tranexamic acid group (group T) . Anesthesia was induced with iv injection of midazolam 0.1 mg/kg, fentanyl 5-10μg/kg and pipecuronium 0.1 mg/kg. The patients were tracheal intubated and mechanically ventilated. PEr CO2 was maintained at 35-45 mm Hg. A bolus of tranexamic acid 1 g was infused intravenously within 30 min after indution followed by continuous infusion at 400 mg/h until the end of operation in group T. While equal volume of normal saline was given in control group. Anesthesia was maintained with inhalation of isoflurane and intermittent iv injection of fentanyl and pipecuronium. Venous blood samples were taken before induction, at the end of operation and at 24 h after operation for determination of Hb, platelet count (P1t), prothrombin time (PT) and international normalized ratio (INR). The volume of chest tube drainage was collected and recorded at 6 and 24 h after operation. The requirement for transfusion of allogeneic red blood cells and fresh frozen plasma was also recorded. Results There was no significant difference in Hb, Plt, PTand INR at each time point between the two groups ( P ＞ 0.05). The requirement for transfusion of allogeneic red blood cells and fresh frozen plasma was significantly reduced in group T as compared with group C ( P ＜ 0.05 or 0.01 ). No deaths and complications occurred during hospital stay in the two groups. Conclusion Tranexamic acid exerts the blood-saving effect in OPCAB. Key words: Tranexamic acid; Coronary artery bypass, off-pump; Postoperative hemorrhage; Blood transfusion

The conundrum of persistent inappropriate use of frozen plasma

Frozen plasma (FP) is commonly used for the treatment of bleeding or the prevention of bleeding in critically ill patients, but clinical evidence to help aid the critical care clinician make decisions on whether to transfuse or not is at present limited. Despite the limited evidence, it appears FP is administered not infrequently in the absence of bleeding or with no required procedure when the international normalized ratio (INR) is essentially normal (<1.5) or only mildly deranged (<2.5). The study by Stanworth and colleagues in a recent issue of Critical Care raises awareness of FP transfusion use in the critically ill, should prompt a consideration of curbing its use when it is not clearly appropriate, and illustrates the need for future high quality evidence to guide FP use in the critically ill when the risk:benefit ratio is less clear.

Atypical Respiratory Distress and Transient Decrease in Absolute Neutrophils Associated With Fresh Frozen Plasma Transfusion: Table 1

Background: Transfusion-related acute lung injury (TRALI) is a clinical diagnosis of exclusion to explain acute respiratory distress following a transfusion. Post-transfusion decrease in absolute neutrophils can increase clinical suspicion for this entity. Case Report: Acute respiratory distress requiring intubation occurred following the transfusion of 1 unit of fresh frozen plasma (FFP) to reverse Coumadin in a 65-yearold male. Radiographs were negative for pulmonary infiltrates, and there were no electrocardiography (EKG) changes or clinical indications of volume overload with the clinical assessment being respiratory distress related to transfusion. Sequential complete blood counts showed transient 27-hour decrease in absolute neutrophils and weak reacting neutrophil antibodies in the never transfused male donor. Conclusion: Acute respiratory distress with no bilateral pulmonary infiltrates differentiates this case from TRALI. A male donor with no history of transfusions (not traditionally considered a TRALI risk) was found to have neutrophil antibodies. We therefore suggest that physicians consider (1) investigating cases not meeting full TRALI criteria and (2) testing donors with no risk for human leukocyte antigen (HLA)/neutrophil antibodies.

Clinical Analysis of 159 Times Acute Transfusion Reaction in Single Center.

Abstract 4196 ObjectiveRetrospective analysis of acute transfusion reactions occurred in our hospital in recent years. MethodsInvestigate all hospitalized patients who transfused various blood components from November 2006 to July 2009. ResultsDuring study period, there were 27,672 times transfusion with 80,112 units various blood components, mainly red blood cells(RBCs), frozen plasma(FP) and leukocyte-depleted platelets(PLTs). Acute transfusion reactions occured in 143 patients of 159 times transfusion, including febrile nonhemolytic transfusion reactions(FNHTR), allergic transfusion reactions(ATR), transfusion-related acute lung injury(TRALI), transfusion-associated circulatory overload(TACO) and hemorrhagic tendency. The 143 enrolled patients, 87male and 56female, were between the age of 16 and 94. The incidence rate of acute transfusion reaction was 0.57%, FNHTR and ATR accounted for 96.23%. Of all blood components, the incidence rates of acute reaction were 0.35%, 0.50% and 1.82% respectively in RBCs, FP and PLTs transfusions. In 159 times of acute transfusion reactions, the constituent ratios of 0∼3 times and more than 3 times transfusion were 23.27%, 18.87%, 7.55%, 4.40% and 45.91%, respectively. ConclusionMost of acute transfusion reactions were FNHTR and ATR. The highest incidence rate was in platelets transfusion, and the most constituent ratio was in patients who have received more than 3 times transfusion. Disclosures:No relevant conflicts of interest to declare.