Hemoglobin Threshold Research Articles

Preoperative risk assessment and optimization integrating surgical and anesthetic principles and practices: a national survey for internists

BackgroundThe integration of procedure-specific risks into preoperative patient assessment and optimization are crucial aspects of perioperative care. However, data on internists’ knowledge of surgical and anesthetic principles and practices are limited. We thus sought to identify internists’ knowledge gaps in terms of surgical- and anesthetic-specific risk factors and characteristics.MethodsAn open and voluntary e-survey was conducted via LimeSurvey between April and July 2021 to evaluate Canadian internists’ knowledge of surgical and anesthetic principles and practices. The survey included the perceived importance and knowledge of several key surgical and anesthetic aspects, such as surgery duration, procedure-specific cardiac risk, bleeding risk, and thrombotic risk. It also assessed pre- and post-survey self-reported confidence levels in one’s knowledge of these characteristics. Finally, we investigated how internists optimize some of the preoperative risks.ResultsA total of 173 Canadian internists opened the survey link, and 121 completed it (completion rate 70%). While the majority of respondents considered surgical and anesthetic principles and practices as important, most identified knowledge gaps. Participants generally estimated surgery duration and procedure-specific cardiac risk adequately. However, they tended to underestimate procedure-specific bleeding risk for general (58%) and orthopedic (76%) surgeries and to overestimate procedure-specific thrombotic risk for vascular (63%) and genitourinary (60%) surgeries. Furthermore, there is a lack of consensus regarding the appropriate hemoglobin A1c target and 0% of respondents reported using the guideline-suggested hemoglobin threshold for investigation and intervention.ConclusionsOverall, our findings identify significant knowledge gaps among Canadian internists in preoperative assessment of procedure-specific risk factors and can be used to inform both the development of educational initiatives and future research to improve the quality of preoperative patient care.

ACUTE MYOCARDIAL INJURY AFTER SURGICAL LUNG RESECTION: INCIDENCE, CLINICAL FEATURES, PREDICTORS

HighlightsAcute perioperative myocardial injury develops in 38.5% of patients with non – small cell lung cancer and is associated with the ThRCRI major cardiac events risk index, preoperative hemoglobin level and postoperative heart rate. Aim. To determine the incidence and predictors of acute myocardial injury after surgical treatment of patients with non – small cell lung cancer (NSCLC).Methods. The study included 104 men aged 63.0 [58–67] years who underwent lung resection for NSCLC. Blood levels of cardiac troponin I (cTnI) were determined before and 24 and 48 hours after surgery. Myocardial injury after noncardiac surgery (MINS) was diagnosed when postoperative cTnI increased > 99th percentile of the upper reference limit. Two patients with elevated cTnI of non-ischemic origin were excluded from the analysis. In groups with and without MINS, clinical parameters were compared and their relationships with the MINS development were assessed using univariate regression. Multivariate logistic regression analysis was performed to identify independent MINS predictors. ROC curves were constructed and threshold values of quantitative variables associated with the study outcome were determined.Results. MINS was diagnosed in 40 patients (38.5%). In 36 of them, the cTnI increase was asymptomatic. Among patients with MINS, in contrast to the group without MINS, the share of pneumonectomy, heart rate (HR) after surgery and the cardiac events risk index ThRCRI were higher, as well as hemoglobin level before surgery was lower. Using multiple logistic regression, a combination of factors that provides the greatest accuracy in predicting MINS was identified: ThRCRI index ≥ 1 (adjusted odds ratio (OR) 5.85, 95% confidence interval [1.41–24.28]), hemoglobin before surgery (OR 0.68 [0.5–0.91] for every 10 g/L), HR after surgery (OR 1.99 [1.26–3.13] for every 10 min–1). Threshold levels were established for hemoglobin before surgery (135 g/L), below which the OR for MINS was 2.54 [1.12–5.75], and postoperative HR (88 min–1), above which the OR for MINS was 2.64 [1.16–5.99].Conclusion. The incidence of acute myocardial injury after NSCLC surgery is 38.5%. In 90% of cases the MINS was asymptomatic. A mathematical model was created and following independent predictors of MINS were established: ThRCRI index ≥ 1, hemoglobin level before and heart rate after the surgery. At a threshold hemoglobin value < 135 g/L and HR>88 min–1, the risk of MINS increases significantly.

Should We Regularly Assess Hemoglobin Levels Following Elective Total Knee Arthroplasty, with the Administration of TXA and Without the Usage Tourniquet? An Observational Study from a Single Center.

Background and Objectives: The aim of this study was to test whether there is a necessity for routine postoperative laboratory testing in patients undergoing primary elective unilateral total knee arthroplasty (TKA), with the administration of Tranexamic Acid (TXA) and without the use of tourniquet. Materials and Methods: This observational, retrospective cohort study was conducted at Meir Medical Center. The data were collected in 2018-2022. Patients were collected in a consecutive manner. There were no exclusion criteria for this study. The inclusion criteria were individuals who underwent elective TKA due to end-stage osteoarthritis (OA). We conducted a multivariable logistic regression analysis to determine the factors associated with postoperative hemoglobin (PoOHb) < 9 g/dL and the optimal cutoff to detect those patients postoperatively. Results: A total of 271 patients were included. The mean preoperative hemoglobin (PrOHb) was 13.02 ± 1.42 g/dL, and the mean PoOHb was 11.5 ± 1.34 g/dL. The mean decrease in Hbg levels following surgery was 1.52 ± 0.91 g/dL. In all, 271 patients had a PoOHb level ≥ 9 g/dL or above. A total of 16 patients received packed red blood cells following surgery. Patients with PoOHb < 9 g/dL had a significantly lower PrOHbg. In the current study, all 11 patients who had PoOHb < 9, 10 (90.9%) had PrOHb ≤ 1011.95 55 g/dL, compared to 25 (49.6%) of the 260 patients who had PoOHb ≥ 9. The odds ratio for having PrOHb ≤ 10.9511.55 g/dL if PoOHb < 9 g/dL was 206.6710.4 (95% CI 24.427.164 to 1749.01415.97). A cut-off of 11.2510.25 would have offered a sensitivity of 99% (specificity 93.5%). Conclusions: In conclusion, this study supports using selective post-TKR Hgb monitoring rather than adhering to routine practice. An association between postoperative anemia and the need for blood transfusion was found only when the preoperative baseline hemoglobin threshold was less than 10.95 g/dL.

Red Blood Cell Transfusion Practices.

Opportunities to improve transfusion safety occur at lower hemoglobin (Hgb) thresholds and single-unit transfusions. Efforts to improve compliance with transfusion guidelines and single-unit transfusion practices reduce transfusions and lead to improved outcomes. To evaluate demographic and practice characteristics associated with lower Hgb thresholds and single red blood cell (RBC) unit transfusion practices. This study used the College of American Pathologists (CAP) Q-Probes format with the recent 2020 and 2017 surveys of participating institutions. High rates of transfusion review and compliance were observed with institutions reporting RBC transfusions meeting institutional guidelines. CAP inspection participants and those with a formal policy to encourage single-unit transfusions showed a trend toward greater compliance. Comparison of 2020 and 2017 survey results showed favorable downward trends in the Hgb threshold for transfusion compliance review and pretransfusion and posttransfusion Hgb values. Institutions reporting initiatives to decrease transfusions, teaching hospitals, and those with updated guidelines in alignment with recent literature reported lower pretransfusion Hgb levels in both studies. The 2020 study showed greater single-unit transfusion use among hospitals with patient blood management programs, larger institutions, and those training pathology residents. Single-unit transfusion rates varied by hospital service, with highest rates reported within hematology/oncology (99 of 138 [71.7%]), intensive care (147 of 215 [68.4%]), and medicine (419 of 666 [62.9%]) services. Transfusion practice improvement programs to decrease RBC transfusions include the use of single-unit transfusions and lower institutional pretransfusion Hgb thresholds. Opportunities to lower transfusion thresholds and increase single-unit transfusions exist in surgical and obstetrics services.

Childhood Langerhans cell histiocytosis hematological involvement: severity associated with BRAFV600E loads

AbstractHematological involvement (HI) is one of the life-threatening risk organs (ROs) in Langerhans cell histiocytosis (LCH). Lahey criteria have defined HI since 1975 as hemoglobin <10 g/dL, platelets <100 G/L, leukopenia (white blood cell count <4 G/L), and/or neutrophils <1.5 G/L. Among the 2313 patients aged <18 years enrolled in the French National Histiocytosis Registry (1983-2023), 331 developed HI (median age at diagnosis, 1 year); median follow-up lasted 8.1 years. Bone marrow aspirate smears and biopsies may show reactive histiocytes, hemophagocytosis, or myelofibrosis but never confirm the diagnosis. Fifty-eight patients (17%) developed macrophage-activation syndrome, sometimes related to acute Epstein-Barr virus or cytomegalovirus infection, sometimes months before typical LCH manifestations appeared. Hemoglobin and platelet thresholds for initiating transfusion(s) appear to accurately distinguish 2 groups: mild HI (MHI; >7 g/dL and >20 G/L, respectively) and severe HI (SHI; ≤7 g/dL and ≤20 G/L). Each entity has different organ involvements, laboratory parameters, mutational status, blood BRAFV600E loads, drug sensitivities, and outcomes (MHI and SHI 10-year survival rates, 98% and 73%, respectively). Since 1998, mortality first declined with combination cladribine-cytarabine therapy and then with MAPK inhibitors since 2014. Forty-one patients (12%) developed neurodegenerative complications that have emerged as a risk for long-term survivors. These results suggest limiting the HI-RO definition to SHI, because it encompasses almost all medical complications of LCH. Future clinical trials might demonstrate that targeted therapy approaches would be better adapted for these patients, whereas MHI can be managed with classic therapies.

Effect of four hemoglobin transfusion threshold strategies in patients with acute myocardial infarction and anemia: a target trial emulation using MINT trial data

Abstract Background The hemoglobin (Hgb) threshold at which red blood cell transfusion affords greatest benefit, without increasing transfusion-associated risks, is uncertain for patients with acute myocardial infarction (MI). The Myocardial Ischemia and Transfusion (MINT) trial recently showed a restrictive transfusion strategy (Hgb threshold &amp;lt;7-8g/dL) resulted in a 15% increased risk of 30-day all-cause death or recurrent MI (death/MI) compared with a liberal strategy (Hgb threshold &amp;lt;10g/dL) in 3,504 adults with acute MI and anemia. However, the transfusion effect at different Hgb thresholds remains uncertain. Purpose To better understand the gradient of effects from Hgb threshold transfusion triggers between 7g/dL and 10g/dL. We estimated the effects of four Hgb transfusion thresholds on 30-day death/MI and death in patients with acute MI and anemia. Methods We used data from the MINT trial and applied an innovative causal inference method, target trial emulation, to assess four Hgb thresholds. We emulated a hypothetical, 4-arm target trial of &amp;lt;10g/dL, &amp;lt;9g/dL, &amp;lt;8g/dL, and &amp;lt;7g/dL transfusion strategies in adults with acute MI and Hgb &amp;lt;10g/dL using a "cloning" procedure. The target trial protocol closely mirrored that of the MINT trial. We conducted a per-protocol analysis of the emulated target trial using censoring and inverse probability (IP) weighting; we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) by fitting pooled logistic regression models with a time-dependent intercept for time free of the outcomes. We estimated IP weighted Kaplan-Meier cumulative incidence curves under each strategy for 30-day outcomes. Results Of the MINT trial participants, 3,492 (99.7%) met eligibility criteria for the hypothetical target trial of four transfusion strategies. The unadjusted rate of 30-day death/MI was lowest in the &amp;lt;10g/dL strategy and highest in the &amp;lt;9g/dL strategy, and the rate of transfusions decreased monotonically as Hgb thresholds decreased. Relative to the &amp;lt;10g/dL strategy, the estimated HRs (95% CI) from the IP weighted model of 30-day death/MI were 1.07 (0.77-1.50) for the &amp;lt;9g/dL strategy, 1.14 (0.84-1.55) for the &amp;lt;8g/dL strategy, and 1.44 (0.99-2.09) for the &amp;lt;7g/dL strategy (Figure). A log-linear estimate over strategy thresholds between 7-10g/dL estimated a 1.12 (95% CI 1.00-1.27) times greater average risk of death/MI and a 1.12 (95% CI 0.92, 1.37) times greater average risk of death over 30 days for each 1g/dL decrease in the Hgb threshold. The IP weighted cumulative incidence curves showed similar increase in risk of death/MI as transfusion thresholds decreased throughout 30 days post-randomization. Conclusions Relative to a &amp;lt;10g/dL transfusion strategy, we estimated a progressively greater risk of 30-day death/MI as transfusion Hgb thresholds decreased within the range of 7-10g/dL. Targeting a Hgb concentration of 10g/dL in patients with a recent acute MI may avoid serious risks associated with anemia.Hazard ratios for 30-day death/MI

Effects of restrictive vs liberal transfusion strategies on mortality in patients with acute myocardial infarction and anemia: The 6-month follow up primary results of the MINT trial

Abstract Background The Myocardial Ischemia and Transfusion (MINT) trial identified a statistically non-significant increase in risk of 30-day death or myocardial infarction (MI) (primary endpoint) and all-cause death and a statistically significant increase in cardiac death in patients with an acute MI and anemia assigned to a restrictive transfusion strategy compared to a liberal transfusion strategy. Purpose To determine the effect of a restrictive versus a liberal transfusion strategy on all-cause and cause-specific death 6-months post-randomization (secondary endpoint). Methods The MINT trial randomized 3,504 patients with MI and hemoglobin &amp;lt;10 g/dL to a restrictive (hemoglobin threshold of 7 or 8 g/dL) or liberal (hemoglobin threshold of &amp;lt;10 g/dL) transfusion strategy implemented during the index hospitalization. Sites contacted patients at 30-days and 6-months post-randomization and recorded patient vital status, date of death, and site-reported cause of death (categorized as cardiac, non-cardiac, or unknown). A competing risk analysis (cumulative incidence estimation and Fine-Gray models) was conducted to estimate the effect of transfusion strategy on all-cause and cause-specific death. Results Patients were enrolled from 6 countries between 2017 and 2023; average age was 72 years, and 46% were female. Vital status at 6-months was obtained for 3419 (97.6%) randomized patients (restrictive: 98.1%; liberal: 97.0%); 2,690 (76.8%) patients were alive and 729 (20.8%) had died. At 6-months, all-cause death occurred in 376 patients in the restrictive arm (21.7%) and 353 in the liberal arm (20.5%), hazard ratio [HR]: 1.07, 95% CI: 0.93–1.24. Compared to the liberal arm, a greater proportion of deaths in the restrictive arm were cardiac (41.8% vs. 29.8%). The risk of cardiac death was significantly higher in patients in the restrictive arm (9.0% vs. 6.1%, HR: 1.52; 95% CI: 1.19–1.94) whereas risk of non-cardiac death (HR: 0.87; 95% CI: 0.70–1.08) and unknown cause of death (HR: 0.88; 95% CI: 0.64–1.21) did not differ between the restrictive and the liberal arms. Conclusions In patients with acute MI and anemia, the 6-month incidence of all-cause death did not differ with a restrictive versus a liberal transfusion strategy. However, the numerically higher rate of all-cause mortality, seen with the restrictive strategy at 30-days, persisted through 6-months and was driven by cardiac causes. The long-term findings from the MINT trial suggest that a restrictive transfusion strategy may be harmful for patients with MI and anemia.

Tolerance of Anemia: Autologous Stem Cell Transplantation Among Bloodless Medicine Patients Can Be Safely Conducted At Lower Hemoglobin Thresholds

Tolerance of Anemia: Autologous Stem Cell Transplantation Among Bloodless Medicine Patients Can Be Safely Conducted At Lower Hemoglobin Thresholds

Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury

Blood transfusions are commonly administered to patients with acute brain injury. The optimal hemoglobin transfusion threshold is uncertain in this patient population. To assess the impact on neurological outcome of 2 different hemoglobin thresholds to guide red blood cell transfusions in patients with acute brain injury. Multicenter, phase 3, parallel-group, investigator-initiated, pragmatic, open-label randomized clinical trial conducted in 72 intensive care units across 22 countries. Eligible patients had traumatic brain injury, aneurysmal subarachnoid hemorrhage, or intracerebral hemorrhage; hemoglobin values below 9 g/dL within the first 10 days after injury; and an expected intensive care unit stay of at least 72 hours. Enrollment occurred between September 1, 2017, and December 31, 2022. The last day of follow-up was June 30, 2023. Eight hundred fifty patients were randomly assigned to undergo a liberal (transfusion triggered by hemoglobin <9 g/dL; n = 408) or a restrictive (transfusion triggered by hemoglobin <7 g/dL; n = 442) transfusion strategy over a 28-day period. The primary outcome was occurrence of an unfavorable neurological outcome, defined as a Glasgow Outcome Scale Extended score between 1 and 5, at 180 days following randomization. There were 14 prespecified serious adverse events, including occurrence of cerebral ischemia after randomization. Among 820 patients who completed the trial (mean age, 51 years; 376 [45.9%] women), 806 had available data on the primary outcome, 393 in the liberal strategy group and 413 in the restrictive strategy group. The liberal strategy group received a median of 2 (IQR, 1-3) units of blood, and the restrictive strategy group received a median of 0 (IQR, 0-1) units of blood, with an absolute mean difference of 1.0 unit (95% CI, 0.87-1.12 units). At 180 days after randomization, 246 patients (62.6%) in the liberal strategy group had an unfavorable neurological outcome compared with 300 patients (72.6%) in the restrictive strategy group (absolute difference, -10.0% [95% CI, -16.5% to -3.6%]; adjusted relative risk, 0.86 [95% CI, 0.79-0.94]; P = .002). The effect of the transfusion thresholds on neurological outcome at 180 days was consistent across prespecified subgroups. In the liberal strategy group, 35 (8.8%) of 397 patients had at least 1 cerebral ischemic event compared with 57 (13.5%) of 423 in the restrictive strategy group (relative risk, 0.65 [95% CI, 0.44-0.97]). Patients with acute brain injury and anemia randomized to a liberal transfusion strategy were less likely to have an unfavorable neurological outcome than those randomized to a restrictive strategy. ClinicalTrials.gov Identifier: NCT02968654.

Reducing unnecessary outpatient group and screen testing at a regional cancer center.

Unnecessary group and screens (G&S) can lead to unnecessary antibody investigations, use of technologist time, and laboratory resources. A baseline audit at our institution identified that 25% of G&S from the cancer center were unnecessary. We aimed to reduce the ratio of monthly G&S to CBC samples processed from the cancer center by 10% (from 0.034 to 0.031) by January 2024. This represents an interrupted time series design from November 2022 to January 2024. Using Plan Do Study Act (PDSA) cycles, we aimed to increase the use of an existing reflex testing system, termed "do not test." When this option is selected, the blood bank will only process the G&S sample if specific CBC criteria are met (e.g., hemoglobin <9.0 g/dL). Educational sessions increased awareness of this feature and sought feedback from end-users on its usability. With feedback, the design was updated to include a modifiable hemoglobin threshold for G&S testing, automatic re-selection of the "do not test" feature for future G&S orders, and aesthetic changes to make the feature more visible. The percentage of samples with "do not test" selected increased from 7.2% to 63.0% (p < .0001) and the ratio of G&S to CBC specimens improved from 0.034 to 0.028, exceeding the target of 0.031. We noted an improvement in the appropriateness of G&S orders from 75% at baseline (n = 20) to 97.5% (n = 80) post intervention (p = .003). We describe an effective strategy to improve G&S utilization at our institution's cancer center using a reflex testing system.

Exploring the Intersection of Blood Transfusion and Same-Day Computed Tomography Imaging: An Overview of Clinical Risks and Practices.

The use of transfusions, whether involving whole blood or specific blood components, is essential for managing various clinical conditions. Many cases are acute, often requiring post-transfusion imaging evaluation. While there is no absolute contraindication for chest imaging following blood transfusion, it should be approached cautiously. We conducted a comprehensive search across multiple databases and registries. Research studies were limited to full-text original articles, reviews, and case reports published in English, involved human subjects, and focused on the interplay between blood transfusions and contrast-enhanced imaging. Scientific analyses were excluded if they did not focus on transfusion practices in the context of imaging or failed to address issues such as hemoglobin thresholds, transfusion reactions, or the clinical implications of contrast agents. Our research fills this gap by emphasizing the need for a cautious, multidisciplinary approach to post-transfusion computed tomography (CT) scans, especially in the presence of contrast agents. This study calls for increased awareness of the heightened risk of complications, such as autoimmune hemolysis, when both procedures are performed together. New insights from our research recommend individualized assessments and close patient monitoring when combining these interventions. Nevertheless, patients need to be hemodynamically and clinically stable before undergoing CT. Discussions. Symptoms that develop within the first 24 h post-transfusion are classified as secondary post-transfusion reactions unless proven otherwise. The prevalence of side effects from same-day CT scans and blood transfusions is challenging to quantify, as few studies focus on this combination. Transfusions and contrast-enhanced CT scans share overlapping adverse reactions and carry significant risks. Acute hemolytic red blood cell transfusion reactions are among the most frequent side effects, with a prevalence of 1:12,000-38,000. Conclusion. Our study contributes new insights to the literature by filling the gap concerning the interplay between transfusions and contrast media, paving the way for more informed clinical protocols to enhance patient safety.

Effect of Four Hemoglobin Transfusion Threshold Strategies in Patients With Acute Myocardial Infarction and Anemia : A Target Trial Emulation Using MINT Trial Data.

The optimal hemoglobin threshold to guide red blood cell (RBC) transfusion for patients with acute myocardial infarction (MI) and anemia is uncertain. To estimate the efficacy of 4 individual hemoglobin thresholds (<10 g/dL [<100 g/L], <9 g/dL [<90 g/L], <8 g/dL [<80 g/L], and <7 g/dL [<70 g/L]) to guide transfusion in patients with acute MI and anemia. Prespecified secondary analysis of the MINT (Myocardial Ischemia and Transfusion) trial using target trial emulation methods. (ClinicalTrials.gov: NCT02981407). 144 clinical sites in 6 countries. 3492 MINT trial participants with acute MI and a hemoglobin level below 10 g/dL. Four transfusion strategies to maintain patients' hemoglobin concentrations at or above thresholds of 10, 9, 8, or 7 g/dL. Protocol exceptions were permitted for specified adverse clinical events. Data from the MINT trial were leveraged to emulate 4 transfusion strategies and estimate per protocol effects on the composite outcome of 30-day death or recurrent MI (death/MI) and 30-day death using inverse probability weighting. The 30-day risk for death/MI was 14.8% (95% CI, 11.8% to 18.4%) for a <10-g/dL strategy, 15.1% (CI, 11.7% to 18.2%) for a <9-g/dL strategy, 15.9% (CI, 12.4% to 19.0%) for a <8-g/dL strategy, and 18.3% (CI, 14.6% to 22.0%) for a <7-g/dL strategy. Absolute risk differences and risk ratios relative to the <10-g/dL strategy for 30-day death/MI increased as thresholds decreased, although 95% CIs were wide. Findings were similar and imprecise for 30-day death. Unmeasured confounding may have persisted despite adjustment. The 30-day risks for death/MI and death among patients with acute MI and anemia seem to increase progressively with lower hemoglobin concentration thresholds for transfusion. However, the imprecision around estimates from this target trial analysis precludes definitive conclusions about individual hemoglobin thresholds. National Heart, Lung, and Blood Institute.

Comparison of liberal versus restrictive transfusion strategies after hip surgery in patients with coronary artery disease: a post hoc analysis of the FOCUS trial

BackgroundThere are no clear recommendations for optimal transfusion thresholds for patients with coronary artery disease who undergo noncardiac surgery. By comparing restrictive and liberal transfusion strategies for coronary artery disease combined with hip surgery, this study hopes to provide recommendations for transfusion strategies in this special population.MethodsA total of 805 patients from the FOCUS trial (Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair) with coronary artery disease combined with hip surgery were divided into two groups based on transfusion thresholds: restricted transfusion (a hemoglobin level of 8 g/deciliter) and liberal transfusion (a hemoglobin threshold of 10 g/deciliter). The primary outcome of this study was a composite endpoint including in-hospital death, myocardial infarction, unstable angina, and acute heart failure. The secondary endpoints included other in-hospital adverse events and 30- and 60-day follow-up events. Analyses were performed by intention to treat.ResultsExcept for the proportion of congestive heart failure patients, the baseline levels of the two groups were comparable. The median number of transfusion units in the liberal transfusion group was 2 units, and the median transfusion volume in the restricted transfusion group was 0 units. The primary outcome was not significantly different between the two groups (9.2% vs. 9.4%, p = 0.91). The incidence of in-hospital myocardial infarction events was lower in the liberal transfusion group than in the restricted transfusion group (3.2% vs. 6.2%) (OR = 0.51, P = 0.048). The remaining in-hospital endpoint events, except for myocardial infarction, were not significantly different between the two groups. The 30-day and 60-day endpoints of death and inability to walk independently were not significantly different between the two groups, with ORs (95% CI) of 1.00 (0.75–1.31) and 1.06 (0.80–1.41), respectively. We also found no interaction between transfusion strategies and factors such as age, sex, or multiple underlying comorbidities at the 60-day follow-up.ConclusionsThere was no significant difference in the in-hospital, 30-day or 60-day outcome endpoints between the two groups. However, this study demonstrated that a liberal transfusion strategy tends to reduce the incidence of in-hospital myocardial infarction events in patients with coronary artery disease combined with hip surgery compared to a restrictive transfusion strategy. More high-quality studies should be designed to investigate the optimal transfusion threshold in patients with coronary artery disease treated without cardiac surgery.

A Survey on the Management of Patients with Severe Traumatic Brain Injury During Pregnancy: The MAMA Study.

Trauma, including traumatic brain injury (TBI), is the leading cause of nonobstetric maternal mortality during pregnancy. Few data are available regarding the optimal management of pregnant patients with TBI, leading to a lack of dedicated guidelines. We performed an international survey to examine the management of severe TBI in pregnant patients, focusing on monitoring, therapy, and intensive care practices. This survey, endorsed by the World Society of Emergency Surgery, was composed of a questionnaire with 79 items divided into four sections: (1) general information (items 1-7), (2) management of the maternal-fetal unit (items 8-43), (3) management of intracranial hypertension (items 44-76), and (4) specific considerations (items 77-79). One hundred and twenty-two physicians from 110 centers in 35 countries responded. The main findings related to TBI care in pregnant patients included the following: (1) a lack of availability of a specific TBI protocol in pregnancy; (2) an increase in the utilization of magnetic resonance imaging as the primary neuroimaging tool; (3) higher hemoglobin thresholds for transfusion; and (4) a lower utilization of therapeutic hypothermia, neuromuscular blocking agents, and barbiturate coma. We also report large variability in the timing of cesarean section in pregnant patients with TBI (≥ 23weeks of gestation) needing an emergency craniotomy (simultaneously 23% vs. later cesarean section 50.8%). Great variability in the management of pregnant patients with severe TBI was identified worldwide from the results of our survey. These findings, highlighting the lack of robust evidence on this topic, will be helpful to stimulate future investigations and to promote educational efforts on this difficult scenario.

Myoglobin saturation as an intracellular indicator for transfusion need in oncology patients.

This study aims to demonstrate the potential of myoglobin saturation as an indicator of oxygen delivery adequacy to help determine the need for red cell transfusion. Modern blood management approaches have been established to optimise use of red blood cells for transfusions in patients with anaemia. However, most approaches make recommendations to transfuse based on haemoglobin or haematocrit levels and do not directly address adequacy of oxygen delivery. Intracellular oxygen determined by myoglobin saturation directly measures oxygen delivery at the tissue level. A custom built spectrometer system with an optical fibre probe was used in this pilot study to measure muscle cell myoglobin saturation noninvasively from the first digital interosseous muscles in patients undergoing planned red blood cell transfusion. Patients were recruited from both the in-patient and out-patient oncology service at a major university medical centre. Measurements were made immediately before, immediately after, and 24 h following transfusion. Clinical data and tissue oxygen values from the Somanetics INVOS system were also collected. Myoglobin saturation, and thus cellular oxygen increased in some, but not all patients receiving a transfusion, and was most pronounced in patients who initially had low myoglobin saturation compared with the group as a whole. Clinical decisions to transfuse based on haemoglobin or haematocrit thresholds alone are likely insufficient to optimise use of red blood cell transfusions. The combination of haemoglobin or haematocrit with myoglobin saturation may optimally determine who will benefit physiologically from a transfusion.

Proposals for revised International Working Group–European LeukemiaNet criteria for anemia response in myelofibrosis

AbstractWith emerging new drugs in myelofibrosis (MF), a robust and harmonized framework for defining the severity of anemia and response to treatment will enhance clinical investigation and facilitate interstudy comparisons. Accordingly, the lead authors on the 2013 edition of the International Working Group–European LeukemiaNet (IWG-ELN) response criteria in MF were summoned to revise their document with the intent to (1) account for gender-specific differences in determining hemoglobin levels for eligibility criteria; (2) revise the definition of transfusion-dependent anemia (TDA) based on current restrictive transfusion practices; and (3) provide a structurally simple and easy to apply response criteria that are sensitive enough to detect efficacy signals (minor response) and also account for major responses. The initial draft of the 2024 IWG-ELN proposed criteria was subsequently circulated around a wider group of international experts and their feedback incorporated. The proposed articles include new definitions for TDA (≥3 units in the 12 weeks before study enrollment) and hemoglobin thresholds for eligibility criteria (<10 g/dL for women and <11 g/dL for men). The revised document also provides separate (TDA vs non-TDA) and graded (major vs minor response) response criteria while preserving the requirement for a 12-week period of screening and observation on treatment.

Are outcomes of locally advanced cervical cancer associated with prebrachytherapy hemoglobin values and transfusion practice? An observational study comparing two large academic centres with divergent clinical guidelines

Anemia is common in locally advanced cervical cancer. Clinical practice varies greatly for management of anemia during brachytherapy, with some centres providing red cell transfusion to increase hemoglobin levels above 100 g/L. This is a retrospective observational cohort study of adult patients with cervical cancer treated with brachytherapy at two academic hospitals. One hospital (H1) uses a liberal transfusion strategy with hemoglobin threshold of 100 g/L during brachytherapy and the other uses a restrictive target of 70 g/L (H2). Overall, 336 patients met inclusion criteria (H1: 150 patients, H2: 186 patients). 11 patients were excluded (2 at H1, 9 at H2). Demographics at both sites were comparable, except for cancer stage and smoking history. External beam radiation and chemotherapy provided was similar. Hemoglobin values were compared at baseline (within 4 weeks of oncology consult), and prior to the first and second brachytherapy treatments. In total, 101red blood cell (RBC) units were transfused to patients at H1 and 19 units to patients at H2. Patients were followed for a median of 37.0 months (0.6-80.5) at H1, and 33.3 months (1.6-82.0) at H2. There was no significant difference in progression-free or overall survival. Multivariable logistic regression analysis showed that FIGO stage was a predictor for both overall survival and cancer progression. Age, tumor size, chemotherapy, and hemoglobin levels were not predictors of disease progression or mortality. The practice of liberal transfusion should be re-evaluated in the absence of robust data to support its use.

The choice of blood transfusion strategy in severe traumatic brain injury

Traumatic brain injury (TBI) remains one of the leading causes of long-term disability, especially among young and middle-aged people. One of the main directions of treatment for patients with TBI is to prevent the development of secondary brain damage due to systemic dysfunction. Anemia occupies an important place among them. Anemia is considered a marker of illness severity in critically ill patients and is included in the list of parameters for risk prediction in intensive care units. However, the relationship between anemia and adverse outcomes in patients with TBI is controversial. Aim. The purpose of the work is to analyze the effect of anemia on the course of severe TBI, to determine the position of anemia in the pathophysiological mechanisms of brain damage, the development of blood transfusion-associated complications, to evaluate different blood transfusion strategies (liberal and restrictive) and their impact on treatment results, taking into account individual tolerance to anemia. Studies suggest that the restrictive transfusion strategy could be useful in reducing complications and length of hospital stay. However, the lack of clear evidence for optimal hemoglobin levels as a trigger to initiate blood transfusions reinforces the need for further clinical studies. The use of multimodal neuromonitoring allows to evaluate the latest approaches to assessing individual hemoglobin thresholds. These methods could help in identifying patients at increased risk of complications and determining optimal strategies to manage anemia. Conclusions. The problem of tolerance to anemia in patients with severe TBI remains a controversial topic, and determining hemoglobin thresholds for blood transfusion in this group of patients requires further studies, special attention should therefore be paid to an individual approach to resolving the issue of red blood cell transfusion, in particular, integrating clinical status of a patient and concomitant pathology. The risk of possible brain damage worsening associated with anemia due to deterioration of cerebral oxygenation should always be weighed against the risk of developing transfusion-associated complications.

Association of RBC Transfusion Thresholds and Outcomes in Medical Patients With Acute Respiratory Failure Supported With Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Cohort Study

The hemoglobin value to trigger RBC transfusion for patients receiving venovenous extracorporeal membrane oxygenation (ECMO) is controversial. Previous guidelines recommended transfusing to a normal hemoglobin level, but recent studies suggest that more RBC transfusions are associated with increased adverse outcomes. Is implementation of different institutional RBC transfusion thresholds for patients receiving venovenous ECMO associated with changes in RBC use and patient outcomes? This single-center retrospective study of patients receiving venovenous ECMO used segmented regression to test associations between implementation of institutional transfusion thresholds and trends in RBC use. Associations with secondary outcomes, including in-hospital survival, also were assessed. The study included 229 patients: 91 in the no threshold cohort, 48 in the hemoglobin< 8 g/dL cohort, and 90 in the hemoglobin< 7 g/dL cohort. Despite a decrease in number of RBC units transfused per day of ECMO support after implementation of different thresholds (mean ± SD: 0.6 ± 1.0 in the no threshold cohort, 0.3 ± 0.8 in the hemoglobin< 8 g/dL cohort, and 0.3 ± 1.1 in the hemoglobin< 7 g/dL cohort; P< .001), segmented regression showed no association between implementation of transfusion thresholds and changes in trends in number of RBC units per day of ECMO. We observed an increased hazard of death in the no threshold cohort compared with the hemoglobin< 8 g/dL cohort (adjusted hazard ratio [aHR], 2.08; 95%CI, 1.12-3.88) and in the hemoglobin< 7 g/dL cohort compared with the hemoglobin< 8 g/dL cohort (aHR, 1.93; 95%CI, 1.02-3.62). No difference was found in the hazard of death between the no threshold and hemoglobin< 7 g/dL cohorts (aHR, 1.08; 95%CI, 0.69-1.69). We observed a decrease in number of RBC units per day of ECMO over time, but changes were not associated temporally with implementation of transfusion thresholds. A transfusion threshold of hemoglobin< 8 g/dL was associated with a lower hazard of death, but these findings are limited by study methodology. Further research is needed to investigate optimal RBC transfusion practices for patients supported with venovenous ECMO.

Identification of Data-Driven Preoperative Hemoglobin Strata That Predict the Likelihood of Blood Transfusion and the Risk of Major Complications and Prosthetic Joint Infection After Total Hip Arthroplasty.

Preoperative anemia is an independent risk factor of complications after primary total hip arthroplasty (THA). Currently used hemoglobin thresholds are not developed for risk stratification of arthroplasty patients and do not provide surgery-specific information on postoperative complication risk. Thus, we aimed to calculate THA-specific preoperative hemoglobin strata that observe the likelihood of 90-day blood transfusion and determine whether these strata are associated with increased risk of 90-day complications and 2-year prosthetic joint infection (PJI). A retrospective cohort analysis identified 56,101 patients who underwent primary THA from 2013 to 2022. Using the lowest hemoglobin value for each patient one month before THA, stratum-specific likelihood ratio (SSLR) analysis calculated sex-based hemoglobin strata associated with the likelihood of 90-day postoperative blood transfusion. Propensity score matching was performed. Incidence rates and risk of 90-day major complications and 2-year PJI were observed for each identified preoperative hemoglobin stratum. SSLR analysis identified five male (strata, likelihood ratio [<10.4 g/dL, 12.5; 10.5 to 11.4 g/dL, 8.0; 11.5 to 12.4 g/dL, 2.4; 12.5 to 13.4 g/dL, 1.3; 13.5 to 13.9 g/dL, 0.5]) and five female (<8.9 g/dL, 10.7; 9.0 to 10.9 g/dL, 4.0; 11.0 to 11.4 g/dL, 2.0; 12.0 to 12.9 g/dL, 1.0; 13.0 to 13.4 g/dL, 0.6) preoperative hemoglobin strata associated with varying likelihoods of 90-day blood transfusion after THA. After matching in both male and female cohorts, as the calculated preoperative hemoglobin strata decreased, the relative risk of overall 90-day major complications and 2-year PJI increased incrementally (all P < 0.05). SSLR analysis established THA-specific sex-based preoperative hemoglobin strata that observe the likelihood of 90-day blood transfusion and predict the risk of 90-day medical complications and 2-year PJI. These strata are a first of their kind in THA research. While preoperatively optimizing patients, we recommend using these hemoglobin thresholds to help guide decisions on presurgery anemia optimization and to reduce the need for postoperative blood transfusion. Level III.