Indications For Transfusion Research Articles

Real World Outcomes of Therapeutic Anticoagulation Use in Moderate COVID-19 Infection in Hospitalised Patients

Background For patients hospitalised with moderate COVID-19, the use of therapeutic-dose heparin increases the probability of survival to hospital discharge compared with intermediate or standard prophylactic dose thromboprophylaxis (1-3). However, due to concerns of bleeding, there has been hesitancy to use therapeutic anticoagulation for these patients. Aim To audit the "real world' incidence of bleeding and transfusion requirement in patients receiving therapeutic anticoagulation whilst hospitalised with moderate severity COVID-19 infection. Methods Records from a random sample of patients admitted to a single hospital between September 2021 and January 2022 and who tested positive for COVID-19 were retrospectively audited. Baseline demographics, COVID-19 variant, vaccination status, co-morbidities, concurrent antiplatelet use, haemoglobin, incidence of bleeding and venous thromboembolism, transfusion support, length of stay, and in-hospital mortality data were collected from electronic databases. Hospital approval for the audit was obtained prior to the project's commencement. Results A total of 1304 patients were admitted and tested positive for COVID-19 infection during the study period. Of these, 364 patients were audited. 231 patients had mild infection (63% of those audited), 80 (22%) had moderate, and 53 (15%) had severe. See table 1 for details. Of the 80 patients with moderate severity,45 (12% of those audited) received therapeutic anticoagulation in accordance with the hospital's thromboprophylaxis guideline. Within these 45 patients, none suffered from in hospital bleeding complications. However, 4 (1% of those audited) patients required red cell transfusion, 3 (1% of those audited) of whom required transfusion due to sickle cell crisis management and one for post chemotherapy anaemia. Conclusion This real-world study demonstrates that therapeutic anticoagulation for moderate severity COVID-19 infection is reassuringly not associated with high rates of bleeding. Indications for transfusion in this group was due to other co-morbidities.

Overwhelming Intravascular Hemolysis and Acute Renal Failure in Babesiosis Requiring Erythrocytapheresis

Babesia is an obligate intra-erythrocytic parasite transmitted by a tick called Ixodes scapularis . They invade erythrocytes and can present in various hematologic manifestations that can range from mild anemia to severe pancytopenia, splenic rupture, disseminated intravascular coagulation(DIC) or even hemophagocytic lymphohistocytosis1. They are typically self limiting in immunocompetent hosts, however management in splenectomized patients is complex and requires multidisciplinary care. We present the case of a 60 year old homeless male with a history of splenectomy secondary to a motor vehicle accident 6 years ago who presented to us with severe sepsis. On arrival his systolic blood pressure was in low 90s, tachycardic, tachypneic and saturating 93% on room air. Initial labs were significant for hyponatremia (125), hyperkalemia (5.6), acute renal failure (creatinine 2.18, baseline 0.8-1 and GFR 32, baseline 96-98), hyperuricemia(12.5), hyperphosphatemia(5) with congruent hypocalcemia(7.3).On blood counts hemoglobin(hb) was noted at 9.2 with baseline of 15 with appropriate reticulocytosis, leukocytosis(17.4) with monocytosis(26, normal is less than 11). Other labs include lactate dehydrogenase(LDH) which was elevated five times the normal limit(852) and serum haptoglobin was less than 8 (normal:11-44). He was appropriately fluid resuscitated and started on vancomycin and cefepime by emergency department. Overnight, a critical lab result was received, peripheral smear(pic 1) was showing intraerythrocytic parasites. By next morning, hematology confirmed the presence of Maltese cross on peripheral smear and parasite burden was determined at 20%. We subsequently transitioned the patient to atovaquone 750mg twice daily and IV azithromycin 500 mg daily. Doxycycline 100mg BID was later added by Infectious diseases(ID)to the regimen to empirically cover Lyme disease as both babesia and borrelia share the same tick vector. By day 2 of hospitalization patient was producing less than 0.5ml/kg/hour of urine output with decrease in GFR to 16 and concomitant rise in creatinine to 3.86, hb dropped to 7.8 with with notable rise in LDH(1080). Hematology opined for an urgent exchange transfusion specifically erythrocytapheresis and IR was consulted for a peripherally inserted central catheter insertion for the same. Post exchange transfusion, patient was noted to have improving kidney functions with decrease in parasite burden on serial peripheral smears. His hb remained stable around 10 and GFR improved to 63, at which point he was deemed stable for discharge. ID stepped down therapy to oral azithromycin 500mg daily and atovaquone 750 mg BID and doxycycline for total duration of two weeks at discharge. The indications of exchange transfusion in severe babesiosis are not well established. Erythrocytapheresis is typically considered in patients with severe hemolysis (hb less than 10), parasitemia greater than 10% or organ failure. However we did not find any prospective randomized studies to support this approach. The data to support erythrocytapheresis versus whole blood or plasma exchange is limited at best in immunocompetent patients2,3,4,5 .Though it should be noted that a prompt reduction in parasitemia markedly improves mortality in immunocompromised patient such as ours especially when used adjunctively to antimicrobial therapy 6.

New Areas of Consensus for the Management of Sickle Cell Disease (SCD) in Pregnancy: An International Delphi Panel

Introduction and aim Sickle cell disease (SCD) is an autosomal recessive disorder characterized by a single nucleotide substitution in the beta-globin gene, resulting in the production of hemoglobin (Hb) S, and is the most common hematologic genetic disorder worldwide. As a result of Hb polymerization, oxidative stress and chronic hemolysis, complications occur during pregnancy for women with SCD, impacting both maternal and fetal health. We aimed to identify areas of consensus for the management of pregnancy-related complications in SCD, with a focus on prophylactic transfusion therapy (PTT). Methods A Delphi panel consisting of 13 experts from 4 countries replied to 2 rounds of questions (1 panelist dropped out between the 1st and 2nd survey). The 1st survey (October-November 2021) consisted of open-ended questions, while the 2nd one (April-May 2022, used to identify the degree of consensus or changes in opinion among panelists) was comprised of multiple-choice or closed questions based on the answers from the 1st survey. The thresholds were: <9/12 panelists (<75%) for no consensus, 9-10/12 panelists (75-90%) for consensus, and ≥11/12 panelists (>90%) for strong consensus. The Delphi panel covered topics where no global standardization or little evidence exists to guide management and prevention of maternal complications during pregnancy in SCD. These included antenatal care, hydroxyurea (HU) therapy, transfusion, prevention and treatment of complications, delivery and follow-up, bottlenecks and knowledge gaps. Results The panelists achieved strong consensus in the following areas of management: antenatal care (specifically, that pregnant women with SCD should be followed at least every 4 weeks by a multi-disciplinary team of specialists who would decide on the required tests and treatments), HU (discontinuation ≥3 months before conception; experts would not recommend discontinuation of pregnancy in case of exposure to HU during pregnancy), delivery and follow-up (that a multidisciplinary team should decide on labor induction or elective cesarean section). For the following areas of management, no consensus was achieved: continuation of HU therapy (could be considered during pregnancy/lactation if the risks of stopping HU therapy outweigh the benefits and if the patient understands the risks and agrees with continuing therapy), Hb level targeted prior to delivery, or preferred transfusion modality (simple transfusions versus automated red cell exchange [aRCX]) for a pregnant woman with SCD who was not on PTT during pregnancy but needed to be transfused prior to delivery. The input collected for transfusion (including details on when to recommend PTT) is summarized in the Table. The experts felt that target Hb and hematocrit should be set by clinical experience and would be impacted by the time interval between transfusions and the clinical indication for transfusion. There was no consensus on the most suitable transfusion modality. The experts identified a strong interest to prioritize the use of routine PTT in pregnant women with SCD as an area of research. Conclusion The experts did not achieve uniform consensus to support the standardized use of PTT in pregnant women with SCD. They achieved consensus that PTT should be routinely used in pregnant women with ≥2 acute vaso-occlusive pain episodes in a 4-week period regardless of genotype, with a preference for peripheral venous over central venous access, and the use of aRCX over simple transfusion (target HbS <30%) for the prevention of transfusional iron overload. The experts also achieved a strong consensus that prophylactic red cell exchanges should be used to reduce frequency of acute pain episodes in women taking high-dose opioids daily, and recommended consideration of on-demand transfusions for acute fetal complications. Consensus was not achieved on frequency of prophylactic transfusions, timing of PTT initiation during pregnancy in relation to HU discontinuation, target hematocrit levels, methods for the prevention of alloimmunization (extended red cell phenotyping versus genotyping) and the use of PTT for secondary prevention of fetal complications and pregnancy loss. In general, the areas of non-consensus seemed to correspond to areas with the widest knowledge gaps and lack of evidence, highlighting the need for further research in the use of PTT in pregnant women with SCD. Funding: Terumo Blood and Cell Technologies Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Did Physicians Have a Role to Play in National Blood Crisis?

Background: The pandemic of COVID-19 (Coronavirus disease 2019) impacted the practices of blood product procurement and transfusion in multiple ways, including failed blood donation drives, staffing limitations and low donor turnout. On January 1, 2022, the American Red Cross declared the worst national blood crisis in over a decade. The effect was most notable on the community medical centers with limited resources in securing products for blood transfusion. However, evidence is lacking for the usage of blood products in a community teaching hospital during this pandemic. Study Design and Methods: We aimed to contrast the adherence to restrictive transfusion practice in the COVID era with the pre-COVID era irrespective of COVID-19 diagnosis. We performed a retrospective observational study involving packed red blood cell (PRBC) transfusions in patients from June 2020 to August 2020 (COVID era) and September 2019 to November 2019 (pre-COVID era). Patients with hemoglobinopathies were excluded. A detailed chart review to include the number of PRBC transfusions, documented indication for transfusion and it was also determined if transfusions met restrictive blood transfusion criteria (as per guidelines from the Association for the Advancement of Blood & Biotherapies (AABB)) (Table 1). Demographic data included age, gender, history of coronary artery disease (CAD) or prior gastrointestinal bleed, use of antiplatelet and anticoagulation, use of deep vein thrombosis prophylaxis inpatient, and diagnosis on admission. Chi-square was applied to test the statistical association between qualitative variables and Unpaired t-test/Mann Whitney U test was applied to test the mean difference of quantitative. The level of significance was set at 5%. Results: A total of 215 patients were screened and 208 met our inclusion criteria. There were 108 PRBC transfusions in the COVID era group and 100 PRBC transfusions in the pre-COVID era group, with equal distribution in both groups for age, sex, ethnicity and prior gastrointestinal bleed. The leading diagnosis on admission in both COVID era and pre-COVID era groups was acute hypoxia (53.7% and 36% p<0.001), followed by gastrointestinal bleeding. Lower proportion of patients receiving transfusion were on anticoagulant or antiplatelet therapy in COVID era group as compared to pre-COVID era (antiplatelet: 6.2% vs 19%, p<0.001 and anticoagulant: 12.1% vs 27%, p<0.001), though COVID era group had lower fraction of patients receiving pharmacological prophylaxis for deep vein thrombosis (DVT) (13.9% vs 29%, p<0.001). There was a higher percentage of transfusions in critical care units in the COVID era group than pre-COVID era group (38.9% vs 22%, p<0.008). Documented indications for transfusions in both groups were hemoglobin < 7 (47.2% vs 43%), acute coronary syndrome (ACS) or history of CAD (12% vs 11%), active bleed (35.2% vs 35%) and down trending hemoglobin (5.6% vs 11%). Restrictive transfusion criteria were met in only 67% vs 79% in COVID era and pre-COVID era transfusion cases respectively (p=0.008). Subgroup analysis of documented indications for transfusion among both groups is displayed in Graph 1. Conclusions: As evident from our results, the COVID era group despite having comparable, if not fewer risk factors associated with blood loss, received blood transfusion with less stringent adherence to restrictive blood transfusion guidelines. COVID pandemic had a significant impact on the landscape of blood transfusion and our study brought to light the physician's role in more liberal use of blood products. Due to a higher number of critical care admissions and the morbidity/mortality during this pandemic, compel physicians to have a more liberal mindset towards blood transfusions. However, given the acute shortage of blood products it is vital that we adhere to restrictive blood transfusion guidelines. In view of the ongoing National Blood Crisis, please visit RedCrossBlood.org or call 1-800-RED CROSS (1-800-733-2767) to donate blood. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Intraoperative methods for assessing blood loss: A review

Massive blood loss that develops during surgery is a common cause of life-threatening conditions and deaths in patients of any age.&#x0D; This study aimed to analyze domestic and foreign publications that present methods for determining the volume of intraoperative blood loss.&#x0D; The literature sources were searched in PubMed, Scopus, Web of Science, MEDLINE, eLibrary, and Russian Science Citation Index databases. The search was conducted in Russian and English using the following keywords: intraoperative blood loss, severity of blood loss, methods for assessing blood loss, direct methods, and indirect methods. The literature review included five articles from PubMed, nine from Scopus, six from Web of Science, two from MEDLINE, six from eLibrary, and four from Russian Science Citation Index.&#x0D; Massive blood loss is understood as a one-time loss according to some authors of 30% and according to others of 50% of the volume of the circulating blood or blood loss equal in volume to 23 mL/kg/min. Risk factors for the development of intraoperative complications such as massive blood loss are, in addition to surgical interventions, the features of surgical intervention, i.e., size of the incision, surgical duration, and anesthesia, which can increase blood loss. The intensity and degree of blood loss are very important in determining the indications for transfusion of blood components, replenishing the volume of circulating blood, and determining indications for intraoperative hemostasis, both medical and surgical. In neonates and young children, the risk of dangerous intraoperative blood loss is associated with anatomical and physiological features, i.e., a small volume of circulating blood and insufficiently mature compensatory mechanisms. In older children, a high risk of massive blood loss is associated with comorbidities, features of hemostasis, and use of drugs that slow down the blood coagulation process.&#x0D; To date, several methods are available for assessing intraoperative blood loss, but only a few are used in routine clinical practice. Each method has advantages and disadvantages. One of the main disadvantages is the complexity of the mechanisms for assessing blood loss, for example, weighing surgical materials or the patient before and after surgery, determining hemoglobin in the liquid after soaking the used surgical materials, and calculating indices using formulas. Most often, the assessment of blood loss is conducted according to the clinical picture (pallor of the skin and mucous membranes, weak pulse, lowering blood pressure, etc.).&#x0D; The results of the literature analysis showed insufficient research on determining the volume of intraoperative blood loss in pediatric practice, as evidenced by the small number of published scientific papers and the complete absence of randomized trials. Thus, further study of this problem is necessary.

Blood ordering and utilization in patients undergoing elective general surgery procedures in a tertiary care hospital: A prospective audit.

Background Blood ordering is commonly done for patients undergoing major elective surgery. Excessive order of the blood for elective surgery leads to wastage of resources, time and workforce. Auditing preoperative blood ordering decreases the cost of medical care by avoiding unnecessary cross-match without compromising patient safety. Methods For this hospital-based audit, we collected data prospectively from July 2017 to June 2018 regarding the transfusion and transfusion indices, namely cross-match-totransfusion ratio (C/T ratio), transfusion probability (T%), transfusion index (TI) and maximum surgical blood ordering schedule (MSBOS) for elective surgeries done in the Department of Surgery. Results A total of 1151 patients were included in the study. A total of 160 units of blood were issued of which only 138 were transfused to 116 patients. Seventy-one procedures were included in the study. The C/T ratio was less than 2.5 for 16 procedures, T% was >50% for 9 procedures and MSBOS was more than 0.5 for 16 procedures. Conclusion Cross-matching is overused for elective surgical procedures. Only 16 of the 71 procedures had an ideal C/T ratio. Group and screen policy can be adopted for most of the commonly performed procedures, and cross-matching of blood may not be needed.

Evaluation of blood component transfusion in sick neonates- a retrospective study in a rural tertiary new-born care unit of Eastern India

Background: In recent past, blood transfusion in neonates has developed a lot improving the outcome particularly in premature and low birth weight babies. However, there are no globally followed standardised guidelines for neonatal blood transfusion. The present study conducted with the objective to evaluate the frequency, indications, complications and appropriateness of various blood components transfusion in sick newborn care unit (SNCU) of a resource poor setting.Methods: This retrospective, hospital based, single centre observational study is done in a tertiary care SNCU of a teaching hospital of eastern India. All SNCU admitted neonates who received blood/ blood component transfusion from October 2018 to September 2019 were evaluated for blood component usage and their indications and followed up throughout hospital stay. The data were statistically analysed using Microsoft Excel™ software.Results: In this study 219 neonates received a total of 359 bags of blood component transfusion. Out of these packed red blood cell (PRBC), fresh frozen plasma (FFP), random donor platelet and whole blood were 233 (64.90%), 97 (27.01%), 10 (2.78%) and 19 (5.29%) respectively. The major indications for transfusion were anaemia of prematurity (35.37%), sepsis (26.18%) and bleeding disorder (16.71%). The common transfusion-related complications observed in our study were cardiac abnormality (22.35%), electrolyte disturbance (6.40%) and hypoglycaemia (19.17%).Conclusions: Anaemia of prematurity was the foremost indication of transfusion. Multiple transfusions were associated with prematurity and low birth weight.

Blood reservation and utilisation practice for Caesarean section in Ilorin, Nigeria.

Most blood units routinely cross-matched for patients undergoing Caesarean section (CS) in Nigeria are not used for transfusion. Over-ordering increases blood wastage, blood bank running costs, surgery costs and waiting times. A one-year review of all CS performed in the University of Ilorin Teaching Hospital (UITH), Nigeria, was thus conducted to evaluate blood reservation and utilisation practice. Efficiency of blood utilisation was evaluated using a cross-match to transfusion (C/T) ratio, transfusion probability (TP) and transfusion index (TI). The overall C/T ratio, TP and blood wastage were, respectively, 3.1, 24.6%, and 68%, indicative of inefficient blood utilisation. Establishing a Maximal Surgical Blood Order Schedule (MSBOS), which estimates the units of blood required for specific CS indications, is recommended to minimise blood over-ordering. Blood grouping alone should be done for patients at low risk for transfusion. For moderate risk patients, blood type and screen without cross-matching should be done, reserving cross-matching for high-risk patients.

Study of Utilization Pattern of Blood And Blood Components in Obstetrics at A Tertiary Care Hospital

Background: Blood transfusion is a life-saving procedure, but inappropriate use of blood and its components in obstetric emergencies, especially in cases of massive bleeding, increases the risk of morbidity and mortality. The aim of this study was to describe the determinants of blood and blood components in obstetrics in a tertiary care hospital with indications for transfusion for different components during the study. Subjects and Method: A Prospective Observational study was carried from May 2018 to December 2019 at Department of Obstetrics and Gynaecolog,T.N.M.C &amp; B.Y.L.Nair Hospital Mumbai. The independent variables are sociodemographic characteristics, parity, mode of delivery, education, hospital level, while dependent variables are frequency of obstetric transfusion. Frequency of transfusion of blood and its components obtained from case file of patient. The other data were collected by questionnaire. Analysis of 366 Obstetric patients requiring blood transfusion in eighteen months period was done. Qualitative data were presented as frequency and percentages and analysed using the chi-square test. Results: During the whole study 366 of obstetric admission required transfusion of blood and its components. Severe anaemia during pregnancy/postpartum anaemia (51%) were the most common indications for blood product transfusions followed by Accidental Haemorrhage (30%), Caesarean section (10.38%) Genital tract trauma including uterine rupture (11%), Postpartum Haemorrhage’s (13%), Placenta previa (6.5%), Ectopic pregnancies (3.5%), Vesicular mole (3.27%), Retained placenta (3.27%) Ruptured uterus (1%), and Abortion (2.7%). Packed cells (47%) were the most common type of blood and blood products transfused followed by Fresh Frozen Plasma (41.86%). Conclusion: : In obstetric emergencies, correct diagnosis and management of emergencies, A pre- planned, multidisciplinary protocol yields excellent effects in the management. Keywords: blood transfusion, pregnancy, anaemia, obstetric emergencies Correspondence: Avinash N. Jadhao. Associate Professor, Department of Biochemistry Seth GSMC &amp; KEMH Parel Mumbai 400012, India. Email: avinashjadhao@kem.edu. Phone no.91 7718971066.

Analysis of Blood Request Form and Blood Utilization Pattern in a Tertiary Care Specialized Hospital

Background: The growing demands for blood products are vital resources to health care facilities. If requested blood is not transfused, this causes blood wastage. Minimal utilization of requested blood squanders technical time, reagent and imposes extra expenses on patients. This study was conducted to evaluate blood requisition and utilization pattern in a tertiary care hospital. Methods: This retrospective study was conductedin the transfusion medicine dept. of a tertiary care specialized hospital from1 January 2017 to 31 December 2020. Blood request forms were reviewed and blood utilization indices were computed from blood bank registries. Blood utilization was calculated determining cross match to transfusion ratio (C:T), transfusion probability (%T), transfusion index (TI) and non-utilization pattern i.e. wastage. Results: A total of 9,841 recipients were requested to prepare cross match. A total of 13,965 units of blood were cross matched and among these 10316 units were transfused to 9,291 recipients. The overall C:T, %T, and TI were 1.35, 94.41% and 1.05 respectively. The wastage implying in this study was 26.13%. Conclusion: The overallblood utilization was encouraging, but excessive cross matching with minimal transfusion practice was observed implying wastage of blood. Blood transfusion services should adopt blood conserving policies. Bangladesh J Medicine 2022; 33: 259-262

Perioperative inappropriate red blood cell transfusions significantly increase total costs in elective surgical patients, representing an important economic burden for hospitals.

BackgroundRed blood cell (RBC) transfusions in surgical patients are associated with increased morbidity a hospital stay. However, little is known about how clinical and economic outcomes differ between appropriately and inappropriately transfused patients. We hypothesized that inappropriate RBC transfusions in elective surgical patients would significantly increase hospital cost. The aim of this study was to quantify the economic burden associated with inappropriate RBC transfusions.MethodsWe retrospectively included all adult patients admitted for elective non-cardiac surgery between January 2014 and March 2020. Patients were divided into three groups (not transfused, appropriately transfused and inappropriately transfused). The primary outcome was the excess in hospital cost in patients inappropriately transfused compared to non-transfused patients. Costs were calculated using a bottom–up approach and involving cost calculation on a granular level. According to international guidelines, transfusions were considered appropriate if administered with an ASA score of 1–2 and the last hemoglobin level measured before transfusion < 70 g/L, or with an ASA score ≥ 3 and the last hemoglobin level < 80 g/L. Cases where RBC transfusions were deemed necessary regardless of the Hb levels were reviewed by the patient blood management (PBM) board and classified accordingly. Secondary outcomes included total transfusion rate, transfusion index, and length of hospital stay. Statistical analysis was carried out by multivariable regression models.ResultsDuring the study period there were 54,922 consecutive surgical admissions, of these 1,997 received an RBC transfusion, with 1,125 considered inappropriate. The adjusted cost of each inappropriate RBC transfusions was estimated in United States dollars (USD) 9,779 (95% CI, 9,358 – 10,199; p < 0.001) and totaled USD 11,001,410 in our series. Inappropriately transfused patients stayed 1.6 times (95% CI, 1.5–1.6; p < 0.001) longer in hospital (10.6 days vs. 6.7 days) than non-transfused patients and a mean 2.35 RBC units per patient were administered.ConclusionInappropriate RBC transfusions in elective surgical patients seem to be common and may represent a significant economic burden. In our experience, inappropriate transfusions significantly increased hospital costs by an average of USD 9,779 compared to non-transfused patients. Through specific PBM policy, hospitals may improve cost-effectiveness of their elective surgical activity by lowering inappropriate transfusions.

Platelet transfusions and thrombocytopenia in intensive care units: Protocol for an international inception cohort study (PLOT‐ICU)

IntroductionThrombocytopenia is frequent in intensive care unit (ICU) patients and has been associated with worse outcome. Platelet transfusions are often used in the management of ICU patients with severe thrombocytopenia. However, the reported frequencies of thrombocytopenia and platelet transfusion practices in the ICU vary considerably. Therefore, we aim to provide contemporary epidemiological data on thrombocytopenia and platelet transfusion practices in the ICU.MethodsWe will conduct an international inception cohort, including at least 1000 acutely admitted adult ICU patients. Routinely available data will be collected at baseline (ICU admission), and daily during ICU stay up to a maximum of 90 days. The primary outcome will be the number of patients with thrombocytopenia (a recorded platelet count < 150 × 109/L) at baseline and/or during ICU stay. Secondary outcomes include mortality, days alive and out of hospital, days alive without life‐support, the number of patients with at least one bleeding episode, at least one thromboembolic event and at least one platelet transfusion in the ICU, the number of platelet transfusions and the indications for transfusion. The primary and secondary outcomes will be presented descriptively. In addition, we will assess risk factors for developing thrombocytopenia during ICU stay and the association between thrombocytopenia at baseline and 90‐day mortality using logistic regression analyses.ConclusionThe outlined international PLOT‐ICU cohort study will provide contemporary epidemiological data on the burden and clinical significance of thrombocytopenia in adult ICU patients and describe the current platelet transfusion practice.

Aplicación de un programa de ahorro de sangre en cirugía cardiaca: análisis y resultados

Introduction and objectivePreoperative anemia, reexploration for bleeding and need for transfusion are common problems in patients undergoing mayor cardiac surgery and are associated with an increase morbidity and mortality. The objective of the present report is to evaluate our surgical results focusing on hematological parameters after the implementation of a Patient Blood Management (PBM) program. MethodsBetween March 2021 and May 2022, we have consecutively operated on 104 mayor cardiac surgery patients with the PBM program. The mean patient age was 65±11 years, 66% of the patients were male, 21% had a EuroScore II>5, 24% had preoperative anemia, and 2,8% were Jehovah's Witnesses who refused transfusions. The 19,2% of the procedures were off-pump coronary artery bypass grafting, 8,7% endocarditis, 10,6% redo operations, 2,9% acute aortic syndromes, and 34% urgent or emergent cases. ResultsThe incidence of reexploration for bleeding was 1,9% and the perioperative transfusion rate was 25%; 87,5% of the patients operated on electively and 90,5% of the isolated coronary patients did not receive blood components. The mean number of red blood cell concentrates (total transfusion index), fresh frozen plasma, and pooled platelets transfused per patient was 0.47, 0.16, and 0.07, respectively. ConclusionsThe PBM has allowed us to achieve our quality objectives in terms of reintervention for bleeding and perioperative transfusion rate.

O-07: TRANSFUSION PRACTICE, POST-TRANSFUSION COMPLICATIONS AND RISK FACTORS IN SICKLE CELL DISEASE IN SENEGAL

Purpose: Blood transfusion is an indispensable therapy in sickle cell disease, despite its multiple and often harmful complications. The objective of this study was to evaluate the complications of alloimmunization, infection and iron overload secondary to blood transfusion in sickle cell disease patients. Materials and methods: This was a six-month cross-sectional case-control study conducted in the Clinical Hematology Department of Dakar (Senegal) on 253 patients followed for major sickle cell disease (153 polytransfused and 100 non-transfused patients). Transfusion practice (modalities, indications), post-transfusion complications (alloimmunization, iron overload, infections) and risk factors (sociodemographic, clinical, biological) for the occurrence of these complications were evaluated. Results: The median age of the patients was 28.5 years (5-59). The sex ratio (M/F) was 0.86. Homozygous sickle cell disease was more frequent (95.3%). The median follow-up time was 9.1 years (2-26). Simple transfusion was performed in 142 patients, exchange transfusion in 29 patients; 22 patients were on a transfusion program. The indications for transfusion were dominated by acute anemia (57.06%) and prolonged CVO (14%). Red blood cell concentrates were administered in 143 patients (93.46%). The median number of units of blood received per patient was 10 units (2 - 48). The frequency of alloimmunization was 16% and the most frequent alloantibodies were anti-rhesus (34.19%) and anti-Kell (23.67%). The prevalence of hepatitis C in transfused subjects was 1.33% and 1% in non-transfused subjects (p=0.64). The prevalence of HBV was 2% in transfused patients and 3% in non-transfused patients (p=0.45). HIV antibodies were not found in either the transfused or the non-transfused patients. Twelve patients (7.84%) had post-transfusion iron overload (ferritin level >1000 ng/ml). The higher the transfusion, the higher the ferritin level (strong positive correlation, r = 0.8). The number of packed red blood cells transfused was the only risk factor for alloimmunization (p=0.03) and post-transfusion iron overload (p=0.023). The frequency of blood transfusion was not related to the transmission of infectious. Conclusion: The management of sickle cell disease often requires blood transfusion to correct anemia or prevent certain complications. Despite the progress made in transfusion safety, this therapy still remains a risk for the recipient. The authors do not declare any conflict of interest

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

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

EP-370 Contemporary clinical management strategies in lower gastrointestinal bleeding: A single-centre retrospective observational study

Abstract Aim Significant heterogeneity exists in the recommendations for the diagnosis and management of acute lower gastrointestinal bleeding (LGIB). This study aims to demonstrate the contemporary management strategies adopted by a busy tertiary hospital. Methods We conducted a single-centre retrospective review of adults presenting to our institution with LGIB between January and March 2021. Demographic data, observations, laboratory results, endoscopy and radiology reports, operation notes and discharge summaries were collected for each patient via a retrospectively maintained registry. Results 23 patients were included. Mean age was 66.6 years with a mean initial haemoglobin of 10.9 g/dL (Range 4.1–15.5g/dL). 17% of patients were in circulatory shock on presentation. 70% of patients presented with haematochezia. 47.8% of patients were on either an anticoagulant or anti-platelet agent at presentation. The transfusion index in this cohort was 30%. 26.1% of patients had a re-bleed during their admission. The diagnostic yield of cross-sectional imaging amongst 11 patients was 27.3% with no correlation with haemodynamic status or active bleeding. 47.8% of patients underwent endoscopy and 27% of patients who underwent an endoscopic procedure required endoscopic haemostasis. Flexible sigmoidoscopy was the commonest endoscopic modality (55%), followed by gastroscopy (27%) and colonoscopy (18%). No patients required surgical or radiological intervention. No cause of bleeding was identified in 26% of patients. Conclusion This study confirms the variation in diagnosis and management of LGIB. Despite access to onsite interventional radiology, endoscopy remained the predominant diagnostic and therapeutic modality. Routine cross-sectional imaging may not be justified given its suboptimal diagnostic yield.

The practice of blood cross-match request and transfusion in surgical patients at Debre Markos comprehensive Specialized Hospital, Debre Markos, Ethiopia, 2021/2022. A prospective study

BackgroundBlood transfusions play a great role to improve oxygen delivery to tissues for indicated surgical patients. Preoperative ordering of blood, especially in elective surgery, is often based on the worst-case assumptions, demanding large quantities of blood or overestimating the anticipated blood loss, of which little is ultimately used. This study aimed to assess the practices of blood requisite and transfusion in surgical patients. MethodAn institutional-based prospective study was conducted from September to February 2021/2022, in Debre Markos comprehensive Specialized Hospital. Socio-demographic data like age, sex, ASA status, type of anesthesia, and type of surgeries were taken preoperatively. The number of cross-matched and transfused data were collected from patient charts throughout the perioperative periods. Efficacy of blood utilization was evaluated using the following indices like cross-match to transfusion ratio (C/T ratio), transfusion probability (%T), and transfusion index (TI); a ratio of 2.5 and below, A value of 30% and above, and values of 0.5 or more respectively were considered indicative of significant blood usage and this study is registered with a research unique identifying number of researchregistry7989 and reported in line with STROCSS 2021 guideline. ResultIn all procedures, among cross-matched blood units 64.1% were unutilized. Depending on the urgency of the procedures about 77.7% of cross-matched blood units were not utilized in elective patients. In emergency procedures, the majority (64.3%) of cross-matched units were transfused. The overall blood transfusion indices result was C/T ratio, %T, and TI was 2.9, 33.5%, and 0.7, respectively. The overall blood transfusion indices for elective and emergency surgery are set respectively as follows C/T ratio (4.6 vs 1.5), %T (22 vs 78.8), and TI (0.4 vs 1.9). Among elective procedures, blood utilization was significant in orthopedic surgery with the value of C/T ratio 1.3, %T 66, and TI 1.4. In the rest of the elective procedures, blood transfusion indices were not significant. ConclusionThe overall blood utilization indices in emergency surgical patients were better than in elective and preoperative grouping, screening, and hold (GSH) is sufficient for elective surgical procedures to decrease wastage of valuable supplies.

The assessment of cytokine-dependent hematopoietic cell linker and interleukin-3 levels in children with beta-thalassemia major

Beta-thalassemia is caused by a lack of or failure to synthesize beta globin chains in hemoglobin resulting in an excess of alpha chains. Cytokine-dependent hematopoietic cell linker (CLNK) is an adapter protein which is involved in the regulation of immunoreceptor signaling. It was found to be associated with a tyrosine-phosphorylated polypeptide (p92) in response to immunoreceptor stimulation. In thalassemia, oxidative stress causes tyrosine phosphorylation of the cytoplasmic domain of band 3. Therefore, we aimed to see how serum CLNK and interleukin-3 correlated with serum ferritin and annual transfusion index in children with beta-thalassemia major (b-TM). This case-control study included 100 non-splenectomized, transfusion-dependent b-TM pediatric patients receiving oral deferasirox and 100 healthy controls. The study was approved by the Institutional Review Board (IRB) of the Menoufia Faculty of Medicine, the approval number is 19/4/2021.PEDI. All procedures were carried out in accordance with relevant guidelines and regulations. In both groups, serum ferritin, interleukin-3, hemoglobin and CLNK levels were measured. They were found to be significantly higher in the b-TM patients than in the controls (p 0.001). There was a negative correlation between serum CLNK and hemoglobin (r = –0.483, p &lt; 0.001), and a positive correlation between serum CLNK and ferritin levels (r = 0.855, p &lt; 0.001). There was a positive correlation between serum CLNK, ferritin, and annual transfusion index. Increased serum CLNK in transfusion-dependent b-TM patients was associated with elevated serum ferritin concentrations and high annual transfusion index. This could be explained by reciprocal effects between immune signaling system and immature erythrocytes which release signaling molecules, such as CLNK, in the blood.

A Study to Formulate Maximum Surgical Blood Order Schedule at a Tertiary Care Referral Teaching Institute in Andhra Pradesh

Background and Objectives: Blood transfusion is the mainstay of treatment for several serious illnesses, surgical, and trauma patients. The aim of this study is to develop maximum surgical blood order schedule (MSBOS) for surgeries in our institute to formulate certain guidelines to prevent the over-ordering of blood and promote reasonable ordering of blood. Patients and Methods: All the patients undergoing surgeries in General Surgery, Surgical Gastroenterology, surgical oncology, Cardiovascular and Thoracic Surgery, Neurosurgery, Urology, and Orthopedics Departments requesting blood were included in this study. Cross-match-to-transfusion (CT) ratios, transfusion probability (TP), and transfusion index (TI) were calculated for individual specialties and surgeries. Based on these parameters, MSBOS was formulated. Results: During the study period, a total of 2724 patients posted for elective surgical procedures necessitating blood among various surgical departments were included in the study. A total of 5812 units of packed red blood cells were requested and cross-matched for the study population. Among these, 1831 units were transfused with a blood utilization percentage of 31.50% (6%–60%). The overall CT ratio of our study was 4.21. The overall TP was 31.69% and the overall TI was 0.56. Conclusion: Implementation of MSBOS is helpful in achieving the goal of rational usage of blood. Based on the results, we grouped the surgical procedures which need type and screen, type and hold, and type and cross-match.

Economic impact of a machine learning-based strategy for preparation of blood products in brain tumor surgery.

Globally, blood donation has been disturbed due to the pandemic. Consequently, the optimization of preoperative blood preparation should be a point of concern. Machine learning (ML) is one of the modern approaches that have been applied by physicians to help decision-making. The main objective of this study was to identify the cost differences of the ML-based strategy compared with other strategies in preoperative blood products preparation. A secondary objective was to compare the effectiveness indexes of blood products preparation among strategies. The study utilized a retrospective cohort design conducted on brain tumor patients who had undergone surgery between January 2014 and December 2021. Overall data were divided into two cohorts. The first cohort was used for the development and deployment of the ML-based web application, while validation, comparison of the effectiveness indexes, and economic evaluation were performed using the second cohort. Therefore, the effectiveness indexes of blood preparation and cost difference were compared among the ML-based strategy, clinical trial-based strategy, and routine-based strategy. Over a 2-year period, the crossmatch to transfusion (C/T) ratio, transfusion probability (Tp), and transfusion index (Ti) of the ML-based strategy were 1.10, 57.0%, and 1.62, respectively, while the routine-based strategy had a C/T ratio of 4.67%, Tp of 27.9%%, and Ti of 0.79. The overall costs of blood products preparation among the ML-based strategy, clinical trial-based strategy, and routine-based strategy were 30, 061.56$, 57,313.92$, and 136,292.94$, respectively. From the cost difference between the ML-based strategy and routine-based strategy, we observed cost savings of 92,519.97$ (67.88%) for the 2-year period. The ML-based strategy is one of the most effective strategies to balance the unnecessary workloads at blood banks and reduce the cost of unnecessary blood products preparation from low C/T ratio as well as high Tp and Ti. Further studies should be performed to confirm the generalizability and applicability of the ML-based strategy.