Large-volume Transfusion Research Articles

Acute Type A Aortic Dissection Initially Diagnosed with Myocardial Infarction

Acute type A aortic dissection (AAD) is a potentially fatal condition that requires rapid assessment and treatment. However, a correct diagnosis is not always the rule, as misdiagnosis occurs in less than half the cases [1,2]. Among many conditions, AAD is frequently confused with acute myocardial infarction (AMI), leading to delayed diagnosis and inappropriate treatment with antiplatelet, antithrombin, and fibrinolytic therapies [1]. To determine the percentage of AAD patients initially diagnosed with AMI and analyze the clinical course of these patients, we retrospectively reviewed 78 cases of AAD. From July 2003 to May 2012, 48 men and 30 women admitted to our hospital were eventually diagnosed with AAD. Their age ranged from 26 to 83 years, with a mean of 53.3±16.1 years. Six patients (7.7%, 6/78) were initially diagnosed with AMI (Table 1). Emergency coronary angiography was performed on 4 patients at a mean of 64 minutes after their admission. All 6 patients received thrombolysis. Although a correct diagnosis was delayed in all 6 patients, five underwent operations, that is, all except one (patient no. 4) who died of cardiogenic shock before he arrived at the operation room. Patient no. 3, who also had preoperative cardiogenic shock, underwent an emergency operation right after coronary angiogram without undergoing a thoracic computed tomography. Most of the patients received a large transfusion volume even though they did not undergo re-exploration. Table 1 Details of the misdiagnosed patients In 2010, the American Heart Association and American College of Cardiology released guidelines for early detection of thoracic aortic disease (TAD) [3]. The sensitivity of the TAD guideline diagnostic algorithm has been known to be as high as 95.7% [4]. In our cohort, 3 patients were categorized as an intermediate risk group (risk score 1) and the others were categorized as a high risk of AAD (risk score 2) according to this algorithm. If we had followed the TAD guideline, the misdiagnosis could have been avoided in the high risk patients. However, in the case of the intermediate risk patients, application of this guideline would not have had a significant impact. Since all of the 3 intermediate risk patients had ST segment elevation on electrocardiogram (ECG), they would have been put on the AMI track. Therefore, we believe that some modification is needed in the TAD algorithm; in the intermediate risk group, chest X-ray (CXR) findings such as mediastinal widening should be considered in advance of ECG findings. In our cohort, if patient no. 4 in the intermediate risk group who had a widened mediastinum on CXR had been diagnosed earlier, he would have received a rapid and appropriate treatment. Another concern is about the protocol of AMI-evaluation by the Health Insurance Review & Assessment Service (HIRA). According to this protocol, thrombolytic therapy should be started within 60 minutes and primary percutaneous coronary intervention within 120 minutes after AMI patients arrive at a hospital. This protocol also plays some role in delayed diagnosis of AAD and inappropriate treatment. Therefore, we suggest that a nationwide survey of this misdiagnosis issue be done to modify the HIRA protocol.

Guidelines for pre‐transfusion compatibility procedures in blood transfusion laboratories

Guidelines for pre‐transfusion compatibility procedures in blood transfusion laboratories

Transfusion of hemoglobin-based oxygen carriers in the carboxy state is beneficial during transient focal cerebral ischemia

Exchange transfusion of large volumes of hemoglobin (Hb)-based oxygen carriers can protect the brain from middle cerebral artery occlusion (MCAO). Hb in the carboxy state (COHb) may provide protection at relatively low volumes by enhancing vasodilation. We determined whether transfusion of rats with 10 ml/kg PEGylated COHb [polyethylene glycol (PEG)-COHb] at 20 min of 2-h MCAO was more effective in reducing infarct volume compared with non-carbon monoxide (CO) PEG-Hb. After PEG-COHb transfusion, whole blood and plasma COHb was <3%, indicating rapid release of CO. PEG-COHb transfusion significantly reduced infarct volume (15 ± 5% of hemisphere; mean ± SE) compared with that in the control group (35 ± 6%), but non-CO PEG-Hb did not (24 ± 5%). Chemically dissimilar COHb polymers were also effective. Induction of MCAO initially produced 34 ± 2% dilation of pial arterioles in the border region that subsided to 10 ± 1% at 2 h. Transfusion of PEG-COHb at 20 min of MCAO maintained pial arterioles in a dilated state (40 ± 5%) at 2 h, whereas transfusion of non-CO PEG-Hb had an intermediate effect (22 ± 3%). When transfusion of PEG-COHb was delayed by 90 min, laser-Doppler flow in the border region increased from 57 ± 9 to 82 ± 13% of preischemic baseline. These data demonstrate that PEG-COHb is more effective than non-CO PEG-Hb at reducing infarct volume, sustaining cerebral vasodilation, and improving collateral perfusion in a model of transient focal cerebral ischemia when given at a relatively low dose (plasma Hb concentration < 1 g/dl). Use of acellular Hb as a CO donor that is rapidly converted to an oxygen carrier in vivo may permit potent protection at low transfusion volumes.

Predictors of Massive Blood Loss in Women With Placenta Accreta

Objective We examined predictors of massive blood loss for women with placenta accreta who had undergone hysterectomy. Study Design A retrospective review of women who underwent peripartum hysterectomy for pathologically confirmed placenta accreta was performed. Characteristics that are associated with massive blood loss (≥5000 mL) and large-volume transfusion (≥10 units packed red cells) were examined. Results A total of 77 patients were identified. The median blood loss was 3000 mL, with a median of 5 units of red cells transfused. There was no association among maternal age, gravidity, number of previous deliveries, number of previous cesarean deliveries, degree of placental invasion, or antenatal bleeding and massive blood loss or large-volume transfusion ( P > .05). Among women with a known diagnosis of placenta accreta, 41.7% had an estimated blood loss of ≥5000 mL, compared with 12.0% of those who did not receive the diagnosis antenatally with ultrasound scanning ( P = .01). Conclusion There are few reliable predictors of massive blood loss in women with placenta accreta.

Exchange Transfusion Therapy and Its Effects on Real-time Microcirculation in Pediatric Sickle Cell Anemia Patients

Periodic blood exchange transfusion is a treatment modality commonly used to manage pediatric sickle cell anemia at the University of California Davis Medical Center. The goal of exchange transfusion therapy is to ameliorate vasoocclusion and improve tissue perfusion by removing sickled red blood cells and introducing normal red blood cells. Using computer-assisted intravital microscopy, pretransfusion and posttransfusion microvascular characteristics were analyzed. In this study, the bulbar conjunctiva exhibited a "blanched" avascular appearance in all 6 pediatric sickle cell anemia patients before transfusion, indicative of tissue hypoperfusion and ischemia. Immediately after transfusion, substantial improvement in vascularization and tissue perfusion resulted, reflected by the enhanced appearance of capillaries and arterioles. In addition, a decrease in red cell velocity was observed. These observations provide evidence that exchange transfusion therapy is beneficial in ameliorating vasoocclusion and improving tissue perfusion. However, with the paradoxical posttransfusion decrease in red cell velocity presumably due to induced hyperviscosity from the large transfusion volume, blood flow is still impaired. This decreased velocity may thwart efforts to improve oxygen delivery through transfusion and may, to some extent, promote vasoocclusion instead. This paradoxical result warrants further investigation on the effects of transfusion volume and viscosity in the exchange transfusion process.

Exchange transfusion therapy and its effects on real‐time microcirculation in pediatric sickle cell anemia patients

The goal of exchange transfusion therapy is to ameliorate vasoocclusion and improve tissue perfusion by removing sickled red blood cells and introducing normal red blood cells. Using computer‐assisted intravital microscopy, pre‐transfusion and post‐transfusion microvascular characteristics were analyzed and compared. In this study, the bulbar conjunctiva exhibited a “blanched” avascular appearance in all 6 pediatric sickle cell anemia patients before transfusion, indicative of tissue hypoperfusion and ischemia. Immediately after transfusion, substantial improvement in vascularization and tissue perfusion resulted. In addition, a decrease in red cell velocity was observed. These observations provide evidence that exchange transfusion therapy is beneficial in ameliorating vasoocclusion and improving tissue perfusion. However, with the paradoxical post‐transfusion decrease in red cell velocity presumably due to induced hyperviscosity from the large transfusion volume, blood flow is still impaired. This decreased velocity may thwart efforts to improve oxygen delivery through transfusion and may, to some extent, promote vasoocclusion instead.

Applicability of anatomical vascular occlusion in hepatectomy for grand hepatocarcinoma

To retrospectively explore the clinical efficacies and applicability of anatomical vascular occlusion (AVO) in hepatectomy for grand primary hepatocarcinoma at different locations. A total of 212 grand primary hepatocarcinoma cases undergoing hepatectomy were divided into 2 groups by vascular occlusion in the process of resection: AVO group (n = 97) and Pringle group (Pringle maneuver, n = 115). According to whether or not tumor was adjacent to main vessels, the cases were divided into 2 types: centrally (n = 98) and peripherally (n = 114) located lesions. And the perioperative outcomes were compared between 2 groups totally and by types respectively. No significance existed between the AVO and Pringle groups in the demographic characteristics and tumor background (P > 0.05). For total cases, there were no significant differences between 2 groups regarding the intraoperative blood loss volume ((632 ± 437) ml vs (546 ± 549) ml, P = 0.217) and the blood transfusion requirement (44.3% vs 33.0%, P = 0.092). The AVO group showed significantly better postoperative liver functions in terms of serum levels of total bilirubin and aminotransferase (P > 0.05). But no significant difference was found between 2 groups in the postoperative complication rate (18.6% vs 22.6%, P = 0.469) and hospital stay duration ((10.5 ± 4.8) vs (11.8 ± 5.6) days, P = 0.087). In centrally located lesions: the AVO group showed a significantly smaller intraoperative blood loss volume ((722 ± 492) ml vs (1032 ± 618) ml, P = 0.007) and blood transfusion requirement (45.6% vs 68.3%, P = 0.026). Also the AVO group showed significantly better postoperative liver functions in terms of serum levels of total bilirubin and aminotransferase (P < 0.01). As a consequence, the AVO group had a significantly lower postoperative complication rate (19.3% vs 39.0%, P = 0.031) and a shorter hospital stay duration ((10.7 ± 5.0) days vs (13.0 ± 6.2) days, P = 0.042). In peripheral located lesions: there were significantly larger intraoperative blood loss volume (504 ± 307 vs 278 ± 237 ml, P = 0.000) and blood transfusion requirement (42.5% vs 13.5%, P = 0.001) in the AVO group. The postoperative liver functions (total bilirubin and aminotransferase levels, P > 0.05), postoperative complication rate (17.5% vs 13.5%, P = 0.808) and hospital stay duration ((10.3 ± 4.6) days vs (11.1 ± 5.1) days, P = 0.429) showed no significant differences between 2 groups. The technique of AVO is unsuitable for all types of grand hepatocarcinoma. Whether or not the tumor is adjacent to main vessels is an important consideration of choosing the vascular control technique. Considering the risk of vascular damage in the process of hepatectomy, the AVO technique is indicated for the resection of central lesions but not for peripheral lesions.

Cesium cessation? An advantage of pathogen reduction treatments

Cesium cessation? An advantage of pathogen reduction treatments

Predictors of massive blood loss in women with placenta accreta

We examined predictors of massive blood loss for women with placenta accreta who had undergone hysterectomy. A retrospective review of women who underwent peripartum hysterectomy for pathologically confirmed placenta accreta was performed. Characteristics that are associated with massive blood loss (≥ 5000 mL) and large-volume transfusion (≥ 10 units packed red cells) were examined. A total of 77 patients were identified. The median blood loss was 3000 mL, with a median of 5 units of red cells transfused. There was no association among maternal age, gravidity, number of previous deliveries, number of previous cesarean deliveries, degree of placental invasion, or antenatal bleeding and massive blood loss or large-volume transfusion (P > .05). Among women with a known diagnosis of placenta accreta, 41.7% had an estimated blood loss of ≥ 5000 mL, compared with 12.0% of those who did not receive the diagnosis antenatally with ultrasound scanning (P = .01). There are few reliable predictors of massive blood loss in women with placenta accreta.

Prospective study of definitive chemoradiotherapy with S-1 and nedaplatin in patients with stage II/III (non-T4) esophageal cancer

Background Standard chemoradiotherapy (CRT) using 5-FU and CDDP is the optimal treatment for patients with stage II/III (non-T4) esophageal carcinoma. However, patient quality of life (QOL) cannot necessarily be maintained during this therapy, because 5-FU must be continuously infused for 24 h and CDDP administration requires a large transfusion volume. Therefore, hospitalization is unavoidable. We conducted a study of definitive CRT with S-1 and nedaplatin.

Guidelines on the use of irradiated blood components prepared by the British Committee for Standards in Haematology blood transfusion task force

Search terms included: Transfusion-associated graft-versus-host disease, Transfusion-associated graft-versus-host, TA-GvHD. The last guideline covering this topic was published in 1996 (British Committee for Standards in Haematology (BCSH) Blood Transfusion Task Force, 1996. The writing group produced the new draft guideline, which was subsequently revised by consensus by members of the Haemato-oncology and Blood Transfusion Task Forces of the BCSH. The guideline was then reviewed by a sounding board of approximately 100 UK haematologists, the BCSH and the committee of the British Society for Haematology and amended, again by consensus. Criteria used to quote levels and grades of evidence are according to the GRADE system (Guyatt et al, 2006). Strong recommendations (grade 1, ‘recommended’) are made when there is confidence that the benefits either do or do not outweigh the harm and burden and costs of treatment. Where the magnitude of benefit or not is less certain a weaker grade 2 recommendation (‘suggested’) is made. Grade 1 recommendations can be applied uniformly to most patients whereas grade 2 recommendations require judicious application. The quality of evidence is graded as A (high quality randomized clinical trials), moderate (B) or low (C). This publication reports the key recommendations of the Writing Group. It is also accessible at http://www.bcshguide lines.com.

Red Blood Cell Antigen Alloimmunization in Liver Transplant Recipients

Orthotopic liver transplantation (OLT) is a life-saving procedure for patients with end-stage liver disease. Transfusion support is an important part of OLT. Intraoperative transfusion of large volumes of blood products is recognized to be a poor prognostic factor, probably due to the negative effects of blood transfusions, such as transfusion reactions, infectious contamination of blood products, or immune modulation of the transfused patient. The aim of this study was to evaluate the frequency of alloimmunization and its specificity to red blood cell (RBC) antigens among patients undergoing OLT. We identified 74 RBC alloantibodies in 70 (23%) patients when the indirect antiglobulin test (IAT) was performed. The most common RBC alloantibodies were against Rh system antigens. The majority (41.9%) were directed against the E antigen. Despite the ethnic heterogeneity of our population there were no cases of intravascular hemolysis. The incidence of alloimmunization (23%) was slightly higher among patients than in the literature, most probably as a consequence of our ethnic heterogeneity.

Use of SAG-M-suspended red cell concentrate in large volume transfusion associated with cardiac surgery in neonates and infants: a retrospective audit

Use of SAG-M-suspended red cell concentrate in large volume transfusion associated with cardiac surgery in neonates and infants: a retrospective audit

Transfusion Associated Circulatory Overload (TACO) Incidence and Risk Factors.

Abstract 3157Poster Board III-94 IntroductionTransfusion circulatory overload (TACO) is a complication of transfusion, often confused with transfusion acute lung injury (TRALI), and is probably under-reported. The pathophysiology is believed to be caused by increased hydrostatic blood pressure leading to fluid leakage in the alveolar space, emulating congestive cardiac failure. We report on a large cohort of TACO cases in Ireland. MethodsAll consecutive TACO cases reported to the National Haemovigilance Office of Ireland between 2000-2008 were retrospectively reviewed. The incidence of TACO was calculated on units issued from the Irish Blood Transfusion Service (IBTS). Comparative analysis of patient demographic and clinical data was made using Fisher's exact test. Results179 TACO cases were reviewed. 149 (83%) involved red cell concentrate (RCC), platelets (PLT) n=4 (2%); fresh frozen plasma (FFP) /solvent detergent plasma (SDP) n=16 (8%); multiple components n=10 (6%). During the study period, a total 1,614,973 blood components (RCC, FFP, SDP and PLT) were issued corresponding to a TACO incidence of 1/10.000 of all components issued. TACO incidence per RCC, platelets and plasma issued was 1/8000, 1/48000 and 1/15000 respectively, excluding the cases where multiple components were transfused. While the majority of patients developing TACO were elderly (> 70years)(n= 120, 67%), up to eight cases (4%) were reported in young patients (<30 years). There was no difference in gender. An underlying cardiovascular condition was reported in 73% (131) cases. Patient outcome was specified in 178 cases. One hundred and fifty three (85%) patients recovered post reaction. However, 15 (8%) patients experienced morbidity ranging from prolonged resolution of symptoms, to myocardial infarction (n=2), cancellation of surgery (n=1), and admission to intensive care (n=4). 25 (14%) deaths were reported, and TACO was identified as possible cause of death in n=5 (2%) cases. Four of these patients were male and one patient was female. A total of 158 (88%) patients received diuretics before (n=36), during (n=26) or post (n=124). Nineteen patients (11%) did not receive diuretics; four of these patients died, one of which was possibly attributed to transfusion. Information was unavailable in two cases. Patients treated with diuretics post transfusion were more likely to survive (80% vs. 40%); however statistical significance was not reached (p=0.07). The median transfused volume was 275 mls (range 80-9500 mls). There was no statistical significance between actual time of transfusion and time over which transfusion were prescribed. Approximately 10 % (18) cases involved large volume transfusion most likely in an emergency situation. While only three of these transfusion events met the clinical definition of a massive transfusion (150mls per minute), patients in this cohort received between 300 and 8200 mls per hour. The median volume transfused was 1500mls (range 1000mls – 9500mls). Eleven (61%) patients had underlying cardiovascular conditions. Seven patients were > 70 years, all of whom had underlying cardio–vascular conditions. Four (22%) patients died, one death which was possibly attributed to transfusion, and a further three patients (17%) required admission to intensive care. Four (22%) cases involved young female patients (age < 30 years) who had no underlying cardiovascular condition, but one patient had asthma. These patients were being treated for obstetric bleeding, and all recovered. ConclusionThis study reports a TACO incidence of 1 /10 000 units issued from the IBTS. Although this incidence is based on units issued rather than transfused, it probably reflects significant underreporting, and perhaps even under-recognition. This study identified TACO has significant impact on patient outcome with approximately 8% (15) of patients suffering significant morbidity and a further 2% (5) of patients dying following onset of TACO. Finally, patients receiving large volume transfusion in emergency situations even young patients are at risk of developing TACO. DisclosuresNo relevant conflicts of interest to declare.

Use of Prothrombin Complex Concentrate (Beriplex/Octaplex) in Acquired Bleeding Disorders: A Two-Year Single Centre Experience.

Abstract 3160Poster Board III-97The major challenges in acquired bleeding disorders are accurate assessment of bleeding risk and subsequent effective correction of the haemostatic imbalance without increasing the risk of thrombotic complications. The response to Fresh Frozen Plasma (FFP) is extremely variable when used in acquired bleeding disorders. The administration of higher doses of FFP is more effective (Chowdhury et al., Br J Haematology. 2004 Apr; 125(1):69-73), but is limited by the potential risk of fluid overload. In addition, as with the use of all blood products, the risk of transmitting infection and concerns regarding allergic reactions, anaphylaxis and transfusion-related lung injury remain. With the increasing availability of prothrombin complex concentrates (PCCs), it has become possible to give a defined dose of factor II, VII, IX, X and proteins C & S in a small volume. Its efficacy has been well described in patients requiring warfarin reversal, but the indication for its use in other acquired bleeding disorders is less clear and data published on the subject is very limited. Concerns remain regarding the thrombotic risk associated with its use and, as a plasma-derived product, there is also the potential of transmitting blood borne infections. Here we present our two-year experience of the use of PCCs in a wide range of acquired coagulopathies. We collected retrospective data on a total of 200 (n=200) administration events, which we subdivided as follows: (1) Warfarin reversal (n=54), (2) Gastrointestinal bleeding on the background of coagulopathy secondary to chronic liver disease (n=62), (3) Liver transplantation complicated by massive blood loss or renal impairment requiring volume restriction (n=31), (4) Massive haemorrhage (n=10), (5) Coagulopathy due to underlying malignancy (n=10), (6) Correction of coagulopathy prior to procedures (n=20), (7) Miscellaneous (n=13). Dosing of PCCs was decided based on weight of patient, severity of acquired coagulopathy, rate of blood loss and underlying pathology. If required the PCCs were administered in conjunction with fibrinogen concentrate, blood products (packed red cells, platelets, FFP, cryoprecipitate) and antifibrinolytic agents such as aprotinin or tranexamic acid. Our PCC dosing regime of 20 -30 units/kg usually led to an improvement in prothrombin time (PT) and international normalised ratio (INR) in all the above listed clinical settings. No excessive blood loss was noted during the procedures for which PCCs were given. In addition, we did not see a significant increase in thrombotic complications in our cohort of patients, but these findings have to be confirmed in larger studies. At our institution, patients requiring warfarin reversal with an INR >4.0 receive a universal dose of 30u/kg of PCCs based on a previous study (Gatt et al., J. Thrombosis and Haemostasis. 2009 Jul; 7(7); 1123-7), which demonstrated that sufficient thrombin generation is achieved with this dose and the retrospective analysis of our clinical data supports this. In patients with acute and chronic liver failure, the capacity to generate thrombin is probably not significantly impaired in steady state despite a prolonged PT and INR (Gatt et al., Blood, vol.112, No. 11, abstract 1826). However, these patients are more vulnerable to disturbances caused by major blood loss requiring large volume transfusion. We found that administration of PCC in this setting led to improvement of prothrombin time/INR and clinical outcome. We were able to correlate these findings to improvement in the thromboelastogram curves in patients undergoing liver transplant. We conclude that use of PCCs and their dosing must be tailored to the clinical setting. Administration of PCCs can be considered when rapid correction of clotting factors to haemostatic levels is required and/or if there is a significant restriction to volume that can be safely transfused. A comprehensive approach to the management of acquired coagulopathies should also include the addition of FFP, cryoprecipitate, fibrinogen concentrate, antifibrinolytics and recombinant factor VIIa. The correlation between bleeding tendency and standard coagulation tests remains unclear and has to be further investigated to help with future changes of clinical practice. DisclosuresNo relevant conflicts of interest to declare.

Small Bowel Tumor Presenting as Chronic Overt, Obscure Gastrointestinal Bleeding Missed on Capsule Enteroscopy

Purpose: Overt, obscure gastrointestinal bleeding (GIB) leads to increased morbidity and mortality and can require large volume transfusions and multiple diagnostic procedures before identifying the bleeding source. In 5% cases of GIB, no source is identified, and surgical resection must be considered to control life threatening episodes of bleeding. After negative EGD and colonoscopy, capsule enteroscopy (CE) is indicated to evaluate the small bowel (SB) for a bleeding source. Here we report a case of ongoing transfusion dependent, overt, obscure lower GIB from an ileal carcinoid tumor that was missed on initial capsule study. Case: 66 y/o male with chronic intermittent alternating melena and hematochezia with blood loss anemia over one year was referred for evaluation. He underwent multiple diagnostic endoscopies and radiographic imaging without a definitive source for overt bleeding. Colonoscopy revealed blood clots in the cecum and terminal ileum, diverticulosis, and a small 2 mm adenoma in the left colon. Capsule finds an AVM in mid/distal jejunum. Tagged RBC scan lit up in the LUQ. UGI/SBFT was normal. Push enteroscopy was negative for bleeding. Mesenteric angiogram is unrevealing. Then, double balloon enteroscopy (DBE) finds a 1 cm clean based ulcer at 250 cm and India inked. In the proximal jejunum an AVM was cauterized. Follow up CE finds mucosal erosions in the distal jejunum or proximal ileum, but no active bleeding. Finally, retrograde DBE finds a 2-3 cm ulcerated mass proximal to the India ink marking, likely the source of bleeding. He underwent surgical resection of a palpable SB nodule. Pathology diagnosed a 1.6 × 0.9 × 0.6 cm carcinoid tumor in the proximal ileum. Discussion: The management of ongoing, obscure GIB in the SB may require multiple endoscopic and imaging modalities before identification and resolution. CE is often the initial study of choice for SB evaluation. However, up to 20% SB tumors can be missed by CE alone. Repeat CE and/or DBE should be done in the case of ongoing obscure GIB after an initial negative capsule study. Both CE and DBE are comparable in diagnostic efficacy and cost effectiveness. A vigilant approach to finding the source of occult GIB should be maintained to avoid delaying the diagnosis of small bowel tumors.

Perioperative blood conservation strategies: weighing the medical evidence — II

To the Editor: We read, with interest, the recent editorial written by Drs. Karkouti and McCluskey.1 The crux of their editorial is that cardiac anesthesiologists should discontinue most blood conservation methods to avoid transfusions in heart surgery patients, until such methods have been proven safe and efficacious. However, the editorial leaves a number of unanswered questions; most importantly, is receiving blood, or blood component therapy, harmful? The authors suggest a causal relationship between the volume of transfusion and mortality. Work in this area has been based upon retrospective, propensity scored, database analysis which describes an association between transfusion and mortality from small to large volume transfusion.2–4 Possibly the nature of the surgical insult, with a requirement for large volume transfusion, is the major determinant for excess mortality, not the consequent transfusion. The findings of well-controlled trials, which examine simple methods to reduce transfusion requirements, can potentially be dismissed, arguing that they are not powered adequately to detect differences in mortality. However, it should be recognized that these studies were frequently not intended to evaluate mortality. There is enormous variation in transfusion practice across centres performing the same type of cardiac operations.5 Many studies have evaluated methods that might reduce this variation in practice. Simple organizational changes and audit of practice may be just as effective in reducing transfusion rates as using mechanical or pharmacological methods. We have a safe blood supply; but this editorial largely ignores the wider issues around an increasingly scarce and expensive product. In addition, preventing low volume transfusions may be important to functional outcome after cardiac surgery.6 In the void left after the closure of the Blood conservation using antifibrinolytics: a randomized trial in a cardiac surgery population study, have Karkouti and McCluskey stopped using tranexamic acid in patients not involved in randomized clinical trials? Are they suggesting that units should stop using standard tests of coagulation in patients, as the value of these tests have not been validated in hemodiluted post-cardiopulmonary bypass coagulopathic patients? The authors have produced a stimulating editorial. To do no harm, we must first correct the balance between transfusion and conservation approaches. This will require primary and database research into transfusion of blood, use of component therapy, and mechanical and pharmacological methods to reduce transfusion. At a time when aprotinin has been removed from our armamentarium, abandonment of a range of methods of transfusion avoidance may not be timely.

Perioperative blood conservation strategies: weighing the medical evidence — I

To the Editor: We read, with interest, the recent editorial written by Drs. Karkouti and McCluskey.1 The crux of their editorial is that cardiac anesthesiologists should discontinue most blood conservation methods to avoid transfusions in heart surgery patients, until such methods have been proven safe and efficacious. However, the editorial leaves a number of unanswered questions; most importantly, is receiving blood, or blood component therapy, harmful? The authors suggest a causal relationship between the volume of transfusion and mortality. Work in this area has been based upon retrospective, propensity scored, database analysis which describes an association between transfusion and mortality from small to large volume transfusion.2–4 Possibly the nature of the surgical insult, with a requirement for large volume transfusion, is the major determinant for excess mortality, not the consequent transfusion. The findings of well-controlled trials, which examine simple methods to reduce transfusion requirements, can potentially be dismissed, arguing that they are not powered adequately to detect differences in mortality. However, it should be recognized that these studies were frequently not intended to evaluate mortality. There is enormous variation in transfusion practice across centres performing the same type of cardiac operations.5 Many studies have evaluated methods that might reduce this variation in practice. Simple organizational changes and audit of practice may be just as effective in reducing transfusion rates as using mechanical or pharmacological methods. We have a safe blood supply; but this editorial largely ignores the wider issues around an increasingly scarce and expensive product. In addition, preventing low volume transfusions may be important to functional outcome after cardiac surgery.6 In the void left after the closure of the Blood conservation using antifibrinolytics: a randomized trial in a cardiac surgery population study, have Karkouti and McCluskey stopped using tranexamic acid in patients not involved in randomized clinical trials? Are they suggesting that units should stop using standard tests of coagulation in patients, as the value of these tests have not been validated in hemodiluted post-cardiopulmonary bypass coagulopathic patients? The authors have produced a stimulating editorial. To do no harm, we must first correct the balance between transfusion and conservation approaches. This will require primary and database research into transfusion of blood, use of component therapy, and mechanical and pharmacological methods to reduce transfusion. At a time when aprotinin has been removed from our armamentarium, abandonment of a range of methods of transfusion avoidance may not be timely.

SAGM blood for neonatal large volume transfusion

SAGM blood for neonatal large volume transfusion

Leukoreduction is Associated with a Decreased Incidence of Late Onset Acute Respiratory Distress Syndrome after Injury

Transfusions are known to be associated with Acute Respiratory Distress Syndrome (ARDS). Transfusion of leukoreduced products may be associated with a decreased incidence of late posttraumatic ARDS (late ARDS). Data from ventilated and transfused trauma patients were analyzed. Key variables in the first 48 hours of admission were studied for their associations with late ARDS and examined for changes over the 6 year study period. Late ARDS developed in 244 of the 1488 patients studied (16.4%). The incidence in patients given nonleukoreduced (NLR) product was 30.4 per cent (75/247) versus 13.6 per cent (169/1241) for patients not exposed [2.77 (2.02-3.73), P < 0.001]. Exposure to NLR products (50.9% in 2000 vs. 1.9% in 2005) and incidence of ARDS (26.3% in 2000 vs. 6.3% in 2005) significantly decreased. Treatment variables independently associated with late ARDS were NLR product exposure, Total Parenteral Nutrition exposure, Peak Inspiratory Pressure > or =30 mm Hg, fluid balance > or =2 liters at 48 hours, and transfusion of > or =10 units of any product. NLR product exposure has an association with an increased incidence of late onset posttraumatic ARDS which is independent of large volume transfusions. Leukoreduction should be routinely included in an overall treatment strategy to furthermore mitigate this complication in critically ill trauma patients.