Median Pretransfusion Research Articles

Leading digit bias in hemoglobin thresholds for red cell transfusion.

Leading digit bias is a heuristic whereby humans overemphasize the left-most digit when evaluating numbers (e.g., 9.99 vs. 10.00). The bias might affect the interpretation of hemoglobin results and influence red cell transfusion in hospitalized patients. Adults who received a red cell transfusion while registered at the University Health Network (Toronto, Canada) between January 1, 2016 and January 1, 2022 (n = 6 years) were included. The primary analysis excluded apheresis, red cell disorders, radiology suites, and operating rooms. The primary comparison was a regression discontinuity analysis of transfusion occurrence above and below the hemoglobin threshold of 79 g/L (local units). Additional analyses tested other leading digit and control thresholds (71, 81, and 91 g/L). Secondary analyses explored temporal covariates and clinical subgroups. A total of 211,872 red cell transfusions were identified over the study period (median pre-transfusion hemoglobin 76 g/L; interquartile range = 69-92 g/L), with 107,790 inpatient transfusions in the primary analysis. The 79 g/L threshold showed 815 fewer red cell units above the threshold (95% confidence interval [CI]: -1215 to -415). The 69 g/L threshold showed 2813 fewer transfused units (95% CI: -4407 to -1220), and 89 g/L showed 40 fewer units (95% CI: -408 to 328). The effect was accentuated during daytime, weekday, and May-June months, persisted in analyses including all transfusions, and was absent at control thresholds. Leading digit bias might have a modest influence on the decision to transfuse red cells. The findings may inform practice guidelines and quasi-experimental study design in transfusion research.

A novel measure to summarize blood transfusion practice during critical illness.

Large-scale observational studies have summarized transfusion practice using traditional measures of central tendency (e.g., the mean hemoglobin concentration at the time of transfusion). However, the mean hemoglobin concentration fails to identify specific hemoglobin concentration thresholds that drive practice. In the following brief report, we propose a novel measure of "practice discontinuity" that identifies specific practice-defining hemoglobin thresholds. We used the PINC AI Database (2016-2022) to identify adult patients admitted to an intensive care unit with at least one hemoglobin concentration measurement. For each day that hemoglobin was measured, we identified whether the patient received a red blood cell transfusion using hospital charge codes. We defined the "practice discontinuity" measure as the hemoglobin concentration at which there was the largest increase in transfusion use going from a higher to an incrementally lower hemoglobin concentration. We also calculated the mean and median pretransfusion hemoglobin concentrations. We identified 1,298,367 patients and 4,905,839 patient-days for inclusion. RBC transfusion occurred in a total of 530,654 (10.8%) patient-days. The overall pre-transfusion mean and median hemoglobin concentrations were 8.4 and 8.0 g/dL, respectively. The practice discontinuity measure identified 7.0 g/dL as the hemoglobin concentration at which transfusion use increased the most, from 46.6% of patient-days at a concentration of 7.0 g/dL to 74.8% of patient-days at a concentration of 6.9 g/dL. We propose that future studies of red blood cell transfusion practice consider inclusion of the practice discontinuity measure to more fully summarize clinical practice.

Response to apheretic platelet transfusion in children of acute lymphoblastic leukemia receiving induction chemotherapy: a cross-sectional study from Bangladesh.

Disease and therapy-related hypoproliferative thrombocytopenia is a significant barrier to managing acute lymphoblastic leukaemia (ALL) patients. To reduce the risk of haemorrhage, apheretic platelet transfusion is a modern, effective, and expensive option. Since most ALL patients in Bangladesh have financial constraints, this study can shed light on the magnitude of benefit regarding the effectiveness of apheretic platelet prophylactically and therapeutically in children of ALL receiving induction chemotherapy. This observational cross-sectional study was conducted in the department of transfusion medicine and the department of paediatric haematology and oncology at a tertiary level hospital in Bangladesh from June 2020 to June 2021. A total of 33 cases of ALL were enroled in this study according to inclusion and exclusion criteria. After receiving written informed consent, relevant data were collected using a face-to-face interview with the guardian of the patients, thorough clinical examination, and relevant investigation. After the collection of all the required data, analysis was done by Stata (v.16). Mean age of the patients was 7.39±4.46 (SD), ranging from 1 to 18 years. The majority of children were aged younger than or equal to 10 years (69.70%). Male children were slightly predominant (51.5%). Significant post-transfusion platelet increment (Median pre-transfusion count 16×103/μl vs. Median post-transfusion count 133×103/μl, P<0.001) was observed. WHO bleeding grades also improved after apheretic platelet transfusion (P<0.05). Age was a significant factor associated with corrected count increment (CCI) in both univariate and multivariate analysis. In subgroup analysis, age and gender were significant predictors of CCI in therapeutic transfusion group but not in prophylactic transfusion group. Significant improvement in bleeding status and platelet count was observed following apheretic platelet transfusion.

Effect of Red Blood Cell Transfusion on Regional Tissue Oxygenation in Pediatric Cardiac Surgery Patients.

Red blood cell (RBC) transfusions are used frequently in pediatric patients admitted to the intensive care unit (ICU) after cardiac surgery. To improve data-driven transfusion decision-making in the ICU, we conducted a retrospective analysis to assess the effect of RBC transfusion on cerebral and somatic regional oxygenation (rSO2). We evaluated post- versus pre-RBC transfusion cerebral rSO2 and somatic rSO2 in all consecutive pediatric patients (age >28 days to <18 years) who underwent biventricular cardiac surgery at a single center between July 2016 and April 2020. The final data set included 263 RBC postoperative transfusion events in 75 patients who underwent 83 surgeries. The median pretransfusion hemoglobin was 10.6 g/dL (25th-75th percentile, 9.3-11.6). The median pretransfusion cerebral and somatic rSO2 were 63% (54-71) and 69% (55-80), which increased by a median of 3 percentage points (-2 to 6) and 2 percentage points (-3 to 6), respectively, after transfusion. After adjusting for pretransfusion hemoglobin, change in hemoglobin posttransfusion versus pretransfusion, and potential confounders (age, sex, and STAT surgical mortality risk score), the posttransfusion versus pretransfusion change in cerebral or somatic rSO2 was not statistically significant. Pretransfusion cerebral rSO2 (crSO2) was ≤50%, a previously described threshold for increased risk for unfavorable neurological outcome, for 22 of 138 (16%) transfusion events with complete pre- and post-crSO2 data. Sixteen of these 22 (73%) transfusions resulted in a posttransfusion crSO2 >50%. When restricting analysis to the first (index) transfusion after arrival to the ICU from the operating room (administered at a median of 1.15 postoperative days [25th-75th percentile, 0.84-1.93]), between-patient pretransfusion hemoglobin was not associated with pretransfusion crSO2 but within-patient posttransfusion versus pretransfusion hemoglobin difference was significantly associated with posttransfusion versus pretransfusion crSO2 difference (mean posttransfusion versus pretransfusion crSO2 difference, 2.54; 95% confidence interval, 0.50-4.48). In this study, neither cerebral nor somatic rSO2 increased significantly post- versus pre-RBC transfusion in pediatric cardiac surgery patients admitted to the ICU after biventricular repairs. However, almost three-quarters of transfusions administered when pretransfusion crSO2 was below the critical threshold of 50% resulted in a posttransfusion crSO2 >50%. In addition, the significant within-patient change in crSO2 in relation to the change in posttransfusion versus pretransfusion hemoglobin in the immediate postoperative period suggests that a personalized approach to transfusion following within-patient trends of crSO2 rather than absolute between-patient values may be an important focus for future research.

Resuscitation Patterns and Massive Transfusion for the Critical Bleeding Dog-A Multicentric Retrospective Study of 69 Cases (2007-2013).

Objective: To describe resuscitation patterns of critically bleeding dogs, including those receiving massive transfusion (MT).Design: Retrospective study from three universities (2007–2013).Animals: Critically bleeding dogs, defined as dogs who received ≥ 25 ml/kg of blood products for treatment of hemorrhagic shock caused by blood loss.Measurements and Main Results: Sixty-nine dogs were included. Sources of critical bleeding were trauma (26.1%), intra/perioperative surgical period (26.1%), miscellaneous (24.6%), and spontaneous hemoabdomen (23.1%). Median (range) age was 7 years (0.5–18). Median body weight was 20 kg (2.6–57). Median pre-transfusion hematocrit, total protein, systolic blood pressure, and lactate were 25% (10–63), 4.1 g/dl (2–7.1), 80 mm Hg (20–181), and 6.4 mmol/L (1.1–18.2), respectively. Median blood product volume administered was 44 ml/kg (25–137.4). Median plasma to red blood cell ratio was 0.8 (0–4), and median non-blood product resuscitation fluid to blood product ratio was 0.5 (0–3.6). MT was given to 47.8% of dogs. Survival rate was 40.6%. The estimated odds of survival were higher by a factor of 1.8 (95% CI: 1.174, 3.094) for a dog with 1 g/dl higher total protein above reference interval and were lower by a factor of 0.6 (95% CI: 0.340, 0.915) per 100% prolongation of partial thromboplastin time above the reference interval. No predictors of MT were identified.Conclusions: Critical bleeding in dogs was associated with a wide range of resuscitation patterns and carries a guarded to poor prognosis.

Characterising differences in red blood cell usage patterns between healthcare sectors in South Africa: 2014-2019.

South Africa aims to transition from a two-tiered healthcare system (public and private) to universal health coverage. Data on red blood cell (RBC) product usage reveal disparities between the sectors. Blood transfusion services further need to understand differing disease profiles and transfusion prescribing practices between the sectors to ensure blood security should the transition to a two-tiered health system come to fruition. Operational data for public and private healthcare RBC requests between 1 January 2014 and 31 March 2019, obtained from the South African National Blood Service (SANBS), were retrospectively analysed. Sector-specific demographic and utilisation trends were compared for the dominant clinical disciplines. Pre-transfusion haemoglobin (Hb) patterns were also delineated for 2018. Between 2014 and 2019, 2,356,411 public and private sector RBC transfusion events resulted in the issue of 4,020,094 RBC units (1,553,159 transfusion events and 2,495,054 units within the public sector versus 803,282 transfusion events and 1,525,040 units in private). The dominant clinical disciplines within the public sector were Medical (32.9%), Gynaecology/Obstetrics (27.3%), General Surgery (13.6%), and Paediatrics (including Paediatric Surgery) (6.5%), compared to Intensive Care Units (33.2%), Medical (28.3%), General Surgery (10.4%), and Haematology/Oncology (8.3%) in the private sector. Median pre-transfusion Hb values for 2018 were lower in the public than in the private sector: 6.9 g/dL public sector versus 8 g/dL private sector. Clinical drivers of RBC usage within the public and private healthcare sectors in South Africa differ significantly. Disparate pre-transfusion Hb between the sectors are likely due to differing disease profiles and severity, as well as differences in practice in prescribing transfusions. Implementation of a nationally co-ordinated Patient Blood Management programme may help to address these disparities and help ensure a sustainable blood transfusion system.

Retrospective Review of Transfusion Practices in a Single Neonatal Intensive Care Unit (NICU) Compared to Recent Transfusion Guidelines

BackgroundPlatelet and packed red blood cell (pRBC) transfusion practices for preterm infants vary significantly worldwide. Recent randomized trials of preterm infants receiving platelet or pRBC transfusions have not shown any benefit with higher compared to lower transfusion thresholds. In the recent PlaNeT2 study published in January 2019, infants receiving platelets at higher thresholds had significantly higher rates of death and major bleeding. These findings raise concern about transfusing adult platelets into a delicately balanced neonatal hemostatic system with relatively hypofunctional platelets as a potential etiology of this multifactorial outcome. In this retrospective review, we aimed to review transfusion practices and outcomes, including thrombosis, in the neonatal intensive care unit (NICU) at the University of Arizona, Tucson in comparison to the PlaNeT2 study.MethodsAfter Institutional Review Board approval, we reviewed the electronic medical records of all neonates born at < 32 weeks gestation in the NICU or transferred to the NICU within 48 hours of birth between January 1, 2018 and December 31, 2019, corresponding to one year pre- and one year post-publication of the PlaNet2 study. For each patient record reviewed, we collected demographics, reviewed whether transfusions occurred, and documented pre-transfusion hemoglobin, platelet count, international normalized ratio, fibrinogen activity level, and clinical outcomes. We recorded the number of transfusions of each product, clinical central lines placed, and imaging studies performed to detect thrombosis. These data were analyzed using descriptive analysis.ResultsThere were 127 neonates born <32 weeks gestation, all of whom were analyzed. Twenty-eight (35%) of neonates were born at <27 weeks' gestation and twenty-two (17%) were <1500 g at birth and were considered high risk infants. Seventy three percent of these patients were intubated at some point during their NICU admission. The majority of patients had bronchopulmonary dysplasia (63%). Ten patients developed necrotizing enterocolitis (7.8%), 28 had presumed or confirmed sepsis (22%), 52 had congenital heart disease (41%), and 12 had retinopathy of prematurity (9.4%).During the two-year period of this review, 60% of patients had at least one pRBC transfusion, 13% of patients had at least one platelet transfusion, and 6% of patients had at least one fresh frozen plasma (FFP) transfusion. A total of 35 platelet, 370 pRBC, and 11 FFP transfusions were administered with a mean total of 3.3 total transfusions per patient. The mean and median pre-transfusion platelet counts were 79,300/uL and 52,000/uL, respectively. The mean and median pre-transfusion hemoglobin values were 12.1 g/dL and 12.2 g/dL, respectively. Only two of 35 platelet transfusions were given after the publication of the PlaNeT2 study in January 2019; however, both transfusions were given for neonates with pre-transfusion platelet counts >50,000/uL.There were no arterial or venous thrombosis events noted in our population even though 108 patients (85%) had a peripherally inserted central catheters for an average of 12 days, 32 (25%) had umbilical arterial catheters for an average of 7 days, and 66 (52%) had umbilical vein catheters placed for an average of 6 days.ConclusionsThe majority of transfusions given to neonates born at <32 weeks gestation at the University of Arizona, Tucson institution over a two-year retrospective study period were pRBC transfusions with an incidence of 0.6 followed by platelet transfusions (incidence of 0.13) and FFP. Platelet transfusion practices changed drastically following publication of the PlaNet2 study, with only 2 of 35 (5.7%) platelet transfusions given after the publication of this study. No thrombotic events were documented in the study population despite a high prevalence of central venous lines and a mean pre-platelet transfusion threshold of 79,300/uL. Transfusion practice guidelines can affect clinical practices in the NICU and can potentially minimize risks. Larger prospective studies are needed to evaluate risk of thrombosis related to adult platelet transfusions given to neonates. DisclosuresNo relevant conflicts of interest to declare.

Prevalence, Risk Factors, and Outcomes of Platelet Transfusion Refractoriness in Critically Ill Patients: A Retrospective Cohort Study

Background Refractoriness to platelet transfusion is an understudied phenomenon in critically ill patients. Our objective was to evaluate the prevalence, risk factors, and clinical outcomes of platelet refractoriness among patients in a tertiary-care intensive care unit (ICU). Methods A retrospective cohort study included all patients (age >14 years) who were admitted to a tertiary-care medical-surgical ICU between 2011 and 2016 and received ≥2 platelet transfusions during their ICU stay. We calculated platelet increment (PI) and corrected count increment (CCI). Results A total of 267 patients were enrolled in the study, collectively receiving 1357 transfusions with a median of 4.0 (interquartile range: 2.0, 6.0) transfusions per patient. The median pretransfusion platelet count was 31000.0 × 106/L (interquartile range: 16000.0, 50000.0). The median PI was 6000 × 106/L. The prevalence of platelet transfusion refractoriness was 54.8% based on PI < 10000 × 106/L and 57.0% based on CCI <5000. Patients admitted under hepatology/liver transplant had the highest rates of platelet refractoriness (69.6%), while those under general surgery had the lowest rate (43.2%). Younger age, nontrauma admission, and larger spleen size were associated with platelet refractoriness. Finally, refractoriness was associated with increased length of stay in the ICU (p = 0.02), but not with mortality. Conclusions Platelet transfusion refractoriness was highly (>50%) prevalent in ICU patients. However, it was not associated with increased mortality.

MDS-279: Efficacy and Safety of Luspatercept in Patients with Anemia: A Systematic Review

Context: Luspatercept is an erythroid maturation agent that has been shown to improve anemia by influencing late-onset erythropoiesis. Objective: To determine safety and efficacy of luspatercept in patients aged >18 years of age and diagnosed with either myelodysplastic syndrome or beta-thalassemia. Design: Systematic review. Methods: A literature search was performed on PubMed, Embase, clinicaltrials.gov, Web of Science, and Cochrane using the MeSH terms “anemia” and “Immunoglobulin fc fragments” from database inception until 4/20/2021. After screening 420 articles, 2 randomized clinical trials (RCT, N=565) and 2 phase II trials (N=122) were included. Results: In 4 clinical trials (N=687), subcutaneous luspatercept (0.125 mg/dl to 1.75 mg/dl) was administered every 21 days for at least 48 weeks or 5 cycles to treat anemia in beta-thalassemia (N=288) and MDS (N=211) patients. The median pre-transfusion hemoglobin level was 7.6 g/dl in MDS patients and 10 g/dl in beta-thalassemia patients. Median red cell transfusion burden varied between 14 RBC units/24 weeks to 8 RBC units/8 weeks. Cappellini et al. and Piga et al. (N=400) showed >33% reduction in RBC transfusion burden in 71% (n=159/224) of patients (vs 29.5% with placebo) and >20% reduction in 80% (n=51/64) of patients with beta-thalassemia. Platzbecker et al. and Fenaux et al. (N=287) showed more than 4 RBC unit reduction/8 weeks in 47% (n=100/211) of patients with MDS treated with luspatercept (vs 21% with placebo). High-dose-treated patients had a mean increase in Hb ranging from 0.36 g/dl to 1.52 g/dl. The most common side effects included headache, back pain, bone pain, fatigue, and diarrhea in 19.6% (n=98), 19.4% (n=97), 13% (n=65), 9% (n=45), and 7.4% (n=37), respectively. More than grade 3 adverse effects were bone pains, hyperuricemia, and back pain in 6.4% (n=32), 1.2% (n=6), and 0.6% (n=3), respectively. Conclusion: Luspatercept showed better efficacy than placebo in beta-thalassemia and MDS patients to treat anemia and was well-tolerated by these patients. High-dose luspatercept has shown promising results in terms of erythroid response, measured as either a reduction in transfusion burden or a mean increase in hemoglobin levels. A number of clinical trials are ongoing to assess its efficacy in myelofibrotic disorders to further extend its usage.

Impact of universal irradiation on chronic transfusion for sickle cell disease.

Irradiation of blood products prevents transfusion-associated graft-versus-host disease, but most patients do not require this modification which could have an adverse impact on transfusion outcomes. We hypothesized that irradiation may increase transfusion requirements for patients with sickle cell disease (SCD) receiving chronic transfusion. Our pediatric hospital implemented a new policy of universal blood product irradiation in May 2018. We conducted a retrospective chart review of patients with SCD receiving chronic red blood cell (RBC) transfusion throughout the year before and after institution of this policy. The primary outcome was the change in RBC transfusion volume per patient weight transfused during the pre- vs. post- universal irradiation period. Secondary outcomes were the change in median pretransfusion laboratory values. Among 17 patients, 8 (47%) received more RBCs the year before irradiation and 9 (53%) received more the year after irradiation. Implementation of universal irradiation did not significantly increase transfusion volumes needed to clinically manage this population (median change +1.7ml/kg/year, p= .54). Additionally, there were no significant changes in absolute reticulocyte count, hemoglobin, hemoglobin S%, white blood cell count, lactate dehydrogenase, total bilirubin, serum potassium, and ferritin during the two time periods. In a cohort of patients with SCD receiving simple chronic transfusion, irradiation did not impact transfusion requirements or pertinent pretransfusion laboratory values. Irradiation does not appear to have clinically significant consequences for SCD chronic transfusion management.

Chronic Red Blood Cell Exchange Transfusion Therapy Does Not Impact Hospital Utilization or Ascq-Me Pain Domains in Adults Living with Sickle Cell Disease

Introduction: Chronic red blood cell exchange transfusion (CET) therapy is currently used to prevent neurologic and other complications of sickle cell disease (SCD) in children and adults. Despite past pediatric studies showing that CET decreases stroke risk and hospital admissions, few studies have evaluated whether CET decreases hospital utilization or pain in adults with SCD. Data support health care utilization is a poor marker of pain frequency so other ways of assessing the impact of therapy on pain outcomes is necessary and important. We noted that despite receiving CET, our adult patients experienced daily pain requiring home opioid use and intermittent hospitalization for pain crisis. Thus, we conducted a study to examine the effects of CET on the pain experience. Our primary hypothesis was that adults on CET will have similar levels of pain as defined by Adult Sickle Cell Quality of Life Measurement Information System (ASCQ-Me) pain domains as compared to adults not on CET. Our secondary hypothesis was that adults on CET will have similar levels of hospital utilization, opioid use, QOL measures of domains noted to be affected by SCD or inflammatory markers shown to be correlated with pain and SCD pain crisis.Methods: We conducted a pilot cross-sectional study of adults with SCD treated with or without CET. Subjects were enrolled at scheduled clinic visits and subjects not at their heathy baseline or who receive regular simple transfusion were excluded. Our primary outcome was pain as defined by ASCQ-Me pain domains which include pain crisis frequency, pain crisis severity, and 7-day pain interference which allow the tool to measure both crisis pain and chronic pain. Our secondary outcomes were hospital utilization, opioid use, QoL measures included in ASCQ-ME: sleep, stiffness, social impact and emotional impact, Patient Reported Outcome Measurement Information System domains for nausea and anxiety and inflammation measured by WBC and platelet counts, C reactive protein (CRP) and cytokine levels. Hospital utilization (total annual admissions and emergency room visits) was assessed by medical record review over a one-year period (1/1/2016 to 12/31/2016). Weekly opioid use was estimated by review of dispensed prescriptions using the Connecticut Prescription Monitoring Program converted into average weekly oral morphine equivalents. Tumor necrosis factor alpha (TNFα), interleukin 1α and 1β (IL-1α, IL-1β) and interleukin 4 (IL-4) were measured using a luminex multiplex assay. Blood was obtained prior to starting CET. The R statistical software program was used to perform t-tests and Wilcoxon rank-sum tests where normality was not met to compare subjects on CET to those not on CET. Significance was set at p<0.05.Results: We enrolled 27 subjects (n=16 in no CET group and n=11 in CET group); indications for CET included primary (n=1) or secondary (n=10) stroke prophylaxis. There was no difference between groups in mean age (33.3 SD 10.1 vs 29.4 SD 12.4 years, p=0.4) or gender (% female: 45% vs. 63%, p=0.3). No patients on CET and 68.7% of those not on CET were prescribed hydroxyurea. Median time patients were receiving chronic transfusions was 5 (IQR 2-14.5) years, and median pre-transfusion %S was 40.3 (IQR 32.2-44.9) %. Subjects on CET had similar median admissions and ED visits compared to those not on CET (1 (IQR 0-1.5) vs 2 (IQR 0-5) admissions p=0.09, 0 (IQR 0-0.5) vs 0.5 (IQR 0-2) ED visits p=0.07). Subjects in both groups were dispensed similar median weekly doses of opioids (CET: 27.4 (IQR 3.0-200.5) vs No CET: 42.7 (IQR 13.0-171.6) mg oral morphine equivalents p=0.7). Subjects on CET had similar ASCQ-ME scores to subjects not on CET for pain episode frequency, severity, and 7-day pain impact (Table 1). Those on CET had superior scores for sleep, nausea, and anxiety (Table 1). Subjects on CET had higher baseline platelet and WBC counts and there was no difference in CRP or cytokines measured between groups (Table 1).Conclusions: Collectively, our pilot data suggest despite patients receiving CET pain could still develop. Thus, additional therapies in combination with CET may be needed to optimize pain and quality of life in adults living with SCD. We may have failed to show a difference in hospital utilization due to our subjects being placed on CET for neurologic events, not frequent crisis. A larger prospective cohort study should be done to confirm our preliminary findings. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Transfusion practices in a large cohort of hospitalized children.

While previous studies have described the use of blood components in subsets of children, such as the critically ill, little is known about transfusion practices in hospitalized children across all departments and diagnostic categories. We sought to describe the utilization of red blood cell, platelet, plasma, and cryoprecipitate transfusions across hospital settings and diagnostic categories in a large cohort of hospitalized children. The public datasets from 11 US academic and community hospitals that participated in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) were accessed. All nonbirth inpatient encounters of children 0-18 years of age from 2013 to 2016 were included. 61,770 inpatient encounters from 41,943 unique patients were analyzed. Nine percent of encounters involved the transfusion of at least one blood component. RBC transfusions were most common (7.5%), followed by platelets (3.9%), plasma (2.5%), and cryoprecipitate (0.9%). Children undergoing cardiopulmonary bypass were most likely to be transfused. For the entire cohort, the median (interquartile range) pretransfusion laboratory values were as follows: hemoglobin, 7.9 g/dl (7.1-10.4 g/dl); platelet count, 27 × 109 cells/L (14-54 × 109 cells/L); and international normalized ratio was 1.6 (1.4-2.0). Recipient age differences were observed in the frequency of RBC irradiation (95% in infants, 67% in children, p < .001) and storage duration of RBC transfusions (median storage duration of 12 [8-17] days in infants and 20 [12-29] days in children, p < .001). Based on a cohort of patients from 2013 to 2016, the transfusion of blood components is relatively common in the care of hospitalized children. The frequency of transfusion across all pediatric hospital settings, especially in children undergoing cardiopulmonary bypass, highlights the opportunities for the development of institutional transfusion guidelines and patient blood management initiatives.

Variation in Neonatal Transfusion Practice

To estimate the incidence of blood product transfusion, including red blood cells, platelets, and plasma, and characterize pretransfusion hematologic values for infants during their initial hospitalization after birth. Retrospective cohort study using data from 7 geographically diverse US academic and community hospitals that participated in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) from 2013 to 2016. Pretransfusion hematologic values were evaluated closest to each transfusion and no more than 24hours beforehand. Data from 60 243 infants were evaluated. The incidence of any transfusion differed by gestational age (P<.0001), with 80% (95% CI 76%-84%) transfused at <27weeks of gestation (n=329) and 0.5% (95% CI 0.5%-0.6%) transfused at ≥37weeks of gestation (n=53 919). The median pretransfusion hemoglobin was 11.2g/dL (10th-90th percentile 8.8-14.1) for the entire cohort, ranging from 10.5g/dL (8.8-12.3) for infants born extremely preterm at <27weeks of gestation to 13.0g/dL (10.5-15.5) for infants born at term. The median pretransfusion platelet count (×109/L) was 71 (10th-90th percentile 26-135) for the entire cohort, and was >45 for all gestational age groups examined. The median pretransfusion international normalized ratio for the entire cohort was 1.7 (10th-90th percentile 1.2-2.8). There is wide variability in pretransfusion hemoglobin, platelet count, and international normalized ratio values for neonatal transfusions. Our findings suggest that a large proportion of neonatal transfusions in the US are administered at thresholds greater than supported by the best-available evidence and highlight an opportunity for improved patient blood management.

A prospective multi-faceted interventional study of blood bank technologist screening of red blood cell transfusion orders: The START study.

Transfusion of red blood cells (RBC) is a common procedure, which when prescribed inappropriately can result in adverse patient outcomes. This study sought to determine the impact of a multi-faceted intervention on unnecessary RBC transfusions at hospitals with a baseline appropriateness below 90%. A prospective medical chart audit of RBC transfusions was conducted across 15 hospitals. For each site, 10 RBCs per month transfused to inpatients were audited for a 5-month pre- and 10-month post-intervention period, with each transfusion adjudicated for appropriateness based on pre-set criteria. Hospitals with appropriateness rates below 90% underwent a 3-month intervention which included: adoption of standardized RBC guidelines, staff education, and prospective transfusion order screening by blood bank technologists. Proportions of RBC transfusions adjudicated as appropriate and the total number of RBC units transfused per month in the pre- and post-intervention period were examined. Over the 15-month audit period, at the 13 hospital sites with a baseline appropriateness below 90%, 1950 patients were audited of which 81.2% were adjudicated as appropriate. Proportions of appropriateness and single-unit orders increased from 73.5% to 85% and 46.2% to 68.2%, respectively from pre- to post-intervention (P < .0001). Pre- and post-transfusion hemoglobin levels and the total number of RBCs transfused decreased from baseline (P < .05). The median pre-transfusion hemoglobin decreased from a baseline of 72.0 g/L to 69.0 g/L in the post-intervention period (P < .0001). RBC transfusions per acute inpatient days decreased significantly in intervention hospitals, but not in control hospitals (P < .001). The intervention had no impact on patient length of stay, need for intensive care support, or in-hospital mortality. This multifaceted intervention demonstrated a marked improvement in RBC transfusion appropriateness and reduced overall RBC utilization without impacts on patient safety.

Effects of red blood cell transfusions given to non-septic critically ill patients: apropensity score matched study.

Previous studies have demonstrated that low-grade red blood cell transfusions (RBC) given to septic patients are harmful. The objectives of the present study were to compare mortality and morbidity in non-septic critically ill patients who were given low-grade RBC transfusions at haemoglobin level > 70 γ L-1 with patients without RBC-transfusions any of the first 5 days in intensive care. Adult patients admitted to ageneral intensive care unit between 2007 and 2018 at auniversity hospital were eligible for inclusion. Patients who received > 2 units RBC transfusion per day during the first 5 days after admisasion, with pre-transfusion haemoglobin level < 70 γ L-1 or with severe sepsis or septic shock, were excluded. In total, 9491 admissions were recorded during the study period. Propensity score matching resulted in 2 well matched groups with 674 unique patients in each. Median pre-transfusion haemoglobin was 98 γ L-1 (interquartile range 91-107 γ L-1). Mortality was higher in the RBC group with an absolute risk increase for death at 180 days of 5.9% (95% CI: 3.6-8.3; P < 0.001). Low-grade RBC-transfusion was also associated with renal, circulatory, and respiratory failure as well as ahigher SOFA-max score. Sensitivity analyses suggested that disease trajectories during the exposure time did not significantly differ between the groups. Low-grade RBC-transfusions given to non-septic critically ill patients without significant anaemia were associated with increased mortality, increased kidney, circulatory, and respiratory failure, as well as higher SOFA-max score.

Transition from room temperature to cold-stored platelets for the preservation of blood inventories during the COVID-19 pandemic.

BackgroundThe COVID‐19 pandemic has placed great strain on blood resources. In an effort to extend platelet (PLT) shelf life and minimize waste, our institution transitioned room temperature to cold‐stored PLTs for administration to bleeding patients.Study Design and MethodsWe describe the administrative and technical processes involved in transitioning room temperature PLTs to cold storage in April 2020. Additionally, we describe the clinical utilization of cold‐stored PLTs in the first month of this practice change, with a focus on changes in PLT counts after transfusion, hemostasis, and safety outcomes.ResultsA total of 61 cold‐stored PLT units were transfused to 40 bleeding patients, with a median (interquartile range [IQR]) of 1 (1‐2) units per patient. The median age was 68 (59‐73) years; 58% male. Median pretransfusion and posttransfusion PLTs counts were 88 (67‐109) and 115 (93‐145). A total of 95% of transfusions were administered in the operating room: 57% cardiac surgery, 20% vascular surgery, 8% general surgery, and 5% solid organ transplantation. Hemostasis was deemed to be adequate in all cases after transfusion. There were no transfusion reactions. One patient (3%) experienced a fever and infection within 5 days of transfusion, which was unrelated to transfusion. Median (IQR) hospital length of stay was 8.5 (6‐17) days. Two patients (5%) died in the hospital of complications not related to transfusion.ConclusionCold‐stored PLT utilization was associated with adequate hemostasis and no overt signal for patient harm. Conversion from room temperature to cold‐stored PLTs may be one method of reducing waste in times of scarce blood inventories.

Impact of Universal Irradiation on Chronic Transfusion for Sickle Cell Disease

Introduction: Irradiation of blood products is necessary to prevent transfusion-associated graft-versus-host disease (TA-GVHD) for patients at risk of this fatal transfusion complication. Despite the implementation of protocols to identify patients at risk of TA-GVHD, missed irradiation events still occur; therefore, some institutions have adopted a policy of universal irradiation of blood products to prioritize safety. Universal irradiation, however, could have an adverse impact on transfusion outcomes as red blood cell (RBC) unit irradiation has been associated with smaller hemoglobin (Hb) increments, biological changes to the RBC membrane, shortened RBC survival, and potassium release. These potential adverse effects of irradiation may be especially important for patients with sickle cell disease (SCD) receiving chronic transfusion, a group that does not require irradiated blood products. Methods: Our pediatric institution implemented a policy of universal blood product irradiation in May 2018 in which all RBC units are irradiated typically at time of issue. We conducted a retrospective chart review of patients with SCD receiving simple chronic RBC transfusion throughout the year before (5/3/2017-5/3/2018) and the year after (5/4/2018-5/4/2019) this policy change. Patients were excluded if during either time period they received fewer than 10 transfusions, chronic transfusion targets were modified, hydroxyurea was started, they received more than 5 RBC units for an acute complication, or they were transfused at an outside institution. The primary outcome was the change in RBC transfusion volume per patient weight transfused during the pre- vs. post- universal irradiation time period. Secondary outcomes were the change in median pretransfusion laboratory values. The change in these outcomes was analyzed with the Wilcoxon matched-pairs signed rank test. Results: Among 59 chronic transfusion patients, we identified 12 who fit our inclusion/exclusion criteria (5 males, 7 females), all of whom were on chronic transfusion for either primary or secondary stroke prevention. Regarding SCD genotype, 10 patients had Hb SS, and 1 patient had Hb Sβ0 thalassemia. The median patient age at the time of the irradiation policy change was 10 years (range 3 to 18 years). During the pre- universal irradiation time period only 4% (10/230) of units transfused to these patients were irradiated, likely due to reallocation from other patients. As expected per the policy change, 100% (271/271) of units were irradiated in the universal irradiation time period. During both time periods, patients received a median of 12 transfusions. When comparing the volume transfused per patient weight during these two time periods for each patient, 5 patients (42%) received more RBCs the year prior to universal irradiation and 7 (58%) received more RBCs in the year following the policy change (Figure). For the entire group, the median difference in volume per patient weight was +4.7 ml/kg, p=0.26. When comparing the change in median pretransfusion Hb, Hb S, lactate dehydrogenase, total bilirubin, potassium, and ferritin, there were no significant differences (Table). Conclusions: In a cohort of patients with SCD receiving simple chronic transfusion for stroke prevention, a new policy of universal irradiation did not impact transfusion requirements or pertinent pretransfusion laboratory values. Universal irradiation does not appear to have clinically significant consequences for SCD chronic transfusion management. Disclosures No relevant conflicts of interest to declare.

Sustained Reductions in Red Blood Cell (RBC) Transfusion Burden and Events in β-Thalassemia with Luspatercept: Longitudinal Results of the Believe Trial

Sustained Reductions in Red Blood Cell (RBC) Transfusion Burden and Events in β-Thalassemia with Luspatercept: Longitudinal Results of the Believe Trial

Prevalence and risk factors for red blood cell alloimmunisation among sickle cell patients in Mwanza City, Tanzania.

BackgroundErythrocyte alloimmunisation can lead to complications such as delayed haemolytic transfusion reaction.ObjectiveThis study investigated the prevalence of and risk factors for red blood cell alloimmunisation among multiply transfused sickle cell disease (SCD) patients in Mwanza City, Tanzania.MethodsFrom May 2017 to July 2017, this descriptive, cross-sectional, hospital-based study enrolled 200 participants with SCD who had received at least two units of blood in the previous year. Blood count was performed using a Sysmex haematology analyser. Antibody screening was done by the tube method using a panel of three screening cells with known antigenicity.ResultsOf the 200 patients enrolled, 108 (54%) were female. The median age was 4.5 years (interquartile range [IQR] = 6), the median number of transfusions was 3 (IQR = 1), and the median pre-transfusion haemoglobin level was 6.6 g/dl (IQR = 2.7). Prevalence of alloimmunisation was 8.5% (17/200) with immunoglobulin G, and one patient developed cold immunoglobulin M antibodies. Blood groups reported were Rhesus C and E, Kell, Kidd and Duffy. There was no statistically significant association between the number of transfusions and the risk of alloimmunisation.ConclusionThe rate of alloimmunisation in multiply transfused SCD patients was 8.5% and higher than other studies in East Africa. Thus, there is a need for extensive red blood cell screening and matching to minimize alloimmunisation and risk of delayed haemolytic transfusion reaction, particularly in SCD and chronically transfused patients.

FEEding DURing red cell transfusion (FEEDUR RCT): a multi-arm randomised controlled trial

BackgroundNecrotising Enterocolitis (NEC) is a devastating neonatal disease. A temporal association between red cell transfusion and NEC has been recognized and there have been concerns about the effects of feeding during transfusion. We aimed to assess the effect of different enteral feeding regimens on splanchnic oxygenation in preterm infants receiving red cell transfusions.MethodsThis was an open, multi-arm, parallel-group, randomised controlled trial conducted in a single centre in Australia. We compared three different enteral feeding regimes during a single red cell transfusion in preterm infants < 35 weeks gestational age at birth. Infants were randomised to either: (1) Withholding enteral feeds for 12 h from the start of transfusion or; (2) Continuing enteral feeds or; (3) Restriction of enteral feed volume to 120 ml/kg/day (maximum 20 kcal/30 ml) for 12 h. The primary outcome was mean splanchnic-cerebral oxygenation ratio (SCOR) and mean splanchnic fractional oxygen extraction (FOE) before (1 h prior), during (1 h into transfusion) and after (end of transfusion; 12 and 24 h post) transfusion.ResultsThere were 60 transfusion episodes (20 transfusion episodes in each group) included in the analysis. 41 infants with a median gestational age at birth of 27 weeks (range 23–32 weeks) were enrolled. The median postnatal age was 43 days (range 19–94 days) and the median pre-transfusion haematocrit was 0.27 (range 0.22–0.32). All three groups were similar at baseline. There were no differences in mean SCOR and mean splanchnic FOE at any of the pre-specified time points. There were also no differences in clinical outcomes. There were no episodes of NEC in any infant. Across all groups the mean SCOR increased from the start to the end of each transfusion (0.97 [CI95% 0.96–0.98] vs 1.00 [CI95% 0.99–1.01]; p = 0.04) and the mean FOE decreased from the start to the end of each transfusion (0.22 [CI95% 0.21–0.23] vs 0.17 [CI95% 0.16–0.18]; p < 0.001).ConclusionsThere were no differences in splanchnic oxygenation when enteral feeds were either withheld, continued or restricted during a transfusion. However, the successful conduct of this study supports the feasibility of a large trial powered to assess clinical outcomes.Trial registrationANZCTR, ACTRN12616000160437. Registered 10 February 2016, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370069