Need For Red Blood Cell Transfusion Research Articles

Review of available evidence supporting different transfusion thresholds in different patient groups with anemia

In patients with anemia, transfusion of red blood cells (RBCs) can save lives and improve quality of life. The choice to transfuse should be cautiously made owing to risks of transfusion, economic costs, and limitations on the blood supply. Until the 1980s, the decision for RBC transfusion was guided by Hb threshold, with the aim of maintaining the patient's blood Hb level over 100 grams per liter. Since then, multiple randomized controlled trials and key systematic reviews have provided evidence-based guidelines as to appropriate transfusion thresholds in a number of clinical settings. Here, we aimed to address the outcome of defining different anemia criteria in specific clinical populations exclusively on the basis of the need for RBC transfusion based on Hb concentration. We focused on the patient populations, where there were the most available data on differing transfusion thresholds, which looked at transfusing to a higher or liberal transfusion threshold in comparison with a lower or restrictive transfusion threshold. These included patients in intensive care with or without septic shock, hip fracture surgery, cardiovascular surgery, and upper gastrointestinal bleeding, the pediatric population, and also those with malaria, by reviewing key randomized controlled trials and systematic reviews. Twenty-four randomized controlled studies and 12 systematic reviews have been included, and these are discussed below.

Red Blood Cell Transfusion Practices in the Neurointensive Care Unit: A Narrative Review

AbstractAnemia is common in neurointensive care unit (NICU) patients and is one of the common causes of systemic insults to the brain. Though the recent literature favors restrictive blood transfusion practices over liberal transfusion to correct anemia in the general ICU, whether a similar practice can be adopted in NICU patients is doubtful due to lack of strong evidence. Impairment of cerebral autoregulation and cardiac function following acute brain injury affects the body's compensatory mechanism to anemia and renders the brain susceptible to anemic hypoxia at different hemoglobin (Hb) thresholds. Hence, red blood cell transfusion (RBCT) practice based on a single Hb threshold value might be inappropriate. On the other hand, allogenic RBCT has its own risks, both in short and in long run, leading to adverse outcomes. Thus, instead of relying only on arbitrary Hb values, a better way to decide the need for RBCT in NICU patients is to target parameters based on systemic and regional cerebral oxygenation. This approach will help us to individualize RBCT practices. In this narrative review, based on the available literature, authors have discussed the impact of anemia and blood transfusion on the immediate and late neurological outcomes and the current role of regional brain monitoring in guiding blood transfusion practices. In the end, authors have tried to update on the current RBCT practices in neurosurgical and neuromedical patients admitted to the NICU.

RISK FACTORS FOR BLOOD TRANSFUSION IN WOMEN UNDERGOING GYNAECOLOGICAL SURGERY

Objectives A common complication of surgery is peri-operative blood loss, which increases the likelihood of red blood cell (RBC) transfusion and its associated risks. The objective of this study was to identify demographic, medical, and surgical factors that may predict the need for RBC transfusion in patients undergoing benign gynaecological surgery. Methods We performed a retrospective cohort study of patients undergoing benign gynaecological surgery between April 1st 2016 to March 31st 2017 in a tertiary care hospital. Log binomial regression model was used to calculate risk ratios and adjusted risk ratios, while controlling for the effect of preoperative anaemia. Results Among the 988 patients included, 41 patients (4.1%) received an RBC transfusion and 185 (18.7%) had preoperative anemia. In the total cohort, mean haemoglobin was 126.19+/-15.43g/L, while itwas 104.39+/-21.59g/L among those who received RBC transfusion. Patients had an increased risk of requiring RBC transfusion if they had preoperative anemia (RR 8.37[95%CI 4.48-15.64]), abnormal uterine or vaginal bleeding (RR 2.47[95%CI 1.21-5.03]), underwent vaginal/hysteroscopic myomectomy (RR 6.28[95%CI 1.82-21.69]), or had a salpingectomy (RR 2.13[95%CI 1.01-4.48]). Risk of RBC transfusion was lower among patients with vaginal hysterectomy (RR 0.08[95%CI 0.01-0.57]) and prolapse repair (RR 0.06[95%CI 0.01-0.44]). After controlling for preoperative anemia, only vaginal/hysteroscopic myomectomy showed increased risk of requiring RBC transfusion (RR 3.36[95%CI 1.13-10.01]). Conclusions Preoperative anemia and vaginal/hysteroscopic myomectomy are important independent risk factors for predicting the need for increased RBC transfusion in the peri-operative period. Identifying risk factors can facilitate peri-operative management to minimize the need for transfusion.

44 Inhalation Injury Does Not Increase Blood Transfusion Requirements Following Burn Injury in Adults

Patients with major burns receive numerous red blood cell (RBC) transfusions for many indications, but it is not known whether an accompanying inhalation injury (INHI) influences the amount of blood transfused. The purpose of this study was to examine the effect of INHI on RBC transfusion in burned adults. This was a secondary analysis of a multi-center prospective randomized controlled trial that compared a liberal and restrictive blood transfusion threshold in adults with burns ≥ 20% TBSA. We compared 25 response variables between patients with and without INHI but here focus on the total number of RBC transfusions per patient (nRBC), the number of RBC transfusions per day (RBC/day), and the number of RBC transfusions/%TBSA burn (RBC/%). Generalized estimating equations (GEE) were used to account for clustering by facility. P values for response variable tests were adjusted for multiple comparisons. Multiple regression with GEE was used to identify variables that determined RBC/day. Values are shown as mean ± SD or median [25th,75th Q] as appropriate. Of 345 patients (age 42.9 +/- 16.8 years, %TBSA burn 38.0 +/- 17.6, 20.9% female, and admission APACHE 18.4 +/- 8.1) there were 78 (23%) with INHI. The table compares patients with and without INHI. The regression found that %TBSA burn (p<0.001), age (p=0.004), and requiring at least one day of mechanical ventilation(MV) (p < 0.0001) were significant determinants of RBC/day whereas INHI (p=0.251), and presence of at least one blood stream infection (p=0.107) were not. While patients with INHI tended to get more blood transfusions, this appears to have been determined by burn extent and requiring MV rather than the INHI itself. Presence of an INHI does not independently increase the need for RBC transfusions following a major burn injury. Table a P-values were not adjusted for multiple testing. Table a P-values were not adjusted for multiple testing.

Retrograde autologous priming in surgery of thoracic aortic aneurysm.

Surgery of thoracic aortic aneurysm (TAA) is associated with blood loss and coagulopathy and a high need for red blood cell (RBC) volume. Retrograde autologous priming (RAP) decreases haemodilution during cardiopulmonary bypass (CPB). The aim of this study was to show the effect of RAP during surgery of TAA repair on haemodilution, the need for RBC transfusion and the postoperative course compared to conventional CPB (cCPB). A retrospective study was performed on 120 patients with TAA. Half of these patients underwent cCPB and the other half received RAP. Statistical analysis was performed using IBM SPSS statistics 23. The χ2 test, the Fisher's exact tests, the independent t-test and the Mann-Whitney U-test were used. Statistical significance was assumed at P-value <0.05. Lower blood product requirements were observed for the RAP group regarding the transfusion of intraoperative RBC (0.87 ± 1.33 vs 1.97 ± 2.43, P = 0.013), postoperative RBC (0.57 ± 1.4 vs 1.32 ± 1.82, P = 0.002) and postoperative fresh frozen plasma (0.52 ± 1.63 vs 1.48 ± 3.32, P = 0.036). The postoperative drainage loss showed significantly lower measurements for the RAP group after 6 h (295.9 ± 342.6 vs 490.6 ± 414.4 ml, P ≤ 0.001), 12 h (450.1 ± 415.5 vs 652.1 ± 463.9 ml, P < 0.001) and 24 h (693.1 ± 483.9 vs 866.4 ± 508.4 ml, P = 0.004). RAP is a safe and easy method to reduce RBC transfusion in TAA surgery without any adverse effects on the clinical outcome. We were also able to show beneficial effects on fresh frozen plasma requirements and postoperative chest drainage volume. Furthermore, improved microcirculation can be suspected. In consequence, we have implemented RAP as a clinical standard during thoracic aortic surgery.

Blood Loss Due to Laboratory Testing in Critical Care Patients: A Retrospective Cohort Study

Background: Anemia and red blood cell (RBC) transfusions occur frequently in intensive care unit (ICU) patients and are associated with morbidity and mortality. Observational data suggest that anemia (nadir hemoglobin ≤ 9 g/dL) in ICU patients is associated with an increased risk of death within 30 days (OR 1.54, 95% confidence interval [CI] 1.12-2.12). Although anemia in this population is likely multifactorial, phlebotomy for laboratory testing is substantial (up to 41 mL/day) and may be a modifiable contributor as only 10% of the blood collected is required for analysis. This study aims to (i) characterize the blood volume taken for laboratory testing in ICU patients, and (ii) explore the effect of blood taken for testing on rates of RBC transfusion and anemia in a contemporary cohort of ICU patients.Methods: We conducted a retrospective cohort study of consecutive adult patients, age ≥18 years, admitted to a medical-surgical ICU for ≥48 hours in Hamilton, Ontario between November 1, 2012 to October 1, 2015. We extracted data from previously validated administrative databases. The primary outcome was estimated volume of blood drawn for laboratory testing during index ICU admission calculated using the number of unique blood specimens drawn and known sampling tube volumes. Secondary outcomes included: incidence of severe anemia (hemoglobin ≤9 g/dL), discharge hemoglobin adjusted for RBC transfusion (1.0 g/dL subtracted for each RBC transfusion administered), proportion of patients receiving RBC transfusion, number of RBC units transfused per patient, duration of ICU admission and ICU mortality. Categorical data are reported as counts and proportions. Continuous data are reported as means with standard deviations (SD) or medians with interquartile range (IQR). Predictors of RBC transfusion were examined using Cox regression analysis. P-values <0.05 were considered statistically significant.Results: We included 7,273 ICU patients. The median age was 66 years (IQR 54-76 years) and 40.8% of patients were female. Most responsible diagnosis was circulatory (33.3%), followed by injury/poisoning (15.9%), respiratory (12.8%), and gastrointestinal (9.2%). The ICU mortality rate was 13.8% and the median ICU length of stay was 5 days (IQR 3-10 days). On ICU admission, median hemoglobin value was 9.7 g/dL (IQR 8.2-11.6 g/dL) and 39.6% of patients had hemoglobin ≤ 9.0 g/dL.Median blood loss due to laboratory testing was 25 mL per patient per day (IQR 14-43 mL) and 213 mL per patient for the ICU admission (IQR 133-382 mL). On ICU discharge, median hemoglobin was 8.4 g/dL (IQR 5.8-10.5 g/dL), and 67.0% of patients had hemoglobin ≤ 9.0 g/dL while in ICU. After adjusting for RBC transfusions, the median decrease in hemoglobin from ICU admission to discharge was 1.2 g/dL (IQR 0-2.9 g/dL). RBC transfusions were administered to 47.5% of patients while in the ICU with 37.3% of these patients receiving 5 or more units. The median number of RBC units received in transfused patients was 3 (IQR 2-7). Additional blood drawn for laboratory testing of 150 mL from day 2 to day 7 of ICU admission (hazard ratio [HR] 2.3, 95%CI 2.1-2.5), hematologic diagnosis vs. other (HR 1.5, 95%CI 1.2-2.0), and RBC transfusion prior to ICU admission vs. none (HR 1.5, 95%CI 1.2-1.9) were associated with a higher risk of RBC transfusion in the ICU.Conclusions: Anemia and RBC transfusions are frequent in ICU patients with two-thirds of patients developing severe anemia (hemoglobin <9.0 g/dL) and 47.5% receiving RBC transfusion, respectively. Our results suggest that blood loss for laboratory testing remains substantial in contemporary medical-surgical ICU patients and is associated with the need for RBC transfusion. Strategies to reduce blood loss from laboratory testing represent an area for further prospective investigation. DisclosuresSiegal:BMS-Pfizer: Honoraria; Bayer: Honoraria; Portola Pharmaceuticals: Honoraria.

The need for red blood cell transfusions in the emergency department as a risk factor for failure of non-operative management of splenic trauma: a multicenter prospective study.

The majority of patients with splenic trauma undergo non-operative management (NOM); around 15% of these cases fail NOM and require surgery. The aim of the current study is to assess whether the hemodynamic status of the patient represents a risk factor for failure of NOM (fNOM) and if this may be considered a relevant factor in the decision-making process, especially in Centers where AE (angioembolization), intensive monitoring and 24-h-operating room are not available. Furthermore, the presence of additional risk factors for fNOM was investigated. This is a multicentre prospective observational study, including patients presenting with blunt splenic trauma older than 17years, managed between 2014 and 2016 in two Italian trauma centres (ASST Papa Giovanni XXIII in Bergamo and Sant'Anna University Hospital in Ferrara-Italy). The risk factors for fNOM were analyzed with univariate and multivariate analyses. In total, 124 patients were included in the study. In univariate analysis, the risk factors for fNOM were AAST grade > 3 (fNOM 37.5% vs 9.1%, p = 0.024), and the need of red blood cell (RBC) transfusion in the emergency department (ED) (fNOM 42.9% vs 8.9%, p = 0.011). Multivariate analysis showed that the only significant risk factor for fNOM was the need for RBC transfusion in the ED (p = 0.049). The current study confirms the contraindication to NOM in case of hemodynamically instability in case of splenic trauma, as indicated by the most recent guidelines; attention should be paid to patients with transient hemodynamic stability, including patients who require transfusion of RBC in the ED. These patients could benefit from AE; in centers where AE, intensive monitoring and an 24-h-operating room are not available, this particular subgroup of patients should probably be treated with operative management.

Relation of Use of Red Blood Cell Transfusion After Acute Coronary Syndrome to Long-Term Mortality

Registry studies have associated red blood cell (RBC) transfusion with increased in-hospital mortality in patients with acute coronary syndrome (ACS). The impact on long-term mortality after 1-year follow-up remains unknown. Consecutive patients with ACS (n = 2,009) of a prospective Genetic Predisposition of Coronary Artery Disease cohort were followed for a median of 8.6 years (95% confidence interval [CI] 8.59 to 8.69). After discharge, 1,937 (96%) patients survived for over 30 days. Of those survivors, a subgroup of previously transfusion-naïve patients 85/1,937 (4.4%) who had received at least 1 RBC transfusion during hospitalization were compared with 1,278/1,937 patients (66.0%) who had not received any transfusion either during the hospitalization or the entire follow-up. Unadjusted long-term mortality was significantly higher in the patients transfused with RBC compared with their counterparts not transfused with RBC (58.8% vs 20.3%, p <0.001). The results remained significant for hazard ratio (HR) 1.91, 95% CI 1.39 to 2.63, p <0.001, after multivariate Cox proportional hazards model analysis and were similar after 1-year landmark analysis (HR 1.90, 95% CI 1.34 to 2.70, p <0.001). The higher all-cause mortality was largely explained by cancer mortality (15.3% vs 4.1%, p <0.001) and cardiovascular mortality (34.1% vs 12.1%, p <0.001). After 1:1 propensity score matching (n = 65 vs 65), the association of RBC transfusion with worse survival remained significant (HR 2.70, 95% CI 1.48 to 4.95, p = 0.001). Inverse probability weighted Cox analyses turned out similar results (HR 2.07, 95% CI 1.38 to 3.11, p <0.001). In conclusion, the strong association of need for RBC transfusion with increased mortality continued for patients with ACS even after a 1-year follow-up.

Red Blood Cell Transfusion Need for Elective Primary Posterior Lumbar Fusion in A High-Volume Center for Spine Surgery.

(1) Background: This study evaluated the perioperative red blood cell (RBC) transfusion need and determined predictors for transfusion in patients undergoing elective primary lumbar posterior spine fusion in a high-volume center for spine surgery. (2) Methods: Data from all patients undergoing spine surgery between 1 January 2014 and 31 December 2016 were reviewed. Patients’ demographics and comorbidities, perioperative laboratory results, and operative time were analyzed in relation to RBC transfusion. Multivariate logistic regression analysis was performed to identify the predictors of transfusion. (3) Results: A total of 874 elective surgeries for primary spine fusion were performed over the three years. Only 54 cases (6%) required RBC transfusion. Compared to the non-transfused patients, transfused patients were mainly female (p = 0.0008), significantly older, with a higher ASA grade (p = 0.0002), and with lower pre-surgery hemoglobin (HB) level and hematocrit (p < 0.0001). In the multivariate logistic regression, a lower pre-surgery HB (OR (95% CI) 2.84 (2.11–3.82)), a higher ASA class (1.77 (1.03–3.05)) and a longer operative time (1.02 (1.01–1.02)) were independently associated with RBC transfusion. (4) Conclusions: In the instance of elective surgery for primary posterior lumbar fusion in a high-volume center for spine surgery, the need for RBC transfusion is low. Factors anticipating transfusion should be taken into consideration in the patient’s pre-surgery preparation.

Hypochloremia, blood transfusion, and neuromuscular drug use can be associated with prolonged mechanical ventilation in pediatric intensive care

Background: Mechanical ventilation (MV) is one of the most important components of modern intensive care practice. Longer MV time is associated with increased morbidity and mortality. Therefore, it is important to identify the risk factors associated with longer duration of MV. The objective of this study was to determine the clinical and the laboratory risk factors for prolonged invasive MV in the pediatric intensive care unit (PICU). Methods: We performed a retrospective analysis of the records of all patients admitted to our PICU between October 2016 and March 2018. Patients with invasive MV were included in the study. Results: A total of 121 children with a mean age of 3.58 ± 4.84 years were enrolled in this study. The most frequent diagnosis at the time of admission to the PICU was primary respiratory disease (31.4%), followed by neurological diseases (22.3%), and sepsis (17.4%). Pressure control was the most commonly used MV method in 97 (80.2%) patients. Pressure regulated volume control was used in the other (19.8%) patients. The mean duration of mechanical ventilation was 9.17 ± 8.12 days. Risk factors for prolonged MV in the PICU included red blood cell (RBC) transfusion, hypochloremia, high gamma-glutamyl transferase (GGT), and low body mass index (BMI). The logistic regression analysis showed that hypochloremia prolonged MV by 3.234 fold, neuromuscular blocker drug uses prolonged MV by 3.689 fold, and RBC transfusion prolonged MV by 8.031 fold. Conclusion: Hypochloremia, need for RBC transfusion, and neuromuscular blocker drug use may be early predictors of prolonged MV in critically ill children.

Prehospital identification of trauma patients requiring transfusion: results of a retrospective study evaluating the use of the trauma induced coagulopathy clinical score (TICCS) in 33,385 patients from the TraumaRegister DGU®

Background: Identifying trauma patients that need emergent blood product transfusion is crucial. The Trauma Induced Coagulopathy Clinical Score (TICCS) is an easy-to-measure score developed to meet this medical need. We hypothesized that TICCS would assist in identifying patients that need a transfusion in a large cohort of severe trauma patients from the TraumaRegister DGU® (TR-DGU).Materials and methods: A total of 33,385 severe trauma patients were extracted from the TR-DGU for retrospective analysis. The TICCS was adapted for the registry structure. Blood transfusion was defined as the use of at least one unit of red blood cells (RBC) during acute hospital treatment.Results: With an area under the receiving operating curve (AUC) of 0.700 (95% CI: 0.691–0.709), the TICCS appeared to be moderately discriminant for determining the need for RBC transfusion in the trauma population of the TR-DGU. A TICCS cut-off value of ≥12 yielded the best trade-off between true positives and false positives. The corresponding positive predictive value and negative predictive values were 48.4% and 89.1%, respectively.Conclusion: This retrospective study confirms that the TICCS is a useful and simple score for discriminating between trauma patients with and without the need for emergent blood product transfusion.

Blood transfusion in the surgical treatment of adolescent idiopathic scoliosis-a single-center experience of patient blood management in 210 cases.

The surgical treatment of adolescent idiopathic scoliosis can be associated with substantial blood loss, requiring allogeneic red blood cell (RBC) transfusion. This study describes the use of RBC and the effect of a standardized perioperative patient blood management program. Patients treated with posterior instrumented fusion were consecutively enrolled over a 6-year period. Patient blood management strategies were implemented in 2011, including prophylactic tranexamic acid, intraoperative permissive hypotension, restrictive fluid therapy (including avoidance of synthetic colloids), restrictive RBC trigger according to institutional standardized protocol, the use of cell savage, and goal-directed therapy according to thrombelastography. In total, 210 patients were included. 64 patients (31%) received RBC transfusions. A decline in the intraoperative rate of RBC transfusion was observed, from 77% in 2011 to 13% in 2016 (p < 0.001). Patients in the transfusion group had a significantly larger major curve, lower preoperative hemoglobin, higher estimated blood loss, and an increased use of crystalloid volume resuscitation. Multiple logistic regression showed that significant predictors for RBC transfusion were preoperative hemoglobin level (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.27-0.57), estimated blood loss (OR, 1.26; 95% CI, 1.15-1.42), and year of surgery (indicating the effect of patient blood management) (OR per year, 0.76; 95% CI, 0.58-0.99). A perioperative patient blood management program substantially reduced the need for RBC transfusion. A preoperative evaluation of anemia is essential to further minimize transfusion rates.

Subnormal Lymphocyte Count Predicts Inferior Survival in Myelodysplastic Syndromes: A Single Center Experience in 889 Patients

▪BackgroundIn myelodysplastic syndromes (MDS), we have previously shown the adverse prognostic effect of ALC <1.2 x 10(9)/L (Nisha et al. Am J Hematol 2010;85:160). In the current larger study of 889 patients with MDS, we sought to validate and expand on our previous observations and also examine the effect of lymphocyte-to-monocyte ratio (LMR).MethodsWe retrospectively recruited 889 consecutive patients with primary MDS who were untreated at the time of referral to our institution, and in whom ALC and absolute monocyte count (AMC) at time of referral was documented. The diagnosis of MDS and leukemic transformation (LT) was according to WHO criteria (Blood. 2009;114:937). Complete follow-up information was updated in January 2015. Comparison of laboratory and clinical features was made between patients with subnormal and normal ALC; patients with above normal ALC were considered separately. Overall and leukemia-free survivals of patients with normal ALC was compared to those with either subnormal ALC or, in order to validate our previous observation, with ALC <1.2 x 10(9)/L.ResultsPatient characteristics:Median (range) values for the 889 study patients (69% males) included: age 72 (18-98), hemoglobin 9.6 g/dL (5.4-15.7), leukocyte count 3.4 x 10(9)/L (0.4-35), AMC 0.2 x 10(9)/L (0-1.7), platelet count 106 x 10(9)/L (2-1804), circulating blasts 0% (0-18) and bone marrow blasts 3% (0-19). Transfusion need was documented in 33% of patients and abnormal karyotype in 49%. Risk stratification by the revised international prognostic scoring system (IPSS-R) was very high in 10%, high in 16%, intermediate in 20%, low in 36% and very low in 16%. The median (range) ALC for the entire study population of 889 patients was 1.16 x 10(9)/L (0.02-8.9). The normal range of ALC at our institution was 0.9-2.9 x 10(9)/L; the number of patients with subnormal, normal and above normal ALC was 261 (29%), 598 (67%) and 30 (4%), respectively. In addition, 442 (50%) and 417 (47%) patients had ALC below 1.2 x 10(9)/L and ALC between 1.2 and the upper limit of normal, respectively. After a median follow-up of 27 months, 712 (80%) deaths and 116 (13%) leukemic transformations were documented.Comparison of patients stratified by absolute lymphocyte countCompared to patients with normal ALC, patients with subnormal ALC displayed lower hemoglobin (p=0.002), higher red blood cell transfusion need (p=0.0003), lower leukocyte count (p<0.0001), lower monocyte count (p=0.002) and lower platelet count (p<0.0001), whereas borderline association was also apparent for older age (p=0.06). In univariate analysis, survival was adversely affected by lower ALC, treated as a continuous variable (p=0.01). Similarly, when compared to patients with normal ALC, patients with subnormal ALC (p=0.001; HR 1.3, 95% CI 1.1-1.5) and those with ALC <1.2 x 10(9)/L (p=0.0002; HR 1.3, 95% CI 1.2-1.6) experienced significantly shortened survival. There was no difference in survival between patients with above normal ALC and those with either subnormal (p=0.58) or normal (p=0.41) ALC; accordingly, patients with above normal ALC were excluded from subsequent analysis.In multivariable analysis, the adverse effect of subnormal ALC was shown to be independent of age, gender, anemia, thrombocytopenia, neutropenia , circulating blast percentage, bone marrow blast percentage or cytogenetic risk stratification by and IPSS; the same held true for ALC <1.2 x 10(9)/L. The association with IPSS-R was of borderline significance for both ALC <1.2 x 10(9)/L (p=0.06) and subnormal ALC (p=0.1). The adverse effect of ALC was most apparent in patients with very low or low risk disease per IPSS-R (p=0.0007 for subnormal ALC and 0.0003 for ALC <1.2 x 10(9)/L), compared to those with higher risk status (p=0.67 and 0.7, respectively). Neither subnormal ALC (p=0.4) nor ALC <1.2 x 10(9)/L (p=0.1) affected leukemia free survival. Analysis using LMR in place of ALC showed similar but not necessarily superior results.ConclusionsCompared to those with normal ALC, MDS patients with either subnormal ALC or with ALC below 1.2 x 10(9)/L experienced shorter overall, but not leukemia-free, survival; this adverse effect was most apparent in lower risk patients and was independent of most of the currently established risk factors for survival in MDS. The observations from the current study suggest the possible therapeutic value of augmenting host immunity in lower risk MDS. DisclosuresAl-Kali:Onconova Therapeutics, Inc.: Research Funding; Celgene: Research Funding.

Multicentre, open-label, randomised, parallel-group, superiority study to compare the efficacy of octreotide therapy 40 mg monthly versus standard of care in patients with refractory anaemia due to gastrointestinal bleeding from small bowel angiodysplasias: a protocol of the OCEAN trial

IntroductionGastrointestinal angiodysplasias are an important cause of difficult-to-manage bleeding, especially in older patients. Endoscopic coagulation of angiodysplasias is the mainstay of treatment, but may be difficult for small bowel angiodysplasias because of the inability to reach them for endoscopic intervention. Some patients are red blood cell (RBC) transfusion dependent due to frequent rebleeding despite endoscopic treatment. In small cohort studies, octreotide appears to decrease the number of bleeding episodes in patients with RBC transfusion dependency due to gastrointestinal angiodysplasias. This trial will assess the efficacy of octreotide in decreasing the need for RBC transfusions and parenteral iron in patients with anaemia due to gastrointestinal bleeding of small bowel angiodysplasias despite endoscopic intervention.Study designRandomised controlled, superiority, open-label multicentre trial.Participants62 patients will be included with refractory anaemia due to small bowel angiodysplasias, who are RBC transfusion or iron infusion dependent despite endoscopic intervention and oral iron supplementation.InterventionPatients will be randomly assigned (1:1) to standard care or 40 mg long-acting octreotide once every 4 weeks for 52 weeks, in addition to standard care. The follow-up period is 8 weeks.Main outcome measuresThe primary outcome is the difference in the number of blood and iron infusions between the year prior to inclusion and the treatment period of 1 year. Important secondary outcomes are the per cent change in the number of rebleeds from baseline to end point, adverse events and quality of life.Ethics and disseminationThe trial received ethical approval from the Central Committee on Research Involving Human Subjects and from the local accredited Medical Research Ethics Committee of the region Arnhem-Nijmegen, the Netherlands (reference number: 2014-1433). Results will be published in a peer-reviewed journal and presented at international conferences.Trial registration numberNCT02384122; Pre-results.

Research Opportunities to Improve Neonatal Red Blood Cell Transfusion.

Red blood cell (RBC) transfusion is a common and lifesaving therapy for anemic neonates and infants, particularly among those born prematurely or undergoing surgery. However, evidence-based indications for when to administer RBCs and adverse effects of RBC transfusion on important outcomes including necrotizing enterocolitis, survival, and long-term neurodevelopmental impairment remain uncertain. In addition, blood-banking practices for preterm and term neonates and infants have been largely developed using studies from older children and adults. Use of and refinements in emerging technologies and advances in biomarker discovery and neonatal-specific RBC transfusion databases may allow clinicians to better define and tailor RBC transfusion needs and practices to individual neonates. Decreasing the need for RBC transfusion and developing neonatal-specific approaches in the preparation of donor RBCs have potential for reducing resource utilization and cost, improving outcomes, and assuring blood safety. Finally, large donor-recipient-linked cohort studies can provide data to better understand the balance of the risks and benefits of RBC transfusion in neonates. These studies may also guide the translation of new research into best practices that can rapidly be integrated into routine care. This review highlights key opportunities in transfusion medicine and neonatology for improving the preparation and transfusion of RBCs into neonates and infants. We focus on timely, currently addressable knowledge gaps that can increase the safety and efficacy of preterm and term neonatal and infant RBC transfusion practices.

Blood management after total joint arthroplasty in the United States: 19-year trend analysis.

Recent studies have failed to show reductions in rates of red blood cell (RBC) transfusion after total joint arthroplasty (TJA) in the United States. This study aims to report the 19-year trend analysis of blood use in TJA, to determine predictors of RBC transfusion and association between RBC transfusion and in-hospital mortality after TJA using a nationally representative database. Nationwide inpatient sample (NIS) data from 1993 to 2011 were used. ICD-9-CM codes were used to identify TJA cases, RBC transfusion, autologous blood transfusion, and/or transfusion from cell salvage. Logistic regression analysis was performed to determine predictors of RBC transfusion and if transfusion increases risk of in-hospital mortality. A total of 2,225,054 TJA cases were identified. Using multivariate analysis, there was an increase in the rate of RBC transfusion over the study period (odds ratio [OR], 1.049; 95% confidence interval [CI], 1.048-1.050; p < 0.001). One-stage bilateral TJA (OR, 3.30; 95% CI, 3.24-3.37; p < 0.001), anemia due to chronic blood loss (OR, 2.69; 95% CI, 2.59-2.74, p < 0.001), deficiency anemia (OR, 2.59; 95% CI, 2.56-2.62; p < 0.001), and Charlson comorbidity index (OR, 1.24; 95% CI, 1.23-1.24; p < 0.001) were independent predictors of allogeneic blood transfusion. Transfusion of autologous blood reduced need for RBC transfusion (OR, 0.84; 95% CI, 0.82-0.85; p < 0.001). RBC transfusion was an independent predictor of in-hospital mortality (OR, 1.537; 95% CI, 1.395-1.694; p < 0.001). An increase in the rate of RBC use after TJA and the association between allogeneic blood transfusion and mortality are worrisome. Implementing more effective blood conservation strategies is recommended.

Predictive factors and practice trends in red blood cell transfusions for very-low-birth-weight infants.

BackgroundRed blood cell (RBC) transfusions in very low birthweight (VLBW) infants, while common, carry risk. Our objective was to determine clinical predictors of and trends in RBC transfusions among VLBW infants.MethodsRBC transfusion practice and its clinical predictors in 1,750 VLBW (≤1500 g) infants were analyzed in a single-center cohort across sequential epochs: 2000–2004 (Epoch 1), 2005– 2009 (Epoch 2), and 2010–2013 (Epoch 3).ResultsOverall, 1,168 (67 %) infants received ≥1 transfusions. The adjusted likelihood of ≥1 transfusions decreased for each 1-g/dL increment in initial hemoglobin concentration following birth, for females, and for each 100-g increment in birthweight. The adjusted likelihood of ≥1 transfusions increased with infants receiving mechanical ventilation, with increasing length of hospital stay, with necrotizing enterocolitis and with non-lethal congenital anomalies requiring surgery. The adjusted mean (SEM) number of transfusions per patient was decreased in Epoch 3, compared with Epoch 1 and Epoch 2. For an initial hemoglobin of ≥16.5 g/dL, the predicted probability of being transfused was ≤50%.ConclusionAdjusted RBC transfusions declined and female sex conferred an unexplained protection over the study period. Modest increases in initial hemoglobin by placentofetal transfusion at delivery may reduce the need for RBC transfusion.

Is central venous pressure still relevant in the contemporary era of liver resection?

BackgroundPerioperative red blood cell transfusion (RBCT) remains common after liver resection and carries risk of increased morbidity and worse oncologic outcomes. We sought to assess the factors associated with perioperative RBCT after hepatectomy with a focus on intraoperative hemodynamics. MethodsWe performed a retrospective review of our prospective hepatectomy database, supplemented by a review of anesthetic records of all patients undergoing hepatectomy with hemodynamic monitoring (arterial and central venous pressures [CVP]) from 2003–2012. Primary outcome was perioperative RBCT (during and within 30 d after surgery). After descriptive and univariate comparisons, multivariate analysis was conducted to identify factors associated with RBCT. ResultsOf 851 hepatectomies, 530 had complete hemodynamic data and 30.2% (161 of 530) received RBCT. Among transfused patients, female gender (P = 0.01), preoperative anemia (P < 0.001), and major liver resection (P = 0.02) were more common. Mean estimated blood loss was 1.1 L higher (2.0 versus 0.9 L; P < 0.001) and operating time was 1.1 h longer (5.8 versus 4.7 h; P < 0.001) in transfused patients. Trends in intraoperative CVP differed significantly based on transfusion status (P = 0.007). Independent factors associated with RBCT included female gender (odds ratio [OR], 2.27; P = 0.01), preoperative anemia (OR, 2.38; P = 0.03), longer operative time (OR, 1.19 per hour; P = 0.03), and higher intraoperative CVP at 1 h during surgery (OR, 1.10 per mm Hg; P = 0.005). ConclusionsLikelihood of RBCT is independently associated with female gender, preoperative anemia, longer operative time, and higher intraoperative CVP. Focus on management of preoperative anemia, operative efficiency, and low intraoperative CVP is needed to minimize the need for RBCTs.

Prediction of escape red blood cell transfusion in expectantly managed women with acute anaemia after postpartum haemorrhage.

To determine clinical predictors of escape red blood cell (RBC) transfusion in postpartum anaemic women, initially managed expectantly, and the additional predictive value of health-related quality of life (HRQoL) measures. Secondary analysis of women after postpartum haemorrhage, either randomly allocated to, or opting for expectant management. Thirty-seven hospitals in the Netherlands. A total of 261 randomised and 362 nonrandomised women. We developed prediction models to assess the need for RBC transfusion: one using clinical variables (model 1), and one extended with scores on the HRQoL-measures Multidimensional Fatigue Inventory (MFI) and EuroQol-5D (model 2). Model performance was assessed by discrimination and calibration. Models were internally validated with bootstrapping techniques to correct for overfitting. Escape RBC transfusion. Seventy-five women (12%) received escape RBC transfusion. Independent predictors of escape RBC transfusion (model 1) were primiparity, multiple pregnancy, total blood loss during delivery and haemoglobin concentration postpartum. Maternal age, body mass index, ethnicity, education, medical indication of pregnancy, mode of delivery, preterm delivery, placental removal, perineal laceration, Apgar score and breastfeeding intention had no predictive value. Addition of HRQoL-scores (model 2), significantly improved the model's discriminative ability: c-statistics of model 1 and 2 were 0.65 (95% CI 0.58-0.72) and 0.72 (95% CI 0.65-0.79), respectively. The calibration of both models was good. In postpartum anaemic women, several clinical variables predict the need for escape RBC transfusion. Adding HRQoL-scores improves model performance. After external validation, the extended model may be an important tool for counselling and decision making in clinical practice.

Prevention of the anaemia of prematurity.

Despite recent advances in neonatal and perinatal medicine, extremely low birth weight infants (ELBW) are at high risk of developing anaemia of prematurity (AOP) requiring packed red blood cell (RBC) transfusions. The benefit of transfusing allogenic RBCs for AOP is a controversial issue, except for disturbances in tissue oxygenation. Although the role of erythropoietin (EPO) in the pathophysiology of AOP is well known, neither early nor late recombinant human EPO therapy alters the number or volume of RBC transfusions. It is also known that one-half of the feto-placental blood volume remains outside the newborn infant's circulation at 30 weeks of gestation if the umbilical cord is clamped immediately. Delayed cord clamping (DCC) and umbilical cord milking (UCM) are the main methods for enhancing placental transfusion. The basic principle of these approaches depends on providing high haemoglobin (Hb) levels to premature infants in the delivery room. The enhancement of placental transfusion clearly results in higher Hb levels at birth, reducing the need for RBC transfusions as well as creating a better haemodynamic status during the initial hours of life. To date, enhancement of placental transfusion in the delivery room by either DCC or UCM seems to be the best preventive measure for AOP. Yet, studies on the associated neurodevelopmental outcomes are insufficient to reach a conclusion. This review summarizes the pathophysiology, treatment and preventative strategies of anaemia of prematurity in light of the current literature.