Number Of Red Blood Cell Units Research Articles

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

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

Restrictive Versus Liberal Red Blood Cell Transfusion Strategies for Patients with Hematologic Malignancies Receiving Intensive Chemotherapy

Background: It is estimated that one-quarter to one-half of people diagnosed with hematologic malignancies experience anemia and red blood cell (RBC) transfusion plays an essential supportive role in their management. There are different strategies for RBC transfusions to treat anemia. A restrictive transfusion strategy seeks to maintain a lower hemoglobin level (usually between 70 g/L to 90 g/L with a trigger for transfusion when the hemoglobin drops below 70 g/L), whereas a liberal transfusion strategy aims to maintain a higher hemoglobin (usually between 100 g/L to 120 g/L, with a threshold for transfusion when hemoglobin drops below 100 g/L). The most effective and safest strategy is unknown in people with hematological malignancies. Objectives: To determine the efficacy and safety of a restrictive versus liberal RBC transfusion strategies for people diagnosed with hematological malignancies treated with intensive chemotherapy, radiotherapy, or both, with or without a hematopoietic stem cell transplant (HSCT). Methods: Review was completed using Cochrane standard methodological procedures. We included randomized controlled trials RCTs and prospective non-randomized studies NRS that evaluated a liberal compared with a restrictive RBC transfusion strategy in children or adults with malignant hematological disorders receiving intensive chemotherapy/radiotherapy or undergoing HSCT. We searched for RCTs and NRS in MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and eight other databases and three trial registries to 21 March 2023. For dichotomous outcomes such as mortality, results were presented as a risk ratio (RR) with 95% confidence interval (CI) to compare restrictive versus liberal transfusion strategies. For continuous outcomes using the same scale, we assessed the mean difference (MD) with 95% CI. Where outcome measures were heterogenous, a narrative synthesis was used. Review Manager Web was used to meta-analyze the data. GRADE rating methodology was used for the overall certainty of evidence from included studies. Main Results: Nine studies were included: eight RCTs and one NRS. 644 participants were included in analyses from six completed RCTs (n=560) and one completed NRS (n=84). Two ongoing RCTs consisting of 294 participants (260 adult and 34 pediatric) are pending inclusion. One completed RCT included children receiving HSCT (n=6) and five RCTs only included adults (n=239 with acute leukemia receiving chemotherapy and n=315 with a hematological malignancy receiving HSCT). The restrictive strategies varied from 70 g/L to 80 g/L and liberal strategies from 80 g/L to 120 g/L. A restrictive strategy was found to result in a reduction in the number of RBC units per participant compared to a liberal strategy (Four studies; 457 participants; MD: -2.39, 95%CI -3.38 to -1.39, P = &amp;lt;0.00001). No difference was seen in bleeding between strategies although there was high concern for bias in included trials. Effects were reported in the summary of findings tables for RCTs (Table 1) which included results from adults only to reduce indirectness as a result of limited information from the single published pediatric RCT which was terminated early. Overall, a restrictive RBC transfusion strategy may result in little to no difference in the risk of death at 31 to 100 days compared to a liberal transfusion strategy (three studies; 382 participants; RR 0.74, 95% CI 0.13 to 4.09, P= 0.73; I 2=28%; low-certainty evidence). Two outcomes (mortality at 31 to 100 days and clinically significant bleeding) were reported from the one NRS (Table 2). The evidence is very uncertain whether there is a difference in mortality and clinically significant bleeding between the transfusion strategies based on the very low-certainty evidence. Conclusions: A restrictive transfusion strategy demonstrated a reduction in RBC usage, while there may be no impact on mortality. Definite conclusions are challenging given the relatively few studies with low numbers of included participants, concern for bias, heterogeneity of intervention and outcome reporting and overall certainty of evidence. There is a need for larger and methodologically better designed and executed studies. There is insufficient evidence to answer this review's primary outcome. Further RCTs are required overall, particularly trials inclusive of pediatric participants.

A pilot randomized study for optimal red cell transfusion in acute myeloid leukemia patients with intensive chemotherapy.

Although blood transfusion is fundamental throughout the course of hematologic malignancies, acute myeloid leukemia (AML) patients requiring intensive chemotherapy are left at the edges of patient blood management programs because current guidelines do not have established recommendations for red blood cell (RBC) transfusion threshold in patients treated for hematological disorders with anemia and accompanied severe thrombocytopenia. To provide answers for the trigger and doses of ideal RBC transfusion in such situation, we conducted this prospective randomized trial. Newly diagnosed non-acute promyelocytic AML patients undergoing chemotherapy were considered eligible for enrollment. Patients were randomized into 4 groups using a 2 by 2 factorial design, according to the RBC transfusion trigger (hemoglobin [Hb], 7 vs 8 g/dL) and the number of units per transfusion episode (quantity, single vs double-unit). Initially 91 patients were randomized into 4 groups, but the protocol adherence rate was 90.1%. Hb trigger did not affect the amount of RBC transfusion required during treatment. Patients receiving RBC transfusion at Hb <7 g/dL used a median of 4 units of RBC (range 0-12), and those receiving transfusion at Hb <8 g/dL also used a median of 4 units of RBC (range 0-24) (p=0.305). The number of RBC units per transfusion did not affect the total amount of RBC transfusion required during treatment. AML treatment outcomes and bleeding events did not differ across the 4 groups. This study demonstrated the feasibility for restrictive RBC transfusion (Hb <7 g/dL, RBC 1 unit) in AML patients undergoing chemotherapy, regardless of chemotherapy intensity.

A Prospective Randomized Study for Optimal Red Blood Cell Use Patients with Acute Myeloid Leukemia Receiving Dose Intensive Chemotherapy

Background: Although blood transfusion is fundamental throughout the course of hematologic malignancy, acute myeloid leukemia (AML) patients requiring intensive chemotherapy are left at the edges of patient blood management programs because current guidelines do not have established recommendations for a transfusion threshold in patients treated for hematological disorders nor for those with severe thrombocytopenia who are at risk of bleeding. Especially in the past 2 years, patient blood management programs gained more popularity with the spread of COVID-19. Due to blood inventory shortages, majority of the institutions lowered the hemoglobin (Hb) threshold to 7g/dL and this hit patients with hematologic malignancies especially hard. To close the gaps in inconsistencies of RBC transfusion care, we conducted a prospective trial focusing on newly diagnosed AML patients undergoing intensive chemotherapy. To the best of our knowledge, this is the first trial focusing on this unique subpopulation of patients. Also by doing so, we were able to shed some light on RBC transfusion optimization for patients with thrombocytopenia. Methods: This was a randomized trial of newly diagnosed AML diagnosed and treated between September 2018 and February 2022. Figure A outlines the study design. Patients were randomized into 4 groups using 2 by 2 factorial design, according to trigger (Hb 7 vs 8g/dL) and quantity (single-unit vs double-unit). In case patients became hemodynamically unstable due to major bleeding, severe infection, ischemic heart disease, stroke or any other compromising conditions, liberal RBC transfusion was allowed regardless of the grouping to ensure patients’ safety. Platelet transfusion was done liberally to maintain target platelet count between 10 - 20 x 109/L. Non-acute promyelocytic leukemia AML aged between 19 to 70 years old, undergoing cytarabine ± anthracycline chemotherapy were considered eligible for enrollment. The primary objective of the study was to compare the differences in the number of RBC units per case across the groups. The secondary outcomes included major bleeding and clinical relevant non-major bleeding (CRNM) according to ISTH, AML treatment outcomes according to International Working Group, platelet transfusion, RBC transfusion adherence rates (events of out of specification transfusion), transfusion related adverse events (AE), and infection complications Results: Initially 91 patients were randomized into 4 groups, but the protocol adherence rate was 90.1% (Figure B). As whole, patients received a median of 4 units of RBC (range 0-24) and AE rate associated with RBC transfusion was 16.9% (13/77). All 13 cases of AE were mild allergic and non-hemolytic reactions. There were no cases of fatal AEs such as anaphylaxis, acute hemolysis or transfusion-associated lung injury. Hemoglobin trigger did not affect the amount of RBC transfusion required during treatment. Patients receiving RBC transfusion at Hb < 7 g/dL used a median of 4 units of RBC (range 0-12), and those receiving transfusion at Hb < 8g/dL also used a median of 4 units of RBC (range 0-24) (P=0.305). The AE rates associated with RBC transfusion were similar between the 2 groups (P=0.286). As for platelet transfusion, there were no differences regards to transfusion frequency (P=0.256) or amount (P=0.258) between the 2 groups. Quantity of RBC per transfusion did not affect the total amount of RBC transfusion required during treatment. Patients receiving 2 units of RBC per transfusion used similar amount of RBC as patients receiving 1 unit of RBC per transfusion. There were no differences in platelet transfusion frequency (P=0.256) or amount (P=0.258) between the 2 groups. Overall, treatment outcomes did not differ across the 4 groups. There were 3 cases of major bleeding: 2 cases of gastrointestinal bleeding and 1 case of muscle hematoma. There was 1 case of CRNM: the patient had grade 1 epistaxis that did not require intervention. There were 4 deaths during the follow-up: 2 due to uncontrolled AML and 2 due to infection. Conclusion: This study establishes feasibility for restrictive RBC transfusion in AML patients undergoing chemotherapy. For stable patients without significant medical history, RBC transfusion can be safely initiated when Hb < 7g/dL and 1 unit is adequate. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Clinical practice for outpatients that are chronically red cell dependent: A survey in the Netherlands.

Background and ObjectivesLimited data are available to guide physicians on how to determine the red blood cell (RBC) transfusion regimen in chronically transfusion‐dependent patients. The lack of clarity on thresholds and targets to be used for transfusion could easily result in either under or over transfusion in these patients. The aim of our survey is to investigate (1) transfusion thresholds; (2) number of RBC units given per transfusion episode; (3) interval between transfusions and (4) patient factors, like decreased cardiac function modulating the former.Materials and MethodsWe sent a web‐based 44‐question survey to members of the Dutch Haematology Association.ResultsFifty physicians responded between June and October 2020 (response rate 30%), well‐distributed between community and academic hospitals. A wide variation in transfusion strategies was reported: Most patients have transfused 1–2 RBC units (range: 0–3 units) every 2–4 weeks (range: 1–12 weeks) with a median threshold of 8.0 g/dl ranging from 6.4 to 9.6 g/dl. Patient‐specific clinical factors that are most frequently reported to influence the transfusion strategy are angina pectoris, cardiac failure and dyspnoea, softer parameters that are of influence are the quality of life and self‐sustainability.ConclusionThe results of this survey indicate a broad variation in RBC transfusion strategies in Dutch patients with chronic transfusion dependency. While the current variation in transfusion strategies may be unavoidable in an individualized approach, randomized trials and better defined usable parameters to evaluate the effect of transfusion strategies are required to reach a consensus on how to determine the transfusion strategy.

Erythropoietin plus iron versus control treatment including placebo or iron for preoperative anaemic adults undergoing non-cardiac surgery.

Erythropoietin plus iron versus control treatment including placebo or iron for preoperative anaemic adults undergoing non-cardiac surgery.

360o View of a Day Hospital Program Performing Exchange Transfusion and Outpatient Pain Management on Adults with Sickle Cell Disease

Purpose: Therapeutic erythrocytapheresis, known also as automated red blood cell exchange transfusion (RBC exchange), is standard of care for patients with sickle cell disease (SCD) presenting with severe complications and for primary prevention of CNS events in those with increased risks. There is limited data on the framework and experience of performing this procedure in a large adult population and even less on challenges and outcomes. Here, we present demographic and statistical data highlighting characteristics of the chronic exchange transfusion program at a comprehensive and multidisciplinary adult SCD center. Methods: Data were collected from adults (18 years and older) with a diagnosis of SCD that were receiving blood transfusions in the outpatient treatment facility from September 1st, 2017 to August 31st, 2018. Data gathered included age, gender, procedure indications and frequency, hemoglobin S percentage (Hb S%), target pre and post Hb S%, ferritin trend, and type of intravascular device used for procedure. Three hundred and forty-four (344) episodes of transfusions, were performed in 52 unique patients, corresponding to 21 % of the unique patients treated at our center during that period. Two hundred and sixty-two (262) of the transfusion procedures were RBC exchanges. These RBC exchanges were performed in 35 (14%) of the unique patients. Since a sizable proportion of our patients received pain treatment during RBC exchange, we explored how the pain visual analog score (VAS) changed while undergoing pain treatment during RBC exchange and in relation to multiple opiate doses. Descriptive and basic statistical analysis were performed on the data obtained for those receiving RBC exchange alone or in combination with pain management. Results: Thirty-five unique patients underwent RBC exchange during the study period. All but two (2) patients had the procedure via an implanted dual lumen Vortex port, one (1) by an arteriovenous fistula and one (1) via his native veins. Most of the RBC exchanges were performed as part of a chronic transfusion program for one of the following indications: primary prevention of stroke; secondary prevention of stroke; recurrent acute chest syndrome (ACS); intractable pain; presence of multiple comorbidities including pulmonary hypertension, chronic kidney disease and intractable leg ulcers. One patient received RBC exchange in preparation for bone marrow transplant. The three (3) other patients that only received one (1) RBC exchange during that period were previously on exchange transfusion but discontinued the procedure due lack of venous access or benefit from the procedure. The frequency of RBC exchange varied depending of the patient's specific indication for the procedure and the ability to reach a target Hb S% goal of &lt; 30%. The RBC exchange occurred in patients as frequently as every four (4) to seven (7) weeks. The number of transfusions per patient/year ranged from one (1) to thirteen (13) with a mean and median of eight (8). Number of RBC units used per procedure ranged from four (4) to thirteen (13) with a mean of eight (8.6), with each unique patient usually receiving the same amount. Twenty-three (66%) unique patients received, at least once, acute pain treatment - oral, intravenous, or a combination during RBC exchange. The mean change of VAS between presentation and end of the pain management period was 1.9 (p&lt;0.0001). Conclusion: Our data shows that therapeutic RBC exchange are performed on a regular basis on a small but significant subgroup of patients living with SCD and treated at a comprehensive SCD center. Intravenous opioid management of acute pain can be effectively performed while receiving RBC exchange which provides patients with multimodal interventions in the outpatient setting. The relationship between change in VAS and concurrent transfusion deserves further investigation. Although there are standard indications for RBC exchange, we and others use it for indications for which there is low level of evidence or no evidence of efficacy (i.e. leg ulcers). We found that there great variability on the frequency of the procedure, total number of RBC exchanges per year and number of RBC units used. Prospective studies are needed to better understand the short and long-term effects, complications and outcomes of chronic RBC exchange in adults living with SCD. Figure Disclosures Kato: Bayer: Research Funding; Novartis, Global Blood Therapeutics: Consultancy, Research Funding. De Castro:Pfizer: Consultancy; Novartis: Membership on an entity's Board of Directors or advisory committees; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees.

Increased Incidence of Infection in Patients with Myelofibrosis and Transfusion-Associated Iron Overload: A Monocentric Experience

Background. Transfusion-associated iron overload may increase the risk of infections both increasing bacterial or fungal growth and leading to the production of free iron that impairs immune system response. Anemia and transfusion dependency (TD) represent well known prognostic factors of survival in patients with myelofibrosis (MF). Compared to myelodysplastic syndrome (MDS), the role of iron overload on infection in MF has been scarcely explored. Methods. We identified consecutive adult patients diagnosed at our Centre with primary or secondary MF, between 1998 and 2018. Patients were stratified in 2 groups according to transfusion dependence defined as having received &gt;2 unit of red blood cells (RBC) over 3 months. The total number of RBC units infused was also collected. All infections were recorded and graded according to Common Terminology Criteria for Adverse Events (CTCAE). Results. A total of 106 patients, median age 72 years (range 44-89) were retrospectively evaluated. A diagnosis of primary MF was performed in 75 of cases (71%), post Essential Thrombocythemia myelofibrosis (PET-MF) in 27 (25%) and post Polycythemia Vera myelofibrosis (PPV-MF) in 4 (4%). Splenomegaly was present in 83 patients (78%) and 30 (28%) reported constitutional symptoms.According to the IPSS, 43 patients (40 %) were classified at low or intermediate-1 risk, and 63 (60 %) at intermediate-2 or high risk. Molecular analysis was performed in 76 patients (72%): 54 of 76 patients (71%) were positive for the JAK2V617F mutation, 10 (13%) for CALR mutation, 4 (5%) for MPL, and 8 (11%) were negative for all tested mutations. Over time, 56 patients (53%) received hydroxyurea or other cytoreductive treatment, and 23 (22%) ruxolitinib. Overall, 39 patients (37%) were transfusion dependent with a median of 14 RBC units received during follow-up (range 4-199). The median serum ferritin level in the TD cohort was 840 ng/mL (range 130-12.129). Median observation time was 36 months (range 3-203). At last follow-up, 48 patients (45%) presented one or more infectious episodes. Total infectious events were 69 and 13 of them (19%) were defined as severe (grade 3-4 CTCAE). Anatomical site of infections was the respiratory tract in 28 (41%) of cases, gastro-intestinal in 22 (32%), gynecological-urological in 8 (11%), sepsis in 2 (3%), unspecified in the remaining cases. When detected, the etiological agents were bacterial in 8 (12%), viral in 5 (7%) and fungal in 4 (6%). The 60-month cumulative incidence of infection from diagnosis of MF was 64.1±6.5%. TD patients showed a higher incidence of infection (99±8.8% vs 53.3±8%, p=0.007) (Figure 1). In multivariate analysis no association was found between infection incidence and primary vs secondary MF, splenomegaly, age &gt;65 years, ruxolitinib treatment; only transfusion dependencemaintained a significant association (p=0.019; HR=2.13; 95% C.I.=1.13-4.01). Among the 39 TD patients, the transfusion burden was significantly higher in those with infectious complication (median 24 RBC units vs 15 RBC units; p=0.012). The 60-month overall survival was 40±5.9%. Lower IPSS-risk (p&lt;0.0001) and ruxolitinib treatment (p=0.027) were significantly associated with higher survival. Conclusions. This retrospective monocentric real-life study showed an increased risk of infections in MF patients with higher transfusion burden. The role of iron chelation in improving infection free survival in patients with MF and iron overload should be further investigated. Figure 1 Disclosures No relevant conflicts of interest to declare.

Intraoperative Transfusion of Red Blood Cell Units Stored >14 Days is Associated with an Increased Risk of Prosthetic Joint Infection.

Background: The aim of the present study was to evaluate the association between prosthetic joint infection (PJI) after joint arthroplasty and the length of red blood cell (RBC) storage, timing of RBC transfusion, and the number of RBC units transfused.Study design and Methods: All patients who underwent a primary or revision joint artrhoplasty between January 2000 and December 2012 were retrospectively reviewed. For this study, only patients who received RBC transfusions during the day of the surgery (early transfusion group) or within the first 4 days after surgery (late transfusion group) were included.Results: A total of 9906 patients were reviewed. In the early transfusion group (n=1153, 11.6%), patients receiving 1 or 2 RBC units (3.5% vs 6.3%, P=0.041), 3 or 4 RBC (1.3% vs 13.3%, P=0.004) or ≥5 RBC units (5.0% vs 37.5%, P=0.026) had a higher PJI rate only when >50% of RBC units transfused had been stored >14 days. In the late transfusion group (n=920, 9.3%) these differences were not significant. Early transfusion of RBCs stored >14 days was an independent variable associated with an increased risk of PJI (OR:2.50, 95%CI:1.44-4.33)Conclusion: Transfusion of RBC within the first 6h after joint arthroplasty was an independent variable associated with PJI risk when RBC units are stored >14 days. The rate of PJI increased with the number of old RBC units transfused within this critical period.

Post-transfusion hemoglobin values and patient blood management

Objectives: The objective of this retrospective study was to evaluate the added value of communicating post-transfusion hemoglobin values to clinicians as a strategy to improve RBC utilization in a 500-bed hospital.Methods: The total number of RBC transfusions, the mean number of RBC units transfused per patient, the mean pre- and post-transfusion hemoglobin values, the ratio of patients transfused and the ratio of patients with a post-transfusion hemoglobin > 10.5 g/dL were calculated per service and per department for six months. The data were reported to each service and compared with the data of the department as peer group. The impact of this communication strategy was evaluated in the following six months.Results: In the six months pre-intervention, the mean post-transfusion hemoglobin value was 9.2 g/dL. Post-transfusion hemoglobin was > 10.5 g/dL in 13.4% of patients (112/835). Following communication of these data, RBC consumption decreased 21.0% (p < 0.01) and 21% (p < 0.01) fewer patients received transfusions despite an increase in mean post-transfusion hemoglobin value to 9.4 g/dL (p < 0.01).Conclusion: Providing feedback on post-transfusion hemoglobin data and the global consumption of RBC units to prescribing physicians can be an additional, feasible and effective strategy to encourage self-assessment and to improve blood utilization.

The Effectiveness of Standard Single Dose Omeprazole vs. High Dose Continuous Infusion in High-risk Critically Ill Patients

Objectives: The present study was carried out to investigate the beneficial effects of high dose omeprazole versus standard low dose as a prophylaxis against upper GIT bleeding in high risk critically ill patients. Methods: A hundred and ten high risk critically ill patients were divided into two groups, fifty-five patients each. Group A received intravenous (IV) omeprazole 40 mg bolus dose once daily followed by normal saline infusion. Group B received IV bolus of 80 mg omeprazole followed by 8 mg/h infusion. The treatment was for the whole period of ICU stay. Early morning gastric pH, residual gastric volume, signs of significant upper GIT bleeding, ICU stay Hb, number of ICU days without ventilator, ICU stay hemoglobin (Hb), number of red cell units transfused in ICU, ICU stay, and numbers of ICU survivors were recorded. Results: Gastric pH was higher in group B compared to group A (p<0.05). The number of patients developed significant upper GIT bleeding were significantly higher in group A. Group A had lower ICU Hb levels and used significant higher number of RBC units. ICU stay was significantly higher in group A compared to group B (p=0.02). There were no statistical differences regarding the number of ICU days without ventilator and ICU survivors between both groups (P<0.05). Conclusions: High dose PPI continuous infusion can reduce the incidence of upper GIT bleeding in high risk critically ill patients. High dose PPI can reduce ICU stay with no effect on ICU survivor rate.

Significance of the age of transfused blood for prognosis after transcatheter aortic valve implantation.

INTRODUCTION Blood transfusion after transcatheter aortic valve implantation (TAVI) is frequently required owing to the high vulnerability of this patient group and procedure-related bleeding. OBJECTIVES We assessed the impact of postprocedural blood transfusion and the age of transfused red blood cell (RBC) units on prognosis after TAVI. PATIENTS AND METHODS This was a single-center, observational analysis conducted between the years 2009 and 2014. The adopted endpoints were early and long-term mortality after TAVI. The risk factors for mortality included in-hospital bleeding and vascular complications, the number of transfused RBC units, transfusion of at least 2 RBC units, the age of transfused RBCs, and standard deviation of the age of RBCs. RESULTS The study included 178 patients (mean [SD] age, 80.07 [7.47] years; range, 55-91 years). The follow-up ranged between 1 month and 5.8 years (mean [SD], 20.1 [15.2] months) after discharge; 14 early deaths (7.8%) and 27 late deaths (16.5%) were noted. In-hospital bleeding and vascular complications increased the risk of early deaths (hazard ratio [HR], 2.113; 95% CI, 1.011-4.418; P = 0.046 and HR, 2.265; 95% CI, 1.270-4.039; P = 0.005). Transfusion of younger RBCs (HR, 1.044; 95% CI, 1.004-1.085; P = 0.028) and a greater discrepancy in the age of transfused RBCs (HR, 1.153; 95% CI, 1.042-1.275; P = 0.006) were positively correlated with the risk of late deaths only in a univariate analysis. A higher number of transfused RBC units was the only independent predictor of long-term mortality (HR, 1.149; 95% CI, 1.024-1.291; P = 0.018). CONCLUSIONS The higher number of RBC units transfused early after TAVI worsens long-term prognosis. Shorter-storage RBCs and a greater discrepancy in RBC age in multitransfused elderly patients after TAVI might have a deleterious effect on life expectancy.

Mild volume acute normovolemic hemodilution is associated with lower intraoperative transfusion and postoperative pulmonary infection in patients undergoing cardiac surgery -- a retrospective, propensity matching study

BackgroundPerioperative allogenic transfusion is required in almost 50% of patients undergoing cardiac surgery and is associated with higher risk of mortality and morbidity (Xue et al., Lancet 387:1905, 2016; Ferraris et al., Ann Thorac Surg 91:944–82, 2011). Acute normovolemic hemodilution (ANH) is recommended as a potential strategy during cardiac surgery, but the blood conservation effect and the degree of ANH was still controversial. There is also an increasing concern about the improved outcomes associated with ANH. Therefore, a better understanding of the effect of mild volume ANH during cardiac surgery is urgently needed.MethodsThis retrospective study included 2058 patients who underwent cardiac surgery between 2010 and 2015. The study population was split into two groups (with and without mild volume ANH). Propensity score adjustment analysis was applied. We reported the association between the use of mild volume ANH and perioperative outcomes.ResultsA total of 1289 patients were identified. ANH was performed in 358 patients, and the remaining 931 patients did not receive any ANH. Five hundred of the total patients (38.8%) received perioperative RBC transfusions, 10% (129/1289) of patients received platelet, and 56.4% (727/1289) of patients received fresh frozen plasma transfusions. Mild volume ANH administration was significantly associated with decreased intraoperative RBC transfuse rate (8.5% vs. 14.4%; p = 0.013), number of RBC units (p = 0.019), and decreased postoperative pulmonary infection (6.8 vs. 11.3%; p = 0.036) during cardiac surgery. However, there was no significant difference regarding intraoperative fresh frozen plasma (FFP) and platelet concentrate transfusions, as well as postoperative and total perioperative allogeneic transfusions. Furthermore, there was no significant difference regarding postoperative outcomes including mortality, prolonged wound healing, stroke, atrial fibrillation, reoperation for postoperative bleeding and acute kidney injury. There was also no difference in postoperative ventilation time, length of ICU and hospital stay.ConclusionBased on the 5-year experience of mild volume ANH in cardiac surgeries with CPB in our large retrospective cohort, mild volume ANH was associated with decreased intraoperative RBC transfusion and postoperative pulmonary infection in Chinese patients undergoing cardiac surgery. However, there was no significant difference regarding postoperative and total perioperative allogeneic transfusions.

Changes in blood product utilization in a seven-hospital system after the implementation of a patient blood management program: A 9-year follow-up

Objectives: To analyze changes in red blood cell (RBC), platelet (PLT), and plasma transfusion volumes 9 years after the implementation of a multifaceted patient blood management (PBM) program across multiple hospitals.Methods: Between fiscal years 2007 and 2015, the annual transfusion volumes for seven hospitals in a regional healthcare system were analyzed by hospital, and between 2014 and 2015, by four service lines including emergency department, intensive care unit (ICU), medical/surgical ward, and operating room at each hospital. The number of units of RBCs administered to transfused recipients on the wards and in ICUs was also enumerated.Results: For these seven hospitals combined, there was a 29.9% reduction in the number of RBCs transfused between 2007 and 2015, a 24.8% reduction in plasma units, and a 25.7% reduction in PLT units. The two largest hospitals saw some of the largest reductions in RBC transfusions (40.1, 25.1%), and plasma transfusions (26.1, 33.8%), and one of those hospitals had a 49.5% reduction in PLT transfusions. Smaller-sized hospitals also had reductions in transfusion volumes, while some volumes increased at hospitals when new or expanded clinical services were introduced. The number of RBC units per transfused recipient was generally between 1.5 and 2 units on the wards and slightly higher in the ICUs.Discussion: Although the overall volume of transfusions has generally decreased at each hospital site over time, the appropriateness of the administered transfusions cannot be evaluated by these data.Conclusion: The system-wide implementation of a PBM program has reduced transfusion volumes.

Implementation of a patient blood management programme in pediatric scoliosis surgery

ObjectivesTo determine whether the implementation of a blood conservation programme, and the adoption and progressive association of different methods, reduces transfusion requirements in paediatric patients undergoing scoliosis surgery of different origins. Material and methodQuasi-experimental, nonrandomized, descriptive study, approved by the Ethics Committee for Research of our institution. 50 paediatric patients (ASA I-III) aged 5–18 years, undergoing scoliosis surgery of any aetiology by a single posterior or double approach (anterior and posterior) were included. A historical group with no alternatives to transfusion: Group No ahorro=15 patients (retrospective data collection) was compared with another 3 prospective study groups: Group HNA (acute normovolemic hemodilution)=9 patients; Group HNA+Rec (intraoperative blood salvage)=14 patients, and Group EPO (HNA+Rec+erythropoietin±preoperative donation)=12 patients; according with the implementation schedule of the transfusion alternatives in our institution. ResultsThe rate of transfusion in different groups (No ahorro, HNA, HNA+Rec, EPO) was 100, 66, 57, and 0% of the patients, respectively, with a mean±SD of 3.40±1.59; 1.33±1.41; 1.43±1.50; 0±0 RBC units transfused per patient, respectively. Statistically significant differences (p<.001) were found in both the transfusion rate and number of RBC units. ConclusionsThe application of a multimodal blood transfusion alternatives programme, individualised for each paediatric patient undergoing scoliosis surgery can avoid transfusion in all cases.

Red Blood Cell Transfusions Impact Pneumonia Rates After Coronary Artery Bypass Grafting

Pneumonia, a known complication of coronary artery bypass grafting (CABG), significantly increases a patient's risk of morbidity and mortality. Although not well characterized, red blood cell (RBC) transfusions may increase a patient's risk of pneumonia. We describe the relationship between RBC transfusion and postoperative pneumonia after CABG. A total of 16,182 consecutive patients underwent isolated CABG between 2011 and 2013 at 1 of 33 hospitals in the state of Michigan. We used multivariable logistic regression to estimate the relative odds of pneumonia associated with the use or number of RBC units (0, 1, 2, 3, 4, 5, and ≥ 6). We adjusted for predicted risk of mortality, preoperative hematocrit values, history of pneumonia, cardiopulmonary bypass duration, and medical center. We confirmed the strength and direction of these relationships among selected clinical subgroups in a secondary analysis. Five hundred seventy-six (3.6%) patients had pneumonia and 6,451 (39.9%) received RBC transfusions. There was a significant association between any RBC transfusion and pneumonia (adjusted odds ratio [ORadj], 3.4; p < 0.001). There was a dose response between number of units and odds of pneumonia, with a ptrend less than 0.001. Patients receiving only 2 units of RBCs had a 2-fold (ORadj, 2.1; p < 0.001) increased odds of developing pneumonia. These findings were consistent across clinical subgroups. We found a significant volume-dependent association between an increasing number of RBCs and the odds of pneumonia, which persisted after risk adjustment. Clinical teams should explore opportunities for preventing a patient's risk of RBC transfusions, including reducing hemodilution or adopting a lower transfusion threshold in a stable patient.

Implementación de un programa de alternativas a la transfusión sanguínea en cirugía de escoliosis en pediatría

ObjectivesTo determine whether the implementation of a blood conservation program, and the adoption and progressive association of different methods, reduces transfusion requirements in pediatric patients undergoing scoliosis surgery of different origins. Material and methodQuasi-experimental, nonrandomized, descriptive study, approved by the Ethics Committee for Research of our institution. 50 pediatric patients (ASA I-III) aged 5 to 18 years, undergoing scoliosis surgery of any etiology by a single posterior or double approach (anterior and posterior) were included. A historical group with no alternatives to transfusion: Group No ahorro=15 patients (retrospective data collection) was compared with another 3 prospective study groups: Group HNA (acute normovolemic hemodilution)=9 patients; Group HNA+Rec (intraoperative blood salvage)=14 patients, and Group EPO (HNA+Rec+erythropoietin±preoperative donation)=12 patients; according with the implementation schedule of the transfusion alternatives in our institution. ResultsThe rate of transfusion in different groups (No ahorro, HNA, HNA+Rec, EPO) was 100, 66, 57, and 0% of the patients, respectively, with a mean±SD of 3.40±1.59; 1.33±1.41; 1.43±1.50; 0±0 RBC units transfused per patient, respectively. Statistically significant differences (P<.001) were found in both the transfusion rate and number of RBC units. ConclusionsThe application of a multimodal blood transfusion alternatives program, individualized for each pediatric patient undergoing scoliosis surgery can avoid transfusion in all cases.

The impact of perioperative red blood cell transfusion on long-term survival after hepatectomy for colorectal liver metastases.

725 Background: Perioperative red blood cell transfusions (RBCT) are associated with postoperative morbidity and may increase cancer recurrence through immunologic mechanisms following resection of colorectal liver metastases (CRLM). We sought to explore the relationship between RBCTs and long-term survival following resection of CRLM in the contemporary surgical era. Methods: We conducted a retrospective review of a prospective database including all patients undergoing partial hepatectomy for CRLM from 2003-2012. Data regarding date of death was abstracted from a validated, population-based cancer registry. Primary outcome was overall survival (OS), compared based on RBCT (defined as time of surgery to 30 days following surgery) and on number of RBC units received using Kaplan-Meier curves. Cox regression analysis was performed to examine the association between RBCT and OS, while adjusting for prognostic factors including Fong score and period of treatment (2003-2007 vs. 2008-2012). Results: We included 483 patients operated for CRLM, of which 27.5% received RBCT. 90-day post-operative mortality was 4.8% and median follow-up was 33 (IQR: 20.1-54.8) months. Median survival in patients who received RBCT was 44.5 months compared with 93.5 months in patients who did not(p&lt;0.0001). The difference persisted in subgroup analysis excluding patients who died within 90 days of surgery (62.3 vs. 93.5 months, p=0.023). After adjustment for Fong score and period of treatment, RBCT was independently associated with decreased OS (HR 2.15; 95% CI: 1.52-3.04). Conclusions: Perioperative RBCT is independently associated with decreased OS following hepatectomy for CRLM. Interventions to minimize and rationalize the use of RBCT for hepatectomy are warranted in order to mitigate this detrimental effect on long-term outcomes.

Geographic variability in potentially discretionary red blood cell transfusions after coronary artery bypass graft surgery

A number of established regional quality improvement collaboratives have partnered to assess and improve care across their regions under the umbrella of the Cardiac Surgery Quality Improvement (IMPROVE) Network. The first effort of the IMPROVE Network has been to assess regional differences in potentially discretionary transfusions (<3 units red blood cells [RBCs]). We examined 11,200 patients undergoing isolated nonemergent coronary artery bypass graft surgery across 56 medical centers in 4 IMPROVE Network regions between January 2008 and June 2012. Each center submitted the most recent 200 patients who received 0, 1, or 2 units of RBC transfusion during the index admission. Patient and disease characteristics, intraoperative practices, and percentage of patients receiving RBC transfusions were collected. Region-specific transfusion rates were calculated after adjusting for pre- and intraoperative factors among region-specific centers. There were small but significant differences in patient case mix across regions. RBC transfusions of 1 or 2 units occurred among 25.2% of coronary artery bypass graft procedures (2826 out of 11,200). Significant variation in the number of RBC units used existed across regions (no units, 74.8% [min-max, 70.0%-84.1%], 1 unit, 9.7% [min-max, 5.1%-11.8%], 2 units, 15.5% [min-max, 9.1%-18.2%]; P < .001). Variation in overall transfusion rates remained after adjustment (9.1%-31.7%; P < .001). Delivery of small volumes of RBC transfusions was common, yet varied across geographic regions. These data suggest that differences in regional practice environments, including transfusion triggers and anemia management, may contribute to variability in RBC transfusion rates.

Alloantibody Formation In Sickle Cell Disease

BackgroundTransfusion of red blood cells (RBC) is a common intervention to treat and prevent complications in sickle cell disease (SCD). However, frequent transfusions may lead to erythrocyte alloimmunization, thereby complicating donor matching procedures and posing patients at risk for hemolytic transfusion reactions. Little information is available about the risk of alloimmunization of sickle cell patients living in European countries. In the Netherlands extensive matching procedures to prevent alloimmunization were introduced a decade ago, but the effect on alloimmunization has not been evaluated yet. AimsThe primary aim of this study is to evaluate the cumulative incidence of first alloantibody formation in a Dutch cohort of transfused SCD patients, and to compare this with a general Dutch RBC-transfused population. In addition, the effect of extended RBC matching protocols on the incidence of alloantibody formation in SCD and potential clinical determinants of alloimmunization will be assessed. MethodsWe conducted a retrospective cohort study and collected data on SCD patients (genotypes HbSS, HbSC, HbSβ0 and HbSβ+ thalassemia), diagnosed in three Dutch Sickle Cell Treatment Centers that received non-extended matched (ABO, RhD) RBC transfusions between 1984-2004 and extended matched (at least ABO, Rhesus phenotype, Kell) RBC transfusions between 2004-2011.In addition, we compared this population with a general population of 3 042 patients that received non-extended matched (ABO, RhD) RBC transfusions between 2005-2009 in the Leiden University Medical Center (Zalpuri et al. 2012). Cohorts were not matched for ethnicity. Alloimmunization risk was calculated as Kaplan-Meier incidence with cumulative number of transfusions as time variable. The association with the clinical determinants gender, SCD-phenotype and ethnicity was analyzed with Cox-regression analysis. ResultsA total of 291 SCD patients received 7 957 RBC units. Alloantibody formation occurred in 52 (17.9%) patients. The cumulative incidence of alloimmunization was 9% after 5 RBC units, 15% after 10, 24% after 20 and 34% after 40 RBC units. Multivariate analysis, correcting for the cumulative number of transfusions, demonstrated a significantly increased risk of alloantibody formation in our SCD cohort when compared to a general population of transfused patients (HR 7.5 (95% CI: 5.06-11.14), where the cumulative incidence of alloimmunization was 1.1% after 5, 2.4% after 10, 3.4% after 20 and 6.5% after 40 RBC units. No association could be demonstrated between alloantibody formation and clinical determinants such as gender, SCD-phenotype or ethnicity. However, a significant reduction in alloimmunization was observed in SCD patients that received their first transfusion from the year 2004 onwards, after preventive matching for Rhesus phenotype and Kell was introduced for SCD patients (HR 0.48 (95% CI: 0.24-0.97)). ConclusionThe overall rate of first RBC alloantibody formation in our cohort was 17.9% and the risk of alloimmunization increased substantially with an increasing number of RBC transfusions. A unique comparison with a general cohort of Dutch transfused patients demonstrates a significantly higher risk of alloantibody formation in SCD, acknowledging earlier findings. This may partially be explained by differences in RBC antigens between patients of African descent and the predominantly Caucasian donors. Besides the number of RBC units, no other clinical risk factors for allo-immunization in SCD could be identified. The effectiveness of extended RBC matching protocols in the prevention of alloimmunization for chronically transfused patients in the participating centers was confirmed. [Display omitted] Disclosures:No relevant conflicts of interest to declare.