Packed Cell Transfusion Research Articles

Multidisciplinary care to optimise pregnancy outcomes among Jehovah’s Witness: Case series over fifteen years in a tertiary teaching hospital

ObjectiveTo assess the obstetric and neonatal outcomes of Jehovah’s Witness (JW) mothers and the willingness to accept blood products after multidisciplinary management. Study DesignA retrospective case-control study was conducted at Queen Mary Hospital from 2005 to 2020. Delivery records of pregnant women who identified themselves as JW were reviewed. The immediate next age-matched non-JW patient in the booking register was assigned as control. ResultsA total of 96 subjects were identified within the study period (48 JW and 48 non-JW age-matched patients). The haemoglobin levels of JW and non-JW were similar at booking, 28 weeks of gestation, pre-delivery and postnatal day 2. JW mothers were more likely to receive iron supplements in the antenatal period than the control group (27.1 % vs. 6.3 %, p = 0.01) despite the similar rate of antenatal anemia in both groups (4.2 % vs. 4.2 %, p = 1.00). There were no differences in mode of delivery, total blood loss at delivery, rate of primary postpartum haemorrhage, gestational age at delivery, birth weight, and Apgar score at 1 and 5 min between JW and non-JW. There were no maternal deaths, hysterectomy or admissions to the adult intensive care unit in either group. Six JW women accepted packed cell transfusion at the initial consultation and did not receive multidisciplinary care. The remaining 42 JW women had consultant obstetric and anesthesiologist review before delivery. After multidisciplinary consultation, two (4.8 %, 2/42) accepted blood transmission and 11 (26.2 %, 11/42) accepted some components of blood. The remaining 29 (69 %, 29/42) women refused all blood products. ConclusionJW patients who received multidisciplinary care achieved comparable pregnancy and neonatal outcomes to the normal population. Antenatal iron supplement was more common among pregnant JW despite the similar rate of antenatal anemia compared with the non-JW women. 12.5% of JW women agreed packed cell transfusion at the initial consultation and a further 27.1% of JW women agreed to some forms of blood products after multidisciplinary counseling.

Acute paroxysmal cold hemoglobinuria upon dengue fever: A case report

Rationale: Dengue fever is capable of inciting the formation of transient polyclonal antibodies directed at red blood cell antigens, resulting in complement-mediated hemolysis, leading to intravascular hemolysis and hemoglobinuria. Patient’s concern: A 12-year-old male patient who recovered from dengue fever a week ago had red blood cell agglutination, spherocytes, and engulfment of red blood cells (erythrophagocytosis) by monocytes and neutrophils on routine hematological peripheral blood smear. The unexpected blood smear results prompted the lab physicians to investigate autoimmune hemolytic anemia, which revealed a monospecific positive direct antiglobulin test for complement (C3d, C3b) and the presence of Donath-Landsteiner antibody. Diagnosis: Paroxysmal cold hemoglobinuria (PCH), secondary to dengue fever. Interventions: Oxygen supplements, antibiotics, intravenous immunoglobulins, steroid therapy, and packed cell transfusions were administered. Outcomes: The patient’s condition was improved following the therapy. Lessons: Post-dengue PCH is a rare complication that requires a thorough peripheral smear examination for erythrophagocytosis, as advanced hematology analyzers fail to detect such findings.

Natural Anticoagulant Protein Levels in Patients With Beta-Thalassemia Major: A Case-Control Study.

β-thalassemia is a group of inherited blood disorders that affect the production of β-globin chains, leading to the reduction or absence of these chains. One of the complications observed in patients with β-thalassemia major (β-TM) is thrombosis, especially in those who receive frequent blood transfusions. This may be due to a decrease in the levels of the natural anticoagulants: protein C (PC), total protein S (PS), and antithrombin (AT). In this case-control study, patients with β-TM, who had received at least 20 packed cell transfusions during their lifetime, were included. Patients with other underlying diseases like bleeding or thrombotic disorders were excluded. Totally, 118 patients with β-TM and 120 healthy individuals were included. The mean level of PC and AT was significantly lower in patients with β-TM (48.2 ± 65.4 and 57.42 ± 13.6, respectively) compared to the control group (97.1 ± 21.46 and 81.79 ± 14.3, respectively), with P value of 0.001 and 0.01, respectively. Although the difference was not statistically significant (P = 0.1), a similar trend was observed for total PS (61.12 ± 21.12 for patients versus 72.2 ± 35.2 for the control group). Of note, the decrease in PC, AT, and total PS levels compared to the control group was 50.36%, 27.5%, and 15.34%, respectively. It seems that β-TM patients who receive prolonged blood transfusions frequently are at an increased risk of decreased in natural anticoagulants levels and therefore potentially are at risk of thrombosis.

ANGIOEMBOLISATION OF CREMASTERIC ARTERY FOR SCROTAL HAEMATOMA FOLLOWING HERNIAL REPAIR

Cremasteric artery is a branch of inferior epigastric artery supplying the cremaster muscle and coverings of the cord. The possible consequence of injury to this artery is scrotal haematoma. We present a case of haemorrhage from unexpected cresmastric artery injury post-hernioplasty treated with angioembolisation. To the best of our knowledge, this has not been reported in literature.
 A 66-year-old gentleman with left indirect inguinal hernia underwent a left inguinal hernioplasty in our institution with no immediate complications. However he presented to the emergency department the day after the procedure with complaints of rapidly worsening painful left scrotal swelling accompanied with symptoms of intestinal obstruction. Emergency laparotomy and re-do left hernioplasty was performed, revealing a strangulated inguinoscrotal hernia. Post-operatively, there was non-resolving scrotal swelling with a drop in the haemoglobin level; from 11.9g/dl to 8.5g/dl requiring packed cell transfusion. CT angiogram revealed active contrast extravasation from the left cremasteric artery. Angiographic run confirmed the finding and the left cresmatric artery was superselectively cannulated with a 1.9Fr microcatheter and embolization done with 0.5mm microcoil. Ultrasound scan 24-hour post-procedure showed patent proximal vessel. Clinically there was a reduction of the left scrotal swelling and the haemoglobin remained stable. 
 Cremasteric artery courses laterally deep into the fascia transversalis entering the cord deep to the internal spermatic fascia to supply the cremaster muscle and coverings of the cord. This course renders the artery to be prone for injury during procedure such as hernioplasty; one of the possible consequences is scrotal haematoma. This artery is usually small in caliber and its identification is important for efficient and effective treatment.
 Angioembolisation is able to treat this injury with superior precision owing to its ability for localization and selective cannulation of the offending vessel.

Partial Exchange Transfusion in the Management of a Preterm Neonate with Severe Anaemia from Acute Foetomaternal Haemorrhage: A Case Report

Foetomaternal Haemorrhage (FMH) refers to the passage of foetal blood into the maternal circulation. FMH is rarely diagnosed antenatally as clinical findings are subtle and non specific. Massive FMH is suspected when foetal movements are decreased, and Cardiotocographic (CTG) findings are abnormal with decreased heart rate variability, saw-tooth or a sinusoidal pattern. Massive FMH can lead to foetal demise, stillbirth, hydrops, or the birth of a severely anaemic infant with hypovolaemic shock. A 35-week pregnant woman presented with decreased foetal movements, and an emergency caesarean section was performed due to late deceleration on the cardiotocograph. The baby was very pale at birth and in shock. The Kleihauer-Betke (KB) test performed on the mother’s blood shortly after delivery showed 2.7% foetal red cells, suggesting 135 cc of FMH. The clinical features and outcome of FMH depend on the gestational age, volume, and rapidity of FMH, as well as, whether it is acute or chronic. Packed cell transfusion is recommended, but in babies with severe anaemia and cardiac failure, partial exchange transfusion is performed. The baby was managed with a fluid bolus, inotropic support, respiratory support, and partial exchange transfusion, resulting in a successful outcome. A high index of suspicion enables the obstetrician to undertake diagnostic tests, cordocentesis, plan for intrauterine transfusion or delivery, and alert the neonatal team for a better outcome.

Challenging the Interpretation of White Blood Cell Counts in Patients with Sepsis Following Packed Cell Transfusion.

Critically ill patients with sepsis often require packed cell transfusions (PCT). However, PCT may affect white blood cell (WBC) counts. We conducted a population-based retrospective cohort study to trace changes in WBC count following PCT in critically ill patients with sepsis. We included 962 patients who received one unit of PCT while hospitalized in a general intensive care unit, and 994 matched patients who did not receive PCT. We calculated the mean values of WBC count for the 24 h before and 24 h after PCT. Multivariable analyses using a mixed linear regression model were performed. The mean WBC count decreased in both groups, but more in the non-PCT group (from 13.9 × 109/L to 12.2 × 109/L versus 13.9 × 109/L to 12.8 × 109/L). A linear regression model showed a mean decrease of 0.45 × 109/L in WBC count over the 24 h following the start of PCT. Every 1.0 × 109/L increase in the WBC count prior to PCT administration showed a corresponding decrease of 0.19 × 109/L in the final WBC count. In conclusion, among critically ill patients with sepsis, PCT causes only mild and clinically non-prominent changes in WBC count.

Management Outcomes of Large Renal Angiomyolipoma Presenting with Wunderlich Syndrome-Experience from a Tertiary Center.

Renal angiomyolipoma is an uncommon, benign-mixed mesenchymal tumor consisting of thick-walled blood vessels, smooth muscles, and mature adipose tissues. Twenty percent of these tumors are associated with tuberous sclerosis. Wunderlich syndrome (WS), an acute nontraumatic spontaneous perirenal hemorrhage, can be a presentation of large angiomyolipoma. This study evaluated the presentation, management, and complications of renal angiomyolipoma with WS in eight patients who presented to the emergency department between January 2019 and December 2021. The presenting symptoms included flank pain, palpable mass, hematuria, and bleeding in the perinephric space on computerized tomography. Demographic data, symptoms at presentation, comorbidities, hemodynamic parameters, the association with tuberous sclerosis, transfusion requirements, need for angioembolization, surgical management, Clavien-Dindo complication, duration of hospital stay, and 30-day readmission rates were evaluated. The mean age of presentation was 38 years. Of the eight patients, five (62.5%) were females and 3(37.5%) were males. Two (25%) patients had tuberous sclerosis with angiomyolipoma, and three (37.5%) patients presented with hypotension. The mean packed cell transfusion was three units, and the mean tumor size was 7.85 cm (3.5-25 cm). Three of them (37.5%) required emergency angioembolization to prevent exsanguination. Embolization was unsuccessful in one patient (33%) who underwent emergency open partial nephrectomy, and one (33%) patient developed post-embolization syndrome. A total of six patients underwent elective surgery-four underwent partial nephrectomy (laparoscopic - 1, robotic - 1, open - 2) and two underwent open nephrectomy. Three patients encountered Clavien-Dindo complications (Grade 1, n = 2 and IIIA, n = 2). WS is a rare, life-threatening complication in patients with large angiomyolipoma. Judicious optimization, angioembolization, and prompt surgical intervention will help deliver better outcomes.

Comparing Tubeless and Tubed Approaches in Percutaneous Nephrolithotomy for Moderate Renal Calculi: Outcomes on Safety, Efficacy, Pain Management, Recovery Time, and Cost-Effectiveness.

Introduction This study focuses on investigating the effect of routine nephrostomy tube placement in patients with moderate renal calculi of size 2.5 cm or less who undergo uncomplicated percutaneous nephrolithotomy (PCNL) procedures. Previous studies have not specified whether only uncomplicated cases were included in the analysis, which may affect the results. This study aims to provide a clearer understanding of the effect of routine nephrostomy tube placement on blood loss in a more homogeneous patient population. Materials and methods A prospective randomized controlled trial (RCT) was conducted at our department over 18 months, dividing 60 patients with a single renal or upper ureteric calculus of size ≤2.5 cm into two groups: 30 patients in each group (group 1: tubed PCNL, group 2: tubeless PCNL). The primary outcome was the drop in perioperative hemoglobin leveland the number of packed cell transfusions necessary. The secondary outcome included the mean pain score, analgesic requirement, length of hospital stay, time to return to normal activities, and the total cost of the procedure. Results The two groups were comparable in age, gender, comorbidities, and stone size. The postoperative hemoglobin level was significantly lower in the tubeless PCNL group (9.56 ± 2.13 gm/dL) compared to the tube PCNL group (11.32 ± 2.35 gm/dL) (p = 0.0037), and two patients in the tubeless group required blood transfusion. The duration of surgery, pain scores, and analgesic requirement were comparable between the two groups. The total procedure cost was significantly lower in the tubeless group (p = 0.0019), and the duration of hospital stay and time to return to daily activities were significantly shorter in the tubeless group (p < 0.0001). Conclusions Tubeless PCNL is a safe and effective alternative to conventional tube PCNL, with the advantages of shorter hospital stay, faster recovery, and lower procedure costs. Tube PCNL is associated with less blood loss and the need for transfusions. Patient preferences and bleeding risk should be considered when choosing between the two procedures.

Risk factors for maternal complications following uterine rupture: a 12-year single-center experience.

To determine maternal outcomes and risk factors for composite maternal morbidity following uterine rupture during pregnancy. A retrospective cohort study including all women diagnosed with uterine rupture during pregnancy, between 2011 and 2023, at a single-center. Patients with partial uterine rupture or dehiscence were excluded. We compared women who had composite maternal morbidity following uterine rupture to those without. Composite maternal morbidity was defined as any of the following: maternal death; hysterectomy; severe postpartum hemorrhage; disseminated intravascular coagulation; injury to adjacent organs; admission to the intensive care unit; or the need for relaparotomy. The primary outcome was risk factors associated with composite maternal morbidity following uterine rupture. The secondary outcome was the incidence of maternal and neonatal complications following uterine rupture. During the study period, 147,037 women delivered. Of them, 120 were diagnosed with uterine rupture. Among these, 44 (36.7%) had composite maternal morbidity. There were no cases of maternal death and two cases of neonatal death (1.7%); packed cell transfusion was the major contributor to maternal morbidity [occurring in 36 patients (30%)]. Patients with composite maternal morbidity, compared to those without, were characterized by: increased maternal age (34.7 vs. 32.8years, p = 0.03); lower gestational age at delivery (35 + 5 vs. 38 + 1weeks, p = 0.01); a higher rate of unscarred uteri (22.7% vs. 2.6%, p < 0.01); and rupture occurring outside the lower uterine segment (52.3% vs. 10.5%, p < 0.01). Uterine rupture entails increased risk for several adverse maternal outcomes, though possibly more favorable than previously described. Numerous risk factors for composite maternal morbidity following rupture exist and should be carefully assessed in these patients.

BODY TEMPERATURE VARIATION AFTER PACKED CELL TRANSFUSION IN ADULT PATIENTS WITH SEPSIS-WHERE WILL THE PENDULUM STOP?

Background : Critically ill patients with sepsis often require packed cell transfusions (PCTs). Packed cell transfusion causes changes in body's core temperature. Objective : To trace the course and amplitude of body core temperature after PCT in adults with sepsis. Methods : We conducted a population-based retrospective cohort study of patients with sepsis who received one unit of PCT during their hospitalization in a general intensive care unit during 2000-2019. A control group was established by matching each of these patients to a patient who did not receive PCT. We calculated the mean values of urinary bladder temperature for the 24 h before and 24 h after PCT. To evaluate the effect of PCT on body core temperature, multivariable analyses using a mixed linear regression model were performed. Results : The study comprised 1,100 patients who received one unit of PCT and 1,100 matched patients. The mean temperature before PCT was 37.3°C. Immediately from initiation of PCT, body temperature decreased, to a minimum of 37.0°C. During the 24 subsequent hours, the temperature increased gradually and consistently, until a peak temperature of 37.4°C. In a linear regression model, body core temperature increased by a mean 0.06°C in the first 24 h after PCT and decreased by a mean 0.65°C for every 1.0°C increase before PCT. Conclusions : Among critically ill patients with sepsis, PCT itself causes only mild and clinically insignificant temperature changes. Thus, significant changes in core temperature during the 24 h after PCT may indicate an unusual clinical event that requires clinicians' immediate attention.

Effects of serum fibrinogen correction on outcome of traumatic cranial surgery: A randomized, single-blind, placebo-controlled clinical trial

BackgroundTraumatic brain injury (TBI) is strongly associated with coagulopathy that occurs in 25–35% of patients. This complication is linked to higher mortality and morbidity. Recent lines of evidance have supported administration of fibrinogen concentrate (FC) in patients with severe TBI, while its efficacy remains controversial. In this study we aim to evaluate the effectiveness of serum fibrinogen level correction from 1.5 and 2.0 g/l to more than 2.0 g/l in patients with severe TBI undergoing traumatic cranial surgery. MethodThis randomized, single-blind, placebo-controlled clinical trial included trauma patients who had abbreviated injury scale (AIS) more than 3 in head and below 3 in other organs. FC was administered intravenously to patients with severe TBI undergoing TBI to correct the fibrinogen level above 2 g/l. Patients were randomly assigned to FC and control groups. The amount of intra-operative blood loss, packed cell (PC) transfusion, formation of new intracranial hemorrhage, and hemovac drainage were compared between the two study groups. ResultsForty-seven of 65 participants received the study intervention within 40–112 min of admission. Intra-operative PC transfusion was higher in FC group (80%) compared to control group (55.5%) while the differance was not statistically significant (p > 0.05). Intra-operative blood loss was significantly higher in control group than FC group (P = 0.036). Chance of re-operation and new intracranial hematoma were not significantly different between two study groups. ConclusionEarly delivery of FC, decreases intraoperative bleeding. Although based on our findings it has no other effect on other parameters, further multicenter studies are recommended to investigate the role of early FC administration in management of post traumatic coagulopathy.

The Use of Extracorporeal Circulation to Facilitate the Resection of a Large Retroperitoneal Sarcoma With Major Vessel Involvement: A Single-Center Review of 20 Cases

To describe the introduction of extracorporeal corporeal oxygenation (ECMO) to facilitate the surgical resection of large retroperitoneal sarcomas involving major vessels and to report preliminary outcomes. A case series. At a tertiary university hospital and state sarcoma center. Patients undergoing retroperitoneal sarcoma resection requiring inferior vena cava (IVC) reconstruction between June 2018 and March 2022. ECMO for retroperitoneal tumor resection requiring IVC reconstruction. A total of 20 patients underwent ECMO-assisted retroperitoneal sarcoma resection and IVC reconstruction. The median age was 60.5 years (IQR 48-69); 15 women and 5 men. The median procedure and ECMO durations were 10.8 hours (IQR 8.5-12.4 hours) and 2.2 hours (IQR 62-218 minutes), respectively. The median intensive care unit and hospital lengths of stay were 4 days (IQR 3-5 days) and 21 days (IQR 14-31 days), respectively. All 20 patients received packed cell transfusions (median 8 per patient [IQR 4-14]); 11 patients required fresh frozen plasma, 6 required platelets, and 11 required fibrinogen supplementation. One patient required recombinant activated factor VII. Sixteen patients experienced acute kidney injury, with 12 patients progressing to chronic kidney disease. Three patients were required to return to the operating room within 7 days, with no returns within the first 24 hours. There was no in-hospital or 30-day mortality. Survival at 3 years was 84%. ECMO for resecting large retroperitoneal tumor resection was introduced successfully and facilitated satisfactory outcomes for many patients who might otherwise have been considered too high risk.

The Causes of Postpartum Hemorrhage Leading to Packed-Cell Transfusion

The Causes of Postpartum Hemorrhage Leading to Packed-Cell Transfusion

Integration of palliative care in the management of oral squamous cell carcinoma.

Oral Squamous cell Cancers (OSCC) is strongly associated with tobacco consumption. We here in present a case study of a OSCC patient who refused standard oncological care (SOC), to highlight the importance of integrating palliative care (PC) for improved patient outcomes. A 61 years male patient, with history of chewing tobacco for more than 20 years and diagnosed to have OSCC for 1.5 years presented with severe anaemia and a cauliflower-like growth (12 x 10 cm) in the left oral cavity and cheek with greenish-yellow discharge. Pus culture was positive for K. pneumoniae and P. aeruginosa. Patient is also a known hypertensive for 15 years and a diabetic for 7 years on allopathic treatment. However, the patient refused SOC for oral cancer and relied on siddha treatment. Packed cell transfusions were given to correct anaemia and the blood glucose levels was kept under control. Frequent wound debridement, oral care, antibiotics, balanced-diet and hydration improved wound-bed granulation. Patient and family members were counselled and explained in detail on the need for SOC by sharing previous OSCC patients' care and outcomes at our centre. Patient gained trust and courage and agreed for chemotherapy, which reduced the disease burden and improved the quality of life (QoL) considerably. Therefore, PC integration at an early stage of treatment is imperative as it reduced (i) the burden of secondary infection, (ii) pain and distress, and (iii) improved the QoL.

Admission Hypocalcemia and the Need for Endoscopic and Clinical Interventions among Patients with Upper Gastrointestinal Bleeding

Introduction: Calcium is an essential co-factor in the coagulation cascade, and hypocalcemia is associated with adverse outcomes in bleeding patients, including trauma patients, women with postpartum hemorrhage, and patients with intracranial hemorrhage. In this retrospective, single-center, cohort study, we aimed to determine whether admission-ionized calcium (Ca⁺⁺) is associated with higher rates of therapeutic interventions among patients presenting with acute nonvariceal upper gastrointestinal bleeding (NV-UGIB). Methods: Adult patients admitted due to NV-UGIB between January 2009 and April 2020 were identified. The primary outcome was defined as a need for clinical intervention (two or more packed cell transfusions, need for endoscopic, surgical, or angiographic intervention). Univariate and multivariable logistic regression analyses were performed to determine whether Ca⁺⁺ was an independent predictor of the need for therapeutic interventions. Propensity score matching was performed to adjust the imbalances of covariates between the groups. Results: A total of 434 patients were included, of whom 148 (34.1%) had hypocalcemia (Ca⁺⁺ <1.15 mmol/L). Patients with hypocalcemia were more likely to require therapeutic interventions than those without hypocalcemia (48.0% vs. 18.5%, p < 0.001). Specifically, patients with hypocalcemia were more likely to require endoscopic intervention for control of bleeding (25.0% vs. 15.7%, p = 0.03) and multiple packed cell transfusions (6.8% vs. 0.3%, p < 0.001). Additionally, they had significantly longer hospital stay (5.0 days [IQR 3.0–8.0] vs. 4.0 days [IQR 3.0–6.0], p = 0.01). After adjusting for multiple covariates, Ca⁺⁺ was an independent predictor of the need for therapeutic intervention (aOR 1.62, 95% confidence interval [CI] 1.22–2.14, p < 0.001). The addition of Ca⁺⁺ to the Modified Glasgow Blatchford score improved its accuracy in the prediction of therapeutic intervention from AUC of 0.68 (95% CI 0.63–0.72) to 0.72 (95% CI 0.67–0.76), p = 0.02. After incorporation of the propensity score, the results did not change significantly. Conclusion: These findings suggest that hypocalcemia is common and is associated with an adverse clinical course in patients with NV-UGIB. Measurement of Ca⁺⁺ on admission may facilitate risk stratification in these patients. Trials are needed to assess whether the correction of hypocalcemia will lead to improved outcomes.

Clinical features, management and outcome in patients admitted with liver cirrhosis to the ICU - A retrospective study

Background: Hepatic cirrhosis is an important cause of morbidity and mortality in the intensive care unit (ICU). Objective: To determine the precipitating factors, presenting complaints, course of the disease and predictors of mortality in patients with liver cirrhosis admitted to the ICU. Methods: This retrospective study was conducted mat Multidisciplinary ICU at tertiary care hospital from April 2013 to March 2014. A total of 107 patients diagnosed with liver cirrhosis were admitted to the ICU. Of these, 17 were discharged against medical advice. The remaining 90 patients were included in the study. Their case notes were examined for data such as severity of disease, precipitating events and their course in the ICU. The survivors were followed up telephonically to assess survival at six months. Results: There were 30 survivors and 60 nonsurvivors. The stage of cirrhosis (based on modified Child-Pugh criteria) had significant association with hospital mortality and disease outcome. Mortality was significantly higher in patients presenting with sepsis and septic shock (P=0.022) and hepatic encephalopathy (P=0.007). Interventions such as mechanical ventilatory support (P=0.002), inotropes (P=0.001) and vasopressors (P=0.048), variceal banding (P=0.005), need for transfusion of fresh frozen plasma (P=0.001) and packed cell transfusion (P=0.036) showed significant association with clinical outcome. Conclusion: Overall mortality rate of patients admitted in the ICU with liver cirrhosis is high (66.7%). Mortality rate is higher in those with Stage C cirrhosis, sepsis and septic shock and hepatic failure. Among the patients who survive, one third may not survive beyond six months after hospital discharge.

What factors influence the cost of orthognathic surgery among patients in the US?

The purpose of our study was to analyze what factors influence the cost of orthognathic surgery performed within the US. This retrospective cohort study was completed using the Kids' Inpatient Database (KID) from 2000 to 2012 on all patients aged 14 to 20 years who had undergone orthognathic surgery. The predictor variables included patient and hospitalization characteristics. The primary outcome variable was hospital charge ($). Multivariate linear regression was conducted to determine independent predictors for increased/decreased hospital charge. The final sample consisted of 14 191 patients (mean age, 17.4 ± 1.6 years; females, 59.2%). Each additional day in the hospital added $8123 in hospital charges (P < .01). Relative to mandibular osteotomy, maxillary osteotomy (+$5703, P < .01) and bimaxillary osteotomy (+$9419, P < .01) were each associated with increased hospital charges. Genioplasty (+$3499, P < .01), transfusion of packed cells (TPC) (+$11 719, P < .01), continuous invasive mechanical ventilation (CIMV) <96 hours (+$23 502, P < .01), and CIMV ≥96 hours (+$30 901, P < .01) were each associated with significantly increased hospital charges. Obstructive sleep apnea (OSA) added $6560 in hospital charges (P < .01). Maxillary osteotomy and bimaxillary surgery were each associated with significantly increased charges relative to mandibular osteotomy. Concomitant genioplasty, TPC, CIMV, and OSA each significantly increased the charges. Each additional day to the length of stay significantly increased the charges.

Plasmodium vivax Malaria Associated with Severe Autoimmune Hemolytic Anemia

Background: Severe and/or persistent anemia due to autoimmune hemolytic anemia (AIHA) secondary to vivax malaria is a rare association. Very few cases are reported worldwide, and even less from India. AIHA occurs when immunoglobulins and/or complements target red blood cell surface antigens resulting in hemolysis. Awareness of this complication helps in early recognition, investigation, and prompt initiation of treatment. Clinical Description: A 15-year-old boy presented with a history of high fever associated with chills for 2 days. Examination revealed the presence of severe pallor and icterus. Systemic examination was unremarkable. Investigations showed anemia (Hb: 3.6 g/dl) with reticulocytosis (6.6%), malaria (trophozoites of Plasmodium vivax and antigen test positive), and indirect evidence of hemolysis (indirect hyperbilirubinemia and elevated lactate dehydrogenase of 668 U/l). Management and Outcome: Treatment was started with intravenous artesunate and packed cells transfusion was planned. Cross-matching showed autoantibodies which raised suspicion of AIHA. Coomb's test was positive. Least incompatible packed red blood cells were transfused. A repeat peripheral smear was negative for malaria. Posttransfusion, the Hb levels rose to 8.3 g/dl before falling to 5.3 g/dl over the next 2 days. The direct antiglobulin test was positive. High doses of oral prednisolone resulted in progressive improvement in Hb levels to 8 g/dl within a week. He was discharged on oral prednisolone with daily oral folic acid supplements. The steroids were tapered when Hb reached 10.6 g/dl and continued for 3 months. Conclusion: If a patient with malaria (falciparum or vivax) exhibits persistent severe anemia, indirect evidence of hemolysis is found on investigations and/or autoantibodies identified on cross-matching, AIHA should be suspected and investigated accordingly.

COVID-19 pandemic and care of transfusion-dependent patients of thalassaemia: Experience from a paediatric centre in North India.

AimCovid‐19 has presented an unprecedented challenge to health services and has significantly affected the management of non‐Covid illnesses, like thalassemia. The present study documents the impact of Covid‐associated restrictions and disruptions on working of the pediatric thalassemia day care centre (TDCC), and measures taken by TDCC and blood transfusion services to adapt to and mitigate the negative impact of Covid pandemic and associated lockdown on patient care.MethodsPre‐transfusion haemoglobin and packed cell transfusion requirement were compared across three time periods, namely pre‐lockdown, lockdown and post‐lockdown in paediatric transfusion‐dependent thalassaemia (TDT) patients. Caregivers were interviewed to document any problems faced by them.ResultsThe study involved 181 TDT patients. There was a significant reduction in mean pre‐transfusion haemoglobin and red cells transfused during lockdown phase as compared to pre‐lockdown phase. Regular care was interrupted in 45% of patients and 76% of patients getting blood from outside could not get leukoreduced red cells. Investigations, monitoring and continuity of iron chelation were also affected. Blood centre faced 30.5% reduction in blood supply during lockdown. TDCC and blood centre took several steps, including prolongation of service hours and staggering of transfusions to ensure maximum transfusions while ensuring social distancing.ConclusionThe Covid‐19 pandemic imposed many unprecedented challenges to the routine care of thalassaemic patients; however, some of them could be dealt with by a proactive approach and micro‐planning at the institution level. Other similar resource‐limited settings could learn from experiences for continued quality care for chronic medical conditions during pandemic like situations.

INDISCRIMINATE COAGULATION TESTING FOR BLEEDING RISK ASSESSMENT PRIOR TO ORTHOPEDIC SURGERY. IS IT A RATIONAL APPROACH?

Abstract Objective: Indiscriminative preoperative coagulation testing to identify patients at risk of bleeding is commonly practiced. However, this practice is no longer supported by current recommendations. We conducted this study with an aim to evaluate the advantage of doing screening testing for coagulation and hemostasis in unselected patients prior to elective orthopedic surgeries in our setting. Material and Methods: It was a retrospective, cross sectional study carried out at Medicare Cardiac and General Hospital, Jinnah Medical and Dental College, Karachi. All the patients admitted for elective orthopedic bilateral total knee replacement and Hip replacement surgeries from March 2016 to December 2018 were included in the study. Electronic data of patients’ pre-operative test results for Prothrombin time, activated partial Thromboplastin time was retrieved. Frequency of patients with deranged coagulation screening was calculated. Results: A total of 367 patients underwent pre-surgical coagulation testing. Male to female ratio was 1:3. Median age of patients was 61±5 years. A total of 2.9% (n=11) patients were found to have deranged coagulation profile. Out of which 3 patients did not undergo surgery and were loss to follow up. Out of total 0.54% (n=2) patients had both prolonged PT and APTT, 1.6% (n=6) patients had prolonged APTT and 0.3% (n=1) patient experienced intraoperative bleeding requiring one unit of packed cell transfusion. Only 0.3% (n=1) patient experienced post-operative bleeding and dropped her Hemoglobin and received transfusion. Conclusion: The overall results of the study suggest that indiscriminate coagulation screening does not provide any additional information unless further detailed hemostatic evaluation is carried out. It is suggested that routine screening tests should not be performed unless a medical history is indicative of bleeding tendency. Key Words: Coagulation screening, Bleeding risk, Orthopedic surgery.