Use Of Packed Red Blood Cells Research Articles

The assessment of collection and utilization of blood and blood components in Zanzibar

Background: Assessment of blood and blood components requisition and utilization is essential for better planning and improvement of transfusion services to meet requests and demands. The main aim of this study is to assess the collection and utilization of blood and blood components in Zanzibar National Blood Transfusion Services (ZNBTS). Method: It is a retrospective study in which data relating to the collection and usage of blood and its components from January 2021 to December 2021 at ZNBTS was collected and analyzed. Results: A total of 16,388 units of blood were collected from January to December 2021. 21,265 units of blood components were generated from 8,585(55.0%) units of Whole Blood (WB), while the remaining 7,030 (45.0%) units were issued as WB. In Unguja, there was a significant increase in the use of Packed Red Blood Cells (PRBC) 10,177 (61.3%), followed by WB 3,759 (22.6%), Fresh Frozen Plasma (FFP) 1, 562 (9.4%) and Platelets (PLT) 10 (0.06%) respectively. In Pemba, the use of WB was high (n = 1,526; 69.8%), followed by PRBC 878 (3.6%) and FFP 68(0.4%). The monthly mean blood request was 2,975 units (WB 460 and Blood components 1,028). Blood collection was above ZNBTS annual target of 16,000 units but blood and blood components request was met only by 50%. Conclusion: There is a gradual shift in clinical practice from the traditional use of WB to the use of PRBC and other blood components. For the appropriate use of blood and blood components, Transfusion Medicine training among Medical Students and junior clinicians is strongly recommended.

Reduced blood product utilization via implementation of an anemia clinic and consult service in a large health system hospital.

e18716 Background: An Anemia Clinic program was started Sept. 2016 as part of system wide implementation of Patient Blood Management (PBM) initiated in 2015. Methods: The Anemia Clinic accepted referrals for non-cancer anemia, predominantly preoperative cardiovascular surgery (CVS) Pts. Hgb thresholds were < 13 g/dL in men and < 12 g/dL in women. Non-anemia cytopenias triggered Hematology referral. All Pts were screened for iron, B12, folate, and reticulocyte count. Nutrient deficiencies were supplemented. Pts with CKD or chronic disease were considered for erythropoiesis stimulating agents. Results: PBM implementation resulted in a drop in packed red blood cell (PRBC) usage (Table). Of CVS Pts pre-operatively anemic in 2022, 211 were referred to the Anemia Clinic and 373 were not. The percentage of Pts who received PRBCs after Anemia Clinic referral was not statistically different from those who were not referred (61.1% vs. 54.2% chi-square p = 0.10). Of preoperatively anemic Pts who were transfused in 2022, an average of 2.41 PRBCs were used in the referred group vs. an average of 2.21 PRBCs in those in the not referred group (negative binomial p = 0.25). Length of stay (LOS) which was a median 10d ( P25= 6d, P75 =17d) in the referred group vs a median 10d ( P25= 7d, P75 =17d) in the non-referred group was not statistically different between groups (Kolmogorov-Smirnov p = 0.84). LOS analyses of observed-to-expected (O/E) ratios used the Premier Healthcare Providers Alliance Database (PHD) which contains data on approximately 45% of US hospital discharges. For 2022 through Nov. the referred group had an O/E = 0.93 (observed LOS μgeo = 10.51 days, expected LOS μgeo = 11.32 days, N = 183). The not referred group had an O/E = 1.10 (observed LOS μgeo = 10.44 days, expected LOS μgeo = 9.50 days, N = 321). Conclusions: PBM decreased PRBC use through systematization of best practices during the initial year, and that decrease has persisted for seven years. Subsequent addition of Anemia Clinic services did not decrease PRBC use further. A trend toward shorter LOS for patients referred to Anemia Clinic was not observed this year, but the difference in LOS from the not referred group is not statistically significant and observed LOS for the referred group was lower than expected LOS. Our methods improved nutrient deficiency identification which may improve both later health outcomes not detected here and access to treatment for hematologic malignancies. [Table: see text]

Refraining from Packed Red Blood Cells in Cardiopulmonary Bypass Priming as a Method of Neuroprotection in Pediatric Cardiac Surgery

This study included 40 children, and the mean age was 14 (12-22.5) months and the mean weight was 8.8 (7.25-11) kg. All patients underwent CHD closure using CPB. The patients were divided into two groups depending on the use of PRBCs in the priming solution. Brain injury was assessed using three specific blood serum markers, namely S100 calcium-binding protein β (S100β), neuron-specific enolase (NSE) and glial fibrillary acidic protein (GFAP) before surgery, after the completion of CPB and 16 h after surgery (first, second and third control points). Markers of systemic inflammatory response were also analyzed, including interleukin-1, -6, -10 and tumor necrosis factor alpha (TNF-α). A clinical assessment of brain injury was carried out using a valid, rapid, observational tool for screening delirium in children of this age group, i.e., "Cornell Assessment of Pediatric Delirium". Factors of the intra- and postoperative period were analyzed, such as hemoglobin levels, oxygen delivery (cerebral tissue oxygenation, blood lactate level and venous oxygen saturation) and indicators of organ dysfunction (creatinine, urea, bilirubin levels, duration of CPB and length of stay in the ICU). Following the procedure, there were no significant differences between the groups and all indicators were within the reference values, thus demonstrating the safety of CHD closure without transfusion. Moreover, the highest level of specific markers of brain injury were noted immediately after the completion of CPB in both groups. The concentration of all three markers was significantly higher in the group with transfusion after the completion of CPB. Moreover, GFAP levels were higher in the transfusion group and 16 h after surgery. The results of the study show the safety and effectiveness of brain injury prevention strategies that consist of not conducting PRBC transfusion.

Multi-center Retrospective Study of Factors Affecting Perioperative Transfusion of Packed Red Blood Cells for Pelvic Fracture Patients.

ObjectiveTo analyze the use of packed red blood cells (PRBCs) for patients with pelvic fracture and evaluate factors associated with PRBC transfusion for patients with pelvic fracture.MethodsThis retrospective cohort study collected 551 patients with pelvic fractures from six hospitals between September 1, 2012, and June 31, 2019. The age span of patients varied from 10 to 95 years old, and they were classified into two groups based on high‐energy pelvic fractures (HE‐PFs) or low‐energy pelvic fractures (LE‐PFs). The study's outcome was the use of PRBCs, fresh frozen plasma (FFP), and albumin. Demographic data, characteristics, laboratory tests, clinical treatment details, and clinical outcomes were compared between the two groups. Factors that were statistically associated with perioperative PRBCs in univariate analyses were included to conduct an optimal scale regression to determine the independent factors for perioperative PRBCs.ResultsA total of 551 patients were screened from six hospitals, and after inclusion and exclusion, 319 were finally included and finished the follow‐up from admission to discharge, while four patients died during hospitalization. Three hundred and nineteen patients were classified into two groups by their injury mechanisms. A total of 230/319 (72.1%) patients were classified into the HE‐PF group, and 89/319 (27.8%) patients were classified into the LE‐PF group. Patients in the HE‐PF group were transfused with 4.5 (3–8) units of PRBCs, 300 (0–600) ml of FFP, and 0 (0–30) g of albumin, while patients in the LE‐PF group were transfused with 3.5 (2–4.5) units of PRBCs, 0 (0–295) ml of FFP, and 0 (0–0) g of albumin (all P < 0.001). There were higher proportions of male patients and patients under 65 in the HE‐PF group (all P < 0.001). HE‐PF group patients were more severely injured and likely to take external fixation. The optimal scale regression revealed four significant factors associated with perioperative transfused PRBCs, which were patients on admission with hemorrhagic shock (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.148, P = 0.039), and methods of pelvic fixation (importance = 0.008, P = 0.026), ranked by the importance.ConclusionPatients with HE‐PFs had increased transfusions of PRBCs, FFP, and albumin, and hemorrhagic shock on admission, Tile classification, Hb levels, and stabilization methods were found to be associated with perioperative PRBCs.

Reduced blood product utilization via implementation of an anemia clinic and consult service in a large health system hospital.

e18799 Background: An Anemia Clinic program was started Sept. 2016 as part of system wide implementation of Patient Blood Management (PBM) initiated in 2015. Methods: The Anemia Clinic accepted referrals for non-cancer anemia, predominantly preoperative cardiovascular surgery (CVS) Pts. Hgb thresholds were &lt; 13 g/dL in men and &lt; 12 g/dL in women. Non-anemia cytopenias triggered Hematology referral. All Pts were screened for iron, B12, folate, and reticulocyte count. Nutrient deficiencies were supplemented. Pts with CKD or chronic disease were considered for erythropoiesis stimulating agents. Results: PBM implementation resulted in a drop in packed red blood cell (PRBC) usage (Table). Of CVS Pts pre-operatively anemic in 2021, 169 were referred to the Anemia Clinic and 352 were not. The percentage of Pts who received PRBCs after Anemia Clinic referral was statistically different from those who were not referred (67.5% vs. 52.8% chi-square p = 0.002). Of preoperatively anemic Pts who were transfused in 2021, an average of 2.67 PRBCs were used in the referred group vs. an average of 2.36 PRBCs in those in the not referred group (negative binomial p = 0.18). Length of stay (LOS) which was a median 10d ( P25= 7d, P75 =18d) in the referred group vs a median 10d ( P25= 6d, P75 =16.5d) in the non-referred group was not statistically different between groups (Smirnov p = 0.36). LOS analyses of observed-to-expected (O/E) ratios used the Premier Healthcare Providers Alliance Database (PHD) which contains data on approximately 45% of US hospital discharges. For 2021 through Nov. the referred group had an O/E = 0.93 (observed LOS μgeo = 10.88 days, expected LOS μgeo = 11.67 days, N = 154). The not referred group had an O/E = 1.04 (observed LOS μgeo = 10.56 days, expected LOS μgeo = 10.18 days, N = 305). Conclusions: PBM decreased PRBC use through systematization of best practices during the initial year, and that decrease has persisted for six years. Subsequent addition of Anemia Clinic services did not decrease PRBC use further. A trend toward shorter LOS for patients referred to Anemia Clinic did not continue this year, but the difference in LOS from the not referred group was not statistically significant and observed LOS for the referred group was lower than expected LOS. Our methods improved nutrient deficiency identification which may improve both later health outcomes not detected here and access to treatment for hematologic malignancies.[Table: see text]

Reduced blood product utilization via implementation of an anemia clinic and consult service in a large health system hospital.

e18654 Background: An Anemia Clinic program was started Sept. 2016 as part of system wide implementation of Patient Blood Management (PBM) initiated in 2015. Methods: The Anemia Clinic accepted referrals for non-cancer anemia, predominantly preoperative cardiovascular surgery (CVS) Pts. Hgb thresholds were &lt;13 g/dL in men and &lt;12 g/dL in women. Non-anemia cytopenias triggered Hematology referral. All Pts were screened for iron, B12, folate, and reticulocyte. Nutrient deficiencies were supplemented. Pts with CKD or chronic disease were considered for erythropoiesis stimulating agents. Results: PBM implementation resulted in a drop in packed red blood cell (PRBC) usage (Table). Of CVS Pts pre-operatively anemic in 2020, 181 were referred to the Anemia Clinic and 259 were not. The percentage of Pts who received PRBCs after Anemia Clinic referral was not statistically different from those who were not referred (52.5% vs. 43.6% Chi-Square p=0.07). Of preoperatively anemic Pts who were transfused in 2020, an average of 1.49 PRBCs were used in the referred group vs. an average of 2.12 PRBCs in those in the not referred group (Poisson Means p=0.0009). Length of stay (LOS) which was a median 9d ( P25=6d, P75=16d) in the referred group vs a median 10d ( P25=6d, P75=16d) in the non-referred group was not statistically different between groups (Smirnov p=0.99). LOS analyses of observed-to-expected (O/E) ratios used the Premier Healthcare Providers Alliance Database (PHD) which contains data on approximately 45% of US hospital discharges. For 2020 through Nov. the referred group had an O/E = 0.89 (observed LOS μgeo = 9.97 days, expected LOS μgeo = 11.17 days, N=159). The not referred group had an O/E = 0.94 (observed LOS μgeo = 10.14 days, expected LOS μgeo = 10.83 days, N=232). Conclusions: PBM decreased PRBC use through systematization of best practices during the initial year. Subsequent addition of Anemia Clinic services did not decrease PRBC use further at first but appears to have contributed to this past year’s decrease. There is a trend toward shorter LOS for patients referred to Anemia Clinic but it is not statistically significant. Our methods improved nutrient deficiency identification which may improve both later health outcomes not detected here and access to treatment for hematologic malignancies.[Table: see text]

Long-term Impact of Perioperative Red Blood Cell Transfusion on Patients Undergoing Cardiac Surgery

There is a known association between need for transfusion and short-term outcomes in patients undergoing cardiac surgery. However long-term data are lacking in the contemporary literature. All patients who underwent open cardiac surgery from 2010 to 2018 were included, except those undergoing transplant, with a ventricular-assist device, and requiring circulatory arrest. Primary outcome included short- and long-term mortality. Secondary outcomes included postoperative complications and hospital readmissions. The total patient population included 14,281 patients with a median follow-up of 4.03 years (range, 2.25-6.1). Outcomes were stratified into patients with (n= 6239) or without (n= 8042) packed red blood cell (PRBC) use. Patients with PRBC transfusions had significantly (P < .001) worse postoperative outcomes compared with those without PRBC use, including higher operative mortality (6.89% vs 0.98%), return to the operating room (17.8% vs 1.61%), pneumonia (7.84% vs 0.98%), stroke (3.22% vs 1.51%), sepsis (2.66% vs 0.20%), renal failure (8.42% vs 1.12%), and dialysis (5.74% vs 0.42%). On multivariate analysis PRBC transfusion was an independent predictor of mortality (hazard ratio [[HR], 2.39; 95% confidence interval [CI], 2.08-2.64; P < .001) and hospital readmission (HR, 1.15; 95% CI, 1.09-1.21; P < .001). Total units of PRBCs were directly associated with mortality (HR, 1.09; 95% CI, 1.08-1.09; P < .001) and hospital readmissions (HR, 1.02; 95% CI, 1.01-1.03; P < .005). Patients with perioperative PRBC transfusions have increased operative and long-term mortality and hospital readmissions. Total units of PRBCs transfused were directly associated with mortality and readmissions.

Reduced blood product utilization via implementation of an anemia clinic and consult service in a large health system hospital.

e14142 Background: An Anemia Clinic program was started Sept. 2016 as part of system wide implementation of Patient Blood Management (PBM) initiated in 2015. Methods: The Anemia Clinic accepted referrals for non-cancer anemia, predominantly preoperative cardiovascular surgery (CVS) Pts. Hgb thresholds were &lt; 13 g/dL in men and &lt; 12 g/dL in women. Non-anemia cytopenias triggered Hematology referral. All Pts were screened for iron, B12, folate, and reticulocyte. Nutrient deficiencies were supplemented. Pts with CKD or chronic disease were considered for erythropoiesis stimulating agents. Results: PBM implementation resulted in a drop in packed red blood cell (PRBC) usage (Table). Of CVS Pts pre-operatively anemic in 2019, 180 were referred to the Anemia Clinic and 301 were not. Anemia Clinic identified iron (N = 114), vitamin B12 (N = 24), and folate (N = 18) deficiencies. The percentage of Pts who received PRBCs after Anemia Clinic referral was not statistically different from those who were not referred (65.6% vs. 61.8% Chi-Square p = 0.44). Of preoperatively anemic Pts who were transfused in 2019, an average of 2.34 PRBCs were used in the referred group vs. an average of 2.21 PRBCs in those in the not referred group (Poisson Means p = 0.46). Length of stay (LOS) which was a median 10d ( P25= 7d, P75 =17d) in the referred group vs a median 12d ( P25= 7d, P75 =19d) in the non-referred group was not statistically different between groups (Smirnov p = 0.39). LOS analyses of observed-to-expected (O/E) ratios used the Premier Healthcare Providers Alliance Database (PHD) which contains data on approximately 45% of US hospital discharges. For 2019 through Nov. the referred group had an O/E = 1.03 (observed LOS μgeo = 11.58 days, expected LOS μgeo = 11.21 days, N = 167). The not referred group had an O/E = 1.06 (observed LOS μgeo = 12.24 days, expected LOS μgeo = 11.58 days, N = 272). Conclusions: PBM decreased PRBC use through systematization of best practices during the initial year. Subsequent addition of Anemia Clinic services has not decreased PRBC use further. There is a trend toward shorter LOS for patients referred to Anemia Clinic but it is not statistically significant. Our methods improved nutrient deficiency identification which may improve both later health outcomes not detected here and access to treatment for hematologic malignancies. [Table: see text]

Reduced Packed Red Blood Cell Utilization Via Implementation of Transfusion Guidelines in a Large Health System Hospital

Background: We have previously discussed how implementation of Patient Blood Management (PBM) principles such as transfusion guidelines helped reduce packed red blood cell (PRBC) usage in cardiovascular surgery patients (Bowers et al, Reduced Blood Product Utilization via Implementation of an Anemia Clinic and Consult Service in a Large Health System Hospital https://tinyurl.com/y3ucr3sz). We now discuss the effect of implementing transfusion guidelines on PRBC transfusion practices at an institutional level at St. Luke's Medical Center, Advocate Aurora Health in Milwaukee, WI. Methods: Beginning in 2015 Aurora Health Care made 7 g/dL the standard threshold below which packed red blood cell (PRBC) transfusion is considered appropriate. Additionally, transfusing PRBCs as single units with a hemoglobin (Hgb) measurement between each unit was made standard. Education was provided to clinicians on the new standard including best practice advice in the transfusion ordering workflow. Data was gathered on institutional PRBC use and individual clinician PRBC ordering practices. Further education was provided based on the extent to which data showed conformity to the new standard. Results: PBM implementation 2015-2018 was associated with a drop in institutional PRBC usage from 11,490 to 9301 units. The percentage of transfusions ordered with Hgb &amp;lt; 7 g/dL rose from 41.6% to 71.8%. The percentage of single unit orders increased from 67.3% to 91.8%. See Graph/Table 1 &amp; 2 for further analysis of individual practitioner PRBC ordering. See Table 3 for reporting period volume data. Conclusions: Implementation of PRBC transfusion guidelines was associated with a greater than 2000-unit annual reduction in PRBC usage. Reduction was associated with individual clinician transfusion practices that increasingly conformed with guidelines over time. Disclosures Thompson: Adaptive: Membership on an entity's Board of Directors or advisory committees; AbbVie: Research Funding; UpToDate: Patents &amp; Royalties: Myeloma reviewer; BMS: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees; Lynx Bio: Research Funding; VIA Oncology: Membership on an entity's Board of Directors or advisory committees; GSK: Membership on an entity's Board of Directors or advisory committees; Doximity: Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Takeda: Membership on an entity's Board of Directors or advisory committees, Research Funding.

Reduced blood product utilization via implementation of an anemia clinic and consult service in a large health system hospital: Focus on cardiovascular patients.

e18014 Background: As part of a system wide implementation of Patient Blood Management (PBM), an Anemia Clinic program was implemented at St. Luke’s Medical Center, Advocate Aurora Health in Milwaukee, WI. Methods: September 2016 the Anemia Clinic started accepting referrals for management of non-cancer anemia, predominantly pre-operative cardiovascular surgery (CVS) Pts. Hgb thresholds were &lt; 13 g/dL in men and &lt; 12 g/dL in women. Non-anemia cytopenias triggered Hematology referral. All Pts were screened for iron, B12, folate, and reticulocyte. Nutrient deficiency received appropriate supplementation. Pts with CKD or chronic disease were eligible to receive erythropoiesis stimulating agents. Results: PBM implementation 2015-2018 resulted in a drop in packed red blood cell (PRBC) usage during a surgical episode (Table). Of 508 CVS Pts pre-operatively anemic in 2018, 155 were referred to the Anemia Clinic and 353 were not. There was not a statistical difference between the referred and the non-referred for percentage of Pts who received PRBCs (65.4% vs. 70.3% Chi-Square p = 0.31). Of preoperatively anemic Pts who were transfused in 2018 an average of 2.23 PRBCs were used in the referred group vs. an average of 2.35 PRBCs in those in the not referred group (Poisson Means p = 0.49). Length of stay (LOS) in the referred group was a median 10d ( P25= 7d, P75 =15d) vs LOS in the non-referred group was a median 11d ( P25= 7d, P75 =20d). LOS analyses of observed-to-expected (O/E) ratios used the Premier Healthcare Providers Alliance Database (PHD) which contains data on approximately 45% of US hospital discharges.. For 2018 through Nov. the referred group was observed to have LOS mgeo = 10.19 days vs LOS mgeo = 11.72 days (N = 141, O/E 0.87). The not referred group was observed to have a LOS mgeo = 12.45 days vs. an LOS mgeo = 10.65 days (N = 311, O/E 1.17). Conclusions: Referral to the Anemia Clinic as part of a broader program of PBM was associated with shorter LOS and a decrease in PRBC use. Implementation of PBM at our institution decreased PRBC use even in patients not referred to anemia clinic due to systematization of best practices. Implementation of our methods as the initial approach to general anemia referrals may increase access and efficiencies in the systemization and treatment of hematologic malignancies. [Table: see text]

Prognostic effect of different blood transfusion ratios in trauma patients with massive transfusion

Objective To evaluate the prognostic effect of different ratios of fresh frozen plasma (FFP) to packed red blood cells (PRBC) in massively transfused trauma patients. Methods A retrospective cohort study was conducted for 210 trauma patients who received more than 10 units of PRBC during the initial 24 hours from January 2007 to June 2015. The patients were divided into four groups: Group A(PRBC ∶FFP≤1, n=41), Group B (1 2, n=76). At 24 hours after admission, blood transfusion amount, blood transfusion ratios, post-transfusion adverse reactions (allergy, non-hemolytic febrile transfusion reaction, hemolysis, congestive heart failure, pulmonary edema, etc) and coagulation changes [hemoglobin (Hb), platelet count (PC), prothrombin time(PT), activated partial thromboplastin time(APTT), international normalized ratio (INR), etc] were compared among groups. Prognostic markers including sequential organ failure assessment(SOFA), hospital stay, ICU stay, 30-day mortality and causes of death were also evaluated. Results Use of PRBC was decreased significantly in Group A than in other groups (P 0.05). The coagulation indices (PT, APTT and INR) in Groups A and B were significantly decreased compared to Group D after transfusion (P 0.05). Group D was associated with higher SOFA and higher 30-day mortality than other groups(P 0.05). Meanwhile, ratio of patients died of massive hemorrhage in Group D was also higher than other groups (P<0.01). Kaplan-Meier survival analysis showed the survival interval was the shortest in Group D, while the longest in Group B and C. Conclusions Modest transfusion ratios(1. 5<PRBC ∶FFP≤2)within 24 hours can substantially improve outcomes in trauma patients. Aggressive ratios may improve coagulation indices and reduce use of PRBC, with no more benefit to the outcomes. Key words: Blood component transfusion; Wounds and injuries; Prognosis

Management of major bleeding events in patients treated with rivaroxaban vs. warfarin: results from the ROCKET AF trial

There are no data regarding management and outcomes of major bleeding events in patients treated with oral factor Xa inhibitors. Using data from ROCKET AF, we analysed the management and outcomes of major bleeding overall and according to the randomized treatment. During a median follow-up of 1.9 years, 779 (5.5%) patients experienced major bleeding at a rate of 3.52 events/100 patient-years with a similar event rate in each arm (n = 395 rivaroxaban vs. n = 384 warfarin). The median number of transfused packed red blood cells (PRBC) per episode was similar in both arms [2 (25th, 75th: 2, 4) units]. Overall, few transfusions of whole blood (n = 14), platelets (n = 10), or cryoprecipitate (n = 2) were used. Transfusion of fresh frozen plasma (FFP) was significantly less in the rivaroxaban arm (n = 45 vs. n = 81 units) after adjustment for covariates [odds ratio (OR) 0.43 (95% CI 0.29-0.66); P < 0.0001]. Prothrombin complex concentrates (PCC) were administered less in the rivaroxaban arm (n = 4 vs. n = 9). Outcomes after major bleeding, including stroke or non-central nervous system embolism (4.7% rivaroxaban vs. 5.4% warfarin; HR 0.89; 95% CI 0.42-1.88) and all-cause death (20.4% rivaroxaban vs. 26.1% warfarin; HR 0.69, 95% CI 0.46-1.04) were similar in patients treated with rivaroxaban and warfarin (interaction P = 0.51 and 0.11). Among high-risk patients with atrial fibrillation who experienced major bleeding in ROCKET AF, the use of FFP and PCC was less among those allocated rivaroxaban compared with warfarin. However, use of PRBCs and outcomes after bleeding were similar among patients randomized to rivaroxaban or to warfarin.

Can “Seven Be The New Ten” - Adoption Of Restrictive Transfusion Strategies In a Community Hospital

BackgroundAn estimated 13,785,000 units of packed red blood cells (PRBC) were transfused in the United States in 2011 of which an estimated 57.9% were found to be from the general medical service, the ICU or hematology/oncology. Risks of blood transfusion include infections, transfusion reactions circulatory overload, and transfusion-related immunomodulation. Furthermore, there is an economic cost to the administration of blood and a personal cost to those volunteers who give their time.There have been a number of guidelines published for the administration of PRBCs. In the past year, the American Association of Blood Banks released new guidelines for PRBC transfusion in hospitalized, hemodynamically stable patients. These guidelines set a threshold Hb of ≤7 g/dL in critically-ill patients, and a Hb ≤8 g/dL for surgical patients, for patients with pre-existing cardiovascular disease, or for patients with relevant symptoms. Symptoms were defined as tachycardia, chest pain or hypotension not corrected by crystalloids.We studied the potential impact on our inpatient hospital utilization of PRBC over time in relation to the publication of recent guidelines. MethodsWith IRB approval, a retrospective study of PRBC transfusion at New Hanover Regional Medical Center in Wilmington, NC was conducted. The primary endpoint of the study was to evaluate the impact of the new AABB guidelines on the transfusion utilization in the first 12 months. Secondary endpoints included a cost analysis, an evaluation of the use of PRBC for two pre-specified Hb levels, and a quantification of the number of units transfused.A total of 337 patients were reviewed. 116 were excluded due to one of the following reasons: anemia attributed to active blood loss, the presence of stage 5 chronic kidney disease, the presence of an acute coronary syndrome, the recent administration of outpatient transfusions, the use of blood products besides PRBCS, and the timing of a transfusion in the postoperative period. We randomly assigned two separate timeframes to review transfusions at ≤ 4 months and 8-12 months after the AABB guidelines were published. Data was analyzed using Chi-square and T tests. ResultsThe average pre-treatment hemoglobin for the group ≤4 months was 7.82 ± 0.85 and 7.42 ± 0.92 for the 8-12 month group (p=0.0009). The average number of units transfused were 1.66 ± 0.53 and 1.78 ± 0.58 (P=0.1133), respectively. For those patients whose Hb was ≤ 7.0, there was a 21.6% reduction in inappropriate transfusions 8-12 months after the guidelines were released compared with the first 4 months (Chi-Square p = 0.0070). For those patients whose Hb was ≤ 8.0, the number of inappropriate transfusions went from 40.7% in the first group to 17.3% in the second group (Chi-Square p=0.0001).The total cost of transfusions to the patients was estimated to be $102,400 and $55,600 to the hospital. The potential savings if all transfusions were given according to the new guidelines is estimated to be $66,389 to the patients and $36,037 to the hospital.A total of 11,577 transfusions were given between 6/12/12-3/13/13. If the guidelines had been strictly followed, the number of transfusions would have been reduced to 3,855 transfusions. DiscussionAn improvement in adherence to AABB guidelines with a more restrictive PRBC transfusion strategy was found over time. This can be attributed to physicians practicing evidenced-based medicine. Data of transfusions at pre-treatment Hb ≤7, suggest that physicians are becoming more restrictive in their threshold for transfusions with a statistically significance in the drop of the average pre-treatment hemoglobin. Despite this restrictive pattern, physicians are still uncomfortable at transfusing 1 unit at a time. Although it was not statistically significant between the two groups, the average number of units transfused were ≥1.5, and 67% of the time 2 units were given. Overtransfusion with PRBCs is a problem that needs to be addressed. Physicians should give one unit and reassess for an appropriate response. This strategy will reduce cost to the patient and hospital.We feel that additional improvement is still possible and we are forming a blood management committee to promote better PRBC transfusion practice guidelines. We plan a series of educational presentations to each department along with a new Computerized Physician Order Set to improve patient care and reduce overall cost to the health care system. Disclosures:No relevant conflicts of interest to declare.

Early Aggressive Use of Fresh Frozen Plasma Does Not Improve Outcome in Critically Injured Trauma Patients

Recent data from Iraq supporting early aggressive use of fresh frozen plasma (FFP) in a 1:1 ratio to packed red blood cells (PRBCs) has led many civilian trauma centers to adopt this resource intensive strategy. Prospective data were collected on 806 consecutive trauma patients admitted to the intensive care unit over 2 years. Patients were stratified by PRBC:FFP transfusion ratio over the first 24 hours. Stepwise regression models were performed controlling for age, gender, mechanism of injury, injury severity, and acute physiology and chronic health evaluation (APACHE) 2 score to determine if early aggressive use of PRBC:FFP improved outcome. Seventy-seven percent of patients were male (N = 617) and 85% sustained blunt injury (n = 680). Mean age, injury severity score (ISS), and APACHE score were 43 +/- 20 years, 29 +/- 13, and 13 +/- 7, respectively. Mean number of PRBCs and FFP transfused were 7.7 +/- 12 U, 6 U, and 5 +/- 12 U, respectively. Three hundred sixty-five (45%) patients were transfused in the first 24 hours. Sixty-eight percent (n = 250) of them received both PRBCs and FFP. Analyzing these patients by stepwise regression controlling for all significant variables, the PRBC:FFP ratio did not predict intensive care unit days, hospital days, or mortality even in patients who received massive transfusion (> or = 10 U). Furthermore, there was no significant difference in outcome when comparing patients who had a 1:1 PRBC:FFP ratio with those who did not receive any FFP. Early and aggressive use of FFP does not improve outcome after civilian injury. This may reflect inherent differences compared with military injury; however, this practice should be reevaluated.

Transfusion of packed red blood cells in patients with ischemic heart disease

To review the current literature concerning the utility of and complications associated with transfusion of packed red blood cells (PRBC) in medical and surgical patients with ischemic heart disease. The PubMed database of the National Library of Medicine was searched for all studies investigating the use of PRBC in medical and surgical patients with cardiac disease published since 1999. Relevant background literature from before that date was reviewed for inclusion as well. An extensive body of literature has accumulated evaluating the safety and efficacy of transfusion as a therapeutic modality in a wide variety of critically ill patients, including patients with cardiac disease. Most, but not all, of these studies have been retrospective in nature, and methodologies have varied from study to study. Some have involved retrospective reviews of patient records, some have been retrospective analyses of detailed databases prospectively collected for other purposes, and some have been prospective randomized or observational studies. Despite the variability in data sources and study design, with a handful of exceptions, the preponderance of data indicates that transfusion of PRBC in the population of patients with ischemic heart disease is of limited clinical utility and may carry the potential for serious adverse consequences. Based on the current literature, there appears to be no indication for routine transfusion in patients with non-ST-elevation acute coronary syndrome, although anemic patients with ST-elevation myocardial infarction may benefit from this intervention. However, the specific indications for transfusion in this population remain ill-defined.

Trends in exploitation of packed red blood cells.

The following trends aim to a more efficient exploitation of packed red blood cells (PRBC): 1. Improvement of the operative distribution of PRBCs for transfusions before expiration. 2. Prolongation of the expiration time by monitoring the biochemical and physical processes during banking. Maintenance of native hemoglobin and restoration or substitution of substances involved in transport of energy and of oxygen are of utmost importance. Enzymic conversion of RBCs of blood group A, B to 0 is not supposed to leave laboratory scale soon. While cryo-conservation of RBCs with glycerine is known, freeze-drying of PRBCs remains a speculation. 3. Use of PRBCs after expiration as a raw material for products applicable in medicine and biochemistry. Stroma-free hemoglobin variants (SFH) are known as effective infusable oxygen carriers in experimental animal models. However, there is little convincing evidence on the metabolism and innocuity of SFH variants in human organism. Therefore, systemic infusion of SFH solutions is not yet acceptable to clinicians even in emergency situations. On the other hand, a broader use of SFH and its variants is anticipated and regarded as prospective in organ perfusion, cardioplegy and transplantation as well as in analytical biochemistry.

The Use of Packed Red Blood Cells

THE DEVELOPMENT of plastic containers with connected satellite bags for the collection of whole blood ushered in a new era of blood component therapy. Even before that time, it was recognized that a deficiency in red blood cell (RBC) oxygen-carrying capacity was best treated by the transfusion of packed red blood cells (PRBC). Since then, the need to provide ever-increasing amounts of blood components such as platelet concentrate and fresh frozen plasma has provided the impetus for an increase in the use of PRBC. Today, the only remaining legitimate indication for the transfusion of whole blood is acute blood loss. Many transfusion therapists have even advocated giving one third to one half of all transfusions in the operating room as PRBC. Such practice has been shown to be not only possible but successful if combined when necessary with salt solution or plasma protein fraction.1 Is this ever-increasing emphasis on