Packed Red Blood Cell Transfusion Research Articles

The effects of blood cell salvage on transfusion requirements after decannulation from veno-venous extracorporeal membrane oxygenation: an emulated trial analysis

BackgroundVeno-venous extracorporeal membrane oxygenation (VV-ECMO) is a supportive therapy for acute respiratory failure with increased risk of packed red blood cells (PRBC) transfusion. Blood cell salvage (BCS) aims to reduce blood transfusion, but its efficacy is unclear. This study aimed to estimate the effect of BCS at the time of removal of the ECMO circuit (ECMO decannulation) on PRBC transfused.MethodsTo compare BCS to non-blood cell salvage (n-BCS), we conducted an emulated trial of patients at two ECMO centres in the United Kingdom. We used inverse propensity of treatment weighting to control for confounding and estimated the average treatment effect of BCS on PRBC transfused within two days of decannulation, and on changes in haemoglobin (Hb).ResultsWe included 841 patients who underwent VV-ECMO decannulation. The estimated marginal mean number of PRBC transfused when using BCS was 0·2 (95%CI: 0·16, 0·25) units compared to 0·51 (95%CI: 0·44, 0·59) units with n-BCS; an average treatment effect of −0·31 (95%CI: −0·40, −0·22) units. BCS reduced the risk of receiving any PRBC transfusion by 17·1% (95%CI: 11·1%, 22·9%) equating to a number needed to treat for any PRBC transfusion of 6 (95%CI: 5, 9). The difference in expected Hb levels after decannulation between BCS and n-BCS was 5·0 (95%CI: 4·2, 5·8) g/L.ConclusionsThe use of BCS during VV-ECMO decannulation may be an effective strategy to augment haemoglobin levels and reduce PRBC transfusions.

Prospective Randomized Pilot Study Comparing Bivalirudin Versus Heparin in Neonatal and Pediatric Extracorporeal Membrane Oxygenation.

To test feasibility of a randomized controlled trial (RCT) with an endpoint of time at goal anticoagulation in children on extracorporeal membrane oxygenation (ECMO) randomized to receive bivalirudin vs. unfractionated heparin. Open-label pilot RCT (NCT03318393) carried out 2018-2021. Single-center quaternary U.S. pediatric hospital. Children 0 days to younger than 18 years old supported with ECMO in the PICU or cardiovascular ICU. Randomization to bivalirudin vs. unfractionated heparin while on ECMO. Sixteen patients were randomized to bivalirudin, and 14 patients were randomized to heparin. There was no difference in the primary outcome, time spent at goal anticoagulation, for patients randomized to bivalirudin compared with those randomized to heparin. While hemorrhagic complications were similar between study groups, thrombotic complications were higher with six of 16 patients in the bivalirudin group having one or more circuit changes compared with 0 of 14 patients in heparin group (mean difference, 37.5% [95% CI, 8.7-61.4%]; p = 0.02). Patients in the bivalirudin group received less packed RBC transfusions vs. those receiving heparin (median [interquartile range], 6.3 mL/kg/d [2.5-8.4 mL/kg/d] vs. 12.2 mL/kg/d [5.5-14.5 mL/kg/d]; p = 0.02). In this single-center pilot RCT carried out 2018-2021, we found that the test of anticoagulation therapy of bivalirudin vs. heparin during ECMO was feasible. Larger multicenter studies are required to further assess the safety and efficacy of bivalirudin for pediatric ECMO.

Is Serum Ferritin a Predictor of Blood Transfusions Outcome and Survival in Childhood Lymphomas and Solid Tumors?

Packed red blood cell (PRBC) transfusions are an important part of supportive treatment in oncology; however, when used frequently, they can be a result of transfusion-related iron overload. The aim of the study was to evaluate the role of ferritin as a non-specific marker of neoplastic growth and transfusion-related iron overload in children with lymphomas and solid tumors. We performed a longitudinal analysis of PRBC transfusions and changes in ferritin concentrations during oncological treatment of 88 children with lymphomas and solid tumors. A ferritin concentration above 500 ng/mL was diagnosed in 14.77% of patients at the moment of admission and 18.18% at the end of treatment. No differences were shown in serum ferritin in the context of tumor type-, sex-, and transfusion-related parameters. Those above the age of 10 demonstrated higher ferritin concentrations compared to subjects younger than 5 years of age. In addition, those over than 10 years old or above 30 kg in weight showed a tendency for better survival. All tested patients demonstrated highly significant correlations between ferritin at the 15th month of treatment or after therapy discontinuation and transfusion-related parameters. Interestingly, ferritin levels were found to lower back to the values before therapy shortly after its discontinuation. Transfusion parameters and ferritin levels had no influence on the survival of the studied cancer patients.

Where Do We Stand in Blood Transfusion Practices: Insights From the First Clinical Audit From Khyber Pakhtunkhwa, Pakistan.

Objective To evaluate the appropriateness of packed red blood cell (PRBC) transfusions across different departments of a tertiary care hospital. Methods This audit included 632 patients admitted to the major departments of Hayatabad Medical Complex, Peshawar, Pakistan, who received one or more PRBC transfusions from November 2023 till July 2024. Six categories were defined who had different characteristics and thresholds for PRBC transfusion according to the Association for the Advancement of Blood & Biotherapies Red Blood Cell Transfusion International Guidelines. The appropriateness of PRBC transfusions was evaluated by checking if the pre-transfusion hemoglobin (Hb) met the threshold as specified in the guidelines. The chi-square test was used to test the association between the appropriateness of PRBC transfusions and the gender, department, and category of the patient. The significance of the difference in the mean pre-transfusion Hb was determined using an independent samples t-test. Results The median age was 30 years (IQR: 23-48.75). The majority of the patients were female (n=430, 68%). Patients from the Department of Gynecology and Obstetrics (n=267, 42.2%) outnumbered those from other departments. The majority of PRBC transfusions were inappropriate (n=465, 73.6%). Most transfusions in female patients (83.3%), in the patients of the Department of Gynecology and Obstetrics (95.5%), and in patients in the general category (86.9%) were found inappropriate. In the case of inappropriate transfusion, the mean pre-transfusion Hb was significantly different among departments, with the highest (14.1 gm/dL) value documented in the Department of Gynecology and Obstetrics. Conclusion Female patients, patients in the Department of Gynecology and Obstetrics, and patients in the general category had the highest frequency of inappropriate PRBC transfusions.

A study to reveal the rationales of overnight transfusion in a training and research hospital

BackgroundMonitoring of overnight transfusions would be beneficial to improve blood transfusion safety. The objective of this study was to prospectively evaluate the practice and need for overnight transfusions (OT) in a teaching and research hospital. MethodsThe study was conducted on data from patients who received packed red blood cells (PRBCs) transfusions between 11 September and 13 October 2023 at a Training and Research Hospital in Ankara, Turkey. Clinical data of patients were obtained from the Hospital Database Management System (HDBS) and blood transfusion order forms. The critical time point of the transfusion process was recorded using HDBS. ResultsA total of 1502 PRBCs transfusions were noted during the study period, of which 400 (26.6%) were OT. OT was most frequently administered to patients with symptomatic anemia (34.6%; 138/400) and patients with an Hb level <7 (27.7%; 111/400). The time interval in which OT was most frequently ordered was between 15:00 and 17:00 [20.2% (81/400)], while the most frequent time to start transfusion was between 17:00 and 19:00 [22% (88/400)]. The average time taken from ordering OT to starting OT was 3 hours 41 minutes. The most of patients (36.8%; 91/248) were discharged after 48 hours of transfusion or were still in the hospital for more than 48 hours (20.3%; 50/248). ConclusionTo ensure transfusion safety by reducing OT to a minimum, OT should be used only in emergencies, policies should be put in place to make sure that transfusions can be done during the day easily, and healthcare professionals should be made aware of this issue.

Comparative analysis of four upper gastrointestinal bleeding scoring systems for predicting multiple outcomes: an observational study in the emergency department

Objective: Numerous scoring systems have been developed to assess the risk associated with upper gastrointestinal bleeding (UGIB), and several studies have investigated their comparative accuracy in predicting patient outcomes. This study was undertaken to compare four well-known scoring systems, namely the pre-endoscopy Rockall score, full Rockall score, Glasgow-Blatchford Bleeding score (GBS), and AIMS65, with the aim of predicting five distinct outcomes in cases of non-variceal UGIB. Methods: This prospective observational study was conducted focusing on adult patients with UGIB presenting to the emergency department (ED). The primary endpoints of this study included in-hospital mortality, the need for re-endoscopy, the requirements for packed red blood cell (PRBC) transfusion, massive transfusion, and one-month rebleeding. Results: A total number of 320 patients were enrolled, with 44 (13·75%) in-hospital deaths. Based on the area under the curves (AUC), while certain scores outperformed others in specific outcome prediction, the AIMS65 scoring system demonstrated superior predictive capability for both in-hospital mortality (0.91) and massive transfusion (0.71). Regarding PRBC transfusion requirements, both AIMS65 and GBS exhibited similar predictive capacities (AUC=0.67 and 0.68, respectively). In terms of re-endoscopy and one-month rebleeding, the GBS scoring system displayed slightly better performance compared to the other systems (AUC=0.61 and 0.63, respectively). In the composite outcome, all scores had significant associations, and among them, the AIMS-65 score had the highest AUC (0.76). Conclusion: The AIMS65 scoring system was the most reliable tool for predicting in-hospital mortality and, to a lesser extent, massive transfusion requirements, while GBS and AIMS65 could be moderately and cautiously relied on for preparations regarding the need for PRBC transfusion.

TXA combined with whole blood transfusion in trauma patients does not increase the risk of VTE but shock index does

IntroductionPrevious studies have demonstrated the benefits of tranexamic acid (TXA) administration in combination with packed red blood cell (PRBC) transfusion in trauma patients without increasing the risk of venous thromboembolism (VTE). However, the effect of TXA in combination with whole blood (WB) has not been studied. Injury, abbreviated injury severity scores (ISS and AIS) and the need for blood transfusions are historically associated with VTE. The objective of this study was to determine the relationship between VTE and the combination of TXA administration and transfusion of PRBCs vs. WB. MethodsOur institutional trauma registry was queried for trauma patients between 2015 and 2022 who received either WB ​+ ​TXA or PRBC ​+ ​TXA either prehospital or within 4 ​h of arrival. Multivariate analysis was utilized to determine independent risk factors for VTE, which were defined as either a deep vein thrombosis (DVT) or a pulmonary embolism (PE). Model covariates included age, mechanism of injury (MOI), ISS, lower extremity AIS, comorbid conditions, and shock index (SI). Additional outcomes analyzed were hospital length of stay (LOS), ICU LOS, and ventilator days. ResultsThree hundred and five patients had complete data and were included in the analysis. Of those, 251 received WB ​+ ​TXA and 54 received PRBC ​+ ​TXA. A total of 34 patients were found to have VTE event (11.1 ​%); 28 (11.2 ​%) and 6 (11.1 ​%) from the WB ​+ ​TXA and PRBC ​+ ​TXA groups, respectively. An elevated pre-hospital SI was independently associated with increased VTE rate (OR 1.85, 95 ​% CI 1.07–3.20). WB transfusion, TXA administration, ISS, and MOI did not influence the rate of VTE. ConclusionThese data demonstrate that the combination of WB ​+ ​TXA administered to trauma patients has no higher risk of VTE than patients who receive PRBC ​+ ​TXA, a comparison that has not been studied clinically to date. Despite the pro thrombotic state enhanced by TXA and the decreased dilutional coagulopathy seen in WB resuscitation, there was no increased risk of VTE compared to TXA ​+ ​PRBC. There is no evidence that TXA combined with whole blood transfusion is associated with an increased risk of VTE. However, higher pre-hospital SI was associated with an elevated rate of VTE. These clinical features provide insight into patients who may be at an increased risk of developing VTE and may benefit from targeted prevention strategies.

Implementation of a Standardized Red Blood Cell Transfusion Policy in a Level IV Neonatal Intensive Care Unit: A Quality Improvement Project.

Within the neonatal intensive care unit (NICU), infants frequently receive packed red blood cell (PRBC) transfusions. Although medically necessary, potential negative long- and short-term outcomes exist following PRBC transfusions in very low birth-weight (VLBW) infants (<1500g). Synthesis of the literature demonstrates that the use of a restrictive PRBC transfusion policy can lead to a decreased number of transfusions administered with no increase in long-term neurodevelopmental outcomes. Blood transfusions have also been linked to the diagnosis of necrotizing enterocolitis (NEC) or intraventricular hemorrhage (IVH) in VLBW infants. For this quality improvement project, a restrictive PRBC transfusion policy was implemented in a level IV NICU to promote consistent care and evaluate changes in PRBC administration. The data were collected both pre- and post-policy implementation including: the number of blood transfusions, diagnosis of NEC, and diagnosis of IVH among infants <1500g. The data showed no significant change in the number of PRBC transfusions administered. Likewise, few infants were diagnosed with NEC or IVH during this same time period with minimal change between pre- and post-policy implementation data. Following policy implementation, there was a significant improvement in communication among providers regarding transfusion ordering and the inclusion of hematocrit thresholds in daily progress notes. This unintended outcome has helped to promote sustainability and enhance patient care within the NICU where this policy was implemented. Continued data collection may be beneficial in indicating whether a standardized PRBC transfusion policy will impact the administration of transfusions and diagnosis of NEC or IVH.

Clinical features and prediction of long-term survival after surgery for perihilar cholangiocarcinoma.

The treatment of perihilar Cholangiocarcinoma (pCCA) poses specific challenges not only due to its high perioperative complication rates but also due its dismal long-term prognosis with only a few long-term survivors (LTS) among the patients. Therefore, in this analysis characteristics and predictors of LTS in pCCA patients are investigated. In this single center analysis, patients undergoing curative-intent liver resection for pCCA between 2010 and 2022 were categorized into long-term and short-term survivors (STS) excluding perioperative mortality. Binary logistic regression was used to determine key differences between the groups and to develop a prognostic composite variable. This composite variable was subsequently tested in the whole cohort of surgically treated pCCA patients using Cox Regression analysis for cancer-specific survival (CSS). Within a cohort of 209 individuals, 27 patients were identified as LTS (median CSS = 125 months) and 55 patients as STS (median CSS = 16 months). Multivariable analysis identified preoperative portal vein infiltration (OR = 5.85, p = 0.018) and intraoperative packed red blood cell (PRBC) transfusions (OR = 10.29, p = 0.002) as key differences between the groups. A prognostic composite variable based on these two features was created and transferred into a Cox regression model of the whole cohort. Here, the composite variable (HR = 0.35, p<0.001), lymph node metastases (HR = 2.15, p = 0.001) and postoperative complications (HR = 3.06, p<0.001) were identified as independent predictors of CSS. Long-term survival after surgery for pCCA is possible and is strongly negatively associated with preoperative portal vein infiltration and intraoperative PRBC transfusion. As these variables are part of preoperative staging or can be modulated by intraoperative technique, the proposed prognostic composite variable can easily be transferred into clinical management to predict the oncological outcome of patients undergoing surgery for pCCA.

Impact of Concomitant Traumatic Pancreatic and Colon Injuries on Outcomes.

Colon and pancreatic injuries have both long been independently associated with intraabdominal infectious complications in trauma patients. The goal of this study was to evaluate the impact of concomitant pancreatic injury on outcomes in patients with traumatic colon injuries. Consecutive patients over a 3-year period who underwent operative management of colon injuries were identified. Patient characteristics, severity of injury and shock, presence and grade of pancreatic injury, and intraoperative packed red blood cell (PRBC) transfusions were recorded. Outcomes including intraabdominal abscess formation and suture line failure were collected and compared. Multivariable logistic regression analysis was then performed to determine the impact of concomitant pancreatic injury on intraabdominal abscess formation. 243 patients with traumatic colon injuries were identified. 17 of these also had pancreatic injuries. Patients with combined colon and pancreatic injuries were clinically similar to those with isolated colon injuries with respect to age, gender, penetrating mechanism of injury, admission lactate, ISS, suture line failure, and admission systolic blood pressure. Both intraabdominal abscess rates (88.2% vs 29.6%, P < .001) and intraoperative PRBC transfusions (8 vs 1 units, P = .004) were higher in the combined pancreatic and colon injury group. Multivariable logistic regression identified both intraoperative PRBC transfusions (odds ratio, 1.09; 95% confidence interval, 1.04-1.15; P < .001) and concomitant pancreatic injury (odds ratio, 14.8; 95% confidence interval, 3.92-96.87; P < .001) as independent predictors of intraabdominal abscess formation. Both intraoperative PRBC transfusions and presence of concomitant pancreatic injury are independent predictors of intraabdominal abscess formation in patients with traumatic colon injuries.

Tranexamic acid reduces intraoperative red blood cell transfusion rates in craniosynostosis surgery: a 6-year retrospective analysis

Surgery for craniosynostosis in children is associated with substantial intraoperative bleeding and the need for blood transfusions. Recent studies have supported the efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion requirements. The records of 72 patients under 18 months of age who had undergone 113 surgeries for non-syndromic craniosynostosis in a single institution for 6 years were retrospectively analyzed. The transfusion requirements in infants with and without TXA administration were compared. The concept of patient blood management before and after TXA implementation in practice was also examined. The rate of intraoperative packed red blood cells (PRBC) transfusion was significantly lower in the TXA than in the non-TXA group (26.7% vs. 83%, p < 0.001). The volume of intraoperatively transfused PRBC was also lower in the TXA group compared to the non-TXA group (mean 68.25 mL vs. 101.91 mL, p < 0.001), as was the weight-adjusted volume (mean 11.2 mL/kg vs. 15 mL/kg, p = 0.002). There were no significant differences in the rate and volumes of postoperative PRBC transfusion between groups. The volume of intraoperatively transfused PRBC was dependent on TXA administration, but not on the affected suture and type of intervention. We found that while in the pre-TXA period all patients were transfused intraoperatively, the frequency of intraoperative transfusions in the post-TXA period was reduced by 40.9% even in the patients who had not received TXA. TXA seems to effectively reduce the intraoperative transfusion requirements in children undergoing craniosynostosis surgery. The optimal blood management in this patient population remains to be further evaluated.

Effect of Age of Transfused Red Blood Cell Units on Clinical Outcomes in Critically Ill Patients.

Anemia in critically ill patients requires red cell transfusions to increase oxygen delivery and prevent deleterious outcomes. The primary objective of the present study was to determine the effect of storage age of transfused red cells on 30-day mortality in critically ill patients, with secondary objectives of determining the effect on length of stay, organ failure, and adverse transfusion reactions. This prospective study was conducted on patients admitted to the intensive care unit after obtaining approval from institutional ethics committee. Patients were randomized to transfusion with packed red blood cells (PRBC) with age of collection either ≤ 14days (Group 1) or > 14days (Group 2). APACHE II scores were calculated at admission. Patients were followed up for primary outcome of 30-day mortality, and secondary outcomes including length of stay, infections, organ dysfunction, and adverse transfusion reactions. The 30-day mortality was 20% in Group 1 and 28% in Group 2 (p = 0.508). The mean storage duration of PRBC in Group 1 versus Group 2 was 8.48days versus 21.43days (p < 0.001). There was no significant difference in total number of PRBC transfusions, donor exposures, hemoglobin and hematocrit increment, adverse transfusion reactions, length of stay and organ dysfunction scores between the two groups. Transfusion of packed red cells of less than 14days showed no benefit over red cells stored more than 14days in terms of 30-day mortality, length of stay and infections in critically ill patients, however studies with larger sample size and longer follow up are recommended.

The effect of transfusion on survival in head and neck cancer after free tissue reconstruction.

To examine if perioperative blood transfusion affects overall survival (OS) and recurrence-free survival (RFS) in head and neck cancer patients who undergo free tissue reconstruction. Retrospective cohort study. The medical records of free tissue flaps between 2007 and 2010 were reviewed. Differences in demographics and clinical factors based on the level of transfused packed red blood cells (PRBC) were examined using chi-squared tests, Kruskal-Wallis tests, and/or ANOVA tests. Survival time was compared using a Cox proportional hazard model. Data were available for 183 patients. Patients who had PRBC transfusion significantly differed from the non-transfused group by flap type, flap with bone, Charlson Comorbidity Index (CCI), and hemoglobin and hematocrit. When stratified into three groups based on units of PRBC; flap type, flap with bone, CCI, preoperative hemoglobin, and hematocrit were found to differ significantly. The 2-year Kaplan-Meier plot demonstrated improved OS for those who did not receive any PRBC transfusion. The use of more than 3 units of blood decreased 2-year OS significantly when compared to the non-transfused group. Finally, after adjusting for CCI using a Cox proportional hazard model, survival was significantly affected by CCI. After controlling for patient age, oncologic stage, cancer subsite, histology, type of free flap, vascularized bone-containing flap, recurrence type, CCI, and preoperative hemoglobin and hematocrit, patients who received 3 or more units of PRBC in the perioperative period had significantly decreased OS. RFS did not differ between the transfused versus non-transfused groups. Level 4.

Iron Overload in Children with Acute Lymphoblastic and Acute Myeloblastic Leukemia-Experience of One Center.

Transfusions of packed red blood cells (PRBCs), given due to an oncological disease and its acute complications, are an indispensable part of anticancer therapy. However, they can lead to post-transfusion iron overload. The study aim was to evaluate the role of ferritin as a nonspecific marker of leukemic growth and marker of transfusion-related iron overload. We performed a longitudinal study of PRBC transfusions and changes in ferritin concentrations during the oncological treatment of 135 patients with childhood acute lymphoblastic and acute myeloblastic leukemia (ALL and AML, median age 5.62 years). At the diagnosis, 41% of patients had a ferritin level over 500 ng/mL, and 14% of patients had a ferritin level over 1000 ng/mL. At the cessation of the treatment, 80% of the children had serum ferritin (SF) over 500 ng/mL, and 31% had SF over 1000 ng/mL. There was no significant difference between SF at the beginning of the treatment between ALL and AML patients, but children with AML finished treatment with statistically higher SF. AML patients had also statistically higher number of transfusions. We found statistically significant positive correlations between ferritin and age, and weight and units of transfused blood. Serum ferritin at the moment of diagnosis can be a useful marker of leukemic growth, but high levels of SF are connected with iron overload in both AML and ALL.

Red Blood Cell Transfusion and Pulmonary Complications: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis

BackgroundIntraoperative packed red blood cell (PRBC) transfusion during cardiac surgery is associated with increased postoperative morbidity and mortality; however, data on the association between PRBC transfusion and postoperative pulmonary complications (PPCs) are somewhat conflicting. Using The Society of Thoracic Surgeons Adult Cardiac Surgery Database, we sought to determine whether intraoperative PRBC transfusion was associated with PPCs as well as with longer intensive care unit (ICU) stay after isolated coronary artery bypass grafting (CABG) surgery. MethodsA registry-based cohort study was performed on 751,893 patients with isolated CABG between January 1, 2015, to December 31, 2019. Using propensity score–weighted regression analysis, we analyzed the effect of intraoperative PRBC on the incidence of PPCs (hospital-acquired pneumonia [HAP], mechanical ventilation for >24 hours, or reintubation), ICU length of stay, and ICU readmission. ResultsTransfusion of 1, 2, 3, and ≥4 units of PRBCs was associated with increased odds for HAP (odds ratios [ORs], 1.24 [95% CI, 1.21-1.26], 1.28 [95% CI, 1.26-1.32], 1.36 [95% CI, 1.33-1.39], 1.31 [95% CI, 1.28-1.34]), reintubation (ORs, 1.23 [95% CI, 1.21-1.25], 1.38 [95% CI, 1.35-1.40], 1.57 [95% CI, 1.55-1.60], 1.70 [95% CI, 1.67-1.73]), prolonged ventilation (ORs, 1.34 [95% CI, 1.33-1.36], 1.56 [95% CI, 1.53-1.58], 1.97 [95% CI, 1.94-2.00], 2.27 [95% CI, 2.24-2.30]), initial ICU length of stay (mean difference in hours, 6.79 [95% CI, 6.00-7.58], 9.55 [95% CI, 8.71-10.38], 17.26 [95% CI, 16.38-18.15], 22.14 [95% CI, 21.22-23.06]), readmission to ICU (ORs, 1.14 [95% CI, 1.12-1.64], 1.15 [95% CI, 1.12-1.17], 1.15 [95% CI, 1.13-1.18], 1.32 [95% CI, 1.29-1.35]), and additional ICU length of stay (mean difference in hours, 0.55 [95% CI, 0.18-0.92], 0.38 [95% CI, 0.00-0.77], 1.02 [95% CI, 0.61-1.43], 1.83 [95% CI, 1.40-2.26]), respectively. ConclusionsIntraoperative PRBC transfusion was associated with increased incidence of PPCs, prolonged ICU stay, and ICU readmissions after isolated CABG surgery.

Red blood cell transfusion-related dynamics of extracellular vesicles in intensive care patients: a prospective subanalysis

Extracellular vesicles (EVs) accumulate during packed red blood cell (PRBC) storage. To date, the involvement of EVs in transfusion-related immunomodulation (TRIM) has not been prospectively evaluated in intensive care unit (ICU) patients. This was a prospective subanalysis of a recent observational feasibility study in postoperative ICU patients after: (1) open aortic surgery (Aorta), (2) bilateral lung transplantation (LuTx), and (3) other types of surgery (Comparison). Patient plasma was collected three times each before and after leukoreduced PRBC transfusion at 30-min intervals. The total number of EVs and EVs derived from erythrocytes (EryEVs), total platelets (total PEVs), activated platelets, granulocytes (GEVs), monocytes, and myeloid cells in PRBC samples and patient plasma were analyzed by flow cytometry. Statistical analysis was performed by Spearman’s correlation test, linear mixed models and pairwise comparisons by Wilcoxon matched-pairs test. Twenty-three patients (Aorta n = 5, LuTx n = 9, Comparison n = 9) were included in the final analysis. All EV subgroups analyzed were detectable in all PRBCs samples (n = 23), but concentrations did not correlate with storage time. Moreover, all EVs analyzed were detectable in all plasma samples (n = 138), and EV counts were consistent before transfusion. Concentrations of total EVs, EryEVs, total PEVs, and GEVs increased after transfusion compared with baseline in the entire cohort but not in specific study groups. Furthermore, the change in plasma EV counts (total EVs and EryEVs) after transfusion correlated with PRBC storage time in the entire cohort. Extracellular vesicles were detectable in all PRBC and plasma samples. Individual EV subtypes increased after transfusion in the entire cohort, and in part correlated with storage duration. Future clinical studies to investigate the role of EVs in TRIM are warranted and should anticipate a larger sample size.Trial registration: Clinicaltrials.gov: NCT03782623.

Early Treatment of Acetabular Fractures via an Anterior Approach Increases Blood Loss but not Packed Red Blood Cell Transfusion.

To determine if time from hospital admission to surgery for acetabular fractures using an anterior intrapelvic (AIP) approach affected blood loss. Multicenter retrospective study. Three level 1 trauma centers at 2 academic institutions. 195 adult (age >18) patients with adequate records to complete analysis and no pre-existing coagulopathy. AIP approach without other significant same day procedures (irrigation and debridement and external fixation were the only other allowed procedures). Multiple methods for evaluating blood loss were investigated, including estimated blood loss (EBL), calculated blood loss (CBL), and packed red blood cell (PRBC) transfusion requirement. On continuous linear analysis, increasing time from admission to surgery was significantly associated with decreasing CBL at 24 hours (-1.45 mL per hour by Gross, p=0.003; -0.440 g of Hgb per hour by Hgb balance, p=0.003) and 3 days (-1.69 mL per hour by Gross, p=0.013; -0.497 g of Hgb per hour by Hgb balance, p=0.010) postoperative, but not EBL or PRBC transfusion. Using 48-hours from admission to surgery to define early versus delayed, blood loss was significantly greater in the early group compared to delayed [453 (IQR 277-733) mL early versus 364 (IQR 160-661) delayed by Gross, p=0.017; 165 (IQR 99-249) g early versus 143 (IQR 55-238) g delayed by Hgb balance, p=0.035], but not EBL or PRBC transfusion. Additionally, in multivariate linear regression, neither giving tranexamic acid nor administering prophylactic anticoagulation for venous thromboembolism on the morning of surgery affected blood loss at 24 hours or 3 days postoperative. There is higher blood loss with early surgery using an AIP approach, but early surgery did not affect PRBC transfusion and may not be clinically relevant. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of zinc protoporphyrin/heme ratio and ferritin for assessing iron status in preterm infants.

Since iron is crucial for many tissue processes, we, therefore, aimed to assess ferritin and the zinc protoporphyrin to heme ratio (ZnPP/H) as indicators of iron status in preterm newborns, particularly during certain inflammatory episodes. From 170 preterm babies, paired ferritin and ZnPP/H measurements were collected twice (on the first postnatal day and six weeks later). To compare these measures and assess the impact of anemia, sepsis, and packed red blood cell transfusion (PRBT), three different scenarios were considered. Compared to the non-anemic group, the anemic patients' serum ferritin level was considerably lower (p = 0.044), whereas the anemic patients' ZPP/H ratio was significantly greater (p < 0.001). In neonates with sepsis, ferritin levels were considerably greater in both anemic and non-anemic septic neonates compared to neonates without sepsis (p < 0.001 for each). Regarding ZPP/H ratio, no appreciable variations were found between the two groups. In addition, serum ferritin significantly increased following each PRBT (p < 0.001 for each). As a result of each PRBT, the ZPP/H ratio considerably decreased (p < 0.001). As a measure of iron status during particular inflammatory processes like infection and PRBT, ZnPP/H may be more accurate.

Abnormal Iron Status and Adverse Outcome After Elective Cardiac Surgery: A Prospective, Observational Multicenter Study

ObjectivesTo investigate the incidence of preoperative abnormal iron status and its association with packed red blood cell (PRBC) transfusion, postoperative major complications, and new onset of clinically significant disability in patients undergoing elective cardiac surgery. DesignProspective, observational multicenter cohort study. SettingThree heart surgical centers in the Netherlands, between 2019 and 2021. Recruitment was on hold between March and May 2020, due to COVID-19. Patients427 patients aged 60 years and older who underwent elective on-pump cardiac surgery. Measurements and Main ResultsPrimary endpoint was 30-day packed red blood cell (PRBC) transfusion. Secondary endpoints were postoperative major complications within 30 days (e.g., acute kidney injury, sepsis), and new onset of clinically significant disability within 120 days within surgery. Iron status was evaluated prior to surgery. An abnormal iron status was present in 45.2% of patients (n=193), and most frequently the result of iron deficiency (27.4%, n = 117). An abnormal iron status was not associated with PRBC transfusion (adjusted relative risk (ARR) 1.2; 95% confidence interval (95% CI) 0.9 to 1.8: p = 0.227) or new onset of clinically significant disability (ARR 2.0; 95% CI 0.9 to 4.6: p = 0.098). However, the risk of postoperative major complications was increased in patients with an abnormal iron status (ARR 1.7; 95% CI 1.1 to 2.5: p = 0.012). ConclusionsAn abnormal iron status prior to elective cardiac surgery was associated with an increased risk of postoperative major complications, but not with PRBC-transfusion or new onset of clinically significant disability.

Placenta Accreta Spectrum Disorders - The Impact of the Creation of a Multidisciplinary Team on Maternal Outcomes in Portugal.

To describe a cohort of placenta accreta spectrum (PAS) cases from a tertiary care institution and compare the maternal outcomes before and after the creation of a multidisciplinary team (MDT). Retrospective study using hospital databases. Identification of PAS cases with pathological confirmation between 2010 and 2021. Division in two groups: standard care (SC) group - 2010-2014; and MDT group - 2015-2021. Descriptive analysis of their characteristics and maternal outcomes. During the study period, there were 53 cases of PAS (24 - SC group; 29 - MDT group). Standard care group: 1 placenta increta and 3 percreta; 12.5% (3/24) had antenatal suspicion; 4 cases had a peripartum hysterectomy - one planned due to antenatal suspicion of PAS; 3 due to postpartum hemorrhage. Mean estimated blood loss (EBL) was 2,469 mL; transfusion of packed red blood cells (PRBC) in 25% (6/24) - median 7.5 units. Multidisciplinary team group: 4 cases of placenta increta and 3 percreta. The rate of antenatal suspicion was 24.1% (7/29); 9 hysterectomies were performed, 7 planned due to antenatal suspicion of PAS, 1 after intrapartum diagnosis of PAS and 1 after uterine rupture following a second trimester termination of pregnancy. The mean EBL was 1,250 mL, with transfusion of PRBC in 37.9% (11/29) - median 2 units. After the creation of the MDT, there was a reduction in the mean EBL and in the median number of PRBC units transfused, despite the higher number of invasive PAS disorders.