Perioperative Blood Product Transfusion Research Articles

Thromboelastography - Guided Intraoperative Platelet Transfusion in Pediatric Heart Surgery

Postoperative bleeding is associated with significant resource use and an important contributor to other major adverse events in pediatric patients undergoing complex cardiac surgery procedures. Thromboelastography (TEG®6S) can guide perioperative blood product transfusions to reduce the risk of postoperative bleeding. In this study, we validated the use of a previously developed TEG®6S maximum amplitude (TEG-MA) based platelet transfusion calculator utilized during cardiac surgery to minimize the risk of postoperative bleeding. In this single-center retrospective study of pediatric patients (≤18yr) undergoing cardiac surgery requiring cardiopulmonary bypass at Boston Children's Hospital (N=1000), volume of platelet transfusion administered based on surgical team discretions were compared to the platelet calculator recommended platelet transfusion volume using linear regression analysis. Associations between adequacy of perioperative platelet transfusion and postoperative bleeding/thrombotic complications within the first 24hr postoperatively (bleeding), and until hospital discharge (thrombosis), were evaluated by logistic regression analysis. Lower TEG-MA (≤45mm) measurements following post transfusion, is associated with higher risk for postoperative bleeding (Odds ratio:4.4;95%CI:2.6,7.4; *p<0.01). The platelet transfusion calculator recommended platelet transfusion volume (based on TEG-MA measured at time of rewarming) demonstrated moderate correlation with the measured TEG-MA value after platelet transfusion (Pearson r: 0.7). Intraoperative volumes of platelet transfusion that failed to increase a postoperative TEG-MA of at least 45mm, significantly increased the risk for postoperative bleeding in the first 24hr post-surgery (Odds ratio:3.2;95%CI:1.9,5.4; *p<0.01). Post transfusion TEG-MA was not independently associated with thrombosis. Customizing perioperative platelet transfusion therapy using quantitative diagnostic tests can help reduce postoperative bleeding complications.

Evaluation of the relationship between patient blood management and anesthesia method in cesarean section: A single-center study

Objectives: Patient blood management (PBM) aims to improve patient outcome and safety by reducing the quantity of unnecessary blood transfusions and vitalizing patient-specific anemia reserves. We aimed to determine the efficiency and practicality of patient blood management in the cesarean section operating room in our hospital and the effects of the anesthesia method in cesarean section. Methods: Between 2019 and 2021, 6011 patients who underwent cesarean section were reviewed at Bursa City Hospital. Patients who received perioperative or postoperative blood product transfusion were divided into two groups as Group I (n=614) and patients who were not transfused into Group II (n=5397). Demographic data of the patients, preoperative hemogram laboratory values, performed anesthesia methods, transfusion rate were recorded from the database. Results: There was no statistically significant difference between the two groups in terms of demographic data (p&gt;0.05). The preoperative anemia rate was 35.91% (n=2159) and in these patients the blood transfusion rate was 21.86% (n=472). Total transfusion rate was reported as 10.21% (n=614). Preoperative hemoglobin levels were statistically lower in Group I. The spinal anesthesia method was found to be statistically higher in both groups. Conclusion: Patient blood management is very important. In line with the guidelines on this subject, it will reduce unnecessary transfusions and therefore the risks of transfusion complications. In addition, considering the difficulty of supplying blood products, blood transfusion should not be considered primarily as a treatment. Anemia treatment should be planned before surgery and hemoglobin levels should be optimized. It is recommended to prefer regional anesthesia for PBM at cesarean section. In this way, we think that we will both increase the efficiency of patient blood management and reduce the cost and complications of blood transfusion.

PREDICTING TRANSFUSION REQUIREMENTS FOR PRIMARY HIP AND KNEE ARTHROPLASTY: DESIGNING A REGIONAL SERVICE FOR HIGH-VOLUME ARTHROPLASTY SURGERY

Extended patient waiting lists for assessment and treatment are widely reported for planned elective joint replacement surgery. The development of regionally based Elective Orthopaedic Centres, separate from units that provide acute, urgent or trauma care has been suggested as one solution to provide protected capacity and patient pathways. These centres will adopt protocolised care to allow high volume activity and increased day-case care. We report the plan to establish a new elective orthopaedic centre serving a population of 2.4 million people. A census conducted in 2022 identified that 15000 patients were awaiting joint replacement surgery with predictions for further increases in waiting timesThe principle of care will be to offer routine primary arthroplasty surgery for low risk (ASA 1 and 2) patients at a new regional centre. Pre-operative assessment and preparation will be undertaken digitally, virtually and/or in person at local centres close to the where patients live. This requires new and integrated pathways and ways of working. Predicting which patients will require perioperative transfusion of blood products is an important safety and quality consideration for new pathways. We reviewed all cases of hip and knee arthroplasty surgery conducted at our centre over a 12-month period and identified pre-operative patient related predictive factors to allow us to predict the need for the perioperative transfusion of blood products.We examined patient sex, age, pre-operative haemaglobin and platelet count, use of anti-coagulants, weight and body mass index to allow us to construct the Imperial blood transfusion tool.We have used the results of our study and the transfusion tool to propose the patient pathway for the new regional elective orthopaedic centre which we present.

Accurate protamine:heparin matching (not just smaller protamine doses) decreases postoperative bleeding in cardiac surgery; results from a high-volume academic medical center.

A multidisciplinary Quality Assurance/Performance Improvement study to identify the incidence of "heparin rebound" in our adult cardiac surgical population instead detected a thromboelastometry pattern suggestive of initial protamine overdose in 34% despite Hepcon-guided anticoagulation management. Analysis of our practice led to an intervention that made an additional lower-range Hepcon cartridge available to the perfusionists. One year later, an IRB-approved retrospective study was conducted in >500 patients to analyze the effects of the intervention, specifically focusing on the impact of the initial protamine dose accuracy and 18-h mediastinal chest tube drainage (MCTd). No differences were observed between group demographics, surgical procedures, duration of CPB or perioperative blood product transfusion. Both groups were managed using the same perfusion and anesthesia equipment, strategies, and protocols. The median initial protamine dose decreased by 19% (p < .001) in the intervention group (170 [IQR 140-220] mg; n = 295) versus the control group (210 [180-250] mg; n = 257). Mean 18-h MCTd decreased by 13% (p < .001) in the intervention group (405.15 ± 231.54mL; n = 295) versus the control group (466.13 ± 286.73mL; n = 257). Covariate-adjusted mixed effects model showed a significant reduction of MCTd in the intervention group, starting from hour 11 after surgery (group by time interaction p = .002). Though previous investigators have associated lower protamine doses with less MCTd, this study demonstrates that more accurately matching the initial protamine dose to the remaining circulating heparin concentration reduces postoperative bleeding.

Impacts of in situ donor partial hepatectomy in pediatric liver transplantation

BackgroundPediatric liver transplantation is performed with either whole, reduced, split livers depending on the technical aspects of the surgery and the discrepancy between donor and recipient body dimensions. The optimal method of partial hepatectomy for pediatric transplants remains debated to this day: either in situ (i.e. occurring before liver removal from the donor) or ex situ (i.e. taking place after liver removal). In 2007, our tertiary academic center changed its surgical protocol from ex situ to in situ partial hepatectomy in deceased donor mainly to decrease bleeding complication risk among other amendments. Our study aimed to evaluate the clinical impact of this major modification on the post-operative blood products volume transfusion. MethodsA retrospective analysis of 104 patients who underwent liver transplantation at our pediatric center between 1998 and 2016 was performed. Patients receiving multiple organ transplantations or re-transplantation were excluded from the study. Differences in blood products transfusion volume, post-operative complications and mortality rates were compared between two periods implementing different surgical transplantation protocols: ex situ partial hepatectomy from 1998 to 2006 and in situ partial hepatectomy from 2007 to 2016. Results42 children from the original ex situ protocol group and 62 children from the modified in situ protocol group were included in the study. The median age and weight were 1.5 years (0.7–4.8 kg) and 11.1 kg (7.9–18.2), respectively. There were no significant differences in demographic data between groups. A significant decrease in liver transplant cold ischemia time was observed in the in situ group compared to the ex situ group (p < 0.001). A significant increase in vasopressor use was observed for the in situ group (64% (IS) vs. 24% ex situ group (p < 0.001)), as part of the protocol modifications. Median perioperative blood products transfusion volume was not significantly different between both groups: 275 ml/kg (76–497) ex situ group vs. 229 ml/kg (76–499) in situ group (p = 0.82). We observed a 28-day and 90-day mortality rate of 14.3% and 16.6%, respectively, for the ex situ group and 6.5% and 8.1%, respectively, for the in situ group. Hepatic artery thrombosis was found in the first 7 days in 7% of the ex situ group patients and 6% of the in situ group patients. There were no significant differences in post-operative mortality and morbidity rates observed between groups (p value of 0.29 and 0.28 for 28-days and 90-days mortality rates, respectively). ConclusionsAlthough the median amount of transfusion was higher in the ex-situ group, our study showed no significant differences in perioperative blood product transfusions, morbidity and mortality rates between ex-situ and in-situ partial hepatectomy procedures. Further multicenter studies should be conducted to confirm these results. Level of evidenceIII

Utilization of machine learning to model the effect of blood product transfusion on short-term lung transplant outcomes.

The objective of this study was to identify the relationship between blood product transfusion and short-term morbidity and mortality following lung transplantation utilizing machine learning. Preoperative recipient characterstics, procedural variables, perioperative blood product transfusions, and donor charactersitics were included in the model. The primary composite outcome was occurrence on any of the following six endpoints: mortality during index hospitalization; primary graft dysfunction at 72h post-transplant or the need for postoperative circulatory support; neurological complications (seizure, stroke, or major encephalopathy); perioperative acute coronary syndrome or cardiac arrest; and renal dysfunction requiring renal replacement therapy. The cohort included 369 patients, with the composite outcome occurring in 125 cases (33.9%). Elastic net regression analysis identified 11 significant predictors of composite morbidity: higher packed red blood cell, platelet, cryoprecipitate and plasma volume from the critical period, preoperative functional dependence, any preoperative blood transfusion, VV ECMO bridge to transplant, and antifibrinolytic therapy were associated with higher risk of morbidity. Preoperative steroids, taller height, and primary chest closure were protective against composite morbidity.

Plasma Fibrinogen as a Predictor of Perioperative-Blood-Component Transfusion in Major-Nontraumatic-Orthopedic-Surgery Patients: A Cohort Study.

There is a trend towards increased perioperative bleeding in patients with plasma fibrinogen levels < 200 mg/dL-1. This study aimed to assess whether there is an association between preoperative fibrinogen levels and perioperative blood-product transfusion up to 48 h after major orthopedic surgery. This cohort study included 195 patients who underwent primary or revision hip arthroplasty for nontraumatic etiologies. Plasma fibrinogen, blood count, coagulation tests, and platelet count were measured preoperatively. A plasma fibrinogen level of 200 mg/dL-1 was the cutoff value used to predict blood transfusion. The mean (SD) plasma fibrinogen level was 325 (83) mg/dL-1. Only thirteen patients had levels < 200 mg/dL-1, and only one of them received a blood transfusion, with an absolute risk of 7.69% (1/13; 95%CI: 1.37-33.31%). Preoperative plasma fibrinogen levels were not associated with the need for blood transfusion (p = 0.745). The sensitivity and the positive predictive value of plasma fibrinogen < 200 mg/dL-1 as a predictor of blood transfusion were 4.17% (95%CI: 0.11-21.12%) and 7.69% (95%CI: 1.12-37.99%), respectively. Test accuracy was 82.05% (95%CI: 75.93-87.17%), but positive and negative likelihood ratios were poor. Therefore, preoperative plasma fibrinogen level in hip-arthroplasty patients was not associated with the need for blood-product transfusion.

High versus low blood pressure targets for cardiac surgery while on cardiopulmonary bypass.

Cardiac surgery is performed worldwide. Most types of cardiac surgery are performed using cardiopulmonary bypass (CPB). Cardiac surgery performed with CPB is associated with morbidities. CPB needs an extracorporeal circulation that replaces the heart and lungs, and performs circulation, ventilation, and oxygenation of the blood. The lower limit of mean blood pressure to maintain blood flow to vital organs increases in people with chronic hypertension. Because people undergoing cardiac surgery commonly have chronic hypertension, we hypothesised that maintaining a relatively high blood pressure improves desirable outcomes among the people undergoing cardiac surgery with CPB. To evaluate the benefits and harms of higher versus lower blood pressure targets during cardiac surgery with CPB. We used standard, extensive Cochrane search methods. The latest search of databases was November 2021 and trials registries in January 2020. We included randomised controlled trials (RCTs) comparing a higher blood pressure target (mean arterial pressure 65 mmHg or greater) with a lower blood pressure target (mean arterial pressure less than 65 mmHg) in adults undergoing cardiac surgery with CPB. We used standard Cochrane methods. Primary outcomes were 1. acute kidney injury, 2. cognitive deterioration, and 3. all-cause mortality. Secondary outcomes were 4. quality of life, 5. acute ischaemic stroke, 6. haemorrhagic stroke, 7. length of hospital stay, 8. renal replacement therapy, 9. delirium, 10. perioperative transfusion of blood products, and 11. perioperative myocardial infarction. We used GRADE to assess certainty of evidence. We included three RCTs with 737 people compared a higher blood pressure target with a lower blood pressure target during cardiac surgery with CPB. A high blood pressure target may result in little to no difference in acute kidney injury (risk ratio (RR) 1.30, 95% confidence interval (CI) 0.81 to 2.08; I² = 72%; 2 studies, 487 participants; low-certainty evidence), cognitive deterioration (RR 0.82, 95% CI 0.45 to 1.50; I² = 0%; 2 studies, 389 participants; low-certainty evidence), and all-cause mortality (RR 1.33, 95% CI 0.30 to 5.90; I² = 49%; 3 studies, 737 participants; low-certainty evidence). No study reported haemorrhagic stroke. Although a high blood pressure target may increase the length of hospital stay slightly, we found no differences between a higher and a lower blood pressure target for the other secondary outcomes. We also identified one ongoing RCT which is comparing a higher versus a lower blood pressure target among the people who undergo cardiac surgery with CPB. A high blood pressure target may result in little to no difference in patient outcomes including acute kidney injury and mortality. Given the wide CIs, further studies are needed to confirm the efficacy of a higher blood pressure target among those who undergo cardiac surgery with CPB.

Implications of Transfusion in Adults with Congenital Heart Disease Undergoing Cardiac Surgery.

The number of adults with congenital heart disease (CHD) requiring cardiovascular (CV) surgery is increasing rapidly in today's era. We hypothesized that exposure to perioperative blood products is associated with worse outcomes in adults. All adults (≥ 18years old) undergoing CV surgery with Cardio-Pulmonary Bypass (CPB) between 2015 and 2020 were reviewed retrospectively. Associations between transfusion and outcomes were studied by univariable logistic regression and Wilcoxon rank sum tests. Cox/ logistic regression was used to assess (a) postoperative ventilation time and length of stay, and (b) major complications, respectively. Of 323 patients, 170 (53%) received blood products perioperatively. The median age was 27 (interquartile range [IQR]: 22-36) years, there were 181 (46%) males, and 16 (5%) patients had single ventricle anatomy. Patients receiving products experienced more complications (OR: 6.6, 95% CI: [2.9, 14.7], p < 0.001) specifically, cardiac arrest (OR: 8.8, 95% CI: [1.1, 71.9], p = 0.04). Transfusion was associated with greater frequency of thrombosis ((OR: 7.8, 95% CI: [1.8, 34.7], p = 0.01)), longer ventilation time (HR: 3.0, 95% CI: [2.4, 3.9], p < 0.001), and longer hospital length of stay (HR: 2.7, 95% CI: [2.1, 3.4], p < 0.001). Longer CPB time (OR: 1.0, 95% CI: [1.0, 1.1], p < 0.001) and prior cardiac surgery (OR: 1.6, 95% CI: [1.3, 2.1], p < 0.001) were independent predictors of perioperative blood product transfusion. Adults who received perioperative blood products experienced more complications and worse in-hospital outcomes. Future research on optimizing blood product transfusion based on risk prediction is needed to optimize outcomes in adults with CHD.

Comparison of trauma-dosed tranexamic acid versus aminocaproic acid in cardiac surgery in the setting of drug shortage.

Antifibrinolytic agents, tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), are often used during cardiac surgery to decrease the number of allogenic blood transfusions and to prevent perioperative bleeding. Weight-based TXA dosing regimens have been compared to fixed-dose regimens of EACA with variable outcomes in perioperative blood product transfusions and chest tube output. Serious adverse events, including seizures, have been reported with higher doses of TXA. Fixed-dose TXA regimens have been evaluated in trauma and orthopedic surgery but there is a paucity of evidence in the cardiac surgery population. To compare the safety and efficacy of fixed-dose TXA versus EACA in patients undergoing cardiac surgery. A single-center, retrospective chart review was conducted at a 793-bed tertiary care academic teaching hospital comparing cardiac surgery patients receiving either fixed-dose TXA 1000 mg followed by a 500-1000 mg infusion or EACA-7.5 gintravenousboluses followed by a 1-1.25 g/hinfusion for the duration of the surgery. The major endpoint included chest tube output at 12 h, 24 h, and 7 days postoperatively. Minor endpoints included quantity and incidence of blood product transfusions and reported safety events. There were 1544 patients included. Chest tube output was similar between groups and the TXA group required more intraoperative blood product transfusions (22.7% vs. 18.2%, p = .03). There were no differences in the median quantity of total blood products administered postoperatively at 24 h or at 7 days. Reported safety events were similar between groups. Both fixed-dose TXA and EACA may be considered safe and effective options for antifibrinolytic therapy in cardiac surgery patients.

A Randomized Pilot Trial Assessing the Role of Human Fibrinogen Concentrate in Decreasing Cryoprecipitate Use and Blood Loss in Infants Undergoing Cardiopulmonary Bypass

The objective of this study was to determine whether treatment with human fibrinogen concentrate decreases the need for component blood therapy and blood loss in neonate and infant patients undergoing cardiopulmonary bypass. Pediatric patients (N = 30) undergoing elective cardiac surgery were randomized to receive human fibrinogen concentrate or placebo following cardiopulmonary bypass termination. The primary endpoint was the amount of cryoprecipitate administered. Secondary endpoints included estimated blood loss during the 24 h post-surgery; perioperative blood product transfusion; effects of fibrinogen infusion on global hemostasis, measured by laboratory testing and rotational thromboelastometry; and adverse events. No clinically significant differences were identified in baseline characteristics between groups. A significantly lower volume of cryoprecipitate was administered to the treatment group during the perioperative period [median (interquartile range) 0.0 (0.0–0.0) cc/kg vs 12.0 (8.2–14.3) cc/kg; P < 0.0001] versus placebo. No difference was observed between treatment groups in blood loss, laboratory coagulation tests, use of other blood components, or incidence of adverse events. FIBTEM amplitude of maximum clot firmness values was significantly higher among patients treated with human fibrinogen concentrate versus placebo (P ≤ 0.0001). No significant differences were observed in post-drug HEPTEM, INTEM, and EXTEM results. Human fibrinogen concentrate (70 mg/kg) administered after the termination of cardiopulmonary bypass reduced the need for transfusion with cryoprecipitate in a neonate and infant patient population.ClinicalTrials.gov identifier: NCT02822599.

The Prognostic Role of In-Hospital Transfusion of Fresh Frozen Plasma in Patients with Cholangiocarcinoma Undergoing Curative-Intent Liver Surgery

Introduction: Major hepatectomy for perihilar and intrahepatic cholangiocarcinoma (CCA) is often associated with a significant intraoperative blood loss and the requirement for perioperative transfusion of blood products. The aim of this study was to investigate the oncological impact of fresh frozen plasma (FFP) transfusion during hospitalization in patients undergoing hepatectomy for CCA as adverse effects have been described in other malignancies.

The prognostic role of in-hospital transfusion of fresh frozen plasma in patients with cholangiocarcinoma undergoing curative-intent liver surgery

IntroductionMajor hepatectomy for perihilar and intrahepatic cholangiocarcinoma (CCA) is often associated with a significant intraoperative blood loss and the requirement for perioperative transfusion of blood products. The aim of this study was to investigate the oncological impact of fresh frozen plasma (FFP) transfusion during hospitalization in patients undergoing hepatectomy for CCA as adverse effects have been described in other malignancies. Material and methodsPatients undergoing hepatectomy for CCA from 2010 to 2019 at a single institution were eligible for this study. Survival analysis was carried out according to Kaplan-Meier and the associations of cancer-specific (CSS) and recurrence-free survival (RFS) with in-hospital application of FFP and other clinico-pathological characteristics were assessed using Cox regression models. Perioperatively deceased patients were excluded from the analysis. ResultsA total of 219 CCA patients were included in this survival analysis of which 53.0% (116/219) received FFP during hospitalization. Patients receiving in-hospital FFP showed a median CCS of 33 months (3-year-CSS = 46%, 5-year-CSS = 29%) compared to 83 months (3-year-CSS = 55%, 5-year-CSS = 53%) in patients who did not receive in-hospital FFP (p = 0.006 log rank). Further, in-hospital FFP was identified as an independent predictor of oncological outcome in multivariable analysis (CSS: HR = 1.71, p = 0.016; RFS: HR = 1.89, p = 0.003). ConclusionIn a large European cohort of patients, in-hospital transfusion of FFP was identified as a novel independent prognostic marker in CCA patients undergoing curative-intent liver surgery. A restrictive transfusion policy is therefore recommended to improve long-term outcome in these patients.

Blood product transfusion and lung transplant outcomes: A systematic review.

The perioperative transfusion of blood products has long been linked to development of acute lung injury and associated with mortality across both medical and surgical patient populations.1,2 The need for blood product transfusion during and after lung transplantation is common and, in many instances, unavoidable. However, this practice may potentially be modifiable.3 In this systematic review, we explore and summarize what is known regarding the impact of blood product transfusion on outcomes following lung transplantation, highlighting the most recent work in this area. Overall, the majority of the literature consists of single center retrospective analyses or the work of multicenter working groups referencing the same database. In the end, there are a number of remaining questions regarding blood product transfusion and their downstream effects on graft function and survival.

1-year outcomes for lung transplantation recipients with non-alcoholic fatty liver disease.

Advanced hepatic fibrosis and cirrhosis are absolute contraindications to lung transplantation. [ 1] However, whether fatty liver disease with mild–moderate fibrosis contributes to increased adverse outcomes post-lung transplantation remains unknown. We present a retrospective analysis of patients transplanted at Brigham and Women's Hospital between 2015 and 2017 to identify whether patients with mild–moderate non-alcoholic fatty liver disease (NAFLD) experience increased short-term complications compared to patients with normal liver architecture. Patients with advanced (F3–F4) fibrosis and/or cirrhosis were considered non-suitable transplant candidates, a priori. This study was powered for a difference in index hospital-free days within the first 30 days of 25% (α=0.05, β=0.8). Secondary outcomes included index intensive care unit (ICU)-free days within the first 10 days post-transplant, perioperative blood product transfusion, incidence of index hospitalisation arrhythmias and delirium, need for insulin on discharge post-transplant, tacrolimus dose required to maintain a trough of 8–12 ng·mL−1 at index hospital discharge, and 1-year post-transplant incidence of insulin-dependent diabetes, acute kidney injury, acute cellular rejection, unplanned hospital readmissions and infection. 150 patients underwent lung transplantation between 2015 and 2017 and were included in the analysis; of these patients 40 (27%) had evidence of NAFLD. Median index hospital-free days for patients with NAFLD were non-inferior to those without (16 days, IQR 10.5–19.5 versus 12 days, IQR 0–18.0, p=0.03). Regarding secondary outcomes, both index hospitalisation and 1-year outcomes were non-inferior between patients with NAFLD and those with normal liver architecture. This study demonstrates that mild–moderate severity NAFLD may not be a contraindication to lung transplantation.

Perioperative Cryoprecipitate Waste Reduction.

Improvement of operating room efficiency regarding perioperative blood product transfusion is fundamental for surgical patients. The aim of this study was to 1) assess the use of cryoprecipitate in the operating room at our institution 2) identify and address gaps in knowledge regarding the process of ordering and returning cryoprecipitate 3) aim to reduce cryoprecipitate wastage by 50% over a 14-month period. Institutional data from Dec. 2017 to April 2020 was retrieved on cryoprecipitate that was ordered, thawed, and delivered to the operating room. Additionally, data was collected regarding cryoprecipitate that was wasted. A retrospective analysis of weekly intraoperative cryoprecipitate utilization was performed to compare wastage before and after implementation of interventions. Pre-intervention (Dec 2017 - March 2019), a total of 453 units of cryoprecipitate were issued with 14 units wasted (3% wastage). Between March 2019 and April 2020, the 14 months after our intervention, there were 402 units of cryoprecipitate issued with only 1 unit wasted (0.25% wastage). The overall cryoprecipitate waste rate was reduced by 91.66%. Month-to-month comparison of pre-intervention and post-intervention data identified significant reduction in average monthly wastage (0.875 vs 0.071 units respectively, p < 0.05). Appropriately, there was not a significant change in the mean monthly cryoprecipitate issued to the operating room (28.31 vs. 28.7 units, p = 0.94). These results demonstrate that utilizing educational initiatives for optimization of blood product management can reduce unnecessary ordering, transfusions, and wastage; an outcome that could ultimately reduce costs.

Blood product transfusion in liver transplantation in First Clinical Hospital of Mongolia

Background: Liver transplantation is a well-accepted treatment of end-stage liver diseases. Seven-eight liver transplants have been performed from 2011 to June of 2019 in First Clinical Hospital of Mongolia. Numerous advances in perioperative manage ment, like expertise in surgical techniques, better preoperative optimization, intraoperative monitoring and management, chang es in immunosuppression regime and advances in postoperative management, not only increased the number of this procedure but also the outcome. The role of the anesthesiologist is to provide safe anesthesia and maintain an acceptable hemodynamic performance, ensuring sufficient perfusion to the vital organs. Estimation of the amount of blood products required during liver transplantation can help provision of adequate blood supply, minimize transfusion associated complications and plan for preven tive measures in high risk patients. Methods: Our objective is to investigate some factors impact to perioperative blood product transfusion. We used data of pa tients who underwent liver transplantation between October 2011 and June 2019 at First Clinical Hospital of Mongolia, were reviewed. The all amount of blood product utilized during surgery and some factors, including pretransplant laboratory data, pre transplant clinical data were recorded. Results: We studied 77 patients who underwent liver transplantation. The mean±standard deviation amounts of red blood cells and fresh frozen plasma transfusion during surgery were 1.64±2.36 and 2.22±2.7 liters, respectively. The mean amount of red blood cells and albumin was significantly (P<0.003 and P<0.005) correlated with model for end-stage liver disease (MELD) score of patients. The mean amount of blood products utilized during operation was decreased from 2015 to 2019 except two retrans plantation patients. Conclusions: Some preoperative factors may predict blood transfusion requirements in patients undergoing liver transplanta tion. Therefore, evaluation of patients before operation should be considered to provide adequate blood supply. Understanding preoperative factors associated with rate of transfusion may help us to best utilize the limited available blood resources.

Efficacy of Intravenous Tranexamic Acid in Reducing Perioperative Blood Loss and Blood Product Transfusion Requirements in Patients Undergoing Multilevel Thoracic and Lumbar Spinal Surgeries: A Retrospective Study.

Introduction: Acute perioperative blood loss is a common and potentially major complication of multilevel spinal surgery, usually worsened by the number of levels fused and of osteotomies performed. Pharmacological approaches to blood conservation during spinal surgery include the use of intravenous tranexamic acid (TXA), an anti-fibrinolytic that has been widely used to reduce blood loss in cardiac and orthopedic surgery. The primary objective of this study was to assess the efficacy of intraoperative TXA in reducing estimated blood loss (EBL) and red blood cell (RBC) transfusion requirements in patients undergoing multilevel spinal fusion. Materials and Methods: This a single-center, retrospective study of subjects who underwent multilevel (≥7) spinal fusion surgery who received (TXA group) or did not receive (control group) IV TXA at The Ohio State University Wexner Medical Center between January 1st, 2016 and November 30th, 2018. Patient demographics, EBL, TXA doses, blood product requirements and postoperative complications were recorded. Results: A total of 76 adult subjects were included, of whom 34 received TXA during surgery (TXA group). The mean fusion length was 12 levels. The mean total loading, maintenance surgery and total dose of IV TXA was 1.5, 2.1 mg per kilo (mg/kg) per hour and 33.8 mg/kg, respectively. The mean EBL in the control was higher than the TXA group, 3,594.1 [2,689.7, 4,298.5] vs. 2,184.2 [1,290.2, 3,078.3] ml. Among all subjects, the mean number of intraoperative RBC and FFP units transfused was significantly higher in the control than in the TXA group. The total mean number of RBC and FFP units transfused in the control group was 8.1 [6.6, 9.7] and 7.7 [6.1, 9.4] compared with 5.1 [3.4, 6.8] and 4.6 [2.8, 6.4], respectively. There were no statistically significant differences in postoperative blood product transfusion rates between both groups. Additionally, there were no significant differences in the incidence of 30-days postoperative complications between both groups. Conclusion: Our results suggest that the prophylactic use of TXA may reduce intraoperative EBL and RBC unit transfusion requirements in patients undergoing multilevel spinal fusion procedures ≥7 levels.

Perioperative transfusion practice in patients undergoing lung transplantation – experience from a 7-year period

Introduction Perioperative allogenic blood product transfusion is common in lung transplantation (LTx), particularly after an increased utilization of extracorporeal membrane oxygenation (ECMO) throughout the peritransplant period. The risks of massive transfusion of blood products are well-known, and may negatively influence LTx outcomes (1). We analyzed perioperative transfusion practice among the LTx recipients at our institution. Methods All consecutive patients who underwent LTx at Harefield Hospital between January 2012 and December 2018 were analyzed. Patients bridged to LTx with ECMO and preoperatively mechanically ventilated were included. Data were extracted from our institutional electronic system. The use of red blood cells (RBCs), fresh frozen plasma (FFP), and platelets (PLT) intraoperatively and postoperatively within the first 48 hours was investigated. Transfusion of >10 units of RBCs was considered as massive transfusion. Results A total of 304 LTx recipients (male gender 54.9%, mean age 45.9±12.3 years) underwent bilateral sequential single LTx (97.4%) or single LTx (2.6%). The most common diagnosis was cystic fibrosis (CF; 42.4%). Re-transplantation was performed in 3.3%. The percentage of recipients bridged to LTx with ECMO was 9.2% (20 patients with veno-venous [VV] ECMO, 5 with veno-arterial [VA] ECMO and 3 with Novalung). Intraoperative ECMO was required in 30 (9.9%) patients (11 VV ECMO/19 VA ECMO) and cardiopulmonary bypass (CPB) in 107 (35.2%), whereas 167 (54.9%) patients were operated off-pump. Postoperatively, ECMO was utilized in 35 (11.5%) patients (24 VA ECMO/10 VV ECMO/1 Novalung). Of these, 26 (74.3%) patients required conversion to ECMO following unsuccessful weaning from CPB, 6 (17.1%) continued to be supported after intraoperative ECMO, and 3 (8.6%) were initially operated off-pump. The median number of RBCs in the first 48 hours was 4 (0-71) units, FFP 2 (0-37) and PLT 1 (0-21). The overall incidence of patients requiring >10 units of RBCs in the first 48 hours was 22.1%, including all patients with idiopathic pulmonary arterial hypertension (IPAH), 50% of patients who underwent re-transplantation, and 31.8% of patients with CF. Patients who needed intraoperative MCS support had a higher incidence of massive transfusion (43% in the CPB group vs. 40% in the ECMO group vs. 5.4% in the off-pump group). The overall 30-day mortality rate was 6.9%, which increased to 23.9% among patients with massive transfusion. Discussion We performed a descriptive analysis of perioperative transfusion practice in a tertiary centre over a 7-year period and showed that MCS, IPAH, re-transplantation, and CF were associated with massive transfusion. Overall, we demonstrated a reasonably low incidence of perioperative blood transfusion and excellent 30-day survival. Further analysis is needed to investigate which perioperative factors may help minimize allogenic blood product usage in LTx and improve postoperative outcomes.

Association of Adenosine Diphosphate–Induced Platelet Maximum Amplitude With Postoperative Bleeding and Blood Transfusions in Patients Undergoing Coronary Artery Bypass Grafting

To investigate the association of adenosine diphosphate (ADP)-induced platelet maximum amplitude (MAADP) with postoperative bleeding and blood product transfusions in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). This single-center observational study recruited 200 patients who underwent elective, first-time, isolated CABG with CPB. A rapid thromboelastography with platelet mapping test was conducted for all patients before the surgery. Patients were categorized by the preoperative MAADP into ≤50 mm (MAADP ≤50 group [n = 87]) and MAADP >50 mm (MAADP >50 group [n = 113]). The primary outcome was postoperative bleeding at 6 and 24 hours as measured by chest tube drainage volume. The perioperative blood product transfusions, postoperative complications, postoperative time course, and in-hospital mortality also were evaluated. University hospital. Adult patients scheduled to undergo isolated primary CABG with CPB. None. The study included 200 patients who underwent CABG with CPB. MAADP was >50 mm in 113 (56.5%) patients (MAADP >50 group). Compared with the MAADP >50 group, the postoperative chest tube drainage volume at 6 and 24 hours was significantly greater in the patients with MAADP ≤50 mm (476.90 ± 156.36 mL v 403.36 ± 133.24 mL; p < 0.001 and 935.86 ± 318.43 mL v 667.21 ± 222.75 mL; p < 0.001, respectively). The consumption of blood products in patients with MAADP ≤50 mm was significantly more than those with MAADP >50 mm. The durations of intensive care unit stay and length of postoperative hospital stay were markedly longer in the MAADP ≤50 group than in the MAADP >50 group (p = 0.001 and p = 0.005; respectively). There were no significant differences in adverse outcomes between the 2 groups except for the postoperative atrial fibrillation, which occurred more in the MAADP ≤50 group than in the MAADP >50 group (8.05% v 1.77%; p = 0.043). MAADP (area under the receiver operating characteristic curve of 0.767; p < 0.001) was demonstrated to have significant ability to predict bleeding tendency, with a sensitivity of 76.2% and a specificity of 69.0%. Preoperative MAADP may play a potential role in the prediction of postoperative bleeding and allogeneic blood transfusions and guide clinicians in perioperative management of patients undergoing CABG with CPB.