Post-transfusion Haemoglobin Levels Research Articles

To study the Transfusion Practice with respect to Component Therapy in Major Obstetric Hemorrhage

Introduction: Peripartum hemorrhage is a major complicationrequiring emergency transfusion of packed blood or itscomponents with quick decision-making. We describeour experience of transfusion practices in major obstetrichemorrhage.Materials and Methods: Retrospective observational dataof all the deliveries (n = 1837) over period of one year.All cases were assessed for obstetric hemorrhage andsubsequent transfusion practices done. Demographic details,obstetric history, indications for transfusion, gestational ageat transfusion, pre- and post-transfusion hemoglobin levels,nature and type of transfusion, units of transfusion, adverseevents following transfusion and outcome in terms of morbidityand mortality were noted. Data was analyzed using SPSS 21.0software. Chi-square test was used for analysis.Results: Transfusion was required in 776 (42.2%) pregnantwomen. Obstetric hemorrhage was the indication in 432 (55.7%)of the women receiving a transfusion. Other indications wereanemia during pregnancy (39.7%) and traumatic pph (10.5%),respectively. Among major obstetric hemorrhage cases (n =432), the majority (n = 224; 51.9%) had antepartum hemorrhage(abruptio placentae/placenta previa) and the remaining 208(48.1%) had postpartum hemorrhage change no significantchange seen. A total of 138/432 (31.9%) cases had pretransfusionhemoglobin level <8 g/dl in cases of moderateanemia. PRBC was transfused to 319 (73.8%) followed byplatelets (212; 49.1%) and FFP (n = 29; 6.7%), respectively.The majority of cases required only 2 units of transfusion.There were 21 (4.9%) cases requiring more than 3 units.Post-transfusion hemoglobin levels were >10 g/dl in 319/432(73.8%) cases, thus showing a significant change (p < 0.05).Most common adverse reactions (fever/shivering) were notedin 32 (7.4%) cases. There were 6 (1.4%) mortalities (all havingpre-transfusion Hb <6 g/dl).Conclusion: The study highlighted the significance of packedblood cells and component transfusion in reducing obstetricmorbidity and mortality

The effect of erythroferrone suppression by transfusion on the erythropoietin-erythroferrone-hepcidin axis in transfusion-dependent thalassaemia: A pre-post cohort study.

To track post-transfusion changes on the erythropoietin (EPO)-erythroferrone (ERFE)-hepcidin axis, we collected blood samples from 82 regularly transfused patients with β-thalassaemia major (β-TM) immediately before and 4-6 days after transfusion. The post-transfusion haemoglobin, hepcidin, and ferritin levels were increased, while the EPO, ERFE, and soluble transferrin receptor were suppressed. In addition, hepcidin change was inversely associated with erythropoietic change, which was confirmed by an increase in the hepcidin-to-ERFE ratio after transfusion. Age was the main predictor of serum ERFE, followed by EPO, transfusion frequencies, and ferritin. We found ERFE to be a highly sensitive indicator of erythroid activity in β-TM and that the hepcidin-to-ERFE ratio after transfusion may be used as an appropriateness index of serum hepcidin regulation relative to the degree of erythropoiesis.

708 An Audit of Blood Transfusion Prescription in Peri-Operative Orthopaedic Patients for Those with and Without a Coronary History

Abstract Aim Correct prescription of red blood cells (RBCs) is essential for treatment of peri-operative anaemia and preventing complications to post-operative recovery. However, over prescription is costly, inefficient, and not free of complication. We compared the threshold and targets for the prescription of RBCs in a secondary care orthopaedic department to the NICE Blood Transfusion Guidance (2015) and whether altered thresholds were used or if iron was prescribed. Method Retrospective analysis of all surgically managed orthopaedic patients over a 3-month period receiving peri-operative RBCs in 2020. Pre and post transfusion haemoglobin (Hb) levels, concurrent prescription of iron and documented reasons for altered transfusion thresholds were collected. Exclusions included major trauma, major haemorrhage, or intra-operative transfusion. Results 62 patients were transfused on average 1.5 units post-operatively. 21.4% were transfused in line with the NICE threshold (Hb<70g/dL) and targets (Hb70–90g/dL.) Average Hb threshold was 75.5g/dL (range 60–110). 0% had an ACS on the day of RBC transfusion. In 54.2% 1 unit was prescribed at a time. Iron deficiency anaemia was identified in 11.4% and treated in 7% pre-operatively. Conclusions RBCs are being prescribed out of line with NICE guidance with a 21.4% compliance to the standard. The most common reason was a ‘coronary history’ which was inconsistently defined with no patients having an acute coronary syndrome - the only reason given by NICE for changing this threshold. Departmental education, identification of pre-operative anaemia and a protocol explaining the use of oral and intravenous iron peri-operatively may reduce the amount of erroneous blood transfusion prescribing in this cohort.

Standardizing blood dose using body surface area and analyze the effect of blood storage on hemoglobin increment within pediatric patients

Introduction: Pediatric patients exhibit a wide variation in weight which results in diverse transfusion practices. This study aims to standardize red blood cell (RBC) doses according to body surface area (BSA) and to analyze the role of RBC storage in post-transfusion hemoglobin levels. Material and methods: In this original prospective cohort study on hospitalized pediatric patients aged up to 14, we classified patients into transfusion-dependent (n = 31) and non-transfusion-dependent (n = 158). The non-transfusiondependent group was further classified into ≤10 kg (n = 72) or >10 kg (n = 86) according to body weight (bw). We derived a regression equation between BSA and blood dose in non-transfusion-dependent subjects, and modified the equation by fixing blood dose to 15 mL/kg bw for only BSA based blood dose. We measured pre-transfusion and post-transfusion hemoglobin (Hb) levels, and ascertained effects of blood storage ≤15 days (n = 15) and >15 days (n = 16) on posttransfusion Hb. Results: Pediatric patients ≤10 kg and >10 kg bw (n = 158); mean ± standard deviation of weight and BSA were 4.5 ± 3.1 kg; 22.9 ± 10.4 kg; 0.26 ± 0.14 m 2 ; 0.9 ± 0.28) m 2 respectively. The regression equation ≤10 kg and >10 kg bw when adjusted. Blood dose fixed at 15 mL/kg bw adjusted blood dose ≤10 kg; 15 mL/kg bw = −19.12 + 329.69x BSA m 2 . The regression equation >10 kg bw: adjusted blood dose >10 kg bw; 15 mL/kg bw = −158.8 + 563.3x BSA (m 2 ). The adjusted blood dose with BSA did not exceed 20 mL/kg bw. No significant differences were observed in pre and post-transfusion Hb in transfusion-dependent (n = 31) versus non-transfusion-dependent patients (n = 158) due to the RBC storage duration. Conclusions: RBC blood dose can be standardized by regression equation between standardized RBC dosage and BSA. Post-transfusion Hb is not dependent on days of RBC storage at the blood bank.

Achievement of Pre- and Post-Transfusion Hemoglobin Levels in Adult Transfusion-Dependent Beta Thalassemia: Associated Factors and Relationship to Reduction of Spleen Enlargement.

IntroductionThe achievement of blood transfusion hemoglobin targets in transfusion-dependent beta-thalassemia patients is influenced by several factors such as genotype, hypersplenism, blood compatibility, donor blood adequacy, and transfusion interval. Failure to achieve these targets leads to an increase in the size of the spleen. Meanwhile, the post-transfusion hemoglobin of thalassemia patients that is not regularly evaluated has made it difficult to determine donor adequacy. Therefore, this study aims to determine the proportion of patients who achieve optimal pre- and post-transfusion hemoglobin levels, determine the factors involved, and the relationship between achieving hemoglobin levels with spleen enlargement in adult transfusion-dependent beta-thalassemia patients.MethodsThis retrospective cohort study was conducted using total sampling of adult thalassemia transfusion-dependent patients at Cipto Mangunkusumo Hospital. Data were obtained through medical records.ResultsA hundred and ten study subjects fulfilled inclusion criteria. The results showed that the blood transfusion deficit <30 mL/kg/year was associated with achieving pre- and post-transfusion hemoglobin targets (p = 0.008). Furthermore, there were significant differences between the groups that achieved the pre- and post-transfusion target hemoglobin levels on the reduction of spleen enlargement in centimeters (p < 0.001). However, thalassemia genotype, blood compatibility, and transfusion interval did not correlate with the achievement of pre- and post-transfusion hemoglobin.ConclusionThe achievement of pre- and post-transfusion hemoglobin levels in adult transfusion-dependent beta-thalassemia patients significantly reduced spleen enlargement and contributed to better patient outcomes.

Perbandingan Kadar Hemoglobin Pasca Transfusi Menggunakan Darah Segar dan Darah Simpan Pada Penderita Anemia Aplastik

This study aims to determine the comparison of hemoglobin levels in patients with aplastic anemia who are transfused using fresh blood and save blood in H. Adam Malik General Hospital Medan. This study was conducted descriptively by comparing the results of the increase in post-transfusion hemoglobin levels using fresh blood and save blood in patients with aplastic anemia. The results showed that the average value of hemoglobin in patients with aplastic anemia before being transfused with fresh donor blood was 6.4 gr/dL, increasing to 8.9 gr/dL, while the average value of hemoglobin levels in patients with aplastic anameia before transfusion of save blood is 6.8 gr/dL increased after transfusion to 7.9 gr/dL. It can be concluded that blood transfusion using fresh blood is better than storing blood transfusion in increasing hemoglobin levels in patients with aplastic anemia, with an average percentage increase in fresh blood of 38.0% and donor save blood an average of 17.4%.

Scalp Swelling and Headache in a 12-year-old Boy

1. Kathryn Westphal, MD* 2. Respicius Bakalemwa, MD† 3. Elizabeth Groothuis, MD, MPH* 1. *Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 2. †Department of Pediatrics, Bugando Medical Centre, Mwanza, Tanzania A 12-year-old boy with sickle cell disease (SCD) is admitted to a hospital in Mwanza, Tanzania, with acute onset of periorbital and scalp swelling. Associated symptoms include fever, headache, difficulty breathing, and back pain. Because resources in sub-Saharan Africa are limited, access to comprehensive care for patients with SCD is variable. The general principles of management focus on early diagnosis, parental education, prevention of infection with vaccinations and prophylactic medications, prompt treatment of infection and pain, the use of hydroxyurea for stroke prevention, and blood transfusions for life-threatening anemia. This patient has a known diagnosis of SCD but has infrequent pain episodes and no previous transfusions. He is not receiving hydroxyurea or prophylaxis against bacterial infections or malaria. He has no history of stroke and no known head trauma. On presentation he is afebrile and his heart rate is 120 beats/min, respiratory rate is 40 breaths/min, and blood pressure is 105/75 mm Hg. His oxygen saturation is 92% in room air. Physical examination is significant for pallor, periorbital edema, scalp edema, dyspnea without adventitious lung sounds, and splenomegaly with diffuse abdominal tenderness. His scalp edema is fluctuant and extends posteriorly from the periorbital region, encompassing the entire scalp. Swelling is most prominent in the frontal and parietal areas. The overlying skin is nonerythematous and nontender but is warm to the touch. His neurologic examination has no focal findings, although generally he appears tired. Initial laboratory results demonstrate a white blood cell count of 84,000/μL (84×109/L) with a lymphocytic predominance (57%), a hemoglobin level of …

A prospective multi-faceted interventional study of blood bank technologist screening of red blood cell transfusion orders: The START study.

Transfusion of red blood cells (RBC) is a common procedure, which when prescribed inappropriately can result in adverse patient outcomes. This study sought to determine the impact of a multi-faceted intervention on unnecessary RBC transfusions at hospitals with a baseline appropriateness below 90%. A prospective medical chart audit of RBC transfusions was conducted across 15 hospitals. For each site, 10 RBCs per month transfused to inpatients were audited for a 5-month pre- and 10-month post-intervention period, with each transfusion adjudicated for appropriateness based on pre-set criteria. Hospitals with appropriateness rates below 90% underwent a 3-month intervention which included: adoption of standardized RBC guidelines, staff education, and prospective transfusion order screening by blood bank technologists. Proportions of RBC transfusions adjudicated as appropriate and the total number of RBC units transfused per month in the pre- and post-intervention period were examined. Over the 15-month audit period, at the 13 hospital sites with a baseline appropriateness below 90%, 1950 patients were audited of which 81.2% were adjudicated as appropriate. Proportions of appropriateness and single-unit orders increased from 73.5% to 85% and 46.2% to 68.2%, respectively from pre- to post-intervention (P < .0001). Pre- and post-transfusion hemoglobin levels and the total number of RBCs transfused decreased from baseline (P < .05). The median pre-transfusion hemoglobin decreased from a baseline of 72.0 g/L to 69.0 g/L in the post-intervention period (P < .0001). RBC transfusions per acute inpatient days decreased significantly in intervention hospitals, but not in control hospitals (P < .001). The intervention had no impact on patient length of stay, need for intensive care support, or in-hospital mortality. This multifaceted intervention demonstrated a marked improvement in RBC transfusion appropriateness and reduced overall RBC utilization without impacts on patient safety.

Antenatal blood transfusion in South Africa: indications and practice in a high-HIV-prevalence setting.

Globally, data on antenatal blood transfusion practices are scarce. We sought to characterize the epidemiology of antenatal transfusion in South Africa. A cross-sectional study was conducted of women who were transfused during pregnancy (>48 hr before anticipated delivery) at two hospitals in Durban and Soweto in 2014 to 2015. Medical record data on demographics, obstetric history, anemia, HIV status, and indications for blood transfusion were abstracted. The records on a total of 560 transfused pregnant women were evaluated; mean age was 28 years, 98% were of black African ethnicity, and 28% were HIV positive. At time of transfusion, one-half were in the first trimester. Hemorrhage was noted in 76% of women, most of which was associated with abortion (67%) or ectopic pregnancy (27%). Most women were transfused with red blood cells (RBCs; median, 2 units); 14% of women were transfused with plasma and 2% with platelets. Median pre- and posttransfusion hemoglobin levels were 6.9 g/dL and 9.2 g/dL, respectively; the latter differed by hospital (8.7 g/dL vs. 9.5 g/dL; p < 0.01). Hemorrhage was associated with missing HIV status, lower gestational age, and transfusion of 3 or more RBC units (all p < 0.01). In contrast, diagnoses of anemia (Soweto only) were associated with HIV infection, later gestational age, and lower (<3 units) RBC dose (all p < 0.01). Abortion and ectopic pregnancy with associated hemorrhage were the leading indications for antenatal transfusion and were concentrated in early gestation. By contrast, anemia was associated with HIV infection and transfusion in the third trimester.

Acil Serviste Kan Transfüzyonu Yapılan Hastaların Özellikleri

Bu çalışmanın amacı acil serviste kan ve kan ürünleri transfüzyonu yapılan hastaların transfüzyon sonrası değişim verilerin incelenmesi amacıyla prospektif olarak incelemektir. Bu çalışma Sağlık Bilimleri Üniversitesi Bursa Yüksek İhtisas Eğitim ve Araştırma Hastanesi acil servisine başvuran hastaların yaş ve cinsiyetleri, şikayetleri, muayene bulguları, kan grupları, verilen kan ürünleri ve ünitelerinin dağılımı, transfüzyon öncesi ve sonrası hemoglobin(Hb), hematokrit(Hct) değerleri incelenerek yapıldı. Çalışmaya 92 hasta alınmış olup hastaların %56,5’u 65 yaş ve üzerindeydi. %59,8’i kadındı. %44,6 ile en fazla “halsizlik”şikayeti vardı. Muayenede hastaların %17,4’inde melena %14,1’inde hematokezya vardı. Hastaların %40,2’si anemi ve %35,9’u Gastrointestinal Sistem(GİS) kanaması tanısı almıştı. Hastalar en fazla %45,7 ile A RH+ ve %29,3 ile 0 RH + kan gruplarına sahipti. Hastaların %94,6’sına eritrosit süspansiyonu (ES) ve %5,4’üne ES+ taze donmuş plazma(TDP) transfüzyonu yapıldı. Hastaların %46,7’sine iki ünite ES ve %40,2’sine bir ünite ES verildi. Yaş gruplarının transfüzyon öncesi Hb değerleri arasında istatistiksel olarak önemli bir fark yokken ( p=0,879), transfüzyon sonrası istatistiksel olarak önemli fark olduğu bulundu (p=0,003). ES transfüzyonu sonrası hastaların %58,2’si beklenen Hb değerine ve %50,0’si beklenen Hct değerlerine ulaşmıştı. Yaş, cinsiyet ve tanıya göre beklenen Hb ve Hct düzeylerine ulaşma durumları arasında istatistiksel olarak önemli fark yoktu (p&amp;gt;0,05). Transfüzyon öncesi ve sonrası hastaların nabız, tansiyon ve ateş gibi vital bulgularında istatistiksel olarak fark yoktu (p&amp;gt;0,05), ancak Hb, Hct, MCV ve MCH’de önemli artış vardı (p&amp;lt;0,05). Çalışma sonunda acil serviste yapılan kan ve kan ürünü transfüzyonları incelendiğinde düşünülenin aksine travmaya bağlı acil transfüzyon değil de en fazla GİS kanama ve anemiye bağlı transfüzyon yapıldığı tespit edilmiştir.

International point prevalence study of Intensive Care Unit transfusion practices-Pilot study in the Netherlands.

Anaemia and coagulopathy are common issues in critically ill patients. Transfusion can be lifesaving, however, is associated with potential life threatening adverse events. As an international transfusion guideline for this specific patient population is lacking, we hypothesize that a high heterogeneity in transfusion practices exists. In this pilot-study we assessed transfusion practice in a university hospital in the Netherlands and tested the feasibility of this protocol for an international multi-centre study. A prospective single centre cohort study was conducted. For seven days all consecutive non-readmitted patients to the adult Intensive Care Unit (ICU) were included and followed for 28 days. Patients were prospectively followed until ICU discharge or up to day 28. Patient outcome data was collected at day 28. Workload for this study protocol was scored in hours and missing data. In total, 48 patients were included, needed in total three hours patient to include and collect all data, with 1.6% missing data showing the feasibility of the data acquisition. Six (12.5%) patients received red blood cells (RBCs), three patients (6.3%) received platelet concentrates, and two (4.2%) patients received plasma units. In total eight (16.7%) patients were transfused with one or more blood products. Median pre- and post-transfusion haemoglobin (Hb) levels were 7.6 (6.7-7.7) g/dL and 8.1 (7.6-8.7) g/dL, respectively. In this pilot-study we proved the feasibility of our protocol and observed in this small population a restrictive transfusion practice for all blood products.

Transfusion transmitted infections in frequently transfused thalassemic children living in Fayoum Governorate, Egypt: Current prevalence and risk factors.

Regular blood transfusion therapy remains the primary treatment in thalassemia major (TM). Transfusion-transmitted infections (TTIs) and iron overload are considered to be the major drawbacks of this therapy. This cross-sectional study aimed to update the prevalence of the hepatitis C virus (HCV) antibody, PCR-confirmed HCV, hepatitis B surface antigen (HBsAg), and human immunodeficiency virus (HIV) antibody among TM children. Clinical and epidemiological factors that can affect HCV infection prevalence rate were studied. This study evaluated 121 children with βTM, including 61 males and 60 females with a mean age of 7.99±3.57years. Patients were evaluated for the HCV, HBsAg, and HIV-1 & 2 antibodies. All tests were performed using ELISA. HCV positive cases were confirmed by RT-PCR. Twenty-five patients were positive for the HCV antibody (20.7%); 22 were confirmed positive by PCR. Six patients (5%) were HBsAg-positive. No patients were HIV-positive. Older age were associated with an increased frequency of HCV positive infection (P<0.003). More frequent transfusion, ≥10 times/year, and older age, ≥10years, were reported as predictors of HCV infection (P=0.018 and 0.011, respectively). A significant association of HCV between HBV infections was reported (P value=0.01). There was no significant effect of the pre-transfusion or post-transfusion hemoglobin level on the frequency of HCV positive cases. HCV still represents a major health challenge for frequently transfused Egyptian patients. The prevalence rate of HBV infection remains relatively high. Therefore, it is necessary to implement measures to improve blood transfusion screening.

Haemoglobin responses to transfusion in severe iron deficiency anaemia: potential impact of gastrointestinal disorders.

Red blood cell (RBC) transfusion may be justified in iron deficiency anaemia (IDA) when an increase in oxygen delivery is needed, as sometimes occurs in subjects with haemoglobin <8·0mg/dL, serious comorbidities or at risk of cardiovascular instability. Earlier investigations showed that some patients with severe IDA requiring transfusion had lower than expected post-transfusion haemoglobin levels with poorer clinical outcomes than other patients. After hypothesizing that haemoglobin responses to transfusion were different and that the underlying gastrointestinal (GI) disorders causing IDA could be a confounder explaining this association, these responses were analysed in a prospective cohort of IDA adults referred for outpatient GI investigation. Transfused patients with proven IDA, baseline haemoglobin at referral <9·0g/dL and no extraintestinal bleeding were eligible. To assess a homogeneous population, only GI disorders known to cause occult bleeding were considered. Haemoglobin increments per 100 mL of RBCs were investigated. In total, 2818 patients were enrolled over 10·5 years. On multivariable regression, diffuse angiodysplasias and GI cancer independently predicted for reduced increments in post-transfusion haemoglobin [adjusted regression coefficients: -0·082 (95% confidence interval, -0·093 to -0·072) and -0·073 (95% confidence interval, -0·081 to -0·066), respectively, P<0·001 in both]. Haemoglobin responses in the remaining bleeding disorders were adequate and agreed with the principle that one RBC unit increases the haemoglobin an average of 1g/dL. The potential differential impact of GI disorders on changes in haemoglobin levels after RBC transfusion could be useful for transfusing physicians, especially for diagnostic purposes.

Effectiveness of Provider Education Followed by Computerized Provider Order Entry Alerts in Reducing Inappropriate Red Blood Cell Transfusion.

To reduce the rate of inappropriate red blood cell transfusion, a provider education program, followed by alerts in the computerized provider order entry system (CPOE), was established to encourage AABB transfusion guidelines. Metrics were established for nonemergent inpatient transfusions. Service lines with high order volume were targeted with formal education regarding AABB 2012 transfusion guidelines. Transfusion orders were reviewed in real time with email communications sent to ordering providers falling outside of AABB recommendations. After 12 months of provider education, alerts were activated in CPOE. With provider education alone, the incidence of pretransfusion hemoglobin levels greater than 8 g/dL decreased from 16.64% to 6.36%, posttransfusion hemoglobin levels greater than 10 g/dL from 14.03% to 3.78%, and number of nonemergent two-unit red blood cell orders from 45.26% to 22.66%. Red blood cell utilization decreased by 13%. No additional significant reduction in nonemergent two-unit orders was observed with CPOE alerts. Provider education, an effective and low-cost method, should be considered as a first-line method for reducing inappropriate red blood cell transfusion rates in stable adult inpatients. Alerts in the computerized order entry system did not significantly lower the percentage of two-unit red blood cells orders but may help to maintain educational efforts.

Change in Patient-Reported Outcomes in Single-Unit Transfusion Comparable with Double-Unit Transfusion

▪IntroductionPatient blood management was developed to reduce allogeneic blood exposure and enhance patient outcomes. If transfusion is required in stable and non-bleeding hospitalized patients, prescribing one unit of red blood cells (RBC) followed by reassessment of clinical condition is recommended. Double-unit RBC transfusion, the routine practice in the past, is still widely practiced despite the advocate of restrictive transfusion strategy. One of the reasons could be a lack of evidence to support the optimal number of RBC units per transfusion. Blood transfusion is often performed to alleviate anemic symptoms. However, patient-reported outcomes were seldom measured to evaluate transfusion requirements.MethodThis was a single-center prospective study conducted during Mar to Jun 2016 in the medical department of a regional hospital of Hong Kong. Day-care and hospitalized patients requiring RBC transfusion were recruited. Patients with active bleeding or unstable hemodynamics were excluded. Subjects' demographics, recent transfusion history, comorbidities, transfusion trigger and the number of RBC units transfused were obtained. Patient-reported outcomes were measured on the day of transfusion (Day 0), and on Day 1 and 7 post-transfusion. Two health-related quality of life (HRQOL) instruments, i.e. Short-form 12 version 2 (SF12v2) and Functional Assessment of Cancer Therapy Anemia Subscale (FACT-AnS) in traditional Chinese, were administered to measure the general health status and anemic symptoms respectively. Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were then derived from SF12v2. The number of RBC units transfused in one week and post-transfusion hemoglobin (Hb) level were evaluated. Linear regressions were performed to study the relationship between the changes in PCS, MCS and FACT-AnS on Day 1 and Day 7 from Day 0 with the number of RBC units transfused. Factors associated with the number of RBC units transfused were controlled. Other predictors of the changes in HRQOL were included in the regression analysis.Results34 day-care and 67 hospitalized patients were recruited with HRQOL surveys completed on Day 0. The surveys were completed by 97 patients on Day 1 and 78 patients on Day 7. Forty-seven patients (47%), who were transfused with 2 or more units of RBC, were classified as double-unit group. The median transfusion trigger was 7.6 [IQR 7.0 - 7.9] g/dL in the single-unit group and 7.0 [IQR 6.2 - 7.8] g/dL in the double-unit group (p < 0.05). There was a trend of higher Charlson’s Comorbidity Index (CCI) (p = 0.09) in the single-unit group. Baseline PCS, MCS and FACT-AnS scores on Day 0 were comparable in both groups (p = 0.35, 0.45 and 0.15 respectively).The changes in HRQOL of all subjects were summarized in Table 1. FACIT-AnS improved after transfusion but the effect size was small (Cohen’s d < 0.5). There was improvement of PCS on Day 7. The change of MCS was non-significant.The mean number of transfused RBC in one week was 0.7 units less in the single-unit group (p < 0.001). The post-transfusion Hb level was 0.9g/dL (95% CI: 0.3, 1.6) and 1.1g/dL (95% CI: 0.2, 1.9) higher in the double-unit group on Day 1 and Day 7 respectively.Having controlled for transfusion trigger, CCI and RBC transfused during Day 1 to Day 7, the changes in HRQOL were not associated with the number of RBC units transfused (Table 2). Day-care patients had greater improvement in HRQOL on Day 1 but not on Day 7. The improvement of HRQOL in those having worse baseline scores was more significant. RBC use in the past 7 days was not associated with the change in patient-reported outcomes.ConclusionDouble-unit RBC transfusion was frequently performed, especially in patients with a lower Hb level. Blood transfusion could improve anemic symptoms but the effect on general health status was insignificant during early follow-up. The average number of RBC units transfused in one week was 28% less in the single-unit group. Post-transfusion Hb level was higher after double-unit transfusion, but there was no evidence it led to more significant improvement in patient-reported outcomes. Day-care patients had earlier improvement in HRQOL but the effect disappeared after one week. Patients with worse symptom score at baseline had greater improvement in HRQOL. It is proposed that the practice of single-unit RBC transfusion is appropriate in terms of alleviating anemic symptoms and reducing overall blood use. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Safety and Efficacy of Packed Red Blood Cell Transfusions at Different Doses in Very Low Birth Weight Infants

This double-blinded, randomized, crossover study evaluated the safety and effectiveness of 20 mL/kg aliquots of packed red blood cell (PRBC) transfusions versus 15 mL/kg aliquot transfusions in very low birth weight (VLBW) infants with anemia. The study enrolled 22 hemodynamically stable VLBW infants requiring PRBC transfusions, with a mean gestational age of 25.7 ± 2.2 weeks and birth weight of 804 ± 261 g. Each infant was randomized to receive one of two treatment sequences: 15 mL/kg followed by 20 mL/kg or 20 mL/kg followed by 15 mL/kg. The infants were monitored during and after transfusions, and the efficacy and safety of the treatments were evaluated. Infants had higher posttransfusion hemoglobin (13.2 g/dL vs 11.8 g/dL, P < 0.01) and hematocrit levels (38.6 g/dL vs 34.4 g/dL, P < 0.01) following 20 mL/kg PRBC transfusions when compared to 15 mL/kg transfusions. There were no differences in the incidence of tachypnea, hepatomegaly, edema, hypoxia, necrotizing enterocolitis, or vital sign instability between groups. In conclusion, high-volume PRBC transfusions (20 mL/kg) were associated with higher posttransfusion hemoglobin and hematocrit levels but no adverse effects. Higher-volume transfusions may reduce the need for multiple transfusions and therefore the number of donors the infant is exposed to.

Reduction of red blood cell transfusions by implementation of a concise pretransfusion checklist.

This study assesses the effect of the implementation of a concise pretransfusion checklist as a means for restrictive blood transfusion strategy. To achieve an optimal use of red blood cells and to prevent overdosing of transfusion by implementation of a decision support algorithm. To ensure adequate use of red blood cells, physicians were obliged to complete the checklist with pretransfusion patient information before transfusion was approved. Laboratory employees checked the information and provided approval or refused to process the request. The red blood cell transfusion events, length of stay and mortality were analysed during a pre- and post-implementation period of 1 year. Transfusion requests decreased by 17·0%. The proportion of 1-unit and 2-unit transfusions decreased by 5·6% and 29·2%, respectively, corresponding with a total red blood cell units reduction of 22·6% and a yearly direct local cost reduction of 190·000 €. The median length of stay of transfused patients on wards decreased by 1·07 days (P < 0·05). Average pre- and post-transfusion haemoglobin levels before and after implementation of the checklist decreased by 0·32-0·35 g L(-1) (P < 0·05) for one unit red blood cell transfusions and 0·72-0·87 g L(-1) (P < 0·05) for two units of red blood cell transfusions. Decision support for transfusion necessity, in the form of a concise checklist as part of the transfusion request, is an example of a successful restricted blood transfusion strategy. The checklist can be applied in other hospitals as well.

Determination of optimal timing of serial in-utero transfusions in red-cell alloimmunization.

To assess the performance of middle cerebral artery peak systolic velocity (MCA-PSV) and of the expected daily decrease in fetal hemoglobin in determining the timing of serial in-utero transfusions (IUT) in red-cell alloimmunization. This was a retrospective study of a continuous series of suspected anemic fetuses undergoing IUT between June 2003 and December 2012. Doppler measurement of MCA-PSV and pre- and post-transfusion hemoglobin levels were recorded at the time of the first, second and third IUT. Receiver-operating characteristics (ROC) curves and negative and positive predictive values of MCA-PSV in the prediction of severe fetal anemia were calculated. The daily decrease of fetal hemoglobin (Hb) between IUTs was calculated. Regression analysis was used to assess the correlation between pretransfusion fetal hemoglobin and MCA-PSV, and between observed and expected (by projection of daily decreases) pretransfusion fetal hemoglobin levels. One hundred and eleven fetuses required an IUT, of which 96 and 67 received a second and third IUT, respectively. The area under the ROC curve for MCA-PSV in the prediction of severe fetal anemia was not different for each rank of transfusion. The positive predictive value of MCA-PSV decreased from 75.3% at the first IUT, to 46.7% and 48.8% at the second and third IUTs, respectively, while the negative predictive value for a 1.5-MoM threshold remained high (88.9% at the second and 91.7% at the third IUT). The mean daily decrease in hemoglobin following each transfusion was 0.45, 0.35 and 0.32 g/dL, respectively. There was a persistent linear correlation between fetal hemoglobin and MCA-PSV and between observed and expected fetal hemoglobin levels. Both MCA-PSV and projection of daily decrease in hemoglobin are reliable means of diagnosing fetal anemia following previous IUTs. The high negative predictive value of MCA-PSV could allow subsequent IUTs to be postponed in selected cases.

Factors Associated with Hospitalization among Emergency Department Patients Referred for Quick Investigation of Iron-Deficiency Anemia

BackgroundAlthough patients with anemia are frequently seen in emergency departments (EDs), studies on patients presenting there with symptomatic chronic anemia—usually iron-deficiency anemia (IDA) caused by occult gastrointestinal bleeding—are lacking. Awareness of predictors of hospitalization could direct the ED triage to the appropriate diagnostic setting. ObjectiveBased on initial observations that some patients with IDA were hospitalized after ED referral and initial evaluation at a quick diagnosis unit (QDU), a new cost-effective alternative to hospitalization for diagnostic workup, this study aimed to determine the patient factors associated with hospitalization after the first QDU visit. MethodsAn 8-year prospective cohort study of patients with IDA referred from the ED to the QDU of a third-level university hospital was conducted. Patients with a baseline hemoglobin level of <9 g/dL in the ED, proven iron deficiency, and no overt bleeding were included. The primary outcome was hospitalization after the initial QDU assessment. ResultsTwo hundred eighty-four (7.7%) of 3692 patients were hospitalized. Inter-rater agreement of appropriateness of admissions was 90.6% (κ = 0.82). Overall, 90% of study patients presented to the ED with symptomatic anemia, and 87% were transfused there. On multivariate analysis, age ≥65 years, living alone, a post-transfusion hemoglobin level of <9 g/dL, higher age-adjusted overall comorbidity, heart failure, and poor physical health-related quality of life at first QDU visit independently predicted hospitalization. ConclusionWhile these predictors do not necessarily reflect the need for hospitalization, they are easily evaluated during the initial ED visit and can guide the triage of similar IDA patients to the suitable setting for timely investigation.

Life Threatening Hyperhemolysis in Two Children with Beta-Thalassemia Major (β-TM) Treated with Stem Cell Transplantation (SCT)

Hyperhaemolysis is a rare, poorly understood complication of red cell transfusion. We report the outcomes of SCT in 2 boys of Middle Eastern origin who developed life-threatening hyperhaemolysis each following their third transfusion for β-TM at the ages of 2.5 and 4 years. The diagnosis of hyperhaemolysis was based on laboratory evidence for haemolysis, post-transfusion haemoglobin (Hb) levels lower than pre-transfusion, positive Coomb’s tests and no allo-antibody able to be identified. Haemolysis was intravascular, extravascular and severe. Precipitous drops in Hb made transfusion unavoidable. The first boy responded to prednisolone, intravenous immunoglobulin (IVIG) and splenectomy. Haemosidderosis and fibrosis were present on liver biopsy, he was therefore regarded as a Class 3 thalassaemia patient and received hydroxyurea, azathioprine, erythropoietin, desferrioxamine, busulfan, cyclophosphamide and fludarabine conditioning prior to an HLA identical sibling SCT. He is alive and well 7 years post BMT with 30% stable donor chimerism and a normal Hb. The second child’s hyperhaemolysis failed to respond to prednisolone, IVIG, rituximab and splenectomy. Provision of the large number of suitably matched red cell units required was problematic. After receiving hydroxyurea, azathioprine, desferrioxamine, busulfan, cyclophosphamide, fludarabine, thiotepa and antithymocyte globulin (ATG) preparation for a CD3/CD19 depleted maternal haplotype peripheral blood SCT, the haemolysis finally stopped. Post-transplant severe veno-occlusive disease and multi-organ failure (MOF) required dialysis and ventilation. The maternal graft was rejected so 28 days after the first transplant he received a 4/6 mismatched unrelated cord blood transplant (UCBT) following further fludarabine and ATG, which fully engrafted. He recovered from MOF and was discharged from hospital 47 days after the UCBT, transfusion independent. On day +86 he contracted Respiratory Syncytial Virus chest infection with acute intravascular haemolysis necessitating transfusions. Fulminant liver failure developed, presumably due to iron toxicity, and death occurred on day +102, having received 112 transfusions in the 12 months since presentation. In conclusion, avoiding red cell transfusion is not always possible in hyperhaemolysis, especially in β-TM. Patients may quickly become classified as Class 3 in terms of predicting BMT outcome. Immune modulation therapy and SCT was effective in 1 case but only temporarily stopped haemolysis in the other, despite full engraftment ultimately being achieved with a mismatched UCBT. SCT should be considered early in cases of hyperhaemolysis in β-TM because it can potentially cure both and result in transfusion independence. DisclosuresOff Label Use: Intravenous immunoglobulin and rituximab for treatment of haemolytic anaemia; hydroxyurea, azathioprine, fludarabine, erythropoeitin, busulphan, cyclophosphamide, thiotepa and antithymocyte globulin for use in stem cell transplantation in children with thalassaemia.