pRBC Units Research Articles

Use of adenosine diphosphate receptor inhibitor prior to left ventricular assist device implantation is not associated with increased bleeding

Current guidelines recommend adenosine diphosphate receptor inhibitors (ADPRi) be discontinued 5-7days prior to cardiac surgery due to increased bleeding events, rates of re-exploration, and transfusions. However, the risks of left ventricular assist device (LVAD) implantation in patients taking an ADPRi have not previously been studied. We retrospectively identified 134 eligible patients with ischemic cardiomyopathy that underwent LVAD implantation between July 2009 and August 2013. The cohorts received an ADPRi ≤5days of surgery (n=25) versus >5days prior or not at all (n=109). Subgroup analyses adjusted for differences in frequency of redo sternotomy between cohorts, excluded patients that received an ADPRi >1year prior to surgery, and excluded patients with a redo sternotomy. The ADPRi and control groups did not have significant differences in the primary outcomes, intraoperative PRBC units transfused (3.0 vs. 4.0, p=0.12) or chest tube output within 24h of surgery (1.66 L vs. 1.80 L, p=0.61). After adjusting for differences in frequency of redo sternotomy (ADPRi vs. control, 12 vs. 52%, p≤0.001), no significant difference in PRBC units transfused (3.1 vs. 3.5, p=0.59) or chest tube output (2.04 L vs. 2.04 L, p=0.98) was seen. No significant difference in 30-day mortality (8.0 vs. 11.0%, p=0.63), 90-day mortality (16.4 vs. 23.3%, p=0.42), or length of stay (29.0 vs. 28.0, p = 0.61) was seen. In this single-center experience, use of an ADPRi ≤5days prior to LVAD implantation was not associated with increased bleeding, length of stay, or mortality.

Submitted, Not Presented: Clinical Vignettes/Case Reports - Pediatrics.

Angiodysplasia of the gastrointestinal tract is a well-known pathology causing lower GI bleeding in the adult population. Cases of angiodysplasia are rare in the pediatric literature and usually do not present with life threatening symptoms. We report a patient that presented in hemorrhagic shock due to hematochezia. She required fluid resuscitation and six units of pRBC's for stabilization. Her diagnosis was elusive and extensive diagnostic testing was negative. After discharge and subsequent recurrence of her hematochezia we considered TPA provocation which diagnosed localized angiodysplasia in the proximal ileum prior to TPA administration. This report describes our medical rationale in the diagnostic testing as well as the significant difficulties in reaching the correct diagnosis.

Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients.

Hemorrhage is a leading cause of death in traumatically injured patients. Currently, the importance of earlier administration of packed red blood cells (pRBC) to improve outcomes is limited. We evaluated the association of earlier pRBC administration and mortality when compared with later transfusion initiation. This single-center retrospective cohort study of trauma patients transported by a single helicopter service from the scene of injury to an urban academic trauma center included patients receiving at least one unit of pRBC within 24 hours of hospital arrival. The final cohort included patients transported to the trauma center between March 11, 2010, and October 30, 2013. The helicopter service carries two units of pRBC for protocol-driven prehospital transfusion. Logistic regression was used to model odds of death, and 95% confidence intervals were calculated. The 94 patients meeting inclusion criteria had a mean (SD) age of 43 (19) years; 87 (93%) of 94 were white, 66 (70%) of 94 were male, and 88(94%) of 94 sustained blunt force injuries. Median Injury Severity Score was 29 (range, 2-75), and 31 (33%) of 94 died within 30 days. Most patients [82/94 (87%)] received their first pRBC transfusion during transport or within one hour of arrival at the emergency department (ED). For the 82 patients receiving a first pRBC transfusion within one hour of ED arrival, each 10-minute increase in time to transfusion increased the odds of death [OR, 1.27 (95% CI, 1.01-1.62; p = 0.044)], controlling for TRISS. At 30 days, 29/82 (35%) patients who received a pRBC transfusion within one hour of ED arrival, and 2 (16%) of 12 patients who received delayed transfusion were deceased (difference, 19%; 95% CI, -5% to 42%). In this study, delays in time to pRBC administration of as short as 10 minutes were associated with increased odds of death for patients receiving ultra-early pRBC transfusion. Expedient prehospital and ED transfusion capabilities may improve outcomes after trauma. Therapeutic/care management study, level III.

Freezing and storage of leukodepleted erythrocyte suspensions

Studies on the frozen storage of human blood products have benefited veterinary transfusion medicine in recent years, but the long-term cryopreservation of canine red blood cells (RBCs) has not yet been thoroughly investigated. Further, no studies are available with respect to the frozen storage of leukocyte-depleted canine red blood cells (LD-RBCs). The objective of the current study was to investigate time-dependent effects of long-term frozen storage on leukocyte-depleted canine RBCs. Twelve healthy adult dogs meeting the criteria for blood transfusion were used in the study. Whole blood samples (450 ± 45 ml) collected from each dog were centrifuged for 5 min at 22 °C and 4200 × g in a cryogenic microcentrifuge and concentrated RBC (pRBC) suspensions were obtained. Leukocyte depletion was achieved by filtration (2.6 log<sub>10</sub>). Then, the filtrated samples were prewashed three times in 0.9% NaCl solution and were allocated into three subgroups to be evaluated at three different time points (Day 0, Month 4 and Month 6). The samples for cryopreservation were subjected to glycerolisation and then stored at –80 °C for 4- and 6-month periods. At the end of this period pRBC units were thawed by manual agitation in a water bath maintained at 36–38 °C, centrifuged and then washed in a consecutive series of 12%, 1.6% and 0.9% of NaCl + 0.2 dextrose solutions. 2,3-Diphosphoglycerate (2,3-DPG), adenosine triphosphate (ATP), supernatant haemoglobin (SupHb), sodium (Na<sup>+</sup>) and potassium (K<sup>+</sup>) levels, residual glycerol concentrations and haemograms of thawed and deglycerolised pRBC samples were evaluated together with those of Day 0. Sterility tests were performed on all samples for bacterial contamination. No statistically significant differences were noted except for Hct and SupHb levels. No bacterial contamination was noted in any of the samples on the basis of sterility tests. It was found that the described glycerolisation procedure could be a method of choice in the cryopreservation of leukocyte-depleted pRBCs (LD-pRBCs) since no negative effect was observed on the quality of the products and long-term frozen storage did not cause RBC destruction.

Previous Cryopreservation Alters the Natural History of the Red Blood Cell Storage Lesion.

During storage, packed red blood cells (pRBCs) undergo a number of biochemical, metabolic, and morphologic changes, collectively known as the "storage lesion." We aimed to determine the effect of cryopreservation on the red blood cell storage lesion compared with traditional 4°C storage. Previously cryopreserved human pRBCs were compared with age-matched never-frozen pRBCs obtained from the local blood bank. The development of the red cell storage lesion was evaluated after 7, 14, 21, 28, and 42 days of storage at 4°C in AS-3 storage medium. We measured physiological parameters including cell counts, lactic acid, and potassium concentrations as well as signs of eryptosis including loss of phosphatidylserine (PS) asymmetry, microparticle production, and osmotic fragility in hypotonic saline. Compared with controls, previously cryopreserved pRBC at 7 days of storage in AS-3 showed lower red cell counts (3.7 vs. 5.3 × 10 cells/μL, P < 0.01), hemoglobin (Hgb) (12.0 vs. 16.5 g/dL, P < 0.01), hematocrit (33.0% vs. 46.5%, P < 0.01), and pH (6.27 vs. 6.72, P < 0.01). Over 28 days of storage, storage cryopreserved pRBC developed increased cell-free Hgb (0.7 vs. 0.3 g/dL, P < 0.01), greater PS exposure (10.1% vs. 3.3%, P < 0.01), and microparticle production (30,836 vs. 1,802 MP/μL, P < 0.01). Previously cryopreserved cells were also less resistant to osmotic stress. The red blood cell storage lesion is accelerated in previously cryopreserved pRBC after thawing. Biochemical deterioration of thawed and deglycerolized red cells suggests that storage time before transfusion should be limited to achieve similar risk profiles as never-frozen standard liquid storage pRBC units.

Determining the Rate and Causes of Severe Maternal Morbidity to Improve Obstetric Quality of Care [9R

INTRODUCTION: Identifying cases of severe maternal morbidity (SMM) and reviewing the underlying cause is essential to improving quality of obstetrical care. We sought to determine the rate and causes of SMM using an expanded definition including ICU admission, unanticipated hysterectomies, 2 or more liters blood loss (EBL), transfusion of 4 or more units of any blood product, and select readmissions. METHODS: We prospectively identified women who met criteria for SMM at our institution from July 1, 2014 to June 30, 2015. All cases were reviewed and discussed by a multidisciplinary team. Analysis was limited to patients who delivered at our institution. RESULTS: 4198 deliveries occurred during the 12 month period. Fifty-two (1.2%) women experienced a SMM (62% cesarean deliveries, 89% postpartum). Of the 52 women, 29 (56%) met 1 criteria, 20 (38%) met 2 criteria, and 3 (6%) met 3 or more criteria (33% ICU, 46% blood products, 62% EBL, 6% hysterectomies, 12% readmissions). Women with cesarean delivery were more likely to experience more than 4 units pRBCs as reason for SMM (P=.05). ICU admissions were no different by mode of delivery. Restricting the definition of SMM to ICU admission and 4 or more units of pRBC identified only 69%. CONCLUSION: SMM occurs more postpartum and in women with cesarean deliveries. Restricting the SMM definition leads to missed opportunities in identifying additional cases of SMM, specifically those with large EBL and readmissions with delayed morbidity. Future tracking and evaluation of SMM should include large EBL and postpartum readmission to help identify and improve all aspects of SMM.

Early Trauma-Induced Coagulopathy is Associated with Increased Ventilator-Associated Pneumonia in Spinal Cord Injury Patients.

Early trauma-induced coagulopathy may increase susceptibility to nosocomial infections such as ventilator-associated pneumonia. However, the relationship between trauma- induced coagulopathy and the development of ventilator-associated pneumonia in spinal cord injury patients has not been evaluated. We conducted a 5-year retrospective study of 300 spinal cord injury patients admitted to Level 1 trauma center. Standard coagulation studies were evaluated upon arrival, prior to fluid resuscitative efforts, and at 24 h after admission. Based on these studies, three groups of patients were identified: no coagulopathy, latent coagulopathy, and admission coagulopathy. Ventilator- associated pneumonia was identified utilizing Centers for Disease Control and Prevention criteria. Since we used the data in the trauma registry and did not have the information on FiO2 and PEEP, we elected to use the VAP terminology and not the VAE sequence. Demographic, injury, and clinical characteristics were compared among no coagulopathy, latent coagulopathy, and admission coagulopathy groups using chi-square test and ANOVA for categorical and continuous variables, respectively. A logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between coagulopathy and both ventilator-associated pneumonia and mortality. The incidence of ventilator-associated pneumonia was 54.5% (OR 4.01, 95% CI 1.76-9.15) in spinal cord injury patients with admission coagulopathy, compared with the 17.5% in spinal cord injury patients with no coagulopathy. Mortality was significantly higher in spinal cord injury patients with admission coagulopathy than in spinal cord injury patients with no coagulopathy (OR 6.14, 95% CI 1.73-21.73).After adjusting for age, race, injury mechanism, Injury Severity Score, base deficit at admission, the number of pRBC units transfused in the first 24 h, and hospital stay, only the association of ventilator-associated pneumonia among those with admission coagulopathy remained significant (OR 3.51, 95% CI 1.48-8.32). Compared with those with no coagulopathy, patients with admission coagulopathy had a higher odds of death (4.10, 95% CI 1.53-11.02), though this association lost significance after adjustment (OR 3.56, 95% CI 0.90-14.12). There was no statistical difference in mortality for latent coagulopathy compared with no coagulopathy patients. Coagulopathy on admission in patients with spinal cord injury is associated with a statistically significant increase in ventilator-associated pneumonia incidence. Additional research is warranted to further characterize this association.

Efficacy and safety of pelvic packing after emergency peripartum hysterectomy (EPH) in postpartum hemorrhage (PPH) setting

ObjectivesTo study the safety and effectiveness of pelvic packing in the control of post emergency peripartum hysterectomy (EPH) bleeding in a postpartum hemorrhage (PPH) setting. Study designFrom 39 patients with a severe PPH leading to an EPH (January 2010–December 2013), we identified a group of 17 patients requiring a pelvic packing (packing group) and a second group of 22 patients not requiring a pelvic packing (non-packing group). For each group, transfusion requirements were recorded from time of PPH diagnosis to end of the surgical procedure (P1: Period 1) and from that point to the end management in the SICU (P2: Period 2). Laboratory values, transfusion requirements and complications were compared between the 2 groups. Statistical comparisons were performed using Mann–Whitney test, Fisher's exact test and chi-square test. A p-value <0.05 was considered statistically significant. ResultsPelvic packing was successful in the control of bleeding in all the cases. During the second laparotomy for pack removal, none of the patients developed complications such as bowel injuries or necrosis. The 2 groups were similar in term of laboratory values at the end of the surgical procedure and 24h after the end of the surgical procedure. The number of PRBC units required in P1 was higher in the packing group compared to the non-packing group (16.6±5.3 vs 14±5; p=0.04), however the decrease in the amount of PRBCs transfused between P1 and P2 was higher in the packing group (13.3) compared to the non-packing group (9.1) (p<0.01). The incidence of febrile morbidity was higher in the packing group compared to the non-packing group (53% vs 9%; p=0.04); but no significant difference was shown in term of generalized sepsis, as well as renal failure, ARDS, deep vein thrombosis, pulmonary embolism and MOF. ConclusionThe pelvic packing is a valuable method with a high success rate in the control of hemorrhage after an EPH in PPH setting with a low rate of complications. It is quite simple and quick to perform, and therefore should be kept in mind by all obstetricians as a lifesaving technique.

Intraoperative transfusion practices in Europe

BackgroundTransfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. MethodsWe did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. ResultsThe overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl−1 and increased to 9.8 (1.8) g dl−1 after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). ConclusionAlthough European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7–9 g dl−1), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold. Clinical trial registrationNCT 01604083.

A Randomized Comparison of Hemoglobin Content-Based Versus Standard (Unit-Based) Red Blood Cell Transfusion Policy.

Objective:The hemoglobin (Hb) content of packed red blood cells (pRBCs) differs in standard volume units. The pRBC transfusions are based on the number of units routinely. We aimed to use pRBCs according to total Hb content and compare the rates of achieving the target Hb concentration levels with the current transfusion practice.Materials and Methods:Eighty-nine patients (55 males and 34 females) with median age of 46 years (range: 19-75) were enrolled, and of 178 transfusion episodes, 92 were randomized to the Hb content based-study group and 86 to the unit-based control group. Fifty-one patients were evaluated by 1 and rest of the patients by ≥2 episodes (median: 3; range: 1-7). Suitable pRBCs were detected by the Hemosoft Blood Banking Management & Information System. In the Hb content-based study group, to reduce the number of units, the required Hb was calculated by recipients’ height, weight, and Hb levels. When no appropriate units could be found within the inventory, the actual ordered number of units was sent to clinics, as was done for the control group.Results:In the study group totally, 38 units of pRBCs were transfused with a reduction of 19.8% (38/192) from the original order. The success of finding the matched Hb content was statistically increased with low weight and height and high pRBC storage. The Hb content of transfused pRBC units was significantly higher in the study group than the control group. The ratio of achieving the target Hb level was statistically similar in the control and study group (p=0.125), the successful and unsuccessful group (p=0.325), and the control and unsuccessful group (p=0.438). The relation between the shelf-life of the pRBC units and the rate of achieving the target Hb level was found to be similar between groups (p=0.782).Conclusion:The number of pRBC transfusions can be minimized since we clearly demonstrated that the efficacy of Hb content-based transfusion is similar to that of unit-based transfusion.

Liberal Vs. Restrictive Transfusion Thresholds in Leukemia Patients: A Feasibility Pilot Study

Transfusion of red blood cells (RBCs) is vitally important for the care of patients (pts) undergoing myelosuppressive therapy for acute leukemia (AL). At diagnosis and before bone marrow recovery, RBCs are given liberally with hemoglobin (Hb) transfusion triggers of 8-9 g/dL or higher, often with two RBC units given at a time. Research in a variety of non-oncologic settings suggests that lower Hb triggers (7-8 g/dL) do not increase mortality whereas higher Hb triggers (9 g/dL) may increase mortality. For pts with hematologic malignancies, the ideal Hb threshold is unknown. Also, there is literature to suggest that higher Hb values force platelets to the periphery of capillaries and reduce bleeding events. A study of red cell triggers in pts with thrombocytopenia (as in AL) is important as we may not be able to rely on trigger data from others in this setting. This feasibility study was designed to determine whether a randomized trial of Hb triggers could be performed and what challenges may be encountered with this select population.In this prospective randomized study, we enrolled adult pts with AL (myeloid and lymphoid) undergoing intensive induction therapy to evaluate both patient and physician tolerance for a transfusion threshold of 7g/dL (LOW) compared to the standard threshold of 8g/dL (HIGH), as well as operationalize transfusion to a single unit per episode. Pts were randomized with a 2:1 ratio of LOW threshold to HIGH threshold. Pts were ineligible if there was clinical concern for acute coronary syndrome or active blood loss. Pts were monitored from the study enrollment date through the next marrow evaluation after completion of induction therapy. Vital status at Day 60, accrual rate, and safety endpoints (mortality, length of stay, infection, fatigue scores, renal, respiratory, thrombotic, bleeding events) were monitored. Total transfusions, length of inpatient stay, and percentage of pts who crossed over to HIGH threshold for symptomatic reasons were also monitored.Between April 15, 2014 and July 23, 2015, 162 acute leukemia pts would have been eligible for this trial. Of the eligible pts, 112 (69%) were approached and 90 (of planned 90) have enrolled to date. Twenty-two pts (19.6%) of those offered the trial declined. Seventy-four pts are currently evaluable for response (13 pts have not been on-study long enough to evaluate and 3 pts are not eligible for data analysis): 51 pts in LOW arm and 23 in HIGH arm. Interim data is shown in Table 1. In the LOW arm, three pts withdrew consent due to self-reported fatigue and one patient was removed by physician due to clinical scenario. Seventeen pts (33%) in the LOW arm and six pts (26%) in the HIGH arm were transfused outside their hemoglobin trigger without meeting criteria to discontinue the study. No deaths were attributable to Hb thresholds in this study. Significant bleeding events (Grade 3 or 4 by CTCAE 4.0) were comparable with 4 in LOW arm and 3 in HIGH arm. More minor bleeding events (Grade 1 or 2 by CTCAE 4.0) were higher in LOW (24 events) than in HIGH arm (15 events).Acute leukemia and its therapies carry a significant mortality risk and it is not clear how transfusion thresholds and number of PRBC units transfused impact this mortality. Furthermore, blood is an expensive and scarce resource. Without a clear benefit of higher Hb thresholds, the added risks and costs of transfusion may not be justified. This pilot study shows that both pts and leukemia physicians will tolerate randomization between Hb thresholds and there is not a signal for harm in either Hb threshold at present. Pts in the LOW arm receive fewer transfusions and do not experience higher fatigue scores nor increased significant bleeding events. Length of hospitalization was similar in both arms. This safety data will serve as a platform for a larger mortality study in leukemia and possibly additional studies in other oncologic diseases.Table 1LOWHIGHP valuePatients (n)51 (69%)23 (31%)Gender Male23 (45%)11 (48%)Median Age (Years)58630.35AML44 (86%)18 (78%)ALL5 (10%)5 (22%)APL2 (4%)0Patients Alive at Day 6046 (90%)21 (91%)Red Cell Transfusions in Units (Median)8 (IQR: 5)10 (IQR: 4)0.008*Platelet Transfusions in Episodes (Median)9 (IQR: 6.5)9 (IQR: 5)0.86Length of Stay (Median)35 (IQR: 10)36 (IQR: 15)0.72Fatigue Scale Score (Median)4.33 (IQR: 1)4.54 (IQR: 1.25)0.40AML: acute myeloid leukemia; ALL: acute lymphoid leukemia; APL: acute promyelocytic leukemia DisclosuresNo relevant conflicts of interest to declare.

Management of Left Ventricular Assist Device (LVAD)-Related Gastrointestinal Bleeding (GIB): A Retrospective Case Series: Presidential Poster

Introduction: GIB complicates 17-30% of postoperative LVAD placements. Despite attempts to modulate anticoagulation and prescreening to prevent bleeding, there is no consensus on treatment for these patients. Our objective is to evaluate the potential role of octreotide LAR in patients with an LVAD for secondary prevention of GIB. Methods: Forty patients underwent LVAD implantation at our institution between 12/2012 and 12/2014. Ten developed GIB during their postoperative course (25%). Eight had bleeding secondary to arteriovenous malformations (AVMs) in the small bowel and two secondary to ulcers. Four patients suffered a recurrent GIB which was not controlled by endoscopy and were placed on octreotide. Three of the four were placed on octreotide LAR. We evaluated the clinical scenarios of these patients. Results: Three patients (2 men and 1 woman; ages 60-72) received octreotide LAR. None had a GIB prior to LVAD implantation. Post implantation, patients had a median of 5 endoscopic procedures for GIB prior to starting octreotide(range 2-9). AVMs were the cause of GIB in all 3 cases. The first patient had 7 GIBs with 36 units of packed red blood cells (pRBCs) transfused over the course of 12 months. After octreotide was started, she had 3 GIBs with 16 units of pRBCs transfused over the following 16 months. One GIB was after a missed octreotide dose and required 8 of the 16 units of pRBC. The second patient had 4 GIBs with 32 units of pRBCs transfused over 2 months. After octreotide he had 2 GIBs requiring 8 units of pRBCs over 6 months. The third patient had 2 GIBs with 33 units of pRBC transfused over 11 months. After octreotide he had no further GIBs and no transfusions for 12 months. Overall, these patients required a median of 2 endoscopic procedures (range 0-3) and a median of 8 units pRBCs (0-16) after octreotide LAR was started. In the two patients with GIBs despite octreotide, dosing was increased to twice monthly with no further bleeding. There were no thrombotic events after starting octreotide. Discussion: In post-LVAD patients, octreotide appears to markedly decrease the frequency of GIB with a reduction in transfusion requirements and endoscopic procedures. Octreotide reduces mesenteric blood flow and portal venous pressure, and has been used for treatment of small bowel AVMs with an excellent safety profile. Octreotide may be an effective therapy for secondary prevention of GIB in patients with an LVAD and warrants further prospective investigation.Table 43: Summary of Findings

Hospitalization Rates Are Higher in Non-White Patients Diagnosed With Small Bowel Gastrointestinal Angiodysplasias

Introduction: Small bowel gastrointestinal angiodysplasias (SBGIAD) are vascular lesions that account for 40% of obscure gastrointestinal bleeding cases and is a major cause of occult GI blood loss. SBGIAD and its relationship to racial disparities have not been extensively studied. We performed a retrospective review at a single center institution to examine the relationship between non-Hispanic white (nHw) and non-White veteran patients diagnosed with SBGIAD. Clinical outcomes (which included but were not restricted to transfusion and hospitalization rates), comorbidities, SBGIAD location as well as demographic characteristics were evaluated. Methods: Patients undergoing video capsule endoscopy (VCE) between 2006 and 2013 and diagnosed with SBGIAD were included in this study. Hospitalization was defined as any admission during a 6-month period after the first complete VCE. Re-bleeding was defined as a transfusion of 2 units of pRBC or more in a 1-year period after VCE evaluation. Demographic data, transfusion requirements, hospitalization rates, VCE findings and patient outcomes were analyzed from electronic charts. Analysis was done using X2 and independent samples t test. Results: 425 patients underwent VCE between 2006 and 2013 for obscure occult and obscure overt GI bleeds. 87 patients were diagnosed with SBGIAD on VCE, 47 patients were nHw compared to 40 patients who were non-White. Non-White patients with SBGIAD were 6.2 times more likely to be hospitalized within a 6-month period, compared to nHw patients (CI 0.032-0.800, p= 0.026). No difference was found based on the location of small bowel GIAD, transfusion rates, age and BMI between the two groups. Hyperlipidemia (HLD) was the only comorbid condition that had a significant association between the two groups. On multivariate analysis, nHw patients were 2.5 times more likely to have HLD than non Whites (CI 0.999- 0.295, p= 0.050). Conclusion: The odds of hospitalization were 6.2 times higher in non-White patients compared to nHw in our study. Also, nHw patients had 2.5 times higher odds of having hyperlipidemia compared to non-White patients with GIAD. No significant association between the two subgroups with respect to age, BMI, location of small bowel GIAD, transfusion rates, HTN, DM, CHF or CAD was found. Other factors (number of ER/ acute care visits) before hospitalization and understanding the impact of hyperlipidemia to explain the disparity in hospitalization rates for SBGIAD observed should be the focus of future invesitigation.Figure 1Figure 2

Selective Serotonin Reuptake Inhibitor Use and Perioperative Bleeding and Mortality in Patients Undergoing Coronary Artery Bypass Grafting: A Cohort Study.

Several small studies have reported inconsistent findings about the safety of selective serotonin reuptake inhibitors (SSRIs) among patients undergoing coronary artery bypass grafting (CABG). We sought to investigate post-CABG bleeding and mortality outcomes related to antidepressant exposure. We identified patients who underwent CABG between 2004 and 2008 in the Premier Perspective Comparative Database. We determined whether they received SSRIs, other antidepressants, or no antidepressants on any pre-CABG hospital day and used Cox proportional hazards models to compare bleeding and mortality rates among the exposure groups while adjusting for potential confounders based on administrative data, pre-CABG charge codes, and discharge diagnosis codes. We identified 132,686 eligible patients: 7112 exposed to SSRIs, 1905 exposed to other antidepressants, and 123,668 unexposed. As compared with no exposure, neither SSRIs (hazard ratio [HR] 0.98; 95% confidence interval [CI] 0.90-1.07) nor other antidepressants (HR 1.11; 95% CI 0.96-1.28) increased major bleeds, and neither SSRIs (HR 0.93; 95% CI 0.80-1.07) nor other antidepressants (HR 0.84; 95% CI 0.62-1.14) increased mortality. Both SSRIs (HR 1.14; 95% CI 1.10-1.18) and other antidepressants (HR 1.11; 95% CI 1.03-1.19) were associated with a slight increase in receipt of one or more packed red blood cell (pRBC) units, but neither were associated with substantial increases in receipt of three or more pRBC units (HR 1.06; 95% CI 0.96-1.17 for SSRIs; HR 1.09; 95% CI 0.91-1.31 for other antidepressants). In this large cohort study, neither SSRIs nor other antidepressants were associated with elevated rates of major bleed, or in-hospital mortality.

Coagulation defects associated with massive blood transfusion: A large multicenter study.

The variations in the coagulation indices of patients receiving massive blood transfusion were investigated across 20 large-scale general hospitals in China. The data of 1,601 surgical inpatients receiving massive transfusion were retrospectively collected and the trends in the platelet counts and coagulation indices prior to and at 16 different time points during packed red blood cell (pRBC; after 2–40 units of pRBC) transfusion were evaluated by linear regression analysis. Temporal variations in the means of prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (APTT) and fibrinogen (FIB) concentration were also assessed and the theoretical estimates and actual measurements of the platelet count were compared. The results demonstrated that the platelet count decreased linearly with an increase in the number of pRBC units transfused (Y=150.460−3.041X; R2 linear=0.775). Following transfusion of 18 units of pRBC (0.3 units of pRBC transfused per kilogram of body weight), the average platelet count decreased to 71×109/l (<75×109/l). Furthermore, variations in the means of PT, INR, APTT and FIB did not demonstrate any pronounced trends and actual platelet counts were markedly higher than the theoretical estimates. In conclusion, no variations in the means of traditional coagulation indices were identified, however, the platelet count demonstrated a significant linear decrease with an increase in the number of pRBC units transfused. Furthermore, actual platelet counts were higher than theoretical estimates, indicating the requirement for close monitoring of actual platelet counts during massive pRBC transfusion.

Su2012 A First Case Report of Colorectal Cancer Associated With Chronic Strongyloides Stercoralis Colitis and the Complex Management Decisions That Follow

Rarely pathogenic organisms including parasites can act as carcinogens. To our knowledge, there are no reported cases regarding the association between a Strogyloides stercoralis infection and colon cancer. A 47 year old Columbian man with Vitiligo presented to our Emergency Room with fatigue, 25 lb weight loss in 6 months and iron deficiency anemia. He denied diarrhea or blood per rectum and there was no personal or family history of malignancy, celiac or IBD. On admission, the physical exam was notable for vitiligo and a positive guaiac. The hemoglobinwas 3.1 gm/dL and 26.4% eosinophilia was seen. Endomysial Ab, ESR, and CRP were all normal. 5 units of PRBC's were transfused. The patient had a normal EGD and colonoscopy 6 yrs prior for the workup of anemia, but there were no records available to review. Both EGD and colonoscopy were then performed at our institution. The EGD was grossly normal and biopsies of the duodenum were obtained to exclude occult celiac. The colonoscopy, however, demonstrated a severe right sided colitis, with friable granular mucosa, erosions and confluent loss of vascular markings and haustral folds. In addition, a 3cm ulcerated mass was identified in the colitic ascending colon and biopsies confirmed invasive low grade adenocarcinoma. Of interest, the ileal and rectosigmoid mucosa appeared grossly normal. No metastasis were identified on abdominal and chest CT and the surgeons scheduled a total colectomy for presumptive IBD associated dysplasia. The stool studies and duodenal biopsies returned positive for Strongyloides stercoralis. Treatment was initiated with 2 doses of Ivermectin 200mcg/kg/d. At tumor board, the pattern of a colitis secondary to Strongyloides rather than IBD was emphasized with the consensus for an extended right hemicolectomy with ileocolic anastomosis. Intraoperatively the left colon appeared grossly normal, surgical staging confirmed a T3N0M0 tumor, stage 2b. Given the concerns for hypereosinophilic syndrome with immunosuppressive therapies, fecal confirmation of strongyloides eradication was confirmed 12 weeks postop. Adjuvant chemotherapy was offered but the patient declined after explanation of the risks and benefits. To date, the patient remains asymptomatic and surveillance colonoscopies at 6 months and 2 yrs have demonstrated no evidence of gross colitis or dysplasia, reaffirming the infectious etiology. This case illustrates the only known association of chronic colitis and colon cancer due to Strongyloides stercoralis. In atypical chronic colitis, and in populations at risk for Stronyloidiasis, it is essential to exclude this parasite prior to potentially life threatening immunosuppression that one would choose to treat IBD. However, dysplasia surveillance should also be considered given the potential for malignancy as demonstrated in this patient with strongyloides chronic colitis.

PD8-06 PERIOPERATIVE BLOOD TRANSFUSIONS AS A RISK FACTOR FOR INFECTIOUS COMPLICATIONS AFTER UROLOGIC SURGERY

You have accessJournal of UrologyInfections/Inflammation of the Genitourinary Tract: Kidney & Bladder I1 Apr 2015PD8-06 PERIOPERATIVE BLOOD TRANSFUSIONS AS A RISK FACTOR FOR INFECTIOUS COMPLICATIONS AFTER UROLOGIC SURGERY Richard Matulewicz, Daniel Oberlin, Irene Helenowski, Borko Jovanovic, and Shilajit Kundu Richard MatulewiczRichard Matulewicz More articles by this author , Daniel OberlinDaniel Oberlin More articles by this author , Irene HelenowskiIrene Helenowski More articles by this author , Borko JovanovicBorko Jovanovic More articles by this author , and Shilajit KunduShilajit Kundu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.921AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Several studies have associated perioperative blood transfusions (BT) with significantly increased postoperative infection rates. The effect of BT on infection appears to be related to the state of immunosuppression it induces. We investigated the risk of short-term post-operative infectious outcomes of urologic surgery with perioperative BT. METHODS We identified patients undergoing the thirty most common urologic surgeries captured by the ACS-NSQIP database from 2006 to 2012. The association of preoperative and intraoperative/post operative transfusions with infectious outcomes (surgical site infections (SSI), urinary tract infection (UTI), pneumonia, sepsis/septic shock) was assessed by Chi-square test with continuity correction. Multivariate logistic regression controlling for diabetes, chronic steroid use, recent chemotherapy, and operative wound classification provided odds ratios for infectious outcomes. RESULTS A total of 41,858 cases of the 30 most common urologic operations were reviewed. 30,651 (73.2%) cases met inclusion criteria for review. 0.5% (157/30651) of patients had a transfusion of at least 1 unit of packed red blood cells (pRBC) within 72 hours prior to surgery. 3.7% (1133/30651) of patients received a BT of at least 1 unit pRBC intraoperatively or within 72 hours postoperatively. Multivariate analysis, controlling for potential confounding risks factors, found that preoperative transfusion is associated with a significantly increased risk of pneumonia, UTI, and post-operative sepsis (p<0.01, Table 1). Intraoperative and post-operative transfusion is associated with both superficial and deep SSI, organ space infection, UTI, and post-operative sepsis, including septic shock (p <0.01). CONCLUSIONS Although blood transfusions are beneficial in select patients with perioperative anemia, our study shows that BT is associated with a significantly increased risk of post-operative infectious complications. We found an increase risk of SSI, pneumonia, and sepsis among transfused patients undergoing urologic surgery. Prudent use of BT can potentially mitigate infectious complications. Transfusion Timing Infectious Outcome Odds Ratio Confidence Interval (95%) p value Preoperative Pneumonia 4.0 1.4-11.0 < 0.01 UTI 2.2 1.2-4.1 0.01 Postop Sepsis 2.9 1.2-7.2 0.02 Intraoperative/Postoperative Superficial SSI 4.7 3.2-6.9 < 0.01 Deep SSI 5.4 2.5-11.5 < 0.01 Organ Space Infection 8.0 5.1-12.7 < 0.01 Pneumonia 6.7 4.6-9.8 < 0.01 UTI 1.9 1.5-2.5 < 0.01 Postop Sepsis 6.4 4.8-8.7 < 0.01 Postop Septic Shock 5.6 3.3-9.6 < 0.01 © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e192 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Richard Matulewicz More articles by this author Daniel Oberlin More articles by this author Irene Helenowski More articles by this author Borko Jovanovic More articles by this author Shilajit Kundu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Local use of ankaferd blood clotter in emergent beating heart coronary artery bypass grafting.

Background:Severe beeding which requiring massive blood transfusion after emergent beating heart surgery is shown to be 1–3%. Therefore, complications and side effects of transfusion can be seen. The aim of this study was to investigate the effectiveness of Ankaferd blood clotter (ABC) as a new topical herbal blood clotter to decrease mediastinal bleeding in emergent beating heart CABG patients who medicated with clopidogrel and acetyl salisilic acite (ASA) prior to CABG surgery.Materials and Methods:25 CABG patients received a high dose clopidogrel (600 mgr) and 300 mgr ASA have been included into the study (ABC group). 25 patients have also been included into the study for comparison (placebo group, PG). After the administration of protamine sulphate, a 10 ml of ABC solution has been sprayed to the surgical area including mediastinum and epicardial sac. We compared mediastinal drenaige, reoperation due to tamponade, and required blood and blood products in both groups.Results:The mean amount of bleeding after operation was 230 ml in ABC group, and 490 ml in CG (P=0.001). In ICU, bleeding in ABC group and CG was 410ml and 680ml, respectively (P=0.0022). The mean total bleeding from mediastinum was 530±280 mL and 990±440 mL In ABC and CG group, respectively (P=0.001). The amount of autotransfusion was as follows: 175 mL in ABC group, and 290 mL in CG (P=0.002). No patient needed the surgical revision in ABC group, but four patients (16%) from CG group because of cardiac tamponade. Seventeen patients from CG required blood transfusion due to low hematocrite level postoperatively. In CG, the mean hematocrite level was 17±2,3. Transfusion of fresh frozen plasma and platelets in ABC group and CG were as follows: 0.2 and 0 in ABC group, and 0.3and 0.4 in CG.Conclusion:Our study showed that the local use of 10 mL ABC reduces bleeding significantly. Therefore, transfusion requirements of PRBC, platelets, and total blood units in patients on clopidogrel and ASA undergoing emergent beating heart CABG. To provide cardiac tamponade because of excessive mediastinal bleeding and requirement of blood transfusion after emergent CABG patients who previously administered clopidogrel and ASA, we propose local use of ABC solution as a potent coagulant agent.

Abstract No. 356 - Vascular urologic emergencies: image-guided interventions

Modern imaging studies such as computerized topography (CT) and ultrasound (US) provide an advantage for the detection of vascular urological injuries because of their speed, while digital subtraction angiography (DSA) allows for the precision needed for effective intervention. Minimally invasive techniques offer potentially lower complication rates and faster recovery times than traditional methods. This study demonstrates the role of image-guided percutaneous angiography (PCA) in such emergencies through five cases that cover the scope of neoplastic, iatrogenic, post-operative, and traumatic hemorrhages as well as priapism. PCA has revolutionized vascular interventions. DSA provides both a detailed diagnosis and an avenue for precise interventions. Embolization of pathologic vessels or hemorrhage sites can be achieved using embospheres, microcoils or gel foam. These techniques are easily extrapolated in the context of vascular urologic emergencies. One such case was a 57 year-old woman with an acute hemorrhage following surgical resectioning for renal cellular carcinoma (RCC). The postoperative period was complicated by a difficult extubation followed by acute hemorrhagic shock. The patient’s hemoglobin dropped to 6.5 as her surgical drain emptied serosanguineous fluid. After requiring 6 units of PRBC, 4 units FFP and 1 unit of platelets, IR was consulted and emergent renal DSA was performed of the left main renal artery. Subselective left inferior renal segmental branch angiography showed two small pseudoaneurysms peripheral to the site of resectioning. Microcoil embolization of the left inferior segmental branch was performed, successfully occluding perfusion to the pseudoaneurysms. The patient’s hemodynamic status soon stabilized and she was transferred out of the ICU in the following days. The case above demonstrates the application of interventional radiologic techniques in just one urologic vascular emergency. Furthermore, the methods used in the above case are not dissimilar to those used in the following case reviews, which illustrate the unique treatment options image-guided interventions can offer in the urologic setting.

Determinants of Inter-Procedure Interval in Patients with Sickle Cell Anemia Enrolled a Chronic Red Blood Cell Exchange Program

Background:Sickle cell anemia (SCA) is a genetically inherited disorder that can lead to severe sequelae in any organ system. The most clinically devastating complications, e.g. stroke, are managed with chronic red blood cell (RBC) transfusions as curing the underlying SCA is often not an option. Chronic RBC exchange (RBCx), is an effective alternative to simple transfusions and often performed every 4-5 weeks. Isovolemic Hemodilution-Red Blood Cell Exchange (IHD-RBCx) is a modified RBCx method used at UT Southwestern Medical Center (UTSW) and increases the time interval between transfusions, i.e. inter-procedure interval (IPI), up to 9 weeks while maintaining the desired hemoglobin S targets at safe levels. This minimizes the overall lifetime procedures and blood exposures. The standard operating procedure for IHD-RBCx is published (Matevosyan et al, 2012). However, we observed IPI variability between patients in this chronic IHD-RBCx program. We sought to analyze hematologic characteristics in a cohort of adult SCA patients that may be associated with this noted variability.Methods:This IRB approved cross-sectional study evaluated medical and blood bank records of adult patients with SCA, i.e. hemoglobin SS or Sβ0 thalassemia genotypes, undergoing chronic IHD-RBCx at UTSW adult hospital sites between January 1, 2012 and December 31, 2013. Excluded participants were those with autoimmune disease, non-compliance with IHD-RBCx leading to delays > 7 days, or use of hydroxyurea or steroids within four months of the study period. Patients with < 5 exchanges were excluded as several procedures are needed to determine baseline IPIs. The primary indication for IHD-RBCx was secondary stroke prevention. Three subjects had alternative indications (i.e. recurrent severe acute chest syndrome that failed hydroxyurea therapy, intractable pain and severe anemia ineligible for iron chelation due to end-stage renal disease). Median values during the 2 year study were determined for the IPI, laboratory, and RBC properties for use in subsequent analyses. Correlation and multiple regression analyses were performed to determine variables predictive of IPI.Results:Twenty-four SCA patients in this chronic IHD-RBCx transfusion program met inclusion criteria of which 14 (58.3%) were female with age range 18-41 years. Three subjects had incomplete data. The median number of packed RBC (pRBC) units per IHD-RBCx was 8 (range: 6-11 units). The median volume per unit of pRBCs was 304.5 mL (range: 298.8-326.5 mL) with average age of the pRBCs 5.8 days ± 0.7 days. The median IPI was 55.8 days (range: 36.0-65.5 days).The strongest correlation with IPI was the change from the mid to post-procedure hemoglobin and hematocrit values, r=0.56, p=0.005 and r=0.57, p=0.003, respectively. Participants with documented direct antiglobulin test positivity (n=7), compared to those who remained negative (n=16), had 4.9 days increased IPI. This difference was not statistically significant, p=0.19. ABO differences in blood type also did not show statistical significant differences. However, A+ subjects had a 58 day interval compared to 51, 52, 53 days for B+, O+, O- respectively (Figure). In multiple regression models, log blood urea nitrogen (BUN) and post-procedure white blood cell count (WBC) were found to be independent predictors of IPI, beta=-11.3, p=0.04 and -2.1, p=0.03 respectively, with adjusted R2=0.31.Conclusions:Chronic IHD-RBCx effectively treats severe SCA complications. Discontinuing transfusions lead to repeat stroke events or the recurrence of disease manifestations making chronic transfusion programs an indefinite therapy. Outside of the expected correlation between the IPI and hemoglobin/hematocrit, WBC and BUN were found to have negative associations with IPIs. The decrease in WBCs is likely due to the direct clearing effect by the operating system. The association between BUN and IPI may imply relationship with renal function. Interestingly, association with creatinine was not statistically significant. The study is limited by the small sample size. Future studies of similar cohorts should prospectively evaluate target mechanisms which may lead to interventions that can minimize lifetime blood exposures given the growing demands for continued RBCx in severe SCA. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.