Received Blood Products Research Articles

Prehospital Delta Shock Index Predicts Mortality and Need for Life Saving Interventions in Trauma Patients

Objectives The delta shock index (ΔSI), defined as the change in shock index (SI) over time, is associated with hospital morbidity and mortality, but prehospital studies about ΔSI are limited. We investigate the association of prehospital ΔSI with mortality and resource utilization, hypothesizing that increases in SI among field trauma patients are associated with increased mortality and blood product transfusion. Methods We performed a multicenter, retrospective, observational study from the Linking Investigators in Trauma and Emergency Services (LITES) network. We obtained data from January 2017 to June 2021. We fit logistic regression models to evaluate the association between an increase ΔSI > 0.1 and 28-day mortality and blood product transfusion within 4 h of emergency department (ED) arrival. We used negative binomial models to evaluate the association between ΔSI > 0.1 and days in hospital, intensive care unit (ICU), and on ventilator (up to 28 days). Results We identified 33,219 prehospital patients. We excluded burn patients and those without documented prehospital or ED heart rate or blood pressure, resulting in 30,511 cases for analysis. In adjusted analysis for the primary outcome of 28-day mortality, patients who had a ΔSI > 0.1 based on initial vital signs were 31% more likely to die (adjusted odds ratio (AOR) of 1.31, 95% CI 1.21-1.41) compared to those patients who had a ΔSI ≤0.1. These patients also spent 16% more days in hospital (adjusted incident rate ratio (AIRR) 1.16, 95% CI 1.14-1.19), 34% more days in ICU (AIRR 1.34, 95% CI 1.28-1.41), and 61% more days on ventilator (ARR 1.61, 95% CI 1.47-1.75). Additionally, patients with a ΔSI > 0.1 had higher odds of receiving blood products (AOR 2.00, 95% CI 1.88-2.12) within 4 h of ED arrival. Models fit excluding hypotensive patients performed similarly. Conclusions An increase of greater than 0.1 in the ΔSI was associated with increased 28-day mortality; increased days in hospital, in ICU, and on ventilator; and increased need for blood product transfusion within 4 h of ED arrival. This association held true for initially normotensive patients. Validation and implementation are needed to incorporate ΔSI into prehospital and ED triage.

Assessment of Blood Products Transfusion in Tertiary Neonatal Intensive Care Units Ain Shams University

Abstract Background Preterm Neonates, especially very low birth weight infants, remain a category of patients with high transfusion needs. Appropriate transfusion of neonates is vital when the potential clinical benefit outweighs the risk. However, the association between transfusion and adverse outcomes remains inconclusive. Aim Of The Work To evaluate transfusion practices in Tertiary Neonatal Intensive Care Units at Ain Shams University. Patients and Methods A cross sectional observational study was conducted on patients selected from Tertiary Neonatal Intensive Care Units at Ain Shams University- Children’s hospital. There were 703 neonates (29.64%) who received at least one type of blood products (packed red blood cells, platelets, fresh frozen plasma or cryoprecipitate) transfusion or underwent exchange transfusion during their hospital stay. All neonates receiving blood products transfusions were assessed for full history taking, clinical parameters i.e. gestational age, birth weight and general examination, indications for admission whether medical or surgical indications. Co-morbid illness such as bronchopulmonary dysplasia, necrotizing enterocolitis, retinopathy of prematurity, sepsis and patent ductus arteriosus were also noted. In addition, the indications for each of blood products transfusion i.e. anemia, exchange transfusion, thrombocytopenia, sepsis or other indications. Then, the requisition was assessed for pre- and post-transfusion laboratory parameters. Results Packed red blood cell was the most frequent blood component transfused (82.4%) and the main indication was anemia of prematurity (34.8%). There was a highly statistically significant increase in each of hemoglobin and hematocrit (HCT) post transfusion (with P value <0.0001) and a highly statistically decrease in the required median fraction of inspired oxygen (FiO2) (with P value <0.0001). 681 neonates (96.9%) presented with comorbidities; the most common comorbidity was neonatal sepsis in 81.2%. Packed red blood cells (PRBCs) transfusions were highly statistically significant related to comorbidity development. Conclusion Majority of blood transfusions occur during the first 2 weeks of life. Gestational age, birth weight, underlying disease of neonates, the need for oxygen support and blood collection within first two weeks of birth influence their transfusion needs. Sepsis remains the foremost etiological factor for blood component transfusion.

Blood transfusion in injured older adults: A retrospective cohort study.

We asked how increasing age interacts with transfusion and mortality among older injured adults at our large regional trauma center. Older adults are increasing proportions of acute trauma care and transfusion, but the specific interactions of increasing age with blood product use are unclear. Trauma data (age, injury severity, mechanism, etc.) were linked with transfusion service data (type, timing and numbers of units) for all acute trauma patients treated at our center 2011-2022. Subsets of patients aged ≥55 years were identified by age decade and trends assessed statistically, p < 0.01. Of 73 645 patients, 25 409 (34.5%) were aged ≥55. Within increasing 10-year age cohorts, these older patients were increasingly female (32.2%-67.2%), transferred from outside facilities (55.2%-65.9%) and injured in falls (44.4%-90.3%). Overall, patients ≥55, despite roughly equivalent injury severity, were twice as likely to be transfused (24% vs. 12.8%) as younger patients and to die during hospitalisation (7.5% vs. 2.9%). Cohort survival at all ages and levels of transfusion intensity in the first 4 h of care were more than 50%. Through age 94, numbers of red cell and whole blood units given in the first 4 h of care were a function of injury severity, not age cohort. In our trauma resuscitation practice, patients aged ≥55 years are more likely to receive blood products than younger patients, but numbers of units given in the first 4 h appear based on injury severity. Age equity in acute resuscitation is demonstrated.

Rectus Abdominis Sheath Hematoma Following Cesarean Section: A Case Series

This case series describes two patients who underwent Cesarean section complicated by a rectus abdominis sheath hematoma that did not immediately resolve following exploratory laparotomy. One of the patients required an additional procedure by interventional radiology. Both patients had similar presentations. Both were noted to have symptomatic anemia on postoperative day 1 with an acute drop in hemoglobin. This was accompanied by severe abdominal pain and distension on physical exam. Computerized tomography (CT) abdomen/pelvis demonstrated evidence of active bleeding within the anterior abdominal wall musculature. Due to increasing concern for intrabdominal hemorrhage in the setting of an acute abdominal exam, the decision was made to proceed with an exploratory laparotomy. A substantial amount of blood was evacuated from the abdomen with greater than 1500 cc of estimated blood loss in both cases. A Jackson-Pratt drain was placed and had increased output immediately postoperatively. Both patients received blood products. One developed a consumptive coagulopathy. Interventional Radiology was consulted following exploratory laparotomy to consider intravascular embolization of the inferior epigastric arteries, which was eventually performed in one of the cases. The patients were discharged on hospital day 5 in good condition. Rectus abdominis sheath hematomas are a rare complication that can lead to significant postpartum hemorrhage. Prompt recognition and management is vital to avoid significant morbidity and mortality. Algorithms exist to guide treatment and standardize patient care. Despite using sound clinical judgment in line with existing algorithms, both patients had delayed resolution of their bleeding following initial management, requiring additional intervention.

Multidisciplinary team training in postpartum hemorrhage: impact on the use of blood products.

Compare the number of puerperal women submitted to blood transfusion before and after the implementation of a care protocol for postpartum hemorrhage (PPH) with multidisciplinary team training. Cross-sectional study in a university hospital, analyzing births from 2015 to 2019, compared the use of blood products before and after the adoption of a PPH protocol with multidisciplinary training. Between 2015 and 2019, there were 17,731 births, with 299 (1.7%) postpartum women receiving blood products and 278 postpartum women were considered for this analysis, 128 (0.7%) at Time 1 and 150 (0.8%) at Time 2. After the multiprofessional team training (T2), there was a difference in the complete use of the PPH protocol (use of oxytocin, misoprostol and tranexamic acid) (T1 = 5.1% x T2 = 49.5%, p≤0.0001). An individual categorized analysis revealed that, in the T2 period, there was lower use of blood component units per patient compared to T1 (Mann-Whitney, p=0.006). It should be noted that at T1 and T2, 54% and 24% respectively received two units of blood products. It is important to highlight that after the multidisciplinary team training for the PPH protocol, the goal of zero maternal death due to hemorrhage was reached. The adoption of a specific protocol for PPH, combined with the training of a multidisciplinary team, had an impact on the ability to identify women at high risk of hemorrhage, resulting in a decrease in the use of blood components.

SP6.14 - The Burden of Penetrating Junctional Injuries in a UK Major Trauma Centre: a Retrospective Cohort Study

Abstract Background Junctional injuries occur at the join of ‘anatomically distinct zones’. The emergence of junctional injuries in trauma care has been a consequence of recent battlefield casualties; accounting for 21% of potentially survivable deaths from haemorrhage. Although well described in military literature, there are no civilian studies into junctional injuries. This study aims to examine the epidemiology and resource burden of junctional penetrating injuries. Methods Retrospective study of adult and paediatric patients with penetrating injuries to a junctional zone presenting to an urban MTC in one year. Electronic patient records were searched and data on anatomical distribution of injury, imaging and theatre utilisation, inpatient stay, and discharge codes extracted. Discharge codes were referenced with the National Schedule of NHS costs to produce a cost. Results In 132 patients 92.4% (n=122) were male with median age 27.5 and in hospital mortality 1.6% (n=2). Saturday and Sunday were most frequent 37.9% (n=50) and 81.8% (n=108) attended after 1700 and before 0800. 37.9% (n=50) of injuries were buttock; 22% (n=29) neck; 18.9% (n=25) multiply-injured; 8.3% (n=11) axilla; 6.8% (n=9) diaphragm; and 6.1% (n=8) groin. Median Injury Severity Score (ISS) 8. 46.2% (n=61) underwent surgery; 50.8% (n=67) were admitted, 7.6% (n=10) to ITU. Median length of ward stay was 3 days. 15.9% (n=21) received blood products. The overall cost was £914,076. Conclusion Junctional injuries are a significant resource burden. Buttock wounds were the most common but had the lowest median ISS and cost. Diaphragmatic injuries appear distinct from junctional wounds in terms of ISS and cost, and may be separate to other junctional zones.

Investigation of the Frequency of Reactions and Consequences of Blood Transfusion in an Academic Center Guilan-Iran

Background: Blood transfusion is a life-saving procedure, but there are always potential risks, such as blood transfusion reactions. Objectives: Considering the importance of the subject and the lack of a similar study in Guilan province, this research was conducted to analyze blood transfusion reactions. Methods: This retrospective descriptive study was conducted at Al-Zahra Hospital in Guilan, Iran, between 2020 and 2022. The files of all patients who received blood products at this center and experienced a reaction were reviewed. A checklist was completed, which included details such as the hospital ward, age, blood group, underlying disease, type of surgery, type of injected product, history of transfusion, history of reaction and allergy, type of reaction, and treatment intervention. Results: During the study period, 4,887 cases received transfusions. Among them, 18 cases (0.36%) showed reactions during transfusion, of which 14 cases (0.35% of total packed cell injections) were related to packed cell injection. Shivering was the most common reaction, occurring in 8 cases (15.38%). The main interventions included the administration of steroids in 10 cases (25%), antihistamines in 7 cases (17.5%), and oxygen therapy in 7 cases (17.5%). Three cases (7.5%) were transferred to the ICU, and in three cases (7.5%), the blood transfusion was stopped. One mortality was reported, and no cases of incompatible blood transfusion were documented. Conclusions: The incidence of reactions to blood product injections at this center appears to be acceptable. However, it was found that the information recording systems were very inefficient, and forms were incompletely filled, which should be addressed and corrected.

Rotational Thromboelastometry Reduces the Need for Preemptive Transfusion in Cirrhosis: A Randomized Controlled Trial (NCT:05698134)

Backgrounds and AimViscoelastic tests (VET) like Rotational Thromboelastometry (ROTEM) assess global hemostasis in cirrhosis. We aimed to assess whether ROTEM-guided blood product transfusion results in lower blood product requirement in patients with cirrhosis undergoing elective invasive procedures as compared to standard of care (SOC) based on conventional coagulation test (CCT). MethodsIn this open label randomized controlled trial, patients with cirrhosis and abnormal CCT who were undergoing an invasive procedure were randomized to receive blood products either by ROTEM-guidance or SOC. The primary outcome was the difference in blood products (fresh frozen plasma (FFP) or platelets) transfused between the group. The secondary outcome was procedure-related bleeding or complications within 7 days of the procedure. The trial protocol is registered at clinicaltrails.gov; NCT05698134. ResultsFrom August 2021 to January 2023, a total of 40 patients were recruited (ROTEM: (n=20) and SOC (n=20)). The trial was terminated earlier during interim analyses due to compelling benefit in the ROTEM group after a scheduled interim analysis. The ROTEM group required substantially less blood transfusion than the SOC group (40% [8/20] vs 100% [20/20], p<0.001). The benefit was consistent across all types of blood product including fresh frozen plasma (< 0.001) and pooled platelet (p=0.046). No patients experienced clinically significant bleeding events. Transfusion associated adverse events occurred in one patient (5%) in the SOC group (allergic reaction) and none in ROTEM group (p=NS). The mortality in both groups at 30 and 90 days were similar. ConclusionsViscoelastic tests like ROTEM provides global assessment of hemostasis in patients with cirrhosis. Institution of ROTEM based transfusion strategy significantly reduces the need for blood product transfusion in patients with cirrhosis undergoing elective procedure without any increased risk of bleeding events. Clinical Trial NumberNCT05698134

Can rotational thromboelastometry rapidly identify theragnostic targets in isolated traumatic brain injury?

Coagulation assessment in traumatic brain injury (TBI) typically relies upon laboratory-based standard coagulation tests (SCTs), including the activated partial thromboplastin time (aPTT), INR and platelet count. Rotational thromboelastometry (ROTEM) sigma is an alternative point-of-care assay; however, its role in isolated TBI is under-evaluated. The present study aims to assess the prognostic utility of ROTEM sigma in isolated TBI. ROTEM sigma analysis was performed during the initial evaluation of patients presenting to the Royal Adelaide Hospital between February 2022 and 2023 with radiographically demonstrated traumatic intracranial haemorrhage and GCS ≤14. Patients with concomitant severe extracranial injury, or who received blood products or antifibrinolytic therapy prior to sample collection were excluded. Thirty-six patients had blood samples analysed with ROTEM, 25 of these patients were also evaluated with paired SCTs. Twenty-two per cent (8/36) of patients with isolated TBI had a hypocoaguable ROTEM profile, and this was associated with an increased incidence of head injury-related death (50% [4/8] vs 11% [3/28], P = 0.03). Median diagnostic turn-around-times were shorter for ROTEM parameters compared to SCT counterparts: EXTEM clotting time (CT) versus INR (20 vs 63 min, P < 0.01), and INTEM CT versus aPTT (21 vs 63 min, P < 0.01). EXTEM CT, FIBTEM CT and INR values had similar performance in predicting head injury-related death, area under the receiver operator curves were 0.8, 0.8 and 0.7, respectively. ROTEM sigma expedites the detection of clinically significant coagulopathy in isolated TBI. EXTEM and FIBTEM CT values are more rapidly attainable than INR and comparable in predicting head injury-related death.

242 The Burden of Penetrating Junctional Injuries in a UK Major Trauma Centre: A Retrospective Cohort Study

Abstract Aim Junctional injuries occur at the join of anatomically distinct zones. Recent battlefield casualties have shown junctional wounds account for 21% of potentially survivable deaths from haemorrhage. Although well studied in military literature, this is not the case in civilian setting. This paper aims to describe the civilian injury pattern to improve management and resource allocation. Method Retrospective study of all patients with penetrating injuries to a junctional zone presenting to an urban MTC in 2018. Patient records searched and data extracted on site of injury, management, and discharge code. Discharge codes were referenced with the National Schedule of NHS costs to produce a cost. Results 132 patients, 92.4% (n=122) male; median age 27.5; in hospital mortality 0.8% (n=1). 37.9% (n=50) of injuries were buttock; 22% (n=29) neck; 18.9% (n=25) multiply injured; 8.3% (n=11) axilla; 6.8% (n=9) diaphragm; and 6.1% (n=8) groin. Median Injury Severity Score (ISS) 8; median ISS multiply injured 29; diaphragm 16; groin 9; neck 5; axilla 4; buttock 4. 46.2% (n=61) underwent surgery; 50.8% (n=67) were admitted, 7.6% (n=10) to ITU. Median length of ward-stay 3 days. 15.9% (n=21) received blood products. The overall cost was £914,076; £6925/patient. Per patient for multiply injured £19,676; diaphragm £11,435; groin £7,483; axilla £3,553; neck £3,026; buttock £2,651. Conclusions Junctional injuries are a significant resource burden. Buttock wounds were the most common but had the lowest median ISS and cost. Diaphragmatic injuries appear distinct in terms of ISS and cost and should be considered as separate to other junctional wounds.

Outcomes associated with absent blood product utilization in Jehovah's witness patients compared to the standard of care in cardiac surgery: A ten-year experience.

For Jehovah's Witness (JW) patients requiring cardiac surgery, various strategies such as preoperative use of erythropoietin stimulating agents (ESAs), intravenous iron (IVI), and non-pharmacologic interventions have emerged to prevent complications from blood loss given transfusion is not acceptable in this population. Retrospective case-control of cardiac surgeries performed by the same surgeon between 1/1/2011 and 8/30/2021. JW patients were matched to non-JW who received blood products and non-JW who did not receive blood products on a 1:2:2 basis. Patients were matched on procedure, age, gender, and Society of Thoracic Surgeons morbidity score. Eligible patients were aged >18years and had a sternotomy procedure. The primary efficacy and safety outcomes included mean hematocrit values perioperatively and thrombotic events. A total of 27 JW, 52 non-JW transfused, and 53 non-JW not transfused patients were included in the analysis. JW patients had significantly higher mean hematocrits at every time point when compared to non-JW transfused patients and at all time points except clinic and the last recorded operating room value when compared to non-JW not transfused patients. No significant differences in thrombotic rates were found between groups, however there was a numerically higher incidence in the JW population (JW: 7.4%; non-JW transfused: 0%; non-JW not transfused: 1.9%; p = .106). A blood conservation protocol in a JW population was associated with higher perioperative hematocrit values when compared to matched controls. Further prospective study is warranted before applying similar protocols to other populations given the possibility for an increased rate of venous thromboembolism.

Burns in South Asia: Outcomes from South Asian Burn Registry (SABR)

BackgroundSouth Asian region contributes 59 % to the global mortality due to burns. However, we find a paucity of literature on the outcomes of burns from low- and middle-income countries (LMICs). South Asian Burn Registry (SABR) is a facility-based burns registry that collected data on in-patient burn care. This study assesses factors associated with mortality, length of hospital stay at the burns center, and functional status of burn patients. MethodsProspective data was collected from two specialized public sector burn centers between September 2014 – January 2015 from Bangladesh and Pakistan. Multivariable logistic, linear, and ordinal logistic regression was conducted to assess factors associated with inpatient-mortality, length of hospital stay, and functional status at discharge, respectively. ResultsData on 883 patients was analyzed. Increased association with mortality was observed with administration of blood product (OR:3, 95 % CI:1.18–7.58) and nutritional support (OR:4.32, 95 % CI:1.55–12.02). Conversely, antibiotic regimens greater than 8 days was associated with decreased mortality (OR:0.1, 95 % CI:0.03–0.41). Associated increase in length of hospital stay was observed in patients with trauma associated with their burn injury, history of seizures (CE:47.93, 95 % CI 12.05–83.80), blood product (CE:22.09, 95 % CI:0.83–43.35) and oxygen administration (CE:23.7, 95 % CI:7.34–40.06). Patients who developed sepsis (OR:6.89, 95 % CI:1.92–24.73) and received blood products during hospitalization (OR:2.55, 95 % CI:1.38- 4.73) were more likely to have poor functional status at discharge. ConclusionThis study identified multiple factors associated with worse clinical outcomes for burn patients in South Asia. Understanding these parameters can guide targeted efforts to improve the process and quality of burn care in LMICs.

Weight-Based Dosing for Low-Molecular-Weight Heparin (Enoxaparin) Administration to Achieve Optimal VTE Prophylaxis in Trauma Patients.

Patients admitted after traumatic injuries are at high risk for developing venous thromboembolism (VTE). Low-molecular-weight heparin (LMWH) is commonly used to prevent VTE in this patient population; however, the optimal dosing strategy has yet to be determined. To address this question, a fixed-dosing strategy of LMWH was compared to a weight-based dosing strategy of LMWH for VTE prophylaxis. A retrospective, pre-post implementation cohort study compared a fixed vs a weight-based dosing strategy of LMWH for VTE prophylaxis. Patients admitted to our level 1 trauma center were included if they had an estimated glomerular filtration rate >30mL/min/1.73m2, received at least 3 doses of LMWH, and had an appropriately drawn anti-Xa level on their initial dosing regimen. Patients in the pre-cohort received 30mg LMWH subcutaneously twice daily as the initial dosing regimen. Patients in the post-cohort received .5mg/kg (max 60mg) LMWH subcutaneously every 12h as the initial dosing regimen. A goal anti-Xa of .2-.4 IU/mL was targeted for prophylaxis. There were 817 patients in the fixed-dosing group (FDG) and 874 patients in the weight-based dosing group (WBDG). In the FDG, 42.8% of the patients achieved the goal initial anti-Xa level, with 54.1% and 3.1% reaching sub- and supratherapeutic doses, respectively. In the WBDG, 66.5% of patients reached goal initial anti-Xa levels, with 23.5% and 10.1% at sub- and supratherapeutic levels. The distribution of dose ranges was significantly different between the dosing strategies (P-value <.001). There was no difference in the number of patients who received blood products (39.1% vs 41.7%. P-value = .299). In our study, weight-based dosing of LMWH yielded a significantly higher proportion of patients who achieved goal prophylactic anti-Xa levels than fixed-dosing of LMWH. Larger-scale studies are needed to assess the risk of VTE events and bleeding with these dosing strategies.

Impact of Blood Products Transfusion on Patients in the Immediate Post-Lung Transplant Period: A Cohort Study.

BACKGROUND Anemia is common in post-transplant patients. Blood product transfusion is associated with mortality and rejection in solid organ transplants. In lung transplant recipients, transfusion predisposes to primary graft dysfunction (PGD). The adverse effects and associated mortality of perioperative transfusions in lung transplant recipients have not been evaluated. This study examined the effects of perioperative blood transfusions in lung transplant recipients. MATERIAL AND METHODS We conducted a retrospective study of the effects of blood product transfusions in patients who received single- or double-lung transplantation at Houston Methodist Hospital between August 2017 and September 2019. Univariable and multiple logistic regression modeling were used to determine the characteristics associated with single events as well as a composite outcome within 30 days (including mortality, acute myocardial infarction, acute stroke, lower respiratory tract infection, urinary tract infection, surgical site infections, or PGD). RESULTS A total of 232 patients received lung transplants between December 2015 and September 2019 at our center. Univariable analysis revealed an increased risk of PGD (P<0.001), more mechanical ventilation days (P<0.001), more ICU days post-transplant (P<0.001), and greater need for ECMO support (P=0.001) in patients who received blood product transfusions. In univariate analysis, the composite outcome was also more common (P=0.01) in patients who received any transfusion perioperatively. A total of 7 patients died within 30 days from transplant, and they were all in the transfused group. CONCLUSIONS Among lung transplant recipients, PGD, ICU days, need for mechanical ventilation and ECMO support, and total composite events were significantly greater in patients who received blood transfusion perioperatively.

Anesthetic Management of a Jehovah's Witness Patient for Coronary Artery Bypass Grafting With Antiphospholipid Antibody Syndrome and Renal Transplant.

Anesthesia for cardiac surgical patients with antiphospholipid antibody syndrome (APLS) presents challenges with monitoring anticoagulation during cardiopulmonary bypass. Additionally, this condition is associated with other autoimmune diseases and comorbidities that need to be considered in caring for these patients, and there is minimal evidence for specific strategies during cardiac surgery. Separately, Jehovah's Witness (JW) patients typically do not consent to receiving blood products, presenting an additional challenge for resuscitation during cardiac surgery and especially in the context of APLS. We present our approach to the anesthetic management of a JW patient with systemic lupus erythematosus (SLE) complicated by APLS, thrombocytopenia, and renal failure with history of renal transplant who presented for coronary artery bypass surgery. Management strategies we recommend include administration of antifibrinolytics after heparinization to mitigate bleeding risk and interdisciplinary management with the perfusion, intensive care, surgical, and nephrology teams.

Hematological Indices for Identifying Adverse Outcomes in Children Admitted to Pediatric ICUs.

The pediatric ICU (PICU) is a specialized area where critically sick children are managed. The mortality rates in PICUs are higher in developing countries as compared to developed nations.Many of these deaths could be prevented if very sick children were identified soon after they arrived at the health facility. Hematological indices like platelet lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) have been frequently used in adults as indicators of mortality. However, their use in the pediatric population is limited due to a lack of validated reference intervals. The objective of the study is to assess the role of hematological indices in identifying adverse outcomes in terms of mortality in children admitted to the PICU. It is a prospective, observational study done at a tertiary care hospital. All children aged one year to 12 years admitted to the PICU were enrolled in the study. A sample for complete blood count was taken within one hour of admission to the PICU. Children who had received blood products in the last two months, those on chronic medications (>two weeks) that can affect bone marrow cellularity, and known cases ofhematological disorders such as megaloblastic anemia, hematological malignancies, immune thrombocytopenia, and aplastic anemia were excluded from the study.PLR, NLR, and platelets to mean platelet volume ratio (PLT/MPV) were determined and compared among the survivors and non-survivors. Out of 275 enrolled patients, 119 (43.3%) patients expired during the study period. While PLR had high sensitivity and NLR had high specificity (85.71% and 92.31%, respectively) for predicting mortality, none of these parameters had a good area under the curve (AUC) in our study.PLT/MPV of ≥32 had a sensitivity of 39.5% and a specificity of 56.41%for predicting mortality. Hematological parameters have been used across the world to predict ICU mortality. PLR and NLR are simple hematological biomarkers, easy to calculate, and cost-effective, and ratios are better than individual parameters. More studies and stratified samples are required to evaluate the role of hematological markers in identifying the risk of mortality in children admitted to PICUs.

Blood transfusion reactions and risk of acute kidney injury and major adverse kidney events

BackgroundBlood transfusion reactions may have a negative impact on organ function. It is unknown whether this association holds true for acute kidney injury (AKI). Therefore, we conducted a cohort study to assess the association between transfusion reactions and the incidence of AKI and major adverse kidney events.MethodsIn this retrospective cohort study, we included patients who received transfusion of blood products during hospitalization at the Hospital Civil of Guadalajara. We analyzed them according to the development of transfusion reactions, and the aim was to assess the association between transfusion reactions and AKI during long-term follow-up.ResultsFrom 2017 to 2021, 81,635 patients received a blood product transfusion, and 516 were included in our study. The most common transfusion was red blood cell packaging (50.4%), fresh frozen plasma (28.7%) and platelets (20.9%); of the 516 patients, 129 (25%) had transfusion reactions. Patients who had transfusion reactions were older and had more comorbidities. The most common type of transfusion reaction was allergic reaction (70.5%), followed by febrile nonhemolytic reaction (11.6%) and anaphylactoid reaction (8.5%). Most cases were considered mild. Acute kidney injury was more prevalent among those who had transfusion reactions (14.7%) than among those who did not (7.8%), p = < 0.01; those with AKI had a higher frequency of diabetes, vasopressors, and insulin use. Transfusion reactions were independently associated with the development of AKI (RR 2.1, p = < 0.02). Major adverse kidney events were more common in those with transfusion reactions. The mortality rate was similar between subgroups.ConclusionIn our retrospective cohort of patients who received blood product transfusions, 25% experienced transfusion reactions, and this event was associated with a twofold increase in the probability of developing AKI and some of the major adverse kidney events during long follow-up.Graphical abstract

Comparison of Low Dose Recombinant Factor VIIa and 4-Factor Prothrombin Complex Concentrate for Treatment of Bleeding Related to Cardiac Surgery

Background: Recombinant factor VIIa (rFVIIa) and prothrombin concentrate complex (PCC) are used for uncontrolled bleeding in cardiac surgery (CS), however, there are limited direct comparisons of these agents. Objective: To evaluate the efficacy and safety of rFVIIa and PCC in CS related bleeding. Methods: This retrospective study included adult CS patients who received either low dose rFVIIa (<30 mcg/kg) or 4-factor PCC. The primary outcome was transfusion requirements of packed red blood cells (pRBC) within 6 hours of factor administration. Secondary efficacy outcomes included transfusion requirements 0-18 hours, doses of additional factor product, thrombotic events, and acute kidney injury (AKI). Results: A total of 179 patients were included (n = 78 rFVIIa; n = 101 PCC). Of patients who received blood products, there was no difference in the requirement of pRBCs within 6 hours (73.8 vs 68.9%, P = .5359) or in the median amount of pRBC transfused (500 mL vs 640 mL, P = .0723) in the rFVIIa and PCC groups respectively. Patients in the PCC group were more likely to require additional factor products (24.4% vs 47.5%, P = .0015), develop AKI (12.8% vs 25.7%, P = .0325), have longer ICU lengths of stay [2 (IQR 1-5) vs 4 (IQR 2-6), P = .0487] and greater in-hospital mortality (2.6% vs 10.9%, P = .033). There was no difference in thrombotic events. Conclusion: Although, there was no difference in pRBC transfusion requirements between PCC and rFVIIa, more patients in the PCC group required additional factor products and had increased adverse effects. Further comparisons of PCC and rFVIIa are warranted.

Acute Serum Calcium Level Changes Following Non-Massive Blood and Blood Product Transfusion in Emergency Department; a Cross-sectional Study.

The specific impact on calcium dynamics after non-massive blood transfusions remains relatively unexplored. This study aimed to compare pre- and post-transfusion calcium levels in patients receiving blood and blood product in the emergency department. This is a single-center, prospective, cross-sectional study conducted at the Emergency Department of Gazi University Health Research and Application Center Hospital in Ankara, Turkey, from January 1, 2020, to August 31, 2020. The study included adult patients who underwent blood and blood product transfusions, and serum calcium levels were measured and compared from samples taken before and after transfusion. A total of 292 participants were enrolled in the study, with 242 participants included in the final analysis. The mean total calcium level was 8.41 ± 0.76 mg/dL before transfusion and 8.34 ± 0.71 mg/dL after transfusion (p=0.012). When examining the corrected calcium values after receiving blood products based on the type of blood products, participants who received apheresis platelets had a post-transfusion corrected calcium value of 8.26 ±0.41 mg/dL, with a pre-transfusion value of 9.09 ±0.49 mg/dL (p<0.01). The post-transfusion ionized calcium value for participants receiving apheresis was 1.04 ±0.08 mg/dL, compared to 1.15 ±0.09 mg/dL for those who did not receive apheresis (p=0.049). There was a significant relationship between receiving fresh frozen plasma and post-transfusion ionized calcium values (p=0.024). This study demonstrated that transfusion-associated hypocalcemia can occur even at mild levels in patients receiving blood and blood product transfusions in the emergency department. However, it is suggested that the clinical effects of hypocalcemia, even when occurring based on the type and quantity of blood products, are minimal and negligible.

Interplay between HIV and Human Pegivirus (HPgV) Load in Co-Infected Patients: Insights from Prevalence and Genotype Analysis.

Human pegivirus (HPgV) is transmitted through sexual or parenteral exposure and is common among patients receiving blood products. HPgV is associated with lower levels of human immunodeficiency virus (HIV) RNA and better survival among HIV-infected patients. This study aimed to investigate the prevalence of HPgV and determine its subtypes in HIV-infected individuals living in Istanbul, which has the highest rate of HIV infection in Türkiye. Total RNA extraction from plasma, cDNA synthesis, and nested PCR were performed for HPgV on plasma samples taken from 351 HIV-1-infected patients. The HPgV viral load was quantified on HPgV-positive samples. HPgV genotyping was performed by sequencing the corresponding amplicons. In the present study, the overall prevalence of HPgV RNA in HIV-infected patients was 27.3%. HPgV subtypes 1, 2a, and 2b were found, with subtype 2a being the most frequent (91.6%). Statistical analysis of HIV-1 viral load on HPgV viral load showed an opposing correlation between HIV-1 and HPgV loads. In conclusion, these data show that HPgV infection is common among HIV-positive individuals in Istanbul, Türkiye. Further comprehensive studies are needed to clarify both the cellular and molecular pathways of these two infections and to provide more information on the effect of HPgV on the course of the disease in HIV-infected individuals.