Red Blood Cell Transfusion In Patients Research Articles

Red Blood Cell Transfusions in Patients with Advanced Cancer Receiving Home Palliative Care.

Background: Red blood cell (RBC) transfusion is the standard treatment for anemia in advanced cancer. Nevertheless, guidelines for managing this condition are still not exhaustive. Objective: To investigate frequency, timing, and clinical characteristics associated with RBC transfusions in patients with advanced cancer assisted by at-home oncological care service and to evaluate the association between parameters at the entry and the possibility of receiving RBC transfusions during homecare. Design: Retrospective observational study without medication. Setting/Subjects: Patients with advanced cancer entered in homecare during 2021 living in Bologna (Italy). Measurements: Gender, tumor primary site, oncological therapy, and symptoms at the entry were considered as possible factors in a binary logistic regression for the possibility of receiving at least one RBC transfusion during assistance. Data about transfusions were analyzed, and the transfusion history for each patient from the entry to death was traced. Results: Among the 1108 patients admitted, 179 (16.2%) were given at least one RBC transfusion during homecare. Genitourinary, hematological malignancies, and being still in therapy for advanced cancer are associated with a higher probability of receiving RBC transfusion during assistance (p = 0.017, p < 0.001, and p = 0.032, respectively). Half of the patients (52%) underwent RBC transfusions less than a month before death. Duration of the assistance was correlated with the period from last transfusion to death (p < 0.001). Conclusion: Hematological and genitourinary cancer and being in simultaneous care at the entry were associated with transfusion. Although the appropriateness of this treatment remains to be defined in this population, transfused patients frequently received "late in life" transfusions.

Presurgical circulating platelet-derived microparticles level as a risk factor of blood transfusion in patients with valve heart disease undergoing cardiac surgery

BackgroundCell-derived microparticles (MPs) are membrane vesicles that have emerged as a potential biomarker for various diseases and their clinical complications. This study investigates the role of MPs as a risk factor for blood transfusion in patients with valve heart disease undergoing cardiac surgery. MethodsForty adult patients undergoing heart valve surgery with cardiopulmonary bypass (CPB) were enrolled, and venous blood samples were collected prior to surgical incision. Plasma rich in MPs was prepared by double centrifugation, and the concentration of MPs was determined using the Bradford method. Flow cytometry analysis was performed to determine MPs count and phenotype. Patients were divided into “with transfusion” (n = 18) and “without transfusion” (n = 22) groups based on red blood cell (RBC) transfusion. ResultsThere was no significant difference in MPs concentration between the “with transfusion” and “without transfusion” groups. Although the count of preoperative platelet-derived MPs (PMPs), monocyte-derived MPs (MMPs), and red cell-derived MPs (RMPs) was higher in “without transfusion” group, these differences were not statistically significant. The preoperative PMPs count was negatively correlated with RBC transfusion (P = 0.005, r = -0.65). Multivariate logistic regression analysis revealed that the count of CD41+ PMPs, Hemoglobin (Hb), and RBC count were risk factors for RBC transfusion. ConclusionThis study suggests that the presurgical levels of PMPs, Hb, and RBC count can serve as risk factors of RBC transfusion in patients with valve heart disease undergoing cardiac surgery. The findings provide insights into the potential use of MPs as biomarkers for blood transfusion prediction in cardiac surgery.

Transfusion of red blood cells in venoarterial extracorporeal membrane oxygenation: A multicenter retrospective observational cohort study.

Evidence-based recommendations for transfusion in patients with venoarterial extracorporeal membrane oxygenation (VA ECMO) are scarce. The current literature is limited to single-center studies with small sample sizes, therefore complicating generalizability. This study aims to create an overview of red blood cell (RBC) transfusion in VA ECMO patients. This international mixed-method study combined a survey with a retrospective observational study in 16 centers. The survey inventoried local transfusion guidelines. Additionally, retrospective data of all adult patients with a VA ECMO run >24 h (January 2018 until July 2019) was collected of patient, ECMO, outcome, and daily transfusion parameters. All patients that received VA ECMO for primary cardiac support were included, including surgical (i.e., post-cardiotomy) and non-surgical (i.e., myocardial infarction) indications. The primary outcome was the number of RBC transfusions per day and in total. Univariable logistic regressions and a generalized linear mixed model (GLMM) were performed to assess factors associated with RBC transfusion. Out of 419 patients, 374 (89%) received one or more RBC transfusions. During a median ECMO run of 5 days (1st-3rd quartile 3-8), patients received a median total of eight RBC units (1st-3rd quartile 3-17). A lower hemoglobin (Hb) prior to ECMO, longer ECMO-run duration, and hemorrhage were associated with RBC transfusion. After correcting for duration and hemorrhage using a GLMM, a different transfusion trend was found among the regimens. No unadjusted differences were found in overall survival between either transfusion status or the different regimens, which remained after adjustment for potential confounders. RBC transfusion in patients on VA ECMO is very common. The sum of RBC transfusions increases rapidly after ECMO initiation, and is dependent on the Hb threshold applied. This study supports the rationale for prospective studies focusing on indications and thresholds for RBC transfusion.

Assessment of oxygen extraction rate changes following red blood cell transfusion in the intensive care unit: a protocol for a prospective observational non-interventional study

IntroductionHaemoglobin transfusion thresholds have been used in the intensive care unit (ICU) to guide red blood cell transfusion (RBCT) decisions. Recent research has also focused on physiological indicators of tissue...

Temporal trends and geographic variations in perioperative red blood cell transfusion in major surgical procedures from 2013 to 2018 in China.

Transfusion-related guidelines promote restrictive blood transfusion. However, whether these guidelines have been successfully translated into clinical practice in China is unknown. This study aimed to provide updated information about the temporal trends in the prevalence of perioperative red blood cell (RBC) transfusion in China. We analysed data from the Hospital Quality Monitoring System database (2013-2018) to investigate the prevalence of perioperative RBC transfusion in patients undergoing craniotomy for cerebral aneurysms or arteriovenous malformations, sternotomy for mitral valve replacement, open thoracotomy lobectomy, open gastrectomy and hip arthroplasty. Mixed-effects logistic regression models quantified the likelihood of RBC transfusions. The study included 438,183 patients, with 44,697 (10.20%) receiving perioperative RBC transfusions. Introducing transfusion-related guidelines in China markedly decreased the prevalence of RBC transfusion among patients who underwent major surgical procedures in the following years. The prevalence of RBC transfusion for hip arthroplasty was 17.34% in 2013 and 7.03% in 2018. After adjusting for patient risk factors, the odds ratio of RBC transfusion for hip arthroplasty was significantly lower in 2018 (0.74, 95% confidence intervals [CI] 0.53-1.02) than in 2013 (1.84, 95% CI 1.37-2.48). The prevalence of perioperative RBC transfusion decreased from 2013 to 2018 in China, supporting the potential beneficial effects of transfusion-related guidelines. Considering the geographic variations in RBC transfusion, reducing heterogeneity may impact public health by improving surgical outcomes.

Association of body mass index with 30-day mortality and red blood cell transfusions in open heart surgery.

Obesity is associated with increased burden of cardiovascular risk factors, morbidity and mortality. However, several studies have counterintuitively shown better outcome after cardiac surgery in obese than in normal weight patients, a phenomenon known as obesity paradox. Furthermore, obesity has been linked with decreased need of red blood cell (RBC) transfusions. The purpose of this study was to evaluate the impact of body mass index (BMI) on 30-day mortality and RBC transfusions in patients undergoing cardiac surgery, a clinically important topic with conflicting previous data. We retrospectively investigated 1691 patients who underwent coronary and/or valve or aortic root surgery using cardiopulmonary bypass between 2013 and 2016. The patients were categorized by BMI based on the World Health Organization classification. For analysis, logistic regression was used with adjustment for potential confounding factors. Of the patients, 28.7% were normal weight, 43.3% overweight, 20.5% mildly obese and 7.5% severely obese. Thirty-day mortality was 1.9% without significant differences between the BMI groups. 41.0% of patients received RBC transfusion. Overweight [odds ratio (OR) 0.75, 95% confidence interval (CI) 0.56-0.99, P = 0.045], mildly (OR 0.65, 95% CI 0.46-0.92, P = 0.016) and severely obese (OR 0.41, 95% CI 0.24-0.70, P = 0.001) patients needed less frequently RBC transfusions than patients with normal weight. Obesity was not associated with 30-day mortality but was associated with lower use of RBC transfusions in cardiac surgery.

Prediction of red blood cell transfusion after orthopedic surgery using an interpretable machine learning framework

Postoperative red blood cell (RBC) transfusion is widely used during the perioperative period but is often associated with a high risk of infection and complications. However, prediction models for RBC transfusion in patients with orthopedic surgery have not yet been developed. We aimed to identify predictors and constructed prediction models for RBC transfusion after orthopedic surgery using interpretable machine learning algorithms. This retrospective cohort study reviewed a total of 59,605 patients undergoing orthopedic surgery from June 2013 to January 2019 across 7 tertiary hospitals in China. Patients were randomly split into training (80%) and test subsets (20%). The feature selection method of recursive feature elimination (RFE) was used to identify an optimal feature subset from thirty preoperative variables, and six machine learning algorithms were applied to develop prediction models. The Shapley Additive exPlanations (SHAP) value was employed to evaluate the contribution of each predictor towards the prediction of postoperative RBC transfusion. For simplicity of the clinical utility, a risk score system was further established using the top risk factors identified by machine learning models. Of the 59,605 patients with orthopedic surgery, 19,921 (33.40%) underwent postoperative RBC transfusion. The CatBoost model exhibited an AUC of 0.831 (95% CI: 0.824-0.836) on the test subset, which significantly outperformed five other prediction models. The risk of RBC transfusion was associated with old age (>60 years) and low RBC count (<4.0 × 1012/L) with clear threshold effects. Extremes of BMI, low albumin, prolonged activated partial thromboplastin time, repair and plastic operations on joint structures were additional top predictors for RBC transfusion. The risk score system derived from six risk factors performed well with an AUC of 0.801 (95% CI: 0.794-0.807) on the test subset. By applying an interpretable machine learning framework in a large-scale multicenter retrospective cohort, we identified novel modifiable risk factors and developed prediction models with good performance for postoperative RBC transfusion in patients undergoing orthopedic surgery. Our findings may allow more precise identification of high-risk patients for optimal control of risk factors and achieve personalized RBC transfusion for orthopedic patients.

Transfusion practice in patients undergoing cardiac surgery in New Zealand-impact of the TRICS III study (the TRICS TRIPS study).

Cardiac surgery is the largest perioperative user of donated blood products. There is significant uncertainty as to the optimal threshold for RBC transfusion in patients undergoing cardiac surgery with little evidence to guide practice. We wished to determine whether the results of a large randomised controlled trial had changed practice. A prospective observational study of red blood cell (RBC) transfusions of patients undergoing cardiac surgery utilising cardiopulmonary bypass was undertaken as well as a cross-sectional self-administered online practice survey of clinicians ordering red blood cell transfusions in all publicly funded cardiac centres in New Zealand. Significantly more transfusions were administered to a pre-transfusion haemoglobin <75g/L and thus considered in agreement with the restrictive arm of the TRICS III study after completion of TRICS III study enrolment and before results were known (T1)=44% when compared to after results were known (T2=56.7%, p=0.01). Most respondents in the clinician survey had participated in the TRICS III study. After the publication of the findings of a large multi-national clinical trial, clinicians involved in the care of cardiac surgery patients were more restrictive in their administration of red blood cell transfusions than before the trial findings were published.

A value-based approach to optimize red blood cell transfusion in patients receiving extracorporeal membrane oxygenation.

The risk, cost, and adverse outcomes associated with packed red blood cell (RBC) transfusions in patients with cardiopulmonary failure requiring extracorporeal membrane oxygenation (ECMO) have raised concerns regarding the overutilization of RBC products. It is, therefore, necessary to establish optimal transfusion criteria and protocols for patients supported with ECMO. The goal of this study was to establish specific criteria for RBC transfusions in patients undergoing ECMO. This was a retrospective cohort study conducted at Stanford University Hospital. Data on RBC utilization during the entire hospital stay were obtained, which included patients aged ≥18years who received ECMO support between 1 January 2017, and 30 June 2020 (n = 281). The primary outcome was in-hospital mortality. Hemoglobin (HGB) levels >10g/dL before transfusion did not improve in-hospital survival. Therefore, we revised the HGB threshold to ≤10g/dL to guide transfusion in patients undergoing ECMO. To validate this intervention, we prospectively compared the pre- and post-intervention cohorts for in-hospital mortality. Post-intervention analyses found 100% compliance for all eligible records and a decrease in the requirement for RBC transfusion by 1.2 units per patient without affecting the mortality. As an institution-driven value-based approach to guide transfusion in patients undergoing ECMO, we lowered the threshold HGB level. Validation of this revised intervention demonstrated excellent compliance and reduced the need for RBC transfusion while maintaining the clinical outcome. Our findings can help reform value-based healthcare in this cohort while maintaining the outcome.

P1741: EXAMINING THE BURDEN OF ILLNESS ASSOCIATED WITH TRANSFUSION-DEPENDENT ΒETA-THALASSEMIA FROM THE PATIENT’S PERSPECTIVE

Background: β-thalassemia is a rare genetic blood disorder affecting approximately 1 in 100,000 people globally. Typically diagnosed in childhood, β-thalassemia is marked by the inability to produce hemoglobin, which results in chronic anemia. Transfusion-dependent β-thalassemia (TDβT) is the most severe form of this disorder, with treatment requiring frequent red blood cell transfusions (RBCTs). Recognized complications of the frequent RBCTs include alloimmunization, iron overload, resultant cardiac and liver disease, and reported poor health-related quality of life (HRQoL). Aims: To examine the burden of illness and HRQoL in patients diagnosed with TDβT. Methods: Potential study participants were recruited with the assistance of the Cooley’s Anemia Foundation. Participants were ≥18 years of age, had a self-reported physician diagnosis of β-thalassemia, and had received ≥1 RBCT in the past 6 months. After providing informed consent, patients completed an institutional review board-approved 30-minute online survey that included both validated patient-reported outcome instruments, and other questions written expressly for the purpose of this study. Data were collected in May 2021. Patients who completed the survey earned an incentive payment of 75 US dollars. Results: A total of 100 patients completed the survey; mean age was 36.0 years (standard deviation [SD] 10.4) and 35% of patients were male. Patients had been diagnosed with TDβT for a mean of 34.4 years (SD 10.3) and experienced a mean of 9.6 (SD 4.3) RBCT events in the past 6 months. As an indication of severity, 66% of patients reported requiring >1 RBCT per month, 31% each month, and 3% every other month. Side effects of RBCT included iron overload (in 81% of patients), rashes/hives (74%), fatigue (61%), and pain/bruising at injection site (52%). Mean time required for an RBCT was 7.4 hours (SD 11.3), including transfusion preparation time. Travel and wait times were an additional 7.1 hours. Among all patients, 70% reported a “moderate” to “extremely high” burden of RBCT. On HRQoL, 71% of patients reported “wondering what life would be like without β-thalassemia,” 86% reported “feeling fatigued” leading up to RBCT, and 42% reported “not being as social with friends/family due to the time needed for RBCT.” On validated psychological instruments, 52% of patients reported mild-to-severe depression (Patient Health Questionnaire [PHQ-9]) and 53% reported mild-to-severe anxiety (Generalized Anxiety Disorder Questionnaire [GAD-7]), over the previous 2 weeks. Summary/Conclusion: The survey results suggest there is a substantial time, side-effect, and HRQoL burden associated with treatment by RBCTs in patients diagnosed with TDβT. This includes considerable time devoted to preparing for and receiving transfusions, transfusion-related side effects, and increases in depression and anxiety. These findings contribute to the understanding of the humanistic and psychological burden of RBCT dependency in patients with β-thalassemia. New treatment options that can improve outcomes in this population are needed.

Preoperative Hemoglobin Optimization in Jehovah's Witness Cardiovascular Surgery Patients with Anemia and Barriers to Care

Cardiac surgery has a risk for extensive blood loss which poses a particular challenge in individuals refusing blood transfusions. Additionally, preoperative anemia with a hemoglobin (Hb) below 13 g/dL in men and 12 g/dL in women is associated with increased short and long-term complications and mortality and increases the need for blood transfusion support. The current guidelines for perioperative anemia management recommend optimizing hemoglobin levels prior to surgery and utilizing blood conservation techniques during the procedure. At present red blood cell (RBC) transfusions during cardiac surgery are usually recommended when Hb levels are below 7-8 g/dL a restrictive transfusion strategy to reduce complications. However, the use of any RBC transfusions is associated with worse outcomes in cardiac surgery compared with those who do not receive transfusions.We have found that JW seek out quality health care and accept the vast majority of medical treatments once they are educated. The Transfusion Free Medicine Coordinator's role in the Anemia Clinic is to endorse clinical strategies for managing hemorrhage and anemia without blood transfusion. They educate and counsel the patients so they can decide as to what blood fractions and cell salvage techniques they will accept. We have found that some Health Care Providers are unaware that ESAs also contain albumin so JW patients may be given this product without that knowledge. The vast majority of patients will accept the use of ESAs but find the cost prohibitive.Jehovah's Witness patients have provided a natural case study for examining how well adjuvant therapies can improve preoperative anemia without transfusions and continue with good outcomes. Hb optimization is achieved through the use of intravenous iron and, if needed, erythropoiesis stimulating agents (ESAs). In Table 1 we highlight our single center data in which all cardiovascular surgeries were performed by a surgeon experienced in blood-conservation strategies. Our thirty-day re-admission rates for all patients was zero percent, compared to state-specific data, which estimates about an 11.7% rate of re-admission. The data illustrate the need to have a target Hb 13 or above to allow for the decline that may occur during the hospital stay. Of note no thromboembolic events have occurred with the use of an ESA in this group.Although ESAs are approved to optimize Hb in orthopedic surgery, they are not covered for cardiac surgery which has presented a significant challenge to patients who can not safely proceed to surgery until a target Hb between 13 to 15 g/dL is achieved.These data highlight the utility and safety associated with the use of ESAs for patients who do not accept blood products at an experienced Center for Transfusion-Free Medicine, such as ours. At this time, since insurance companies do not cover the cost of ESAs for patients needing life-saving cardiovascular operations, cost is a prohibitive barrier for patients. Unfortunately, it is not uncommon for patients to have to borrow money from others or set up payment plans. We hope that analyses like ours will help drive changes in reimbursement policies, particularly for patients who based on religious convictions, cannot receive blood products, and thus for whom pre-operative hemoglobin optimization is of utmost importance. [Display omitted] DisclosuresNo relevant conflicts of interest to declare. OffLabel Disclosure:Erythropoiesis-stimulating agent (ESA) are indicated for the treatment of anemia due to Chronic Kidney Disease in patients on dialysis and not on dialysis, Zidovudine in patients with HIV-infection, anemia due to myelosuppressive chemotherapy and reduction of allogeneic RBC transfusions in patients undergoing elective, noncardiac, nonvascular surgery

Withdrawal: “Effect of single preoperative ferric carboxymaltose injection on perioperative transfusion in patients undergoing total hip arthroplasty: A retrospective analysis” Hyun‐Jung Shin, Hun‐Taek Lee, Hyo‐Seok Na

Despite ongoing efforts to reduce perioperative transfusion, there is still high chance of transfusion in total hip arthroplasty (THA). We investigated the requirement of red blood cell (RBC) transfusion according to the administration of single preoperative ferric carboxymaltose (FCM) in patients undergoing THA. This retrospective study included the patients undergoing unilateral THA from November 2014 to July 2018, who received FCM (FCM group) at 2 weeks prior to the surgery or who did not (Non-FCM group). A propensity-score matching method was used to balance the two groups for analysis. The primary endpoint was to evaluate if there was any difference in requirement of RBC transfusion between the two groups. This study included 1,032 cases of THA for final analysis, and the cases were divided into the FCM group (n = 568) and Non-FCM group (n = 464). Propensity matching produced 389 patients in each group. In the FCM group, the amount (0.4 vs. 0.6 units) and incidence (21% vs. 31%) of RBC transfusion was significantly lower compared with the Non-FCM group (P = 0.035 and P = 0.003, respectively). Single preoperative FCM administration without any other supplementation could reduce the requirement of RBC transfusion in patients undergoing THA. This study suggests that single preoperative FCM administration can be recommended as a simple and easy patient blood management strategy in addition to other methods for reducing the RBC transfusion in THA.

Development and Performance Evaluation of a Clinical Predictive Model to Estimate the Risk of Red Blood Cell Requirements in Brain Tumor Surgery.

The identification of factors associated with perioperative red blood cell (RBC) transfusion provides an opportunity to optimize the patient and surgical plan, and to guide perioperative crossmatch and RBC orders. We examined the association among potential bleeding risk factors and RBC requirements to develop a novel predictive model for RBC transfusion in patients undergoing brain tumor surgery. This retrospective study included 696 adults who underwent brain tumor surgery between 2008 and 2018. Multivariable logistic regression with backward stepwise selection for predictor selection was used during modeling. Model performance was evaluated using area under the receiver operating characteristic curve, and calibration was evaluated with Hosmer-Lemeshow goodness-of-fit χ 2 -estimate. Preoperative hemoglobin level was inversely associated with the probability of RBC transfusion (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.39-0.63; P <0.001). The need for RBC transfusion was also greater in patients who had a previous craniotomy (OR: 2.71; 95% CI: 1.32-5.57; P =0.007) and in those with larger brain tumor volume (OR: 1.01; 95% CI: 1.00-1.02; P =0.009). The relationship between number of planned craniotomy sites and RBC transfusion was not statistically significant (OR: 2.11; 95% CI: 0.61-7.32; P =0.238). A predictive model for RBC requirements was built using these 4 variables. The area under the receiver operating characteristic curve was 0.79 (95% CI: 0.70-0.87; P <0.001) showing acceptable calibration for predicting RBC transfusion requirements. RBC requirements in patients undergoing brain tumor surgery can be estimated with acceptable accuracy using a predictive model based on readily available preoperative clinical variables. This predictive model could help to optimize both individual patients and surgical plans, and to guide perioperative crossmatch orders.

Effectiveness of kaolin-impregnated hemostatic gauze use in preperitoneal pelvic packing for patients with pelvic fractures and hemodynamic instability: A propensity score matching analysis.

We evaluated the effectiveness of kaolin-impregnated hemostatic gauze use in preperitoneal pelvic packing (PPP) for patients with hemodynamic instability due to severe pelvic fractures. Between May 2014 and October 2018, 53 of 75 patients who underwent PPP due to hemodynamic instability induced by pelvic fracture were enrolled. Their medical records were prospectively collected and retrospectively analyzed. QuikClot combat gauze (hydrophilic gauze impregnated with kaolin) and general surgical tape were used in 21 patients, while general surgical tape was used in the remaining 32 patients. As there were differences in the characteristics of patients between the hemostatic gauze (HG) group and control group, propensity score matching (PSM) was performed to adjust for age, sex, and lactate levels. After PSM, the clinical characteristics between the two groups became similar. There were no differences in the rates of mortality and hemorrhage-induced mortality between the two groups. However, the packed red blood cell (RBC) requirement for an additional 12 hours in the HG group was significantly lower than that in the control group (4.1 ± 3.5 vs. 7.6 ± 6.1 units, p = 0.035). The lengths of intensive care unit and hospital stays tended to be shorter in the HG group than in the control group (11.6 vs. 18.5 days, p = 0.1582; 30.8 vs. 47.4 days, p = 0.1861, respectively). The use of HG during PPP did not reduce hemorrhage-induced mortality, but did reduce the need for additional packed RBC transfusions in patients with hemodynamic instability due to severe pelvic fractures.

Ulinastatin reduces postoperative bleeding and red blood cell transfusion in patients undergoing cardiac surgery: A PRISMA-compliant systematic review and meta-analysis.

Ulinastatin is a type of glycoprotein and a nonspecific wide-spectrum protease inhibitor like antifibrinolytic agent aprotinin. Whether Ulinastatin has similar beneficial effects on blood conservation in cardiac surgical patients as aprotinin remains undetermined. Therefore, a systematic review and meta-analysis were performed to evaluate the effects of Ulinastatin on perioperative bleeding and transfusion in patients who underwent cardiac surgery. Electronic databases were searched to identify all clinical trials comparing Ulinastatin with placebo/blank on postoperative bleeding and transfusion in patients undergoing cardiac surgery. Primary outcomes included perioperative blood loss, blood transfusion, postoperative re-exploration for bleeding. Secondary outcomes include perioperative hemoglobin level, platelet counts and functions, coagulation tests, inflammatory cytokines level, and so on. For continuous variables, treatment effects were calculated as weighted mean difference (WMD) and 95% confidential interval (CI). For dichotomous data, treatment effects were calculated as odds ratio and 95% CI. Statistical significance was defined as P < .05. Our search yielded 21 studies including 1310 patients, and 617 patients were allocated into Ulinastatin group and 693 into Control (placebo/blank) group. There was no significant difference in intraoperative bleeding volume, postoperative re-exploration for bleeding incidence, intraoperative red blood cell transfusion units, postoperative fresh frozen plasma transfusion volumes and platelet concentrates transfusion units between the 2 groups (all P > .05). Ulinastatin reduces postoperative bleeding (WMD = -0.73, 95% CI: -1.17 to -0.28, P = .001) and red blood cell (RBC) transfusion (WMD = -0.70, 95% CI: -1.26 to -0.14, P = .01), inhibits hyperfibrinolysis as manifested by lower level of postoperative D-dimer (WMD = -0.87, 95% CI: -1.34 to -0.39, P = .0003). This meta-analysis has found some evidence showing that Ulinastatin reduces postoperative bleeding and RBC transfusion in patients undergoing cardiac surgery. However, these findings should be interpreted rigorously. Further well-conducted trials are required to assess the blood-saving effects and mechanisms of Ulinastatin.

Heterogenous treatment effects of transfusion thresholds by patient age: Post-hoc analysis of the TRISS trial.

Use of a lower haemoglobin (Hb) threshold to guide red blood cell (RBC) transfusion is now generally recommended in critically ill patients, but uncertainty remains regarding the optimal Hb threshold for RBC transfusion in patients of different ages. We conducted a post-hoc analysis of 998 patients with septic shock and anaemia randomised to RBC transfusion at a Hb threshold of 7 g/dl [4.3 mmol/l] vs 9 g/dl [5.6 mmol/l] in the Transfusion Requirements in Septic Shock (TRISS) trial. We assessed if there were heterogeneous effects between the allocated Hb threshold and patient age categorised and on the continuous scale. The primary outcome was 1-year mortality; the secondary outcome was 90-day mortality. Both outcomes were analysed using logistic regression models and in sensitivity analyses with additional adjusting for site of enrolment, presence of haematological malignancy and the Sequential Organ Failure Assessment (SOFA) score. The secondary analyses were Kaplan-Meier curves with corresponding log-rank tests. We found no heterogeneity between patient age and the allocated Hb thresholds for RBC transfusion for 1-year mortality or 90-day mortality in the primary analyses. The sensitivity analyses suggested heterogeneity between age groups regarding 90-day mortality, however, this was not consistent for 1-year mortality or when assessing age on the continuous scale. In this post-hoc study of ICU patients with septic shock, we found no reliable heterogeneous effects of transfusion at a Hb threshold of 7 vs 9 g/dl according to patient age on mortality. However, due to low power, this study should only be considered as hypothesis generating.

Identification of rare blood types in southern Brazil: impact on transfusion support

The prevalence of blood group antigens and phenotypes varies significantly in Brazil. To ensure a proper rare blood supply, it is essential to establish a local and regional database of rare donors connected to the national registry. The objective of this study was to create a database of rare blood donors in the northern region of southern Brazil. From November 2011 to December 2018, red blood cell (RBC) phenotyping and genotyping were performed on common and high-prevalence antigens in donors and patients in southern Brazil. During this study period, 17 patients and 33 blood donors with rare phenotypes were identified. Six patients had already been alloimmunized to clinically significant antigens. Patients with the following phenotypes (i.e., negative for highprevalence antigens) were found: Yt(a-), Jk(a-b-), Lu(a-b-), Oh (Bombay), Tc(a-), k-, and Fy(a-b-). Among the donors, Kp(a+b-), Fy(a-b-), Lu(a-b-), and k- phenotypes were identified. We also found four donors with the weak D type 18 phenotype. In conclusion, we observed that the prevalence of rare blood phenotypes in our region corresponds more to the prevalence found in the Caucasian population when compared with other regions in Brazil. Our results show the importance of continuous screening for rare donors in different regions of the country and the creation of a local database to support RBC transfusions in patients who need rare blood.

Impact of Iron Supplementation on Patient Outcomes in Women Undergoing Gynecological Procedures: Systematic Review and Meta-Analysis of Randomized Trials

Background. Perioperative red blood cell (RBC) transfusion is associated with poor patient outcomes. RBC transfusion rates have been decreasing across different types of surgeries as a results of implementing Patient Blood Management (PBM) strategies; while RBC transfusion rates in gynecologic surgeries have remained static. Women are at increased risk of anemia, specifically iron deficiency anemia from gynecologic blood loss putting them at increased risk of requiring perioperative RBC transfusion. PBM encourages preoperative iron supplementation to optimize patients' hemoglobin (Hb) levels; however, evidence specific to gynecological procedures is lacking. This systematic review was conducted to address the question: Does the use of iron supplementation during the perioperative period impact patient outcomes in women undergoing gynecological procedures when compared to no treatment, placebo, or standard of care? Methods. MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science were searched up to July 2019. Additional records were identified through searching theses, conference proceedings, trials, and grey literature. All randomized controlled trials (RCTs) comparing an intervention group provided with iron supplementation perioperatively to women undergoing gynecological procedures with a comparator were included. Two authors independently assessed studies for inclusion and risk of bias using the Cochrane Risk of Bias tool, extracted data, and evaluated the certainty of evidence using the GRADE approach. Data were pooled using the random-effects (DerSimonian and Laird) method of meta-analysis. Results. A total of eleven RCTs met inclusion criteria. Two RCTs were then excluded; one RCT compared iron supplementation to no intervention but subset data for gynecology patients was unavailable and the full text of another RCT was unavailable. Seven RCTs (n=447) were amenable to meta-analysis; however iron supplementation was used in both treatment arms: four compared iron with erythropoietin stimulating agents (ESA) to iron alone and three compared iron with gonadotropin-releasing hormone (GnRH) analogue/agonist to iron alone. Six studies were judged to be overall low risk of bias and one to be at high risk of bias. RBC Transfusions: There was a statistically significant reduction in RBC transfusions during the perioperative period when iron was used in combination with a blood optimization compound (BOC) compared to iron alone (RR 0.33; 95%CI 0.16 to 0.70; p=0.003) (Figure 1). Preoperative Hb Level: Women who had taken a BOC plus iron had a median preoperative Hb level of 12.87g/dl [95% CI 11.13, 14.61 g/dl]), which was significantly higher (Δ1.16 g/dl; 95% CI 1.01, 1.31g/dl; p&amp;lt;0.00001) than those who took oral iron supplements alone. Postoperative Hb Level: Among 336 women in six RCTs, women who had taken a BOC in addition to iron had a postoperative Hb of 11.53g/dl (95% CI 6.92 g/dl, 16.14g/dl). This was significantly higher (Δ0.96 g/dl; 95% CI 0.45 g/dl, 1.47 g/dl; p&amp;lt;0.00001) than those who took iron supplements alone. Adverse Events (AEs): Five studies including 289 participants reported the incidence of AEs. The addition of a BOC did not have a statistically significant effect on the occurrence of AEs (RR 0.98; 95%CI 0.83, 1.17; p=0.85). One RCT with available data compared iron supplementation to placebo. Meta-analysis was not possible; however, the study found a significant increase in postoperative Hb and decrease in RBC transfusions in patients receiving iron supplementation compared to placebo. Conclusion. Perioperative use of iron in combination with a BOC in women undergoing gynecological procedures may reduce the need for perioperative RBC transfusions and improve preoperative Hb levels with high certainty of evidence. There was very low certainty of evidence for the impact of iron plus BOC on postoperative Hb levels and the number of AEs. The results of this systematic review suggest that the use of perioperative iron with BOC may improve patient outcomes. Lack of RCTs comparing iron to placebo is a limitation. More studies are needed to address the role of perioperative iron supplementation for gynecological procedures, including evaluating different routes of administration. Analysis of existing observational studies may offer additional data to supplement the results of this meta-analysis. Disclosures Arnold: Rigel: Consultancy, Research Funding; Bristol-Myers Squibb: Research Funding; Novartis: Honoraria, Research Funding; Principia: Consultancy. Zeller:Pfizer: Other: Advisory Board; Canadian Blood Services: Consultancy; Ontario Ministry of Health and Long Term Care: Consultancy.

Lower vs higher transfusion threshold in septic shock patients of different ages: A study protocol.

Current evidence indicates that it is safe to use a lower haemoglobin (Hb) threshold for red blood cell (RBC) transfusion as compared to a higher Hb-threshold. However, the recent Transfusion Requirements in Cardiac Surgery (TRICS-3) trial reported a significant interaction between patient age and the effect of lower vs higher Hb-thresholds for RBC transfusion. The interaction between patient age and transfusion strategy appears to differ between trials. This is the protocol and statistical analysis plan for a post hoc analysis of the Transfusion Requirements in Septic Shock (TRISS) trial. We will assess the effect of a lower vs a higher Hb-threshold for RBC transfusion in patients of different ages with septic shock. The primary and secondary outcomes are 1-year mortality and 90-day mortality respectively. We will assess age divided into six age groups and as a continuous variable and present baseline characteristics and odds ratios derived from both simple and adjusted (for the Sequential Organ Failure Assessment score, haematological malignancy, age and trial site) logistic regression models and P-values for the test-of-interaction. Furthermore, we will compare outcomes according to Hb-threshold in each age group using Kaplan-Meier curves and log-rank tests. The outlined study will make a detailed assessment of potential interaction of patient age with transfusion strategy in patients with septic shock. This may inform future trials on the benefits and harms of RBC transfusion.

RISK FACTORS FOR BLOOD TRANSFUSION IN WOMEN UNDERGOING GYNAECOLOGICAL SURGERY

Objectives A common complication of surgery is peri-operative blood loss, which increases the likelihood of red blood cell (RBC) transfusion and its associated risks. The objective of this study was to identify demographic, medical, and surgical factors that may predict the need for RBC transfusion in patients undergoing benign gynaecological surgery. Methods We performed a retrospective cohort study of patients undergoing benign gynaecological surgery between April 1st 2016 to March 31st 2017 in a tertiary care hospital. Log binomial regression model was used to calculate risk ratios and adjusted risk ratios, while controlling for the effect of preoperative anaemia. Results Among the 988 patients included, 41 patients (4.1%) received an RBC transfusion and 185 (18.7%) had preoperative anemia. In the total cohort, mean haemoglobin was 126.19+/-15.43g/L, while itwas 104.39+/-21.59g/L among those who received RBC transfusion. Patients had an increased risk of requiring RBC transfusion if they had preoperative anemia (RR 8.37[95%CI 4.48-15.64]), abnormal uterine or vaginal bleeding (RR 2.47[95%CI 1.21-5.03]), underwent vaginal/hysteroscopic myomectomy (RR 6.28[95%CI 1.82-21.69]), or had a salpingectomy (RR 2.13[95%CI 1.01-4.48]). Risk of RBC transfusion was lower among patients with vaginal hysterectomy (RR 0.08[95%CI 0.01-0.57]) and prolapse repair (RR 0.06[95%CI 0.01-0.44]). After controlling for preoperative anemia, only vaginal/hysteroscopic myomectomy showed increased risk of requiring RBC transfusion (RR 3.36[95%CI 1.13-10.01]). Conclusions Preoperative anemia and vaginal/hysteroscopic myomectomy are important independent risk factors for predicting the need for increased RBC transfusion in the peri-operative period. Identifying risk factors can facilitate peri-operative management to minimize the need for transfusion.