Red Blood Cell Transfusion Thresholds Research Articles

Health Care–Associated Infection After Red Blood Cell Transfusion

The association between red blood cell (RBC) transfusion strategies and health care-associated infection is not fully understood. To evaluate whether RBC transfusion thresholds are associated with the risk of infection and whether risk is independent of leukocyte reduction. MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Cochrane Database of Sytematic Reviews, ClinicalTrials.gov, International Clinical Trials Registry, and the International Standard Randomized Controlled Trial Number register were searched through January 22, 2014. Randomized clinical trials with restrictive vs liberal RBC transfusion strategies. Twenty-one randomized trials with 8735 patients met eligibility criteria, of which 18 trials (n = 7593 patients) contained sufficient information for meta-analyses. DerSimonian and Laird random-effects models were used to report pooled risk ratios. Absolute risks of infection were calculated using the profile likelihood random-effects method. Incidence of health care-associated infection such as pneumonia, mediastinitis, wound infection, and sepsis. The pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity (I2 = 0%; τ2 <.0001). The number needed to treat (NNT) with restrictive strategies to prevent serious infection was 38 (95% CI, 24-122). The risk of infection remained reduced with a restrictive strategy, even with leukocyte reduction (RR, 0.80 [95% CI, 0.67-0.95]). For trials with a restrictive hemoglobin threshold of <7.0 g/dL, the RR was 0.82 (95% CI, 0.70-0.97) with NNT of 20 (95% CI, 12-133). With stratification by patient type, the RR was 0.70 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery and 0.51 (95% CI, 0.28-0.95) in patients presenting with sepsis. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight. Among hospitalized patients, a restrictive RBC transfusion strategy was associated with a reduced risk of health care-associated infection compared with a liberal transfusion strategy. Implementing restrictive strategies may have the potential to lower the incidence of health care-associated infection.

Variation in red blood cell transfusion thresholds in critically ill patients

Restrictive transfusion practice in recent randomized trials and systematic reviews continues to have favorable outcomes [1]. Despite this, substantial variability in transfusion practice persists [2]. It is important to identify contemporary variability, and which patient, provider, and institutional factors drive this variability. Therefore, we performed a retrospective analysis hypothesizing that red blood cell (RBC) transfusion practice remains variable and is influenced by patient characteristics and institutional transfusion culture.

Evidence review: Periprocedural use of blood products

Blood product transfusion has not been subject to rigorous clinical study, and great practice variations exist. Of particular concern to hospitalists is the use of red blood cells, plasma, and platelets prior to invasive procedures to correct anemia or perceived bleeding risk. We summarize the known risks associated with periprocedural anemia, prolonged international normalized ratio (INR), and thrombocytopenia, as well as the effects of blood product administration on clinical outcomes. Clinical trial evidence argues for a restrictive red blood cell transfusion threshold (a hemoglobin level of 7-8 g/dL or symptomatic anemia) for most perioperative patients. There are no high-quality data to guide plasma and platelet transfusions around the time of procedures. Available data do not support the use of prothrombin time/INR to guide prophylactic administration of plasma, and there are scarce data to guide platelet use around the time of an invasive procedure. Therefore, we rely on current consensus expert opinion, which recommends administration of plasma in moderate- to high-risk procedures when INR is >1.5. We recommend platelet transfusion in low-risk procedures when platelet count is <20,000/μL, for average-risk procedures when platelet count is <50,000/μL, and for procedures involving the central nervous system when the platelet count is <100,000/μL.

Restrictive versus liberal red blood cell transfusion thresholds in very low birth weight infants: A systematic review and meta‐analysis

A systematic review was conducted to examine the effects of restrictive versus liberal red blood cell (RBC) transfusion thresholds on clinically important outcomes in very low birth weight (VLBW) infants. Randomised controlled trials (RCTs) of varying RBC transfusion thresholds in VLBW infants were identified by searching MEDLINE, EMBASE, CINAHL, all of the Cochrane Library and other supplementary sources. Selected studies included one of the following outcomes: total number of red blood cell transfusions, donor exposure rate, cranial ultrasonographically diagnosed brain injury, retinopathy of prematurity, bronchopulmonary dysplasia, necrotising enterocolitis or death. Studies to be included were selected by two reviewers who also assessed the risk of bias of each trial. Data extraction and analyses were independently performed by two reviewers. All data were analysed using RevMan 5. Six RCTs were identified. One trial did not meet the inclusion criteria, while two had inadequate methodological quality. Pooled analysis of two trials showed that the restrictive transfusion group received a significantly lower mean number of transfusions per infant (mean difference (MD) -1.35, 95% confidence interval (CI) [-2.61, -0.09]) and donor exposure rate (MD -0.54, 95% CI [-0.93, -0.15]). No other statistically significant differences were observed. Restrictive RBC transfusion thresholds in VLBW infants may be utilised without incurring clinically important increases in the risk of death or major short-term neonatal morbidities.

Bleeding Kinetics after Total Hip or Knee Replacement: A Prospective Observational Study

Background and objectives: The objective was to assess the kinetics of postoperative bleeding after total hip or knee replacement, with or without administration of tranexamic acid, in order to anticipate red blood cell transfusion thresholds in the recovery room. Materials and methods: This was a prospective, observational, single-center study. All patients undergoing primary or revision total hip or knee replacement were enrolled for two months. Patients were managed using a multimodal strategy designed to reduce the need for red blood cell transfusion. Postoperative bleeding kinetics was assessed according to the drop of hemoglobin levels between the arrival in the recovery room and day one after surgery. Results: A total of 106 patients were included. The mean transfusion rate was 18%. Nadir hemoglobin levels were observed on day + 2, and about 60% of bleeding occurred during the postoperative period, with a drop of 1.2 ± 0.2 g/dL between the recovery room and day one for patients receiving tranexamic acid, and 1.9 ± 0.2 g/dL for those not receiving tranexamic acid (p=0.018). Discussion: In our center, the hemoglobin transfusion threshold in recovery room might be raised by 1 or 2 g/ dL depending on whether tranexamic acid is used.

Clinical and research issues in neonatal anemia and thrombocytopenia

Anemia and thrombocytopenia are the most common hematological problems in neonates. Red blood cell (RBC) and platelet transfusions are the mainstays of therapy, but data to guide neonatal transfusion practices have been sparse. Recombinant hematopoietic growth factors represent another therapeutic alternative, but their use in this population requires a solid understanding of the developmental differences between fetal and adult hematopoiesis. Recently, follow-up studies from children randomized as neonates to either liberal or restrictive RBC transfusion approaches were published. Results of these studies have so far been contradictory and have generated more questions than answers. New developmental stage-specific problems associated with RBC transfusions were also uncovered, such as the transfusion-associated necrotizing enterocolitis. Finally, two thrombopoietin (Tpo) mimetics were approved by the FDA for the treatment of adults with chronic immune thrombocytopenia, thus offering a novel potential therapeutic alternative for thrombocytopenic neonates. In this review, we will discuss the currently available data regarding neonatal RBC and platelet transfusion thresholds, as well as the potential limitations, and concerns associated with the use of erythropoietin and Tpo mimetics in this patient population. Finally, we will point out specific areas wherein additional research is critically needed.

What Is the Role of Red Blood Cell Transfusion Threshold on Number of Transfusions in Pediatric Patients After Hematopoietic Stem Cell Transplant?

Abstract 1263 Background:Hematopoietic stem cell transplant (HSCT) is offered as curative therapy for many childhood cancers, hematologic disorders, and metabolic diseases. Modern supportive care includes transfusion of red blood cells (RBCs) until hematopoietic recovery. Most pediatric institutions have a pre-determined threshold at which patients are transfused to avoid complications of anemia.The Transfusion Strategies for Patients in Pediatric Intensive Care Units (TRIPICU) trial showed that lowering the RBC transfusion threshold to a hemoglobin (Hb) of 7 g/dl, down from 9.5 g/dl, resulted in 50% fewer patients receiving a transfusion. There was no difference in outcome with respect to worsened multi-organ dysfunction (Lacroix et al, 2007).Unlike the majority of PICU patients, HSCT patients have a prolonged period of marrow aplasia, which makes it difficult to extrapolate the results of the TRIPICU study to this patient population. The objective of this study was to evaluate the impact of a difference in transfusion threshold of 2 g/dl (8 g/dl vs. 10 g/dl) on RBC utilization in the first 28 days post-transplant. We hypothesized that while a lower transfusion threshold will be associated with fewer RBC transfusions, it will not change the overall percent of patients who receive an RBC transfusion. Methods:This study was an IRB-approved retrospective chart review of patients 1–21 years old who had their first HSCT at either Children’s Hospital Colorado at the University of Colorado, Aurora, CO (UCD) or Amplatz Children’s Hospital at the University of Minnesota, Minneapolis, MN (UMN) between 1999–2009. During this time, the RBC transfusion threshold at UCD was 10 g/dl and at UMN was 8 g/dl. Transfusion events were defined as those resulting from a single order regardless of number of units or ml/kg transfused.Patients were divided into 5 groups: 1) autologous (auto) transplant for lymphoma, 2) auto transplant for solid tumor (excluding brain tumors), 3) cord-blood allogeneic (allo) transplant, 4) bone marrow allo transplant, and 5) peripheral blood stem cell (PBSC) allo transplant. The Mann-Whitney U test was used to determine a difference in the means between groups. Results:Overall, more than 98% of patients had ≥1 RBC transfusions. In all groups, patients at UCD had a higher average daily Hb than at UMN. This difference was also seen pre-transplant; at UCD Day 0 average Hb was 11.0 g/dl (range: 8.2–13.9) and at UMN, 9.4 g/dl (6.5–13.7). In both the auto groups, patients at UCD received significantly more RBC transfusions than patients at UMN (Table 1). In allo patients, irrespective of stem cell source, there was no difference in the number of RBC transfusions at UCD and UMN. There was no signficant difference in the time to engraftment between the 2 institutions (data not shown).Table 1Average Hb and RBC transfusions in patient cohorts at UCD and UMN. The number of patients per cohort is given in parentheses below hemoglobin. Data are expressed as the mean ± SEM. *Lower than UCD (p <0.05)Average Daily Hb (g/dl)RBC TransfusionsUCDUMNUCDUMNAutoLymphoma10.80 ± 0.10 n=219.92 ± 0.11* n=253.6 ± 0.62.3 ± 0.3*Solid tumor11.00 ± 0.07 n=609.92 ± 0.13* n=455.0 ± 0.73.6 ± 0.3*AlloCord Blood10.90 ± 0.05 n=1009.50 ± 0.06* n=1425.7 ± 0.35.0 ± 0.2Bone Marrow11.25 ± 0.07 n=439.57 ± 0.06* n=1033.7 ± 0.34.0 ± 0.2PBSC11.27 ± 0.22 n=109.92 ± 0.29* n=135.3 ± 1.53.8 ± 0.8 Conclusion:Almost all patients in this study received at least 1 RBC transfusion in the first 28 days post-transplant. A 2-g/dl difference in RBC transfusion threshold resulted in a ∼1.3-g/dl difference in average daily Hb in the patients at UMN versus UCD. However, there was only a difference in the number of RBC transfusion events between the patients undergoing auto transplant; patients at UCD received about 1.3 transfusions more than their counterparts at UMN. There was a non-significant trend toward increased transfusions in allo patients at UCD receiving either cord blood or PBSC. These data suggest that RBC transfusion trigger is not the sole predictor of RBC utilization in pediatric HSCT patients. Other variables (e. g., patient and disease factors, pre-transplant Hb, and institutional transfusion strategies) likely contribute to a patient’s RBC utilization post-transplant. Prospective studies are needed to investigate these and other factors that affect number of RBC transfusions pediatric HSCT patients receive in the initial post-transplant period. Disclosures:No relevant conflicts of interest to declare.

A Survey of Transfusion Practices in Pediatric Stem Cell Transplant Patients,

Abstract 3370 Background:Until recovery of bone marrow function, pediatric hematopoietic stem cell transplant (HSCT) patients are dependent on prophylactic red blood cell (RBC) and platelet transfusions to avoid the complications associated with anemia and thrombocytopenia. Current transfusion thresholds represent a balance between the risks of transfusion and the risks of anemia and bleeding. There has never been a prospective randomized, controlled trial to evaluate optimal transfusion practices in pediatric patients with prolonged hypo-proliferative anemia and thrombocytopenia. In the absence of specific evidence-based guidelines, there are a variety of clinical practices. This survey was designed to ascertain current transfusion practices in pediatric HSCT patients: both standard prophylactic thresholds as well as clinical circumstances that lead to the change in these thresholds. We hypothesized that there would be variation in transfusion practices for both red blood cells and platelets among pediatric stem cell transplant centers. Methods:Individual directors of pediatric stem cell transplant programs were identified through the Children's Oncology Group member roster (n=83) and were invited via email to participate in a web-based survey (Surveymonkey.com, LLC) regarding the transfusion practices in pediatric HSCT patients at their institutions. A total of 57 individuals responded to the survey for a response rate of 69%. Results:Of the 57 respondents, 95% reported having transfusion thresholds for platelet and RBC transfusions. The hemoglobin thresholds that prompted RBC transfusion ranged from 6–10 g/dl; 62% of institutions reported using 8 g/dl, 26% used ≤ 7 g/dl, 12% used ≥ 8.5 g/dl. Respondents were asked about five hypothetical clinical scenarios under which they would change a patient’s RBC threshold. The percent of respondents who would increase a patient’s threshold is given in parentheses: hypoxia (94%), cardiac disease (75.5%), sepsis (64%), patient comfort (56.6%), and fever (15.4%). Additional reasons to increase RBC threshold included active bleeding, transplant for hemoglobinopathy, or serious illness (i.e., on a ventilator or continuous veno-venous hemodialysis).For platelet transfusion thresholds, respondents were evenly split between using a platelet count of 10 × 109/L and 20 × 109/L (44% and 47%, respectively). A minority of institutions had no threshold (4%) and the remainder used 15 × 109/L. Clinical scenarios that would prompt an increase in platelet transfusion threshold included hematuria (100%), grade III/IV mucositis (56.4%), sepsis (50.9%), and fever (25.5%). Additional situations suggested by respondents included active bleeding, sickle cell disease, persistent CNS tumor, and on anticoagulation therapy.There was no correlation between the number of transplants performed per year at an institution and the thresholds used for RBC and platelet transfusions. Also, institutions that had a transfusion threshold of 7 g/dl for RBC transfusions were slightly more likely to have the lower platelet threshold of 10 × 109/L than 20 × 109/L (60% versus 40%, respectively). Institutions that used 8 g/dl were more evenly split with regards to platelet transfusion threshold: 47% used 10 × 109/L and 53% used 20 × 109/L. Conclusions:There is a paucity of evidence-based transfusion guidelines in pediatric HSCT patients and this survey was designed to evaluate what RBC and platelet transfusion thresholds are currently being used in practice. These data demonstrate equipoise between the different transfusion strategies, which is important in the design of prospective randomized, controlled trials to evaluate the optimal RBC and platelet transfusion thresholds in these patients. Future directions for research include establishing evidence-based transfusion guidelines for both uncomplicated pediatric HSCT patients as well as those with common post-transplant complications. Disclosures:No relevant conflicts of interest to declare.

A Survey of Standardized Management Protocols After Coronary Artery Bypass Grafting Surgery in Canadian Intensive Care Units

Background Patients undergoing surgical coronary revascularization typically recover in an intensive care unit where many aspects of patient care are protocolized despite absence of widespread evidence-based guidelines on perioperative management. It was hypothesized that the postoperative management strategies varied significantly among units. Methods We surveyed 31 Canadian cardiac surgical intensive care units to obtain their postoperative standing orders. Management strategies after coronary bypass surgery were compared to identify areas of variability in the care of frequent clinical scenarios. Results In all, 28 units (90%) responded, and 26 sites (84%) reported using at least 1 formal postoperative protocol. All but 1 of the responding units (96%) have specific orders for coronary artery bypass graft patients. Orders for allogeneic red blood cell transfusion threshold, postoperative extubation pathway, analgesia, and atrial fibrillation management were present in 40%, 74%, 60%, and 57% of the responding units, respectively. A protocolized trigger to notify the surgeon was specified for bleeding and hypotension in 75% and 35% of the centres, respectively. A standing order for aspirin administration was used in 91% of the centres, and statin administration was mentioned in 41%. Despite the frequent use of protocols in postoperative care, the content of the protocol varied significantly from centre to centre. Conclusion The majority of Canadian centres use at least 1 formal protocol for the care of the postoperative coronary revascularization patient. There is, however, significant variability in these management protocols. Future studies should examine whether implementation of standardized protocols improves outcomes and what treatment strategies are optimal in postoperative cardiac surgical patients.

Red blood cell transfusion thresholds in pediatric patients with sepsis*

In children with severe sepsis or septic shock, the optimal red blood cell transfusion threshold is unknown. We analyzed the subgroup of patients with sepsis and transfusion requirements in a pediatric intensive care unit study to determine the impact of a restrictive vs. liberal transfusion strategy on clinical outcome. Subgroup analysis of a prospective, multicenter, randomized, controlled trial. Multicenter pediatric critical care units. Stabilized critically ill children (mean systemic arterial pressure >2 sd below normal mean for age and cardiovascular support not increased for at least 2 hrs before enrollment) with a hemoglobin ≤ 9.5 g/dL within 7 days after pediatric critical care unit admission. One hundred thirty-seven stabilized critically ill children with sepsis were randomized to receive red blood cell transfusion if their hemoglobin decreased to either <7.0 g/dL (restrictive group) or 9.5 g/dL (liberal group). In the restrictive group (69 patients), 30 patients did not receive any red blood cell transfusion, whereas only one patient in the liberal group (68 patients) never underwent transfusion (p < .01). No clinically significant differences were found for the occurrence of new or progressive multiple organ dysfunction syndrome (18.8% vs. 19.1%; p = .97), for pediatric critical care unit length of stay (p = .74), or for pediatric critical care unit mortality (p = .44) in the restrictive vs. liberal group. In this subgroup analysis of children with stable sepsis, we found no evidence that a restrictive red cell transfusion strategy, as compared to a liberal one, increased the rate of new or progressive multiple organ dysfunction syndromes. Furthermore, a restrictive transfusion threshold significantly reduced exposure to blood products. Our data suggest that a hemoglobin level of 7.0 g/dL may be safe stabilized for children with sepsis, but further studies are required to support this recommendation.

Red blood cell transfusion thresholds in pediatric septic patients

Red blood cell transfusion thresholds in pediatric septic patients

Red blood cell transfusion thresholds in pediatric septic patients

In children with severe sepsis or septic shock, the optimal red blood cell (RBC) transfusion threshold is unknown. We analyzed the subgroup of patients with sepsis in the TRIPICU (Transfusion Requirements in Pediatric Intensive Care Units) study in order to determine the impact of a restrictive versus liberal transfusion strategy on clinical outcome.

Red Blood Cell Transfusion Threshold in Postsurgical Pediatric Intensive Care Patients: A Randomized Clinical Trial

Red Blood Cell Transfusion Threshold in Postsurgical Pediatric Intensive Care Patients: A Randomized Clinical Trial

Red Blood Cell Transfusions in the Neonate

Despite recent trends to decrease allogeneic red blood cell (RBC) transfusion thresholds, such transfusions remain an important supportive and life-saving intervention for neonatal intensive care patients. In neonates, apart from concerns about transfusion-associated infections, many controversial questions regarding transfusion practices remain unanswered. Moreover, neonates present specific clinical and immunologic characteristics that require selected blood component products. This article addresses many of these issues from a medical perspective, with emphasis on the best blood banking techniques to provide RBC products for neonatal transfusions.

Related Myeloablative Stem Cell Transplantation (SCT) to Cure Sickle Cell Anemia (SCA): Update of French Results

AbstractAbstract 3518 Background:Despite progress made in sickle cell anemia (SCA) management, such as the prevention of pneumococcal infections, introduction of hydroxyurea therapy and early cerebral vasculopathy detection with transcranial Doppler, SCA remains a disease with high risk of morbidity and early death. Allogeneic hematopoietic stem cell transplantation (HSCT) is the only curative treatment for SCA; nevertheless, its use has been limited by the risk of transplant-related mortality (TRM). Our first experience, reported in Blood 2007, included 87 consecutive severe SCA- patients transplanted in France between 1988 and Dec-2004. We showed that the introduction of rabbit anti-thymocyte globulin (ATG) in the conditioning regimen in 2000 allowed a significant reduction of the rejection rate from 22.6% to 3% and that the outcome improved significantly with time as the DFS rate among the 44 patients transplanted after January 2000 was 95.3%. These data have justified continuing to transplant symptomatic young sickle cell patients having a geno-identical donor with the same conditioning regimen (CR) consisting of intravenous Busulfan (BU), Cyclophosphamide (CY) and rabbit ATG. Patients and Methods:In France, from 1992 to 2010, 144 SCA-patients (84M, 60F) have now been transplanted with a geno-identical donor using BU-CY-ATG as CR at the median age of 9.0 years (range:3.2-27.5). Transplants were performed in 16 different centers but 60 were performed in Hopital St-Louis and 21 in Hopital Debré in Paris. All recipients were SS or Sb0 and 76% of them were CMV+. All had been transfused and 47% had received more than 20 units. The source of cells was the bone marrow (BM) (n=121), cord blood (CB) alone (n=21), CSP (n=1) or BM+CB (n=1). GvHD prophylaxis consisted of the association of cyclosporine (CSA)-short MTX for BMT and CSA alone for CBT. Results:Engraftment was successful in 141/144; the time to absolute neutrophil count > 500/mm3 was significantly shorter after BMT compared to CBT (mean ± SD; 21.3 ± 6.7 vs 32.1 ± 9.8, respectively; p<0.001) and platelets reached 50,000/mm3 sooner after BMT (day 28.3 ± 16.6) than after CBT (day 48.5 ± 20.3; p<0.001). No engraftment occurred in 3 cases (1 BMT, 2 CBT) with gradual autologous reconstitution, and one rejection was observed 3 years post-transplant. GvHA grade ≥ II occurred in 23% of patients, GvHA ≥ III in 4.4%, chronic GvH in 9.6% (extensive in 3 cases). No GvHD ≥ II or chGvHD were observed after CBT. Death occurred in 6 cases (4 were GvHD-related, 1 hemorrhagic stroke in a patient with severe cerebral vasculopathy with Moya and 1 sepsis in aplasia). No veno-occlusive disease was observed, but hemorrhagic cystitis (n=4), EBV proliferative disease requiring anti-CD20 therapy (n=1), nephrotic syndrome (n=1), and cerebral vasculopathy not SCA-related (n=1) were. Despite preventive measures such as anticonvulsant prophylaxis, strict control of hypertension, swift magnesium replacement, and an increase in the red blood cell and platelet transfusion thresholds to 9 g/dL and 50,000/mm3, respectively, seizures and posterior leukoencephalopathy, albeit reversible, remained a particularly frequent adverse effect of CSA and steroid therapy. Replacing CSA in 2002 by mycophenolate mofetil in case of GvHD requiring steroid therapy resulted in a significant reduction of the rate of these complications. With a median follow-up of 3.1 years (range 0.2–15.5), the overall survival at 3 yr was 95% (95%CI:91-99%). Considering as events the non-engraftments, rejections and deaths, the event-free survival (EFS) was 92.9% (95%CI:88.3-97.5). However, comparing the results before (n=23) and after 2000 (n=121) showed significant improvement of EFS at 3 yr: 73.9% (95%CI: 55.5–92.3) for transplants performed before 2000 vs 96.8% (95%CI:93.2-100) after 2000. Conclusion:These results with 121 patients transplanted since 2000 confirm that it is possible to offer more than 95% chances of cure to SCA-children, indicating that HLA-geno-identical HSCT after myeloablative conditioning with ATG should be considered as standard of care for SCA children, not only for those at high risk of stroke but also for children experiencing crises or other complications requiring intensive therapy such as transfusion program or hydroxyurea. Sibling cord-blood cryopreservation should be systematically offered and pre-implantation genetic diagnosis coupled with HLA selection discussed with the parents. Disclosures:No relevant conflicts of interest to declare.

Red Blood Cell Transfusion Threshold in Postsurgical Pediatric Intensive Care Patients

The optimal transfusion threshold after surgery in children is unknown. We analyzed the general surgery subgroup of the TRIPICU (Transfusion Requirements in Pediatric Intensive Care Units) study to determine the impact of a restrictive versus a liberal transfusion strategy on new or progressive multiple organ dysfunction syndrome (MODS). The TRIPICU study, a prospective randomized controlled trial conducted in 17 centers, enrolled a total of 648 critically ill children with a hemoglobin equal to or below 9.5 g/dL within 7 days of pediatric intensive care unit (PICU) admission to receive prestorage leukocyte-reduced red-cell transfusion if their hemoglobin dropped below either 7.0 g/dL (restrictive) or 9.5 g/dL (liberal). A subgroup of 124 postoperative patients (60 randomized to restrictive and 64 to the liberal group) were analyzed. This study was registered at http://www.controlled-trials.com and carries the following ID ISRCTN37246456. Participants in the restrictive and liberal groups were similar at randomization in age (restrictive vs. liberal: 53.5 +/- 51.8 vs. 73.7 +/- 61.8 months), severity of illness (pediatric risk of mortality [PRISM] score: 3.5 +/- 4.0 vs. 4.4 +/- 4.0), MODS (35% vs. 29%), need for mechanical ventilation (77% vs. 74%), and hemoglobin level (7.7 +/- 1.1 vs. 7.9 +/- 1.0 g/dL). The mean hemoglobin level remained 2.3 g/dL lower in the restrictive group after randomization. No significant differences were found for new or progressive MODS (8% vs. 9%; P = 0.83) or for 28-day mortality (2% vs. 2%; P = 0.96) in the restrictive versus liberal group. However, there was a statistically significant difference between groups for PICU length of stay (7.7 +/- 6.6 days for the restrictive group vs. 11.6 +/- 10.2 days for the liberal group; P = 0.03). In this subgroup analysis of pediatric general surgery patients, we found no conclusive evidence that a restrictive red-cell transfusion strategy, as compared with a liberal one, increased the rate of new or progressive MODS or mortality.

Transfusion management of sickle cell patients during bone marrow transplantation with matched sibling donor

Sickle cell disease (SCD) patients have unique transfusion considerations during bone marrow transplantation (BMT), including prophylaxis against stroke and alloimmunization. Characterization of transfusion requirements is important for blood bank and clinician patient management. A retrospective analysis of red blood cell (RBC) and platelet (PLT) transfusion of SCD patients during myeloablative matched sibling donor (MSD) BMT at one institution from 1993 to 2007 was performed. Patient characteristics (RBC blood group antibodies, ABO-incompatible donor, BMT-related morbidity) and transfusion practices (RBC phenotype matching, transfusion threshold, and blood age) were assessed for effect on total RBC transfusion volumes. Twenty-seven patients received MSD BMT with 96% survival and 0% rejection. Six alloimmunized patients received RBCs with extended phenotype matching (C, c, E, e, K, Fy(a), Jk(b)), 14 nonalloimmunized received limited matching (C, c, E, e, K), and 7 did not have phenotype matching. Among 26 survivors, a median seven RBC transfusions (range, 3-15) and 13.5 PLT transfusions (range, 4-48) per patient were administered, equivalent to 64 mL/kg RBCs (range, 22-122 mL/kg) and 106 mL/kg PLTs (range, 26-343 mL/kg). BMT-related morbidity predicted increased RBC transfusions (p = 0.006). Venoocclusive disease was associated with greater RBC (p = 0.016) and PLT transfusion volumes (p = 0.016). Greater phenotype matching was associated with decreased RBC transfusions (p = 0.0247). SCD patients have high transfusion support during MSD BMT. Communication of BMT complications to the blood bank is essential for transfusion inventory management. Phenotype matching decreased RBC transfusions in this cohort and warrants further investigation in SCD transfusion therapy.

Red blood cell transfusion in the treatment and management of anaemia: the search for the elusive transfusion trigger

Therapeutic red blood cell (RBC) transfusion is widely utilized in the management of anaemia. Critically ill intensive care unit (ICU) patients in particular, as well as medical and haematology-oncology patients, are among the largest groups of users of RBC products. While anaemia is common in these patients, its treatment and management, including appropriate thresholds for RBC transfusion, remain controversial. We review here the function of RBCs in oxygen transport and physiology, with a view to their role in supporting and maintaining systemic tissue oxygenation. Adaptive and physiological compensatory mechanisms in the setting of anaemia are discussed, along with the limits of compensation. Finally, data from clinical studies will be examined in search of evidence for, or against, a clinically relevant transfusion trigger.

Prognostic Impact of Blood Transfusion After Primary Angioplasty for Acute Myocardial Infarction: Analysis From the CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) Trial

We sought to determine the relationship between red blood cell (RBC) transfusion and clinical outcomes in patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). The implications of RBC transfusion in patients undergoing primary PCI for AMI have not been evaluated. Clinical outcomes of patients from the prospective, randomized CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) trial were analyzed by administration of in-hospital RBC transfusion not related to coronary artery bypass surgery. Of 2,060 randomized patients, 82 (3.98%) received RBC transfusion during the index hospitalization, including 33 (1.60%) with moderate/severe bleeding and 49 (2.38%) without overt major bleeding. Transfusion was independently associated with baseline anemia (odds ratio [95% confidence interval]: 4.44 [2.60 to 7.58], p < 0.0001), older age (1.03 [1.01 to 1.06], p = 0.002), triple-vessel disease (2.54 [1.47 to 4.38], p = 0.0008), and female sex (1.04 [1.02 to 1.06], p = 0.0008). Patients transfused versus not transfused had significantly higher rates of 1-year mortality (23.9% vs. 3.4%), disabling stroke (2.5% vs. 0.5%), reinfarction (7.0% vs. 2.2%), and composite major adverse cardiac events (41.0% vs. 16.6%) (all p values < 0.01). After multivariable adjustment for potential confounders including transfusion propensity, RBC transfusion was independently associated with mortality at 30 days (hazards ratio: 4.71, p = 0.0005) and 1 year (hazards ratio: 3.16, p = 0.0005). An RBC transfusion after primary PCI in AMI may be harmful, which is consistent with the findings from other studies after PCI in the noninfarct setting. Alternatively, RBC transfusion may be a marker of markedly increased risk. Randomized studies are warranted to determine the optimal threshold for RBC transfusion in patients with AMI undergoing mechanical reperfusion therapy.

Restrictive Versus Liberal Red Blood Cell Transfusion Strategies for Preterm Infants: A Systematic Review of Randomized Controlled Trials

Background: Many neonatal intensive care units have introduced restrictive transfusion policies for preterm infants. The justification for such an approach is debatable. Objective: To systematically review the evidence from randomized controlled trials (RCTs) on the benefit to risk ratio of lower versus higher red blood cell transfusion thresholds in preterm infants. Methods: Systematic review based on an electronic literature search (09/2007) in PubMed and CENTRAL (Cochrane Library, Issue 3 2007) for RCTs on different transfusion strategies in preterm infants. Results: Seven fully published RCTs including 712 preterm infants with various gestational and postnatal ages were found to be eligible for inclusion in this systematic review. Transfusion thresholds differed between trials, as did the duration of studies, the reported outcomes and the methodological quality. The largest RCT included 451 Extremely-Low-Birth- Weight (ELBW) infants, was of high methodological quality and found no difference in reducing mortality before discharge home or survival with any of either severe retinopathy of prematurity, bronchopulmonary dysplasia or brain injury. Conclusions: Clinical and methodological heterogeneity between studies prevents firm conclusions based on the totality of available evidence. According to the results of the largest RCT, maintaining a higher hemoglobin level in ELBW infants seems to confer little clinical benefit. Keywords: Systematic review, preterm infants, transfusion threshold, restrictive, liberal