Red Cell Transfusion Research Articles

A prospective study evaluating patterns of liver siderosis in beta-thalassemia major patients undergoing splenectomy

Background: Hepatic iron overload resulting from multiple red cell transfusions over a long period of time is a complication of thalassemia major. Hepatocellular iron deposits with a decreasing gradient from periportal to centrilobular areas in the liver have been referred to as the HH pattern and those deposits primarily in reticuloendothelial cells and macrophages with occasional heterogeneous deposits in periportal hepatocytes are referred to as the non-HH pattern. Aims and Objectives: The purpose of this study was to evaluate patterns of liver siderosis in these patients and correlate with number of units of blood transfused. Materials and Methods: Thirty beta-thalassemia patients were selected, having splenomegaly and during splenectomy, liver biopsy was taken and sent for histopathology examination and pattern of siderosis was noted as HH (Hepatocytes), non-HH (Reticuloendothelial cells/Kupffer cells/macrophages) or HH; non-HH (Mixed). Results: Mean number of units transfused was 48.429±9.53 (SD) for patients having HH pattern of liver siderosis whereas it was 58.667±13.27 (SD) for patients having HH; non-HH pattern of liver siderosis. Independent-samples non-parametric Mann–Whitney U test was performed and P-value was found to be 0.028 which emphasized that total number of units of blood transfused vary significantly with two groups showing different patterns of siderosis. Conclusion: Hence, pattern of liver siderosis can be a good indicator for transfusional iron overload in beta-thalassemia major patients.

Hypoxic storage of donor red cells preserves deformability after exposure to plasma from adults with sickle cell disease.

Red cell (RBC) transfusions are beneficial for patients with sickle cell disease (SCD), but ex vivo studies suggest that inflamed plasma from patients with SCD during crises may damage these RBCs, diminishing their potential efficacy. The hypoxic storage of RBCs may improve transfusion efficacy by minimizing the storage lesion. We tested the hypotheses that (1) The donor RBCs exposed to the plasma of patients in crisis would have lower deformability and higher hemolysis than those exposed to non-crisis plasma, and (2) hypoxic storage, compared to standard storage, of donor RBCs could preserve deformability and reduce hemolysis. 18 SCD plasma samples from patients who had severe acute-phase symptoms (A-plasma; n=9) or were at a steady-state (S=plasma; n=9) were incubated with 16 RBC samples from eight units that were stored either under conventional(CRBC) or hypoxic(HRBC) conditions. Hemolysis and microcapillary deformability assays of these RBCs were analyzed using linear mixed-effect models after each sample was incubated in patient plasma overnight at 37°C RESULTS: Relative deformability was 0.036 higher (p < 0.0001) in HRBC pairs compared to CRBC pairs regardless of plasma type. Mean donor RBC hemolysis was 0.33% higher after incubation with A-plasma compared to S-plasma either with HRBC or CRBC (p=0.04). HRBCs incubated with steady-state patient plasma demonstrated the highest deformability and lowest hemolysis. Hypoxic storage significantly influenced RBC deformability. Patient condition significantly influenced post-incubation hemolysis. Together, HRBCs in steady-state plasma maximized donor red cell ex vivo function and survival.

84 A PROSPECTIVE AUDIT OF THE MANAGEMENT OF POSTOPERATIVE ANAEMIA IN PATIENTS AFTER OPERATIVE MANAGEMENT OF NECK OF FEMUR FRACTURES

Abstract Background There is limited evidence available to guide the diagnosis and management of anaemia and iron deficiency in post operative patients. Numerous guidelines from professional associations exist for the management of pre-operative anaemia. We identified an international consensus statement that provided guidance on patient care with respect to postoperative anaemia and iron deficiency. Our aim was to determine if our practice was consistent with the best practice recommendations of this document. Methods We conducted a prospective audit on a convenience sample of patients over the age of 60 with neck of femur fractures who underwent operative management between January and April 2022. We collected data on pre and post operative haematological indices including haemoglobin, serum iron, ferritin and transferrin saturation as well as data on patients who received IV iron and red cell transfusions. Results We included 50 patients with neck of femur fractures who underwent hip replacement. All patients had post-op haemoglobin levels performed. Fifteen (30%) patients fulfilled the criteria for diagnosis of postoperative iron deficiency. Only 4/15 of these patients received IV iron postoperatively. Four patients who did not fulfil criteria for post-op iron deficiency received IV iron. Two patients had a post-op haemoglobin between 7-8g/dL and appropriately received red cell transfusions. Four patients received red cell transfusions despite having post-op haemoglobin levels &amp;gt;8g/dL. Conclusion Our findings indicated approximately 1/3 of patients fulfilled criteria for post operative iron deficiency while only a small proportion were treated for this. More data is required to establish the impact of post-op anaemia management strategies on functional recovery and quality of life as well as laboratory and interventional endpoints. A local protocol for the management of post operative iron deficiency with and without anaemia will be developed.

Role of Thromboelastogram in monitoring the activation of the coagulation pathway and assessing the associated risk factors for hypercoagulable state in transfusion dependent thalassemia patients

BackgroundThromboembolic events are rare but one of the fatal complications in thalassemia. Assessment of the hypercoagulable state is not done regularly, and we have assessed the utility of Thromboelastography (TEG) for monitoring the activation of the coagulation pathway in patients with thalassemia. MethodologyA prospective single-center cohort study was conducted in a tertiary care set-up. Transfusion Dependent Thalassemia patients registered with the pediatric unit were screened for hypercoagulability using TEG during six months of the study period and followed up for three years for the development of thromboembolic events. Patient demographics, history of splenectomy, Serum ferritin levels and annual red cell transfusion requirement (mL/kg/year) were assessed. TEG parameters used were R time, K time, alpha angle, Maximum amplitude, Clot index, and Lysis 30. The thrombin generation test (V Curve) obtained from the first-degree derivate of the TEG velocity curve was also used for analysis. ResultsA total of 34 patients were recruited during the six months study period with an average age of 10.6 years ( ± 5.47). The average pre-transfusion hemoglobin level and the volume of packed red cells received were 7.24 g/dL and 152.82 mL/kg/year respectively. The TEG tracing was suggestive of a hypercoagulable state in 58.82% of patients. The mean values of angle (70.74), MA (64.16), CI (2.65) and TG (774.43) in TDT patients compared to age matched reference range (62.81, 57.99, 0.8, 577.83 respectively) was suggestive of prothrombotic changes. Annual blood transfusion requirement was negatively correlated with hypercoagulable status (‐0.344, CI= -0.68 to 0.08). One out of 34 patients developed corona radiata infarct (with annual blood requirement; 112.7 mL/kg/Year). The risk to develop a hypercoagulable state appeared to be higher when the volume of RBCs transfused was less than 154 mL/kg/Year. ConclusionTDT patients are at risk of developing thromboembolism, and screening with TEG may be useful to identify those at high risk.

Application of Topical Tranexamic Acid Reduces Postoperative Blood Loss after Posterior Spinal Fusion with Instrumentation in Patients with Adolescent Idiopathic Scoliosis

Purpose: There is limited literature regarding the topical use of tranexamic acid (TXA) to control postoperative bleeding during spinal deformity correction and fusion procedures, which often require blood transfusions. This study aimed to evaluate the effect of topical TXA on postoperative blood loss in patients undergoing deformity correction and posterior spinal fusion (PSF) surgeries. Methods: A retrospective study was conducted between January 2011 and April 2017 in 51 patients with adolescent idiopathic scoliosis who underwent long-segment PSF with hybrid thoracic-hook pedicle screw instrumentation or pedicle-screw-alone constructs. Twenty-five patients were assigned to receive topical TXA (1 g/20 mL), and the drain was clamped for 2 h. Twenty-six patients in the control group were treated with antifibrinolytic agents. Results: Median drainage blood loss, median day of drain removal, and median postoperative hospitalization were significantly lower in the topical TXA group (all p &lt;0.05). The postoperative packed red cell transfusion rate was significantly lower in the topical TXA group than that in the control group (15 of 25, 60% vs. 23 of 26, 88.5%; p=0.02; risk ratio, 0.68; 95% confidence interval, 0.48–0.96). Conclusions: The use of topically administered 1 g TXA in AIS patients undergoing instrumented PSF effectively reduced postoperative transfusion requirements, decreased the total amount of drainage blood loss, reduced the time till drain removal, and shortened the length of postoperative hospitalization.

Are Viscoelastic Tests Clinically Useful to Identify Platelet-Dependent Bleeding in High-Risk Cardiac Surgery Patients?

Postoperative use of platelet function testing to rule out microvascular bleeding due to platelet dysfunction after cardiac surgery still lacks strong reference data and reliable cutoff values, yielding a clinically adequate sensitivity and specificity. The present study aims to investigate the performance of two different point-of-care viscoelastic devices and platelet aggregometry in expressing surgery-dependent platelet dysfunction and anticipating postoperative major bleeding in a cohort of high-risk patients. Prospective cohort study of 50 adult patients who were on antiplatelet drugs discontinued for no more than 7 days (clopidogrel and prasugrel) or 5 days (ticagrelor) undergoing cardiac surgery with cardiopulmonary bypass (CPB). Coagulation and platelet function testing, including QUANTRA, ROTEM, and Multiplate, were assessed preoperatively and postoperatively. Chest drain blood loss was measured in the first 12 postoperative hours. Perioperative bleeding was assessed using a modified version of the Universal Definition of Perioperative Bleeding (UDPB) in cardiac surgery, modified to not consider anemia-correcting packed red cells transfusions in the absence of bleeding >600 mL/12 h. Major bleeding was identified as UDPB class II or higher. Multiplate adenosine diphosphate (ADPtest) was significantly ( P = .001) reduced after CPB, whereas TRAPtest was not. The platelet component (PC) as extrapolated by ROTEM data (EXTEM MCF-FIBTEM MCF) was unchanged after CPB, while the A10 PC (PC at 10 minutes) was significantly ( P = .001) reduced. The QUANTRA platelet contribution to clot stiffness (PCS) was significantly ( P = .001) reduced, as well. At the ROC analysis for the predictive ability of the post-CPB platelet function testing, the best discrimination was obtained by the QUANTRA PCS, with an area under the curve (AUC) (95% confidence interval [CI]) of 0.80 (0.66-0.91), P = .001, followed by the ROTEM A10 PC with AUC (95% CI) of 0.75 (0.51-0.99), P = .004, and PC with AUC (95% CI) of 0.74 (0.50-0.99), P = .009. The Multiplate ADPtest had an AUC (95% CI) of 0.67 (0.42-0.91), and the TRAPtest had an AUC (95% CI) of 0.62 (0.37-0.86). The cutoff values identified were 13 hPa for the QUANTRA PCS, 40 mm for the ROTEM A10, and 48.5 mm for the ROTEM PC, with negative predictive values of 84%, 81%, and 86%, respectively, and positive predictive values of 55%, 53%, and 69%, respectively. QUANTRA PCS, ROTEM A10 PC, and Multiplate ADPtest showed a significant decrease after CPB, whereas ROTEM PC and Multiplate TRAPtest did not. Major bleeding was predicted with a moderate to good discrimination by the post-CPB viscoelastic tests (PCS, PC, and A10 PC).

T002: Treatment related morbidity in patients with classical Hodgkin Lymphoma: results of the ongoing, randomized phase III HD21 Trial by The German Hodgkin Study Group

Introduction: PET-guided treatment of newly diagnosed advanced stage (AS) classical Hodgkin Lymphoma (cHL) patients with eBEACOPP (escalated doses of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procar-bazine, prednisone) achieves outstanding survival outcomes, but also causes relevant treatment-related morbidity (TRMB). CD30-targeted therapy with brentuximab vedotin (BV) has proven high efficacy and favorable tolerability in patients with cHL. In the HD21 study, we hypothesized that using BV to remodel the eBEACOPP regimen could further decrease TRMB while maintaining its high efficacy. Here, we report the final analysis of the TRMB endpoint. Methods: Adult patients ≤ 60 years of age with AS-cHL were included in this international randomized phase III trial. Patients were randomized in a 1:1 ratio to PET2-guided 4–6 cycles of either standard eBEACOPP or experimental BrECADD treatment (BV, etoposide, cyclophosphamide, doxorubicin, dacarbazine, dexamethasone). PET2 was assessed by blinded panel review (PP-2). Reduction of TRMB was the first part of the co-primary endpoint, whereas non-inferiority of progression-free survival (PFS) was the second part. TRMB was defined as any CTCAE grade 3 or 4 organ toxicity or grade 4 hematological toxicity (anemia, thrombocytopenia, infection) during treatment. TRMB was determined using the Cochran-Mantel-Haenszel method. Stratification factors included sex, age, IPS, and location of trial site. Categorical variables were compared using fisher’ s exact test. Exploratory analyses were performed for further safety outcome parameters. The trial was registered at clinicaltrials.gov (NCT02661503) and conducted according to ICH-GCP guidelines. Results: Between July 2016 and August 2020, we enrolled 1,500 patients from 9 countries. 1,470 patients are in the intention-to-treat (ITT) population (eBEACOPP n=732, BrECADD n=738). Baseline characteristics such as sex (male=56%), age (≤45 years=79%), IPS (0–2=54%), location (Europe=92%) and stage (III/IV=84%) were well balanced between treatment arms. As recommended by PP2, 59% of patients had 4 cycles and 41% received 6 cycles of therapy, without differences between treatment groups. TRMB was documented in 59% of patients in the eBEACOPP group (rel-risk, 1.41; 95% CI, 1.27–1.56, p<0.001) and 42% in the BrECADD group (rel-risk, 0.72; 95% CI, 0.65–0.79, p<0.001). The relative risk estimates remained stable among stratification factors. In the eBEACOPP group 52% of patients had hematological TRMB events compared to 31% in the BrECADD group (p<0.001). At least one red cell transfusion was given in 22% of patients in the eBEACOPP group and in 8% in the BrECADD group and at least one platelet transfusion in 13% and 6%, respectively. Severe leukopenia was observed in 94% and 87%, respectively. TRMB organ toxicity was documented in 17% of patients in the eBEACOPP group and 19% in the BrECADD group (p=0.455). Conclusion: The BrECADD regimen shows a significant and clinically relevant reduction of treatment-related morbidities compared to eBEACOPP in patients with newly diagnosed AS-cHL.

Therapeutic Effects of Mesenchymal Stem Cells Expressing Erythropoietin on Cancer-Related Anemia in Mice Model.

Cancer-related anemia (CRA) negatively influences cancer patients' survival, disease progression, treatment efficacy, and quality of life (QOL). Current treatments such as iron therapy, red cell transfusion, and erythropoietin-stimulating agents (ESAs) may cause severe adverse effects. Therefore, the development of long-lasting and curative therapies is urgently required. In this study, a cell and gene therapy strategy was developed for in vivo delivery of EPO cDNA by way of genetic engineering of human Wharton's jelly mesenchymal stem cells (hWJMSCs) to produce and secrete human EPO protein for extended periods after transplantation into the mice model of CRA. To evaluate CRA's treatment in cancer-free and cancerous conditions, first, a recombinant breast cancer cell line 4T1 which expressed herpes simplex virus type 1 thymidine kinase (HSV1-TK) by a lentiviral vector encoding HSV1-TK was developed and injected into mice. After three weeks, all mice developed metastatic breast cancer associated with acute anemia. Then, ganciclovir (GCV) was administered for ten days in half of the mice to clear cancer cells. Meanwhile, another lentiviral vector encoding EPO to transduce hWJMSCs was developed. Following implantation of rhWJMSCs-EPO in the second group of mice, peripheral blood samples were collected once a week for ten weeks from both groups. Analysis of peripheral blood samples showed that plasma EPO, hemoglobin (Hb), and hematocrit (Hct) concentrations significantly increased and remained at therapeutic for >10 weeks in both treatment groups. Data indicated that rhWJMSCs-EPO increased the circulating level of EPO, Hb, and Hct in both mouse subject groups and improved the anemia of cancer in both cancer-free and cancerous mice.

Site‐specific venous thrombosis in essential thrombocythemia: Impact on subsequent vascular events and survival

Site‐specific venous thrombosis in essential thrombocythemia: Impact on subsequent vascular events and survival

S3637 Not Your Usual Gastritis - A Case of Iron Deficiency Anemia Leading to a Rare Diagnosis of Collagenous Gastritis

Introduction: Collagenous gastritis (CG) is a rare disease characterized by deposition of subepithelial collagen in the gastric mucosa with concomitant inflammatory infiltrate in the lamina propria on histopathology. We report a rare case of CG in a young adult who was treated successfully with topical open capsule budesonide. Case Description/Methods: An 18-year-old male presented to the clinic for evaluation of iron deficiency anemia associated with exertional dyspnea, fatigue and intermittent episodes of melena. Initial studies were significant for hemoglobin of 5 g/dl, serum ferritin 3 ng/mL, serum iron 19 mcg/dL, and iron saturation of 6%. Prior to our evaluation, he had undergone EGD which was reported as having “gastritis” with negative Helicobacter pylori histopathology testing. The patient had required intravenous iron and packed red cell transfusions. We pursued repeat endoscopic evaluation. EGD showed hematin in the stomach with diffuse nodularity and friability in the stomach. No distinct ulcers were seen. Colonoscopy and video capsule endoscopy did not demonstrate any other abnormalities. Biopsies from the stomach revealed thickening of subepithelial collagen plate associated with chronic inflammation consistent with collagenous gastritis. Trichrome stain highlighted the thickened collagen plate and CD117 stain showed scattered mast cells without clustering. Treatment with budesonide 9 mg daily was subsequently started with clinical and hematological response on follow-up. (Figure) Discussion: CG can be further characterized to two distinct phenotypes seen in children and adults. In young patients, the disease often occurs in isolation and presents with symptoms of abdominal pain and anemia. Endoscopic features include nodular patterns, mucosal atrophy and collagen band deposition seen in both age groups. Treatments of this condition remains a challenge due to lack of established effective therapy. Prior reports with conventional treatments such as anti-secretary agents, iron supplementation, hypoallergenic diet, and systemic corticosteroids have produced limited success. Topical budesonide has emerged as effective treatment options in achieving clinical and histopathological improvement. CG is a rare entity that should be kept in mind in young patients who present with iron deficiency and nodularity seen on endoscopic evaluation. Our case adds to the growing body of literature in support of topical budesonide in treatment of CG.Figure 1.: Image A shows diffuse nodular mucosa in the gastric body on EGD. Image B shows thickening of subepithelial collagen plate associated with marked chronic inflammation.

Risk Assessment of Red Cell Transfusion in Congenital Heart Disease.

Background The storage time of packed red blood cells (pRBC) is an indicator of change in the product's pH, potassium, and lactate levels. Blood–gas analysis is a readily available bedside tool on every intensive care ward to measure these factors prior to application, thus facilitating a calculated decision on a transfusion's quantity and duration. Our first goal is to assess the impact of storage time on pH, potassium, and lactate levels in pRBC. The influence of those parameters in the transfused children will then be evaluated.Methods In this retrospective study, we conducted blood–gas analyses of pRBC units before they were administered over 4 hours to neonates, infants, and children in our pediatric cardiac intensive care ward. All patients underwent regular blood–gas analyses themselves, before and after transfusion. Results We observed a highly significant correlation between the storage time of pRBC units and a drop in pH, as well as an increase in potassium and lactate of stored red cells ( p < 0.0001). Median age of recipients with a complete blood–gas dataset was 0.1 (interquartile range [IQR] = 0.0–0.7) years; median pRBC storage duration was 6 (IQR = 5–8) days. Further analyses showed no statistically significant effect on children's blood gases within 4 hours after transfusion, even after stratifying for pRBC storage time ≤7 days and >7 days. Conclusion Stored red blood cells show a rapid decrease in pH and increase in potassium and lactate. Slow transfusion of these units had no adverse effects on the recipients' pH, potassium, and lactate levels.

When should RhD-negative recipients be spared the transfusion of DEL red cells to avoid anti-D alloimmunization?

When should RhD-negative recipients be spared the transfusion of DEL red cells to avoid anti-D alloimmunization?

A randomized trial of blood donor iron repletion on red cell quality for transfusion and donor cognition and well-being

AbstractAlthough altruistic regular blood donors are vital for the blood supply, many become iron deficient from donation-induced iron loss. The effects of blood donation–induced iron deficiency on red cell transfusion quality or donor cognition are unknown. In this double-blind, randomized trial, adult iron-deficient blood donors (n = 79; ferritin < 15 μg/L and zinc protoporphyrin >60 μMol/mol heme) who met donation qualifications were enrolled. A first standard blood donation was followed by the gold-standard measure for red cell storage quality: a 51-chromium posttransfusion red cell recovery study. Donors were then randomized to intravenous iron repletion (1 g low-molecular-weight iron dextran) or placebo. A second donation ∼5 months later was followed by another recovery study. Primary outcome was the within-subject change in posttransfusion recovery. The primary outcome measure of an ancillary study reported here was the National Institutes of Health Toolbox–derived uncorrected standard Cognition Fluid Composite Score. Overall, 983 donors were screened; 110 were iron-deficient, and of these, 39 were randomized to iron repletion and 40 to placebo. Red cell storage quality was unchanged by iron repletion: mean change in posttransfusion recovery was 1.6% (95% confidence interval −0.5 to 3.8) and −0.4% (−2.0 to 1.2) with and without iron, respectively. Iron repletion did not affect any cognition or well-being measures. These data provide evidence that current criteria for blood donation preserve red cell transfusion quality for the recipient and protect adult donors from measurable effects of blood donation–induced iron deficiency on cognition. This trial was registered at www.clinicaltrials.gov as NCT02889133 and NCT02990559.

Perioperative blood transfusion in major abdominal cancer surgery: a multi-centre service evaluation and national survey.

Anaemia is associated with complications and death after surgery. Perioperative red-cell transfusion triggers are not well defined in patients having oncological surgery, or with cardiovascular disease. We carried out a prospective multicentre cohort study and a clinician survey of UK transfusion practice in adult patients undergoing surgery for abdominal malignancy. The primary outcome was red cell transfusion. Secondary outcomes were transfusion trigger haemoglobin, incidence of complications, length of hospital stay, and acute hospital mortality. In this prospective cohort study, data were collected on 412 patients undergoing surgery for intrabdominal malignancy in 14 NHS hospitals. Twenty-two (5.2%) patients received preoperative, 42 (10.2%) intraoperative, and 52 (12.2%) postoperative red blood cell transfusion. The mean postoperative transfusion trigger was 75.3 g L-1, and the mean number of units of red blood cells transfused was 1.5 (standard deviation, 1.1). Seventeen (4.0%) patients had a documented postoperative troponin elevation. Five (1.2%) patients died within 30 days of surgery. In the survey, 117 clinicians submitted complete responses, of whom 62 (53%) indicated that a transfusion threshold of 70 g L-1 was appropriate: however, this decreased to six (5.1%) if there was evidence of recent cardiac ischaemia. There were 100 (86%) respondents who indicated equipoise for a trial of restrictive vs liberal transfusion, decreasing to 56% if there was coexisting cardiovascular disease. Many patients having oncological surgery receive red cell transfusion, the majority being given postoperatively. Restrictive transfusion practice is generally followed; however, variability exists especially in cardiovascular disease. Equipoise exists for a study of transfusion thresholds in this group.

Hyperhaemolysis Syndrome: A Review of Cases

Hyperhaemolysis is characterized by a haemolytic transfusion reaction that leads to life-threatening anaemia. It is usually suspected when there is a drop in haemoglobin level at least 24 hours after receiving allogeneic red cell transfusion. Decreasing haematocrit level, failure to respond to repeated RBC transfusions, markedly elevated LDH, absent haptoglobin, and gross haemoglobinuria are all suggestive of a haemolytic process. The aim of this review is to summarize and evaluate the cases from published literature to determine the features, management and outcome of reported cases of hyperhaemolysis syndrome.

438 Packed Red Cell Transfusion in Acute Surgical Patients, Are We Over-Transfusing?

Abstract Aim To improve a general surgical department's adherence to NICE guidelines on transfusion of packed red cells for low haemoglobin by improving knowledge of relevant haemoglobin thresholds (70g/L or 80g/L in ACS or renal failure requiring chronic transfusion). Method All patients admitted to a large London teaching hospital under the general surgical team in a 4-month period (2020–2021) were audited using their electronic records. Audited data was units transfused; pre-transfusion haemoglobin, heart rate, and blood pressure; pertinent medical history; and location of transfusion (ward/theatre). 10 patients were excluded due to being transfused perioperative or because of haemodynamic instability (covered under different guidelines). 16 patients and a total of 31 units were included in the audit. The interventions were 1) distribution of a poster showing the NICE guideline, reasoning for the guideline, and baseline data; and 2) a teaching session for junior doctors (FY1 to registrar). Results The proportion of transfusions adhering to guidelines increased from 33% (6/18) at baseline to 60% (3/5) after intervention 1 and 100% (8/8) after intervention 2. The combined post-intervention score of 85% (11/13) was statistically significant compared to the baseline (p=0.013). Conclusions Acute surgical patients were frequently over-transfused with packed red cells; risking adverse reactions and increased re-bleeding. An education programme aimed at junior doctors was successful in significantly increasing adherence to national guidelines on transfusion and improving patient care. Simple educational methods are therefore effective at improving care by promoting evidence-based practice. Future auditing would aid in assessing the sustainability of this improvement.

Complications of repeated percutaneous transhepatic biliary drainage (PTBD) for palliation of obstructive jaundice in cholangiocarcinoma patient

Background: Cholangiocarcinoma, a malignancy of the biliary duct system, has been recognized as the second most common cause of biliary tract and primary liver malignancies. The incidence has increased in the last three decades worldwide. Percutaneous transhepatic biliary drainage (PTBD) has been considered a highly important palliative therapy for bile duct obstruction due to its high success rate and low incidence of cholangitis. However, bleeding and catheter dislodgment are still found during the procedure. This case discusses the complications of repeated PTBD stent placement as palliative therapy in a patient with obstructive jaundice due to cholangiocarcinoma. Case Presentation: A 58-year-old female presented with a chief complaint of weakness and pain on the right side of the abdomen, particularly at the site of PTBD stent installation three days before being admitted to Dr. Soetomo General Hospital. In 2017, the patient was diagnosed with cholangiocarcinoma­ with obstructive jaundice and had undergone PTBD procedure five times during the period of July 2017 to March 2018 due to biliary leakages. Laboratory investigation indicated elevated bilirubin, decreased potassium, increased random blood sugar, increased blood urea nitrogen, high levels of the 2-hour postprandial blood glucose, and elevated HbA1c, suggesting the conditions of cholangiocarcinoma with obstructive jaundice complicated with hypokalemia, acute kidney injury and type-2 diabetes. The blood smear also indicated normochromic normocytic anisopoikilocytosis anemia and leukocytosis. The patient improved after PTBD replacement, antibiotics treatment, packed red cells transfusion, and rehydration therapy. Conclusion: This case highlights that the complication of PTBD could occur relatively frequently and to prevent the complications in patients with post-PTBD regular medical check-up is therefore recommended. In addition, it is also critical to improve the patient knowledge on how to prevent the bleeding and to avoid the conditions that are potentially increase the chance of catheter dislodgment.

The Influence of Blood Storage Time on the Potassium Level of Patients Receiving Packed Red Cell (PRC) Transfusion in Adam Malik General Hospital, Medan

The Influence of Blood Storage Time on the Potassium Level of Patients Receiving Packed Red Cell (PRC) Transfusion in Adam Malik General Hospital, Medan

Anemia Profile in Pediatric Patients at Pediatric Intensive Care Unit (PICU) of Dr. Soetomo General Academic Hospital

Introduction: Anemia often occurs in critically ill children and is associated with increased morbidity and mortality in women and children and impaired cognitive and behavioral development in children. Objective: This study aims to understand the profile and characteristics of anemia patients in the critical care population. Materials and Methods: This is a retrospective, descriptive study of the patient's medical records. Data were collected by the total sampling technique. Results: Among 203 patients, 52% were anemic at admission to the Pediatric Intensive Care Unit (PICU), while 45% were anemic at discharge. Anemia tends to be more common in older age and male individuals with their chief complaints being respiratory symptoms, higher mean Red Cell Distribution Width (RDW) levels, and poorer nutritional status. There were 84 patients (41%) who received Packed Red-Cells (PRC) transfusions, among them there were 54 patients (51%) who were anemic at PICU admission. Of the 84 patients who received PRC transfusions during their PICU stay and 43 patients (47%) were anemic on PICU discharge. Conclusion: Anemia is quite common in critically ill children and is dominated by male patients aged under 5 years. Anemia also mostly happens in patients with higher organ dysfunction scores and poorer nutritional status than nonanemic patients. Half of the patients with anemia at the PICU also received PRC blood transfusion.

Systemic bevacizumab as salvage therapy for persistent severe bleeding and anemia in heyde syndrome following aortic valve replacement.

Heyde syndrome is characterized by the co-occurrence of aortic stenosis and bleeding gastrointestinal angiodysplasias, often with acquired von Willebrand syndrome. Current management for bleeding includes hematologic support with red cell transfusion and intravenous iron and correction of aortic stenosis with valve replacement. However, persistent Heyde syndrome after valve replacement occurs in a significant minority of cases, and there is no accepted therapy for these patients. Given that the pathophysiology of angiodysplasia formation in Heyde syndrome involves dysregulated angiogenesis, targeting angiogenesis may be an effective therapeutic option. We describe two cases of persistent Heyde syndrome with severe bleeding and anemia in patients following aortic valve replacement who were treated with systemic bevacizumab, a monoclonal antibody directed against vascular endothelial growth factor. In both cases, treatment was successful, with resolution of bleeding, liberation from hematologic support, and normalization of hemoglobin. In addition to responding to therapy, neither patient had treatment-related adverse events (and both had recurrent anemia upon treatment discontinuation, further evidence of the therapeutic impact of bevacizumab). Additional investigation into the use of systemic antiangiogenic therapy for treatment of Heyde syndrome is warranted.