Restrictive Blood Transfusion Strategy Research Articles

Efficacy and safety of restrictive versus liberal blood transfusion strategies in acute myocardial infarction and anemia: a systematic review and meta-analysis of randomized controlled trials.

Blood transfusion strategies in patients with acute myocardial infarction (AMI) and anemia are yet to be conclusively identified. Thus, we aim to assess the efficacy and safety of restrictive versus liberal blood transfusion strategies for AMI and anemia. A systematic review and meta-analysis of randomized controlled trials (RCTs) retrieved from PubMed, web of science, SCOPUS, EMBASE, and Cochrane Central Register of Controlled Trials were performed through November 2023. We used RevMan V. 5.4 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI). (PROSPERO): ID: CRD42023490692. We included four RCTs with 4.325 patients. There was no significant difference between both groups regarding MACE whether at 30 days (RR: 0.93 with 95% CI [0.57-1.51], P = 0.76) or ≥ six months (RR: 1.17 with 95% CI [0.95-1.45], P = 0.14), all-cause mortality at 30 days (RR: 1.16 with 95% CI [0.95-1.40], P = 0.14) or ≥ six months (RR: 1.16 with 95% CI [0.88-1.53], P = 0.28). However, the liberal strategy was significantly associated with increased hemoglobin level change (MD: -1.44 with 95% CI [-1.68 to -1.20], P < 0.00001). However, the restrictive strategy was significantly associated with a lower incidence of acute lung injury (RR: 0.11 with 95% CI [0.02-0.60], P = 0.01). There was no significant difference between the restrictive blood transfusion strategy and the liberal blood transfusion strategy regarding the clinical outcomes. However, restrictive blood transfusion strategy was significantly associated with a lower incidence of acute lung injury than liberal blood transfusion strategy.

Effect of a restrictive vs. liberal blood transfusion strategy among patients with acute myocardial infarction and anemia according to heart failure. A subgroup analysis of the REALITY trial

Abstract Background/Introduction The optimal Red Blood Cell (RBC) transfusion strategy in patients with acute myocardial infarction (MI) and anemia remains debated. In REALITY, the largest randomized trial to date in this population (n=666), a restrictive compared with a liberal transfusion strategy resulted in a noninferior rate of major adverse cardiovascular events (MACE; composite of all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia) at 30 days, but did not achieve non-inferiority at 1 year. One of the main concerns with RBC transfusion is the risk of fluid overload and acute heart failure (HF). Therefore, the balance of benefit and risk of transfusions strategies may differ between patients with and without heart failure. Purpose We aimed to evaluate the potential interaction between HF and RBC transfusion on outcomes in REALITY. Methods HF was defined as either a history of heart failure or Killip class &amp;gt; 1 at randomization (data available for 658 patients). All events until day 30, including HF, were adjudicated by a Critical Event Committee blinded to the transfusion arm and hemoglobin levels. The primary clinical outcome was MACE at 30 days. Secondary endpoints included MACE at one year, individual components of MACE and new onset of heart failure at 30 days and 1 year. Results Among 658 patients, 311 (47.3 %) had HF. HF patients had a higher rate of MACE and a higher rate of new HF than patients without HF at 30 day and at 1 year (Fig 1). There was no interaction between HF and the effect of randomized assignment on the primary outcome or on new HF. In contrast, a liberal strategy was associated with increased all-cause death at 30 days and at 1 year in patients with HF but not in pts without HF (interaction p = 0.0088 and p = 0.049 respectively, Fig 1). Conclusion(s) Heart failure is frequent in MI patients with anemia (nearly half of the patients) and is associated with higher risks of MACE and of HF. While no interaction was observed between HF and transfusion strategies on the primary outcome of MACE, a liberal transfusion strategy was associated with higher all-cause mortality than a restrictive strategy both at 30-days and 1 year. The mechanism of this interaction deserves further investigation.

Complication Rates and Survival of Nonagenarians after Hip Hemiarthroplasty versus Proximal Femoral Nail Antirotation for Intertrochanteric Fractures: A 15-Year Retrospective Cohort Study of 113 Cases.

Intertrochanteric fracture is a very common but serious type of hip fracture in nonagenarians. The surgical treatment remains a significant challenge for orthopedists. The objective of this study was to investigate postoperative complications and survival outcomes compared between bipolar hemiarthroplasty (HA) and proximal femoral nail anti-rotation (PFNA) in nonagenarians with intertrochanteric fractures, and to evaluate the efficacy and safety of the two surgical procedures in this patient population. A total of 113 consecutive nonagenarians who underwent bipolar HA or PFNA for the treatment of intertrochanteric fractures from January 2006 to August 2021 were retrospectively studied in the current paper. There were 34 males and 79 females, with a mean age of 92.2 years (range 90-101 years) at the time of operation. The average duration of follow-up was 29.7 months (range 1-120 months). The full cohort was divided into bipolar HA (77 cases) and PFNA (36 cases) groups. Damage control orthopedics was used to determine the optimal surgery time and assist in perioperative management. A restrictive blood transfusion strategy was employed, along with appropriate adjustments under multidisciplinary assessment, throughout the perioperative period. Perioperative clinical information and prognostic data were analyzed. Kaplan-Meier survival curves were used for survival analysis, and landmark analysis divided the entire follow-up period into 1-12 months (short-term), 13-42 months (medium-term) and 43-120 months (long-term) according to the configurations of Kaplan-Meier survival curves. Both groups had similar general variables except for the proportion of high adjusted Charlson comorbidity index (aCCI) (≥6 points) (6.5% in bipolar HA group and 22.2% in PFNA group, p = 0.024). Intraoperative blood loss and transfusion requirements were greater, and the intraoperative transfusion rates were higher in the bipolar HA group compared to the PFNA group (all p < 0.05). The complications rates, 1- to 60-month cumulative all-cause mortality, postoperative optimal Harris hip score (HHS), and Barthel index (BI) presented no significant difference between the two groups (all p > 0.05). Both groups had similar overall survival curves (p = 0.37). However, landmark analysis revealed that bipolar HA group exhibited higher survival rates in medium-term (p = 0.01), while similar survival rates were observed in the short- and long-term post-operation periods (both p > 0.05). Cox regression with survival-time-dependent covariate calculated the hazard ratio (HR) of bipolar HA was 0.41 in medium-term (p = 0.039). Bipolar HA is equally effective and reliable as PFNA for treating intertrochanteric fractures in nonagenarians. Despite resulting in more intraoperative blood loss and transfusions, bipolar HA therapy is associated with a higher medium-term survival rate compared to PFNA treatment. The application of damage control orthopedics and precise perioperative patient blood management could contribute to the positive clinical outcomes observed in this patient population.

Preoperative Anemia and Female Gender are Risk Factors for Transfusion in Patients Undergoing Coronary Artery Bypass Grafting with a Restrictive Transfusion Strategy.

Red blood cell (RBC) transfusion in cardiac surgery is associated with increased morbidity and mortality. Even when using patient blood management methods, blood transfusions may still be needed in cardiac surgery. This study examined the risk factors for blood transfusion in isolated coronary artery bypass graft (CABG) surgery with a restrictive transfusion strategy, along with individualized patient blood management. We enrolled 198 patients (age, 61.8 ± 9.9 years; 28 females and 170 males) who underwent isolated CABG surgery in a single private hospital using a restrictive transfusion strategy between April 2015 and October 2020. Pre-, intra-, and postoperative parameters were compared between patients with and without RBC transfusions. The risk factors for transfusion and transfusion probability were analyzed. Patients who received RBC transfusions had higher European System for Cardiac Operative Risk Evaluation values (13.60 ± 18.27%). Preoperative hematocrit (Hct) [odds ratio (OR)=0.752; 95% confidence interval (CI) 0.639-0.884; P=0.001] and female gender (OR=7.874; 95% CI 1.678-36.950; P=0.009) were significant independent risk factors for RBC transfusion in logistic regression analysis. When the preoperative Hct was 30%, the RBC transfusion probability was 61.08% in females and 16.6% in males. Patients who received RBC transfusions had longer intensive care unit (31.40 ± 25.42 hours) and hospital (11.18 ± 6.75 days) stays. Risk factors for RBC transfusion in isolated CABG surgery with a restrictive blood transfusion strategy were preoperative anemia and female gender.

Restrictive vs liberal blood transfusion strategy for patients with burn trauma: a systematic review and meta-analysis

British Journal of Hospital MedicineVol. 84, No. 5 PosterRestrictive vs liberal blood transfusion strategy for patients with burn trauma: a systematic review and meta-analysisValerie J Dirjayanto, Jasmine V Anjani, Tazkiya P Ariviani, Febriyan N Satria, Raisa ZM Abubakar, Cut A Rhania, Muhammad A ArsyafValerie J DirjayantoCorrespondence to: Valerie J Dirjayanto; E-mail Address: [email protected]Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this author, Jasmine V AnjaniFaculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this author, Tazkiya P ArivianiFaculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this author, Febriyan N SatriaFaculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this author, Raisa ZM AbubakarFaculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this author, Cut A RhaniaFaculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this author, Muhammad A ArsyafFaculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this authorValerie J Dirjayanto; Jasmine V Anjani; Tazkiya P Ariviani; Febriyan N Satria; Raisa ZM Abubakar; Cut A Rhania; Muhammad A ArsyafPublished Online:4 May 2023https://doi.org/10.12968/hmed.2023.0144AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Docherty AB, O’Donnell R, Brunskill S et al. Effect of restrictive versus liberal transfusion strategies on outcomes in patients with cardiovascular disease in a non-cardiac surgery setting: systematic review and meta-analysis. BMJ. 2016;352:i1351. https://doi.org/10.1136/bmj.i1351 Crossref, Medline, Google ScholarGomez M, Cartotto R, Knighton J, Smith K, Fish JS. Improved survival following thermal injury in adult patients treated at a regional burn center. J Burn Care Res. 2008;29(1):130-137 Crossref, Medline, Google ScholarHiggins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-60. https://doi.org/10.1136/bmj.327.7414.557 Crossref, Medline, Google ScholarJeschke MG, Chinkes DL, Finnerty CC, Przkora R, Pereira CT, Herndon DN. Blood transfusions are associated with increased risk for development of sepsis in severely burned pediatric patients. Crit Care Med. 2007;35(2):579583. https://doi.org/10.1097/01.CCM.0000253812.09236.98 Crossref, Google ScholarKwan P, Gomez M, Cartotto R. Safe and successful restriction of transfusion in burn patients. J Burn Care Res. 2006;27(6):826-834. https://doi.org/10.1097/01.BCR.0000245494.45125.3E Crossref, Medline, Google ScholarMoher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. https://doi.org/10.1371/journal. pmed.1000097 Crossref, Medline, Google ScholarPalmieri TL, Holmes JH 4th, Arnoldo B et al. Transfusion Requirement in Burn Care Evaluation (TRIBE): a multicenter randomized prospective trial of blood transfusion in major burn injury. Ann Surg. 2017;266(4):595-602. https://doi.org/10.1097/SLA.0000000000002408 Crossref, Medline, Google ScholarPalmieri TL, Holmes JH, Arnoldo B et al. 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Assessing the risk of bias of individual studies in systematic reviews of health care interventions. 2012. https://www.ncbi.nlm.nih.gov/books/NBK91433/ (accessed 18 April 2023) Google ScholarWells GA, Shea B, O’Connell D et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2000. https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp (accessed 18 April 2023) Google ScholarZhang Y, Xu Z, Huang Y et al. Restrictive vs. Liberal red blood cell transfusion strategy in patients with acute myocardial infarction and anemia: a systematic review and meta-analysis. Front Cardiovasc Med. 2021;8:736163. https://doi.org/10.3389/fcvm.2021.736163 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetails 2 May 2023Volume 84Issue 5ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 4 May 2023 Published in print 2 May 2023 Information© MA Healthcare LimitedPDF download

Restrictive versus liberal transfusion for anemic patients with acute myocardial infarction: Systematic review and meta-analysis

• Meta-analysis of RCTs comparing transfusion thresholds for patients with acute MI and anemia failed to exclude either appreciable harm or benefit. • The mechanism by which blood transfusions are thought to improve outcomes in patients with MI and anemia requires further investigation. • Additional research utilizing published results from larger randomized controlled trials is needed to understand the relative safety of liberal to restrictive blood transfusion strategies and overcome the quality limitations of current evidence. The optimal blood transfusion threshold for patients with acute myocardial infarction (MI) and anemia is unclear. This meta-analysis aimed to assess the safety of restrictive transfusion to liberal thresholds. We searched MEDLINE, EMBASE, Web of Science, and CENTRAL for randomized controlled trials comparing different transfusion strategies in patients with acute MI. Two independent reviewers screened the studies for inclusion, extracted data, evaluated methodological quality, and assessed the quality of evidence. Primary outcomes were all measured at 30-days post-randomization and included: All-cause mortality, heart failure, recurrent MI, and stroke. A random-effects model was used. Our searches yielded a total of 5980 unique results. Three studies were eligible and included in the analysis (n = 821 patients). In all studies, the restrictive and liberal thresholds were equivalent to 8g/dL and 10g/dL hemoglobin, respectively. There was no significant difference in all-cause mortality (RR = 0.63; 95% CI 0.15 to 2.66; P = 0.53; I 2 = 59%), heart failure (RR = 1.17; 95% CI 0.31 to 4.34; P = 0.82; I 2 = 70%), recurrence of MI (RR = 1.61; 95% CI 0.65 to 4.02; P = 0.30; I 2 = 0%), or stroke (RR = 1.41; 95% CI 0.27 to 7.43; P = 0.69; I 2 = 0%). Our meta-analysis found no significant difference in the primary outcomes between transfusion strategies for patients with acute MI and anemia. Results from trials with larger sample sizes is needed to clarify the dilemma between transfusion strategies in this population.

Restrictive versus Liberal Blood Transfusion Strategy in Patients With Acute Myocardial Infarction: A Meta-Analysis of Randomized Clinical Trials.

BackgroundA meta-analysis of observational studies comparing differences in outcomes between restrictive blood transfusion (RBT) and liberal blood transfusion (LBT) in patients with acute myocardial infarction (AMI) reported that LBT is associated with higher all-cause mortality. Few randomized clinical trials (RCTs) have compared RBT to LBT in patients with AMI and anemia, but no meta-analysis of RCTs was performed to date.AimTo assess the clinical effect of RBT compared to LBT in patients with AMI and anemia regarding was all-cause mortality, recurrent MI, revascularization, and heart failure exacerbation.MethodsThe electronic databases Ovid MEDLINE, EMBASE, Cochrane Central, Scopus, and Google Scholar, were systematically searched to identify eligible studies published before June 19th, 2021. RCTs that assessed the effect of RBT compared to LBT were included. The primary endpoint was all-cause mortality. Secondary endpoints included recurrent MI, revascularization, and heart failure exacerbation.ResultsThree RCTs with 821 patients were included (421 received RBT, and 400 received LBT). The mean age was 75.9 ± 6.1 years, and 56% were male. Our meta-analysis showed that RBT was not associated with reduced all-cause mortality (RR = 1.61; 95% CI = 0.38–6.96, p = 0.52), recurrent MI (RR = 0.98; 95% CI = 0.48–1.96, p = 0.94), revascularization (RR = 1.18; 95% CI = 0.26–5.44, p = 0.83) and heart failure exacerbation (RR = 0.86; 95% CI = 0.23–3.22, p = 0.82) when compared to LBT.ConclusionRBT was not associated with reduced all-cause mortality, recurrence of MI, need for revascularization, or heart failure exacerbation in patients with AMI and anemia compared to LBT. A larger RCT is required to confirm the above findings.

Management of safe and adequate blood supply in covid-19 pandemic amid national lockdown: Experience of a standalone blood center in India

Background and Objectives: Blood centers around the globe are dependent on voluntary blood donation from healthy individuals to meet their blood supplies. The severe acute respiratory syndrome coronavirus-2 pandemic has become one of the most critical global health emergencies of modern times. Blood transfusion service (BTS) in India faced numerous challenges during the COVID-19 outbreak and the following imposed country lockdown. We aim to identify the challenges faced by a standalone blood center and explore the mitigation strategies implemented during the COVID-19 pandemic and subsequent lockdown. Methods: A cross-sectional study conducted at a standalone blood center done over a time period of 05 months including the nationwide lockdown phase. Personal invitation of donors, social media awareness, and in-house donation drives were implemented to improve donor inflow. Restricted donor entry, stringent donor selection, and adequate sanitization strategies were the key steps adopted to ensure the safety of donors and staffs. Results: After a declaration of nationwide lockdown in India, blood donation showed a drop of 13.36% and blood demand was also reduced by 25.70% in our study. Conclusions: The COVID-19 pandemic affected blood donation process and blood supply and adversely affected BTSs. BTS should always be vigilant to adopt new practices even before guidelines are set by regulatory authorities in adverse situations. Restrictive blood transfusion strategies need to be emphasized in the country.

Management of retinopathy of prematurity: an updated review

Retinopathy of prematurity (ROP), previously named retrolental fibroplasia, is a vascular disease of the premature retina that appeared after the advances in preterm neonatal care, potentially causing irreversible vision loss. The most vital part of ROP management is reducing modifiable risk factors such as blending protocols for oxygen delivery, rigorous infection control, restrictive blood transfusion strategies, and parents' education. Laser remains a highly effective therapeutic modality and the gold standard of care in most ROP cases. On the other hand, Anti-VEGF agents emerged as a potential solution to clinical situations where laser delivery is not feasible, as in poor pupillary dilatation with advanced tunica vasculosa lentis (TVL), vitreous haze, corneal opacification, rubeosis iridis, and vitreous hemorrhage. The current recommendations indicate surgery for ROP stages 4-5. For stage 4, surgical modalities incorporate scleral buckling and lens-sparing vitrectomy (LSV).

International clinical research of critical care medicine in 2021

The progress of critical care medicine in 2021 is still encouraging. The new international guideline for management of sepsis and septic shock came out after 4 years. Besides, a couple of preferable clinical evidences were released including restrictive blood transfusion strategy for patients with acute myocardial infarction, prevention of peripheral venous catheter infection, heparin inhalation and driving pressure setting in patients with acute respiratory distress syndrome (ARDS), lower oxygenation target for acute hypoxemic respiratory failure, low level positive end-expiratory pressure in non-ARDS patients with respiratory failure, light sedation or non-sedation strategy, biological phenotypes, as well machine learning in sepsis and ARDS. However, we also encounter negative results such as balanced solution during fluid resuscitation, hypothermia therapy after out-of-hospital cardiac arrest or traumatic brain injury, adrenomedullin-specific antibody adrecizumab therapy and coupled plasma filtration-adsorption (CPFA) therapy for patients with septic shock, extracorporeal carbon dioxide removal (ECCO2R) implementation in acute hypoxic respiratory failure, continuous infusion of hypertonic saline in patients with traumatic brain injury. Collectively, in the future, individualized diagnosis and management based on the principle of "wise choice" will become the daily practice scene for all intensivists.

Restrictive vs liberal blood transfusion strategy in patients with symptomatic coronary artery disease: meta-analysis from randomized controlled trials

Abstract Background Anemia is common in patients with symptomatic coronary artery disease. Observational studies investigated blood transfusion threshold in symptomatic coronary artery disease but results were conflicting. Meta-analyses evaluating transfusion threshold utilized data mainly from observational trials but no meta-analysis, to our knowledge, used data solely from randomized clinical trials. Objective The goal of our study is to evaluate efficacy and safety outcomes in anemic patients presenting with symptomatic coronary artery disease using pooled data from randomized clinical trials. Methods We queried Medline, Embase and Cochrane data bases for randomized clinical trials comparing restrictive blood transfusion (defined as transfusion when hemoglobin is less than 8 gm/dl) vs liberal blood transfusion (transfusion when hemoglobin is less than 10 gm/dl) in patients presenting with symptomatic artery disease or acute coronary syndrome. We identified 3 randomized controlled trials; MINT, CRIT and REALITY trials. Data were pooled from 3 trials. Efficacy outcomes evaluated were all-cause mortality and New or recurrent myocardial infarction. Safety outcomes were congestive heart failure at 30-day follow up. Results A total of 820 patients were included in our meta-analysis; 420 patients in restrictive blood transfusion protocol and 400 in liberal blood transfusion protocol There was no difference between two groups at 30-day follow up in all identified outcomes (all-cause mortality, new or recurrent myocardial infarction, and Congestive heart failure). 55 patients died (22/420 in restrictive group and 33/400 in liberal group). Risk ratio of all-cause mortality in restrictive group was 0.63 [95% CI (0.38–1.07), P=0.09, I2=30%]. 15/420 in restrictive group and 16/400 in liberal group had new or recurrent myocardial infarction. Risk ratio of myocardial infarction in restrictive group was 0.91 [95% CI (0.46–1.80), P=0.78, I2=0%]. 20/420 patients in restrictive group and 24/400 in liberal group had congestive heart failure with risk ratio of 0.80 [95% CI (0.19–3.37), P=0.30, I2=76%] in restrictive group. Conclusion Our meta-analysis showed similar outcomes between restrictive and liberal transfusion policies in patients presenting with symptomatic coronary artery disease of acute myocardial infarction. Our findings are consistent with available data about restricting transfusion in general population. Restricting blood transfusion might be cost-effective. Further studies are warranted to evaluate long term safety and efficacy of such approach. Funding Acknowledgement Type of funding sources: None.

In patients with AMI and anemia, a restrictive vs. liberal blood transfusion strategy was noninferior for 30-d MACE.

Ducrocq G, Gonzalez-Juanatey JR, Puymirat E, et al. Effect of a restrictive vs liberal blood transfusion strategy on major cardiovascular events among patients with acute myocardial infarction and anemia: the REALITY randomized clinical trial. JAMA. 2021;325:552-60. 33560322.

A Restrictive Blood Transfusion Strategy and Patient Blood Management Improved Clinical Outcomes in Cardiac Surgery Patients

A Restrictive Blood Transfusion Strategy and Patient Blood Management Improved Clinical Outcomes in Cardiac Surgery Patients

Endotherapy for Nonvariceal Upper Gastrointestinal Hemorrhage

AbstractNonvariceal upper gastrointestinal hemorrhage (NVUGIH) is a common GI emergency with significant morbidity and mortality. Triaging cases on the basis of patient-related factors, restrictive blood transfusion strategy, and hemodynamic stabilization are key initial steps for the management of patients with NVUGIH. Endoscopy remains a vital step for both diagnosis and definitive management. Multiple studies and guidelines have now defined the optimum timing for performing the endoscopy after hospitalization, to better the outcome. Conventional methods for achieving endoscopic hemostasis, such as injection therapy, contact, and noncontact thermal therapy, and mechanical therapy, such as through-the-scope clips, have reported to have 76 to 90% efficacy for primary hemostasis. Newer modalities to enhance hemostasis rates have come in vogue. Many of these modalities, such as cap-mounted clips, coagulation forceps, and hemostatic powders have proved to be efficacious in multiple studies. Thus, the newer modalities are recommended not only for management of persistent bleed and recurrent bleed after failed initial hemostasis, using conventional modalities but also now being advocated for primary hemostasis. Failure of endotherapy would warrant radiological or surgical intervention. Some newer tools to optimize endotherapy, such as endoscopic Doppler probes, for determining flow in visible or underlying vessels in ulcer bleed are now being evaluated. This review is focused on the technical aspects and efficacy of various endoscopic modalities, both conventional and new. A synopsis of the various studies describing and comparing the modalities have been outlined. Postendoscopic management including Helicobacter pylori therapy and starting of anticoagulants and antiplatelets have also been outlined.

BLOOD TRANSFUSION REQUIREMENTS IN CARDIAC SURGERY

Background: The effect of restrictive blood transfusion in comparison to liberal red cell transfusion strategy on clinical outcome in cardiac surgery remains undetermined. Objectives: The aim of this work is to evaluate the restrictive blood transfusion strategy versus the liberal strategy in open heart surgery in terms of vital organ functions (heart, brain, lung, and kidney) and mortality. Patients and Methods: After approval of Institutional ethical committee and obtaining written informed consent from the patient, in this multicenter randomized prospective study, we assigned 100 adult cardiac surgery patients with Euro score I of 6 or more to a restrictive red cell transfusion trigger (transfuse if hemoglobin level was <7.5g/dl starting from the induction of anesthesia) and liberal red cell transfusion trigger (transfuse if hemoglobin level was <9.5g/dl in the operative room or intensive care unit or <8.5g/dl in the ward). The primary outcome was composite of any cause death, myocardial infarction, stroke, or new onset renal failure with dialysis by discharge from hospital or by day28 whichever came first. Results: There was a significant decrease in RBC transfusion in the restrictive group intraoperative, in the postoperative day (1), and in the ward stay. There was significantly less fresh frozen plasma transfused in the restrictive group during the ward stay only. There were a significant decrease in ventilator time, ICU stay, chest tube drainage, and rapid AF occurrence in the restrictive. Conclusion: The restrictive transfusion strategy showed efficacy and safety in decreasing transfusion requirements in cardiac surgery, thus decreasing morbidities and mortality associated with blood transfusion. It also showed cost effectiveness.

Surviving Extreme Anaemia.

The discovery of vitamin B12 in the 20th century led to the successful and easy treatment of thousands of patients with anaemia.Focus on patient adherence to treatment and medical advice is essential in order to manage chronic conditions such as post-gastrectomy nutritional deficiencies.Extreme anaemia is very rare and associated with high mortality; treatment should be tailored to acute or chronic anaemia and in cases where haemodynamic stability is guaranteed, a restrictive blood transfusion strategy should be considered to reduce the risk of complications.

Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia

The optimal transfusion strategy in patients with acute myocardial infarction and anemia is unclear. To determine whether a restrictive transfusion strategy would be clinically noninferior to a liberal strategy. Open-label, noninferiority, randomized trial conducted in 35 hospitals in France and Spain including 668 patients with myocardial infarction and hemoglobin level between 7 and 10 g/dL. Enrollment could be considered at any time during the index admission for myocardial infarction. The first participant was enrolled in March 2016 and the last was enrolled in September 2019. The final 30-day follow-up was accrued in November 2019. Patients were randomly assigned to undergo a restrictive (transfusion triggered by hemoglobin ≤8; n = 342) or a liberal (transfusion triggered by hemoglobin ≤10 g/dL; n = 324) transfusion strategy. The primary clinical outcome was major adverse cardiovascular events (MACE; composite of all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia) at 30 days. Noninferiority required that the upper bound of the 1-sided 97.5% CI for the relative risk of the primary outcome be less than 1.25. The secondary outcomes included the individual components of the primary outcome. Among 668 patients who were randomized, 666 patients (median [interquartile range] age, 77 [69-84] years; 281 [42.2%] women) completed the 30-day follow-up, including 342 in the restrictive transfusion group (122 [35.7%] received transfusion; 342 total units of packed red blood cells transfused) and 324 in the liberal transfusion group (323 [99.7%] received transfusion; 758 total units transfused). At 30 days, MACE occurred in 36 patients (11.0% [95% CI, 7.5%-14.6%]) in the restrictive group and in 45 patients (14.0% [95% CI, 10.0%-17.9%]) in the liberal group (difference, -3.0% [95% CI, -8.4% to 2.4%]). The relative risk of the primary outcome was 0.79 (1-sided 97.5% CI, 0.00-1.19), meeting the prespecified noninferiority criterion. In the restrictive vs liberal group, all-cause death occurred in 5.6% vs 7.7% of patients, recurrent myocardial infarction occurred in 2.1% vs 3.1%, emergency revascularization prompted by ischemia occurred in 1.5% vs 1.9%, and nonfatal ischemic stroke occurred in 0.6% of patients in both groups. Among patients with acute myocardial infarction and anemia, a restrictive compared with a liberal transfusion strategy resulted in a noninferior rate of MACE after 30 days. However, the CI included what may be a clinically important harm. ClinicalTrials.gov Identifier: NCT02648113.

Liberal and Restrictive Blood Transfusion Strategies in Orthopedic Surgery: Risk Factors for Surgical Site Infection

Background: The identification of risk factors for infections in surgical patients with lower-limb fractures and blood transfusions has increased in recent years. Surgical site infections (SSIs) increase hospitalization, care costs, and patient suffering. Correction surgery for lower-limb fractures and blood transfusion is quite common between surgical procedures. The aim of this study was to describe the relationship between blood transfusion and SSI in patients undergoing orthopedic surgery on lower limbs. Methods: We conducted a prospective cohort study to identify risk factors for SSI in blood transfused patients undergoing fracture repair in lower-limb surgeries between February 2017 and May 2019 in 2 reference tertiary-care hospitals in Belo Horizonte, a city of 3 million people in Brazil. Data regarding patient characteristics, surgical procedures, blood transfusions, and surgical infections were collected. Patient characterization was performed by calculating the absolute and relative frequencies of categorical variables and calculating mean, median, minimum, maximum, standard deviation, and coefficient of variation for quantitative variables. The incidence of surgical site infection, the risk of postoperative hospital death, and the total length of hospital stay were calculated by point estimates and 95% confidence intervals identified by statistical tests of bilateral hypotheses, considering the level of significance of 5%. A multivariate analysis (logistic regression) was performed to identify SSI risk factors. Results: Patients who had an indication for blood transfusion (n = 38) but who did not receive blood (n = 4) had significantly lower hemoglobin, comparing discharge with admission, than the group who received blood. Intraoperative transfusion was a risk factor for SSI (OR, 4.7) (Fig. 1). Among the 205 patients with no indication for transfusion, 98 received blood even without the indication: there was no difference in hemoglobin outcome when discharge and admission were compared, and the 98 patients were exposed to unnecessary risk. Regarding restrictive versus liberal transfusion strategies, there were differences in the variables, age (P = .000), duration of surgery (P = .003), number of comorbidities (P = .000), body mass index (BMI) (P = .027), previous hemoglobin (P = .000), and high hemoglobin (P = .000), considering the transfusion practice employed (Fig. 2). Conclusions: The indications for and definition of protocols and careful evaluation of blood transfusion are critical to avoid infectious complications in orthopedic patients with lower-limb fractures.Funding: NoneDisclosures: None

Are Blood Products Routinely Required in Pediatric Heart Surgery?

A restrictive blood transfusion strategy has emerged in adult cardiac surgery. However, the feasibility in children is poorly investigated. 352 consecutive patients undergoing open-heart surgery were retrospectively reviewed, excluding patients requiring extracorporeal membrane oxygenation. Patient demographics, perioperative blood product usage, and clinical outcome parameters were investigated. Variables predicting the need for blood products were delineated. Of the 352 study patients, 148 patients (42%) underwent bloodless surgery and 204 (58%) were transfused. Of the 204 transfused patients, 170 (83.4%) patients received one blood transfusion and 34 (16.6%) received two or more blood transfusions. Patient's weight and preoperative hematocrit (Hct) were statistically significant in predicting the need for blood priming the CPB circuit (AUC 0.99, p < 0.001, sensitivity 96.6%, specificity 95.2%). A body weight of 8.5kg carried a sensitivity of 100% and specificity of 94.5% (p < 0.001) for a blood prime. Among patients with a weight less than 8.5kg (n = 171), only 27 patients (15.8%, p < 0.001) required additional transfusion of PRBCs. Factors impacting the need for a blood transfusion during CPB included redo surgery [odds ratio (OR) 4.61, p = 0.001] and the highest lactate level on CPB (OR 1.65, p = 0.006). Redo surgery had the highest impact (OR 7.27, p = 0.012) for requiring a postoperative PRBC transfusion. A restrictive transfusion strategy can be safely implemented in pediatric cardiac surgery. The majority of children with a BW > 8.5kg required no blood products and those with a BW ≤ 8.5kg required only 1 unit of blood, to prime the cardiopulmonary bypass circuit.

515 Compliance with a Restrictive Blood Transfusion Strategy: Do We Actually Follow Scientific Evidence?

Abstract Introduction Many burn centers use a restrictive blood transfusion strategy based on randomized controlled trials in burn patients (e.g. Transfusion Requirements in Burn Care Evaluation -TRIBE) and non-burn populations (e.g. Transfusion Requirements in Critical Care – TRICC), which have demonstrated no increased morbidity or mortality between restrictive and liberal transfusion approaches. The purpose of this study was to evaluate the adherence to a restrictive hemoglobin transfusion trigger strategy of 7 g/dL. Methods Retrospective study of all patients admitted to an adult regional ABA-verified burn centre between 15/11/ 2015 and 15/6/2018 who received at least one unit of blood (RBC). We use a restrictive transfusion strategy that administers RBC for a hemoglobin (HGb) &amp;lt; 7 gm/dL, one unit at a time, with a pre and post HGb level for each RBC transfusion, unless the patient is actively bleeding and/or hemodynamically unstable. RBC transfusions in the operating room do not follow this policy and were not studied. Values are presented as mean ± SD or median (IQR) as appropriate. Results We studied 66 patients (30% female) with age 53.2 ± 18.3 years, % TBSA burn 22 (11–41), % TBSA full thickness burn 6.5 (0.5 -21.8), and with 41% having inhalation injury. Overall, there were 691 RBC transfusions (TXns). A pre-TXn HGb was obtained 95% of the time and was 6.8 (6.5–7) gm/dL. TXn for a HGb &amp;gt; 7 gm/dL occurred in 35%. A post TXn HGb was obtained for 92% of these TXns with a HGb of 7.6 (7.2–8) gm/dL. RBC TXns during nighttime (1700 to 0800, n=449) were given for a HGb trigger of 6.8 (6.4–6.9) and were not compliant with our restrictive strategy 22% of the time. Daytime transfusions (0800 to 1700, n=207) were given for a significantly higher HGb [7 (6.7–7.1), p&amp;lt; 0.001] with significantly more non-compliance with the restrictive strategy (50%, p&amp;lt; 0.001). We also compared TXns before and after the TRIBE publication. Pre-TRIBE TXns (n=484) were given for significantly lower HGb than 172 post TRIBE TXns [6.8 (6.4–7) vs 6.9 (6.6–7.1) gm/dL respectively, p=0.001] and at significantly lower rate of non-compliance with the 7 gm/dL threshold than post TRIBE transfusions (28.1% vs 37.8%, respectively, p=0.02). Conclusions While a pre-TXn HGb level was available for 95% of blood transfusions, approximately one-third were given for a HGb &amp;gt; 7 gm/dL. Transfusion during nighttime (being predominantly ordered by housestaff physicians) were administered at a significantly lower HGb trigger and with significantly better compliance with the restrictive strategy than daytime transfusions. Paradoxically, compliance with the restrictive strategy was worse following the TRIBE publication. Applicability of Research to Practice These results identify important areas for improvement in adherence to our restrictive transfusion strategy.