Restrictive Transfusion Guidelines Research Articles

Implementing evidence-based restrictive neonatal intensive care unit platelet transfusion guidelines.

Platelet transfusions are life-saving treatments for specific populations of neonates. However, recent evidence indicates that liberal prophylactic platelet transfusion practices cause harm to premature neonates. New efforts to better balance benefits and risks are leading to the adoption of more restrictive platelet transfusion guidelines in neonatal intensive care units (NICU). Although restrictive guidelines have the potential to improve outcomes, implementation barriers exist. We postulate that as neonatologists become more familiar with the data on the harm of liberal platelet transfusions, enthusiasm for restrictive guidelines will increase and barriers to implementation will decrease. Thus, we focused this educational review on; (1) the adverse effects of platelet transfusions to neonates, (2) awareness of platelet transfusion "refractoriness" in thrombocytopenic neonates and its association with poor outcomes, and (3) the impetus to find alternatives to transfusing platelets from adult donors to NICU patients.

Pre-operative anemia and peri-operative transfusion are associated with poor oncologic outcomes in cancers of the esophagus: potential impact of patient blood management on cancer outcomes

BackgroundBoth Red Blood Cell (RBC) transfusion and anemia are thought to negatively impact cancer survival. These effects have been reported with mixed findings in cancer of the esophagus. The potential impact of the application of restrictive transfusion strategies on this patient population has not been defined.Materials and MethodsWe conducted a retrospective study of esophagectomies and studied cases based on whether they were anemic or were transfused peri-operatively. Clinical characteristics and known clinicopathologic prognosticators were compared between these groups. Survival was compared by Cox proportional hazard modeling. Post-operative transfusions were assessed for compliance with restrictive transfusion thresholds.ResultsThree-hundred ninety-nine esophagectomy cases were reviewed and after exclusions 348 cases were analyzed. The median length of follow-up was 33 months (range 1–152 months). Sixty-four percent of patients were anemic pre-operatively and 22% were transfused. Transfusion and anemia were closely related to each other. Microcytic anemia was uncommon but was evaluated and treated in only 50% of cases. Most anemic patients had normocytic RBC parameters. Transfusion but not anemia was associated with a protracted/prolonged post-operative stay. Transfusion and anemia were both associated with reduced survival however only anemia was associated with decreased survival in multi-variable modeling. Sixty-eight percent of patients were transfused post-operatively and 11% were compliant with the restrictive threshold of 7 g/dL.ConclusionsPre-operative anemia and transfusion are closely associated, however only anemia was found to compromise survival in our esophageal cancer cohort, supporting the need for more aggressive evaluation and treatment of anemia. Adherence to restrictive transfusion guidelines offers an opportunity to reduce transfusion rates which may also improve short-term outcomes.

Did Physicians Have a Role to Play in National Blood Crisis?

Background: The pandemic of COVID-19 (Coronavirus disease 2019) impacted the practices of blood product procurement and transfusion in multiple ways, including failed blood donation drives, staffing limitations and low donor turnout. On January 1, 2022, the American Red Cross declared the worst national blood crisis in over a decade. The effect was most notable on the community medical centers with limited resources in securing products for blood transfusion. However, evidence is lacking for the usage of blood products in a community teaching hospital during this pandemic. Study Design and Methods: We aimed to contrast the adherence to restrictive transfusion practice in the COVID era with the pre-COVID era irrespective of COVID-19 diagnosis. We performed a retrospective observational study involving packed red blood cell (PRBC) transfusions in patients from June 2020 to August 2020 (COVID era) and September 2019 to November 2019 (pre-COVID era). Patients with hemoglobinopathies were excluded. A detailed chart review to include the number of PRBC transfusions, documented indication for transfusion and it was also determined if transfusions met restrictive blood transfusion criteria (as per guidelines from the Association for the Advancement of Blood & Biotherapies (AABB)) (Table 1). Demographic data included age, gender, history of coronary artery disease (CAD) or prior gastrointestinal bleed, use of antiplatelet and anticoagulation, use of deep vein thrombosis prophylaxis inpatient, and diagnosis on admission. Chi-square was applied to test the statistical association between qualitative variables and Unpaired t-test/Mann Whitney U test was applied to test the mean difference of quantitative. The level of significance was set at 5%. Results: A total of 215 patients were screened and 208 met our inclusion criteria. There were 108 PRBC transfusions in the COVID era group and 100 PRBC transfusions in the pre-COVID era group, with equal distribution in both groups for age, sex, ethnicity and prior gastrointestinal bleed. The leading diagnosis on admission in both COVID era and pre-COVID era groups was acute hypoxia (53.7% and 36% p<0.001), followed by gastrointestinal bleeding. Lower proportion of patients receiving transfusion were on anticoagulant or antiplatelet therapy in COVID era group as compared to pre-COVID era (antiplatelet: 6.2% vs 19%, p<0.001 and anticoagulant: 12.1% vs 27%, p<0.001), though COVID era group had lower fraction of patients receiving pharmacological prophylaxis for deep vein thrombosis (DVT) (13.9% vs 29%, p<0.001). There was a higher percentage of transfusions in critical care units in the COVID era group than pre-COVID era group (38.9% vs 22%, p<0.008). Documented indications for transfusions in both groups were hemoglobin < 7 (47.2% vs 43%), acute coronary syndrome (ACS) or history of CAD (12% vs 11%), active bleed (35.2% vs 35%) and down trending hemoglobin (5.6% vs 11%). Restrictive transfusion criteria were met in only 67% vs 79% in COVID era and pre-COVID era transfusion cases respectively (p=0.008). Subgroup analysis of documented indications for transfusion among both groups is displayed in Graph 1. Conclusions: As evident from our results, the COVID era group despite having comparable, if not fewer risk factors associated with blood loss, received blood transfusion with less stringent adherence to restrictive blood transfusion guidelines. COVID pandemic had a significant impact on the landscape of blood transfusion and our study brought to light the physician's role in more liberal use of blood products. Due to a higher number of critical care admissions and the morbidity/mortality during this pandemic, compel physicians to have a more liberal mindset towards blood transfusions. However, given the acute shortage of blood products it is vital that we adhere to restrictive blood transfusion guidelines. In view of the ongoing National Blood Crisis, please visit RedCrossBlood.org or call 1-800-RED CROSS (1-800-733-2767) to donate blood. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

De rol van reticulocyten bij preoperatieve anemie

The significance of reticulocytes in preoperative anemia While a blood transfusion can be a life-saving therapy in patients with severe anemia or active bleeding, it also exposes the patient to multiple safety risks and it represents a significant cost to society. As a result, more restrictive transfusion guidelines have been on the rise in recent years and the concept of ‘patient blood management’ (PBM) was created. PBM is a multidisciplinary and patient-oriented strategy that focuses on one’s own blood instead of allogeneic blood with the ambition to reduce the number of blood transfusions worldwide. Optimizing the erythropoiesis is the first of the 3 pillars of PBM. Diagnosing and treating preoperative anemia belong to this category. Various known laboratory parameters are contributing to the anamnesis and clinical examination, such as hemoglobin, mean corpuscular volume (MCV), red cell distribution width (RDW), reticulocytes, iron parameters, vitamin B12 and folic acid. The company Sysmex, owner of the most widely used hematological analyzers in Belgium, also introduced less well-known red blood cell indices related to the reticulocytes. Several parameters, such as the reticulocyte production index (RPI), the reticulocyte hemoglobin equivalent (RET-He), delta hemoglobin (Delta-He) and the percentage of hypochromic red blood cells (Hypo-He), are gradually finding their way into anemia management. The second pillar of PBM deals with minimizing blood loss. The third pillar focuses on assessing and optimizing the patient’s tolerance for anemia. This article pays particular attention to the preoperative part of the first pillar. A guideline for diagnosing and treating preoperative anemia using various reticulocyte parameters was created.

Blood utilization and quality indicators at a university hospital in the Eastern Province of Saudi Arabia.

BackgroundBlood transfusion is a common, essential procedure when treating many different medical and surgical conditions. Efficient utilization of blood bank facilities by frequent auditing is crucial; however, few studies have examined blood utilization in Saudi Arabia. We aimed to review the blood ordering patterns and transfusion practices, and blood bank audit effectiveness at a single center in Saudi Arabia and compare our results with those of a similar study performed in the same center 20 years ago.Materials and methodsThis study was a retrospective descriptive chart review of all healthy blood donors and recipients from January 1, 2016, to December 31, 2020. We evaluated the crossmatching-to-transfusion ratio (C/T) as an indicator of blood bank utilization and compared the findings with those of the previous study. We also evaluated changes in blood bank utilization during the coronavirus disease 2019 pandemic.ResultsFindings from 27,414 donors (men, 94.9%; mean age, 32.2 + 9.6 years) showed a 71% increase in blood donations compared to that of 2000. The donations gradually increased over the years, peaking just before COVID-19 pandemic started in March 2020. For 3,836 patients, 13,324 units of blood were crossmatched (average, 3.47 crossmatch/patient), with 23% of the crossmatch requests from surgical departments. The average C/T ratio, transfusion index, and transfusion probability (T%) were 1.37, 2.55, and 73.2%, respectively. The C/T ratio decreased by 54% between 2000 and 2020. During the pandemic, crossmatching decreased by 26% between 2019 and 2020, but with comparable C/T ratio in 2019 (1.45) and 2020 (1.39).ConclusionOur hospital blood bank utilization improved over the past 20 years, showing increased donations, reduced C/T ratio, and increased T%. This improvement emphasizes the importance of blood donation campaigns, blood bank auditing, restrictive transfusion guidelines, and physician education.

Adherence to blood product transfusion guidelines-An observational study of the current transfusion practice in a medical intensive care unit.

Blood transfusions though life-saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the 'Choosing Wisely campaign'. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost. In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre-transfusion haemoglobin (Hb) ≥7g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions. We conducted a retrospective observational study in a 64-bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N= 957) requiring packed red blood cell transfusion between January 2015 and December 2015. In total, 3140 units were transfused with a mean pre-transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty-four (30%) transfusion events occurred with a pre-transfusion Hb ≥7g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre-transfusion Hb ≥7g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.88; p= 0.02) and LOS in patients with chronic blood loss (β1 .8.26, 95% CI 4.09-12.43; p< 0.01). A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.

Reducing the red blood cell transfusion threshold from 8·0 g/dl to 7·0 g/dl in acute myeloid leukaemia patients undergoing induction chemotherapy reduces transfusion rates without adversely affecting patient outcome.

Red blood cell (RBC) transfusions are needed by almost every acute myeloid leukaemia (AML) patient undergoing induction chemotherapy and constitute a cornerstone in supportive measures for cancer patients in general. Randomized controlled trials have shown non-inferiority or even superiority of restrictive transfusion guidelines over liberal transfusion guidelines in specific clinical situations outside of medical oncology. In this study, we analysed whether more restrictive RBC transfusion reduces blood use without affecting hard outcomes. A total of 352 AML patients diagnosed between 2007 and 2018 and undergoing intensive induction chemotherapy were included in this retrospective analysis. In the less restrictive transfusion group, patients received RBC transfusion for haemoglobin levels below 8g/dl (2007-2014). In the restrictive transfusion group, patients received RBC transfusion for haemoglobin levels below 7g/dl (2016-2018). Liberal transfusion triggers were never endorsed. A total of 268 (76·1%) and 84 (23·9%) AML patients fell into the less restrictive and restrictive transfusion groups, respectively. The less restrictive transfusion group had 1g/dl higher mean haemoglobin levels, received their first RBC transfusions earlier and needed 1·5 more units of RBC during the hospital stay of induction chemotherapy. Febrile episodes, C-reactive protein levels, admission to the intensive care unit, length of hospital stay as well as response and survival rates did not differ between the two cohorts. From our retrospective analysis, we conclude that a more restrictive transfusion trigger does not affect important outcomes of AML patients. The opportunity to test possible effects of the more severe anaemia in the restrictive transfusion group on quality of life was missed.

7 Is the New 8: Improving Adherence to Restrictive PRBC Transfusions in the Pediatric ICU.

Up to 30%-40% of children admitted to the pediatric intensive care unit (PICU) have anemia, and approximately 15% receive packed red blood cell (pRBC) transfusions. Current literature supports a pRBC transfusion threshold of hemoglobin less than or equal to seven for most PICU patients. Our objective was to determine pRBC transfusion rates, assess compliance with transfusion guidelines, understand patient-level variables that affect transfusion practices, and use cross-industry innovation to implement a practice strategy. This was a pre-post study of pediatric patients admitted to our PICU. We collected baseline data on pRBC transfusion practices. Next, we organized an innovation platform, which generated multi-industry ideas and produced an awareness campaign to effect pRBC ordering behavior. Innovative educational interventions were implemented, and postintervention transfusion practices were monitored. Statistical analysis was performed using linear mixed models. A p value < .05 was considered statistically significant. At baseline, 41% of pRBC transfusions met restrictive transfusion guidelines with a pretransfusion hemoglobin less than or equal to 7 g/dl. In the postintervention period, 53% of transfusions met restrictive transfusion guidelines (odds ratio 1.66, 95% confidence interval 1.21-2.28). Implementation of a behavioral campaign using multi-industry innovation led to improved adherence to pRBC transfusion guidelines in a tertiary care PICU.

Updates in Red Blood Cell and Platelet Transfusions in Preterm Neonates.

Anemia and thrombocytopenia occur frequently in preterm neonates and the majority of them require at least one blood transfusion during the first few weeks of life. However, there is no international consensus on optimal transfusion management neither for red blood cell nor for platelet transfusions, resulting in large worldwide variations in transfusion practices between neonatal intensive care units. In the past decade, several studies performed in adults, infants as well as neonates showed that restrictive transfusion guidelines are just as safe as liberal guidelines. In fact, some studies even showed that liberal guidelines could be associated with an increased risk of morbidity and mortality, suggesting that too many transfusions may have a deleterious effect. In a recent randomized trial in preterm neonates with thrombocytopenia, the liberal transfusion group (receiving more platelet transfusions) had a significantly higher rate of death or major bleeding than the restrictive group (receiving less transfusions). In preterm neonates with anemia, the available evidence is also limited and controversial. Two large randomized controlled trials (ETTNO and TOP) are currently assessing the safety and effectiveness of liberal versus restrictive red blood cell transfusions. Results of these large two studies, including the long-term neurodevelopment outcome, are eagerly awaited. Until then, reduction of anemia of prematurity by implementation of effective preventive measures, such as delayed cord clamping and minimization of iatrogenic blood loss, remain of paramount importance.

Blood Transfusion in Gynecologic Surgery: Adherence to Guidelines in Academic and Community-Based Practice [19H

INTRODUCTION: Blood transfusions are commonly administered during gynecological surgery. Traditionally, multiple units of packed red blood cells (pRBC) were transfused simultaneously, with a goal hemoglobin level (Hb) of 10 g/dL. However, research shows that this is associated with worse patient outcomes. In 2015, Ochsner implemented restrictive transfusion guidelines to improve patient outcomes and reduce costs. This protocol recommends transfusing one unit pRBC at a time, with an Hb goal of 7 (8 g/dL in patients with acute coronary syndrome or who are symptomatic). A retrospective study was conducted to assess gynecologists' understanding and adherence to these guidelines in academic versus community practices. METHODS: IRB approval was obtained from the Ochsner Clinic Foundation. Gynecologists completed an anonymous survey assessing their knowledge of Ochsner's transfusion guidelines. To evaluate adherence to the guidelines, a retrospective chart review was conducted on gynecologic surgeries that utilized pRBC transfusion in 2017. RESULTS: Compared to 2016, awareness of Ochsner's transfusion guidelines amongst practitioners (81.36% vs 72.7%) was increased. Knowledge of the guideline parameters also improved. 175 charts were reviewed from community (n=91), academic (n=53), and oncologic (n=31) sites. Academic sites adhered to guidelines more often than community sites (49% vs 31.8%, P<.017). The most common departure from the guidelines was transfusing multiple units of pRBC at once. CONCLUSION: Although most practitioners were aware of Ochsner's transfusion protocol, they violated these guidelines in practice. Despite overall knowledge of the guidelines, there continues to be a lack of adherence amongst providers. Further studies are needed to identify and address reasons for non-adherence.

Transfusion support in preterm neonates &lt;1500 g and/or &lt;32 weeks in a tertiary care center: A descriptive study

BACKGROUND:Lack of recent studies focusing on indications, pattern, and benefits of transfusions in low birth weight (B.Wt) and low gestational age (GA) preterm neonates prompted us to undertake this study.AIM:To estimate the transfusion requirements and outcomes in preterm neonates <1500 g and/or <32 weeks.SETTINGS AND DESIGN:This is a cross-sectional study conducted over a period of 2 years in a tertiary care center.MATERIALS AND METHODS:This study was conducted with 101 preterm neonates <1500 g and/or <32 weeks who received blood transfusions in the Neonatal Intensive Care Unit. Restrictive pattern of transfusion was followed. Demographic details and antenatal, neonatal, laboratory, and transfusion parameters were collected.STATISTICAL ANALYSIS USED:Statistical analyses were performed using SPSS 16.RESULTS:The study participants received 311 transfusions. Transfusion requirements decreased with increasing GA and B.Wt. Majority of blood transfusions occurred during the first 2 weeks of life. Packed red blood cells (PRBCs) were the most frequent blood components transfused. Ninety-six percent of the study population had an uneventful transfusion. Mean hemoglobin improvement after PRBC transfusions was 2.3 ± 2.1 g/dl. Improvement in apnea occurred in 76% PRBC transfusions. Infants with sepsis, patent ductus arteriosus, bronchopulmonary dysplasia, disseminated intravascular coagulation, and dyselectrolytemia received more number of transfusions.CONCLUSION:This study would serve as an audit for neonatal blood transfusion therapy. Close adherence to neonatal transfusion policy and restrictive transfusion guidelines helps reduce inappropriate use of blood products and adverse transfusion reactions.

Anemic Conditions Acceptable in Restrictive Transfusion Practice Induce Gut Inflammation and Injury in an Animal Model of Preterm Infants

Very low birth weight (VLBW) infants often require multiple transfusions within the first weeks of life. In an effort to minimize transfusion-associated risks, many neonatologists have opted for more restrictive neonatal transfusion practices. However, whether a restrictive transfusion strategy is effective in limiting transfusions without increasing morbidity and mortality in this population remains unclear. Recently, the increasing use of more restrictive neonatal transfusion practices has been associated with a concomitant increase in the incidence of necrotising enterocolitis (NEC) in VLBW infants. Retrospective studies and a meta-analysis of trials comparing restrictive vs. liberal transfusion strategies suggest a higher risk of NEC among preterm infants managed by restrictive transfusion approaches (pooled relative risk 1.6; 95% CI 0.8-3.1). A recent multicenter, prospective observational study evaluating time-varying exposure to anemia also reported a higher risk of NEC among infants with severe anemia compared to those without severe anemia (adjusted hazard ratio 6.0; 95% CI 2.0-18.0). Importantly, while previous studies suggest that transfusion itself may cause transfusion-associated gut injury (TRAGI), this study failed to find an association between transfusion and NEC, strongly suggesting that anemia itself may represent a key risk factor linking increased incidence of NEC to restrictive transfusion practices.To determine whether anemia may directly affect the development of NEC we employed a pre-clinical murine model that utilizes gradual phlebotomy-induced anemia (PIA). Pups were bled twice-daily (5mL/g) beginning at postnatal day 3 (P3) to achieve a hematocrit of 23-25% by P7. Anemic and littermate control pups were then examined for intestinal hypoxia, inflammation and gut barrier disruption at P8. Levels of intestinal hypoxia were evaluated by injection of hypoxyprobe (Hypoxyprobe, Inc.) into control and anemic pups, followed by sacrifice at 1 hour post-injection and detection of protein adducts of pimonidazole in hypoxic tissue by confocal analysis. Inflammation was assessed by evaluation of key immune populations, including macrophages, dendritic cells and T cells for number and function by flow cytrometry. Finally, gut barrier function was assessed by quantification of fluorescein isothiocyanate (FITC)-dextran (4kDa) in the serum 4 hours following oral gavage.While hypoxia within the gut is normally confined to the lumen, neonatal pups exhibited significant increases in gut hypoxia following PIA, which extended beyond the gut lumen to intestinal crypts where key immune populations reside. Comparative analysis of immune populations in the gut between control and anemic neonates indicated no impact of PIA on macrophage, dendritic cell or T cells numbers. However, gut resident macrophages in anemic mice produced significantly more IFNg compared to controls. In contrast, no changes in dendritic cell or T cell cytokine production were observed, strongly suggesting that gut resident macrophages may play a primary role in anemia-induced increases in intestinal inflammation. As inflammation can directly impact gut barrier function, we next investigated intestinal barrier permeability as a marker of gut injury that may precede NEC. When FITC-dextran was administered by oral gavage to anemic and control mice, followed by quantification in the blood 4 hours later, significantly higher blood levels of FITC-dextran could be detected in anemic recipients, demonstrating increased intestinal barrier permeability following PIA.While physiological hypoxia in healthy individuals is localized to epithelial cells adjacent to the lumen, our data demonstrate hypoxic staining throughout the mucosa in neonates following PIA. Additionally, PIA appears to increase macrophage pro-inflammatory cytokine secretion and also compromises gut barrier function, both key factors that can predispose neonates to NEC. Thus, data from this preclinical model suggest that restrictive transfusion guidelines which allow for hematocrits as low as ~24% prior to transfusion may increase morbidity and mortality associated with NEC in preterm infants. DisclosuresNo relevant conflicts of interest to declare.

Daily Lowest Hemoglobin and Risk of Organ Dysfunctions in Critically Ill Patients.

To determine the association between hemoglobin levels and the daily risk of individual organ dysfunctions in critically ill patients. Post hoc analysis of prospectively collected data. Vanderbilt University Medical Center and Saint Thomas Hospital Medical and Surgical ICUs. Medical and surgical ICU patients admitted with respiratory failure or shock. Baseline demographic data, and detailed in-ICU and hospital data, including daily lowest hemoglobin, were collected up to hospital day 30. We assessed patients daily for brain dysfunction (delirium, using Confusion Assessment Method for ICU), for renal and respiratory dysfunction (using the ordinal renal and respiratory Sequential Organ Failure Assessment score), and for ICU mortality. Associations between the lowest hemoglobin on a given day and organ dysfunctions the following day were assessed using multivariable regressions, adjusting for age, Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity index, Framingham Stroke Risk Profile, ICU day, ICU type, sepsis, and current organ dysfunction status. A sensitivity analysis further adjusted for daily transfusions and fluid balance in a subset of our patients. We enrolled 821 patients with a median (interquartile range) age of 61 (51-71) years, Acute Physiology and Chronic Health Evaluation II score of 25 (19-31), and hemoglobin level of 10.0 (9.0-11.1) g/dL. There was no evidence of an association between lowest daily hemoglobin and brain dysfunction (p = 0.69 for delirium), renal dysfunction (p = 0.30), or ICU mortality (p = 0.95). The lowest hemoglobin on a given day was significantly associated with the respiratory Sequential Organ Failure Assessment score the following day; for each increasing hemoglobin unit, the odds of worsened respiratory Sequential Organ Failure Assessment score the following day were decreased by 36% (OR, 0.64; 95% CI, 0.53-0.77; p < 0.001). The sensitivity analysis including daily transfusions and fluid balance (in a subset of 518 patients) did not qualitatively change any of these associations. In this study in ICU patients, lower hemoglobin was associated with a higher probability of worsening respiratory dysfunction scores the following day. There was no evidence of association between hemoglobin and brain or renal dysfunction, or ICU mortality. The possible differential effects of anemia on organ dysfunctions seen in this hypothesis-generating study will have to be studied in a larger prospective study before any alterations to present restrictive transfusion guidelines can be recommended.

Determination of tissue hypoxia by physicochemical approach in premature anemia

Anemia is a common problem in premature infants and its most rapid and effective therapy is erythrocyte transfusion. However, owing to inherent risks of transfusion in this population, transfusions should be administered only when adequate oxygen delivery to tissues is impaired. The aim of this study was to determine tissue acid levels using Stewart method in an attempt to evaluate the tissue oxygenation level and thereby the accuracy of transfusion timing. This study included 47 infants delivered at gestational age below 34 weeks who required erythrocyte transfusion for premature anemia. Strong ion gap (SIG), unmeasurable anions (UMA), tissue acid levels (TA), and Cl/Na ratios were calculated before and after transfusion. The mean birth weight and gestational age of the study population were 1210 ± 365 g and 29.2 ± 2.7 weeks, respectively. Tissue acid levels were increased (TA ≥ 4) and tissue hypoxia developed in 10 (16.6%) of 60 erythrocyte transfusions administered according to the restrictive transfusion approach. The patients were divided into two groups according to tissue acid levels as low (<4) and high (≥4) tissue acid groups. The group with tissue hypoxia (TA ≥ 4) had significantly higher UMA levels but a significantly lower Cl/Na ratio; and UMA levels decreased and Cl/Na ratio increased after transfusion in this group. Tissue hypoxia secondary to anemia was shown to be improved by erythrocyte transfusion. The results of the present study suggest that the determination of the level of tissue hypoxia by the Stewart approach may be an alternative to restrictive transfusion guidelines for timing of transfusion in premature anemia. It also showed that a low Cl/Na ratio can be used as a simple marker of tissue hypoxia.

Factors associated with blood transfusion during intracranial aneurysm surgery

Study objectiveThe purpose of this study was to identify risk factors associated with intraoperative blood transfusions in patients presenting for intracranial aneurysm surgery in the current era of more restrictive transfusion guidelines. DesignRetrospective observational cohort study with stepwise, multivariate binary logistic regression analysis. SettingTertiary care university teaching hospital. PatientsFour hundred seventy-one consecutive patients undergoing intracranial aneurysm surgery at Northwestern Memorial Hospital (Chicago, IL) from 2006 to 2012. InterventionRed blood cell transfusion (retrospective observational). MeasurementsDemographic data, medical comorbidities, hemoglobin levels, Hunt-Hess grades, intracranial aneurysm characteristics, presenting intracranial bleeding states, estimated blood losses, transfused red blood cells, and blood products. Main resultsForty-six patients (9.5%) received intraoperative red blood cell transfusions. Preoperative risk factors associated with transfusions were highly related to aneurysm rupture, including such parameters as older age (P < .001), lower presenting hemoglobin level (P < .001), preoperative rupture (P < .001), and higher Hunt-Hess grade (P < .001). Intraoperative risk factors included larger aneurysm size (>10 mm; P = .03), intraventricular hemorrhage (P < .001), and intracerebral hematoma evacuation (P = .02). Binary logistic regression modeling identified age (P < .001), presenting hemoglobin level (P < .001), larger aneurysm size (>10 mm; P = .003), elevated Hunt-Hess grade (P = .021), and intraoperative rupture (P = .013) as independent predictors of intraoperative red blood cell transfusion. ConclusionThe incidence of intraoperative red blood cell transfusion in intracranial aneurysm surgery in our patient cohort was 9.5%, and the most significant factors associated with transfusion were presenting hemoglobin level less than 11.7 g/dL and age greater than 52 years. It would seem advisable that these patients undergo routine type and cross-matching of red blood cells before intracranial aneurysm surgery.

Perioperative blood transfusion in radical cystectomy: Analysis of the National Surgical Quality Improvement Program database.

To determine whether perioperative blood transfusion is associated with worse 30-day postoperative outcomes in radical cystectomy patients. Utilizing the National Surgical Quality Improvement Program database, we identified 2934 patients diagnosed with bladder cancer (International Classification of Diseases Ninth Revision codes 188-188.9) who underwent radical cystectomy (Current Procedure Terminology codes 51570, 51575, 51580, 51585, 51590, 51595, 51596) between 2005 and 2013. Patients were stratified by transfusion status and assessed based on four composite postoperative outcomes: morbidity, surgical site infection, mortality and readmission. Multivariate regression models were used to determine significant independent predictors of the composite outcomes. Overall, 40.1% of patients received a transfusion, and there were significant differences in baseline variables such as age, sex, body mass index, smoking history and comorbidities. Transfusion was associated with increased morbidity, surgical site infection, readmission, operative time and length of stay on unadjusted analyses. On multivariate regression, transfusion was associated with increased morbidity (OR 1.361, 95% CI 1.131-1.638) and surgical site infection (OR 1.371, 95% CI 1.070-1.757). Perioperative blood transfusion is associated with increased risk of postoperative infection and morbidity. Previous work in this area has focused on negative long-term oncological outcomes, but this is the first study to examine short-term postoperative outcomes. Future research should focus on the immunosuppressive mechanism of perioperative blood transfusion and on restrictive transfusion guidelines for oncology patients.

Restrictive blood transfusion protocol in liver resection patients reduces blood transfusions with no increase in patient morbidity

BackgroundManagement of anemia in surgical oncology patients remains one of the key quality components in overall care and cost. Continued reports demonstrate the effects of hospital transfusion, which has been demonstrated to lead to a longer length of stay, more complications, and possibly worse overall oncologic outcomes. The hypothesis for this study was that a dedicated restrictive transfusion protocol in patients undergoing hepatectomy would lead to less overall blood transfusion with no increase in overall morbidity. MethodsA cohort study was performed using our prospective database from January 2000 to June 2013. September 2011 served as the separation point for the date of operation criteria because this marked the implementation of more restrictive blood transfusion guidelines. ResultsA total of 186 patients undergoing liver resection were reviewed. The restrictive blood transfusion guidelines reduced the percentage of patients that received blood from 31.0% before January 9, 2011 to 23.3% after this date (P = .03). The liver procedure that was most consistently associated with higher levels of transfusion was a right lobectomy (16%). Prior surgery and endoscopic stent were the 2 preoperative interventions associated with receiving blood. Patients who received blood before and after the restrictive period had similar predictive factors: major hepatectomies, higher intraoperative blood loss, lower preoperative hemoglobin level, older age, prior systemic chemotherapy, and lower preoperative nutritional parameters (all P < .05). Patients who received blood did not have worse overall progression-free survival or overall survival. ConclusionsA restrictive blood transfusion protocol reduces the incidence of blood transfusions and the number of packed red blood cells transfused. Patients who require blood have similar preoperative and intraoperative factors that cannot be mitigated in oncology patients. Restrictive use of blood transfusions can reduce cost and does adversely affect patients undergoing liver resection.

Is best transfusion practice alone best clinical practice?

Is best transfusion practice alone best clinical practice?

Donor exposure in neonatal blood transfusion - time to change strategy?

<h3>Background</h3> Previous studies have recommended reserving 8 satellite packs (SP) for extremely low birth weight (ELBW) babies to reduce donor exposure (DE) from blood transfusions.1 However, concentration of transfusions at the beginning and end of neonatal care coupled with short shelf-life of blood result in wastage of SPs and unavoidable DE. Neonatal transfusion practice may have changed due to restrictive transfusion guidelines, micro-sampling methods and practice of delayed cord clamping. We currently reserve only 4 SPs for ELBW babies and strictly follow British Committee for Standards in Haematology 2004 guidelines for blood transfusion². <h3>Aims</h3> To ascertain the root cause of excess DE and SP wastage in multi-transfused ELBW babies and suggest an optimum contemporary strategy that would balance DE with SP wastage. <h3>Methods</h3> Transfusion data was collected for all inborn ELBW babies and those transferred-in within 96 hours of birth in 2010. Rates and determinants of DE were analysed. Projected SP wastage and DE rates were calculated for different SP strategies. <h3>Results</h3> Thirty-eight ELBW babies with a mean gestation of 25.5 weeks and birth weight of 712 grams were included. Eight babies were not transfused while 7 received only one transfusion. Therefore, 23 babies were included for DE and 30 for SP wastage analysis. The mean SP usage was 3.97/baby. The mean DE was 2.47 and mean SP wastage 4.7/baby. The mean age of the donor unit at allocation was 20.2 days (95% CI 18.4, 22). The mean interval between the first and last transfusion was 35 days. Reducing donor unit age to 14 days at allocation would have reduced one donor exposure in 11/23 babies (47.8%). Table 1 shows the effect of different projected SP strategies on DE and SP wastage. <h3>Conclusions</h3> Younger age of blood unit at allocation is the key to reduce DE. A 4-SP strategy appears appropriate for current transfusion practice for ELBW babies.

295 Evaluation of the Efficacy and Safety of Autologous Cord Blood Transfusions in Very Low-Birth-Weight Premature Newborns

Background and aims: To compare the in-vivo efficacy and safety of red cell(RC) concentrates derived from cord blood and banked adult blood in very low-birth-weight premature newborns.Methods: A prospective, randomized, blind-controlled study was conducted between March 2008-September 2009. Thirty-nine premature born before 32nd gestation weeks(GW) and/or with birth weight less than 1500g were included. RC concentrate bags were prepared from the cord blood, labelled and stored in blood bank. Premature infants requiring blood transfusion were randomly assigned to an autologous or allogeneic product. If an autologous source had been consumed, allogeneic product was used. When patients were discharged, transfusion types were resumed. Two randomized groups were compared on the 14, 28, 35th days and >35 days with respect to hemoglobin levels, transfusion numbers, transfusion and phlebotomy volumes, and to hemoglobin, reticulocyte counts and erythropoietin levels in the postnatal 36th and 40th GW.Results: Among 39 newborns, 16 received autologous transfusion(Group-1), 15 received allogeneic transfusion(Group-2) and 8 did not receive any transfusion(Group-3). Group-3 had higher birth weight and gestational week(p< 0.05), and RDS, clinical sepsis doubt and phlebotomy volumes were less(p< 0.05). The reticulocyte counts and erythropoietin levels in the postnatal 36th and 40th GW were lower in Group-1(p< 0.05). The other variables did not differ between Group-1 and 2. The autologous source decreased allogeneic transfusion 28% in Group-1.Conclusions: Autologous cord blood had the same efficacy and safety with RC concentrates derived from banked adult blood. Careful monitorization of phelobotomy losses, implementing more restrictive transfusion guidelines may increase the efficacy of autologous cord blood.