Restrictive Transfusion Policy Research Articles

Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management.

Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.

Part II: Blood Transfusion and Donor Exposure in the Surgical Management of Trigonocephaly Patients: A Protocol From Alder Hey Craniofacial Unit.

Trigonocephaly is a craniofacial malformation caused by premature fusion of the metopic suture. Surgical correction frequently results in the need for blood transfusion. Transfusion complications include transfusion-transmitted infections (TTIs), immune-mediated reactions, and volume overload. Donor exposure (DE) describes the number of blood products from unique donors with increasing DE equating to an increased risk of TTI. We evaluate data on 204 trigonocephaly patients covering 20 years of practice with respect to blood transfusions and DE. This represents the largest series from a single unit to date. A protocol based on our experiences has been devised that summarizes the key interventions we recommend to minimize blood transfusions and DE in craniofacial surgery. Patients operated on between 2000 and 2020 were included. DE and a range of values were calculated including estimated red cell loss (ERCL) and estimated red cell volume transfused (ERCVT). Groups were established by relevant interventions and compared using the Mann-Whitney U test. Mean DE fell from 1.46 at baseline to 0.85 ( P <0.05). Median allogenic transfusion volume fell from 350mL at baseline to 250mL ( P <0.05). Median ERCL fell from 15.05mL/kg at baseline to 12.39mL/kg and median ERCVT fell from 20.85 to 15.98mL/kg. Changes in ERCL and ERCVT did not reach statistical significance. DE can be minimized with the introduction of key interventions such as a restrictive transfusion policy, preoperative iron, cell saver, tranexamic acid, and use of a matchstick burr for osteotomies.

Trends, complications, and readmission of allogeneic red blood cell transfusion in primary total hip arthroplasty in china: a national retrospective cohort study.

Decrease in allogenic red blood cell (RBC) transfusion rates following total hip arthroplasty (THA) has been reported in the United States, but whether other countries share the same trend remains unclear. Additionally, the relation of allogenic RBC transfusion to the risk of complications in THA remains controversial. Using the Chinese national inpatient database, the current study aimed to examine trends, complications, charges, and readmission patterns of allogeneic RBC transfusion in THA. Patients undergoing primary THA between 2013 and 2019 were included, and then stratified into the transfusion and the non-transfusion group based on the database transfusion records. A generalized estimating equation model was used to investigate trends in transfusion rates. After propensity-score matching, a logistic regression model was used to compare the complications, rates and causes of 30-day readmission between two groups. A total of 10,270 patients with transfusion and 123,476 patients without transfusion were included. Transfusion rates decreased from 19.11% in 2013 to 9.94% in 2019 (P for trend < 0.001). After matching, no significant differences in the risk of of in-hospital death (odds ratio [OR], 4.00; 95% confidence interval [CI] 0.85-18.83), wound infection (OR 0.72; 95%CI 0.45-1.17), myocardial infarction (OR 1.17; 95%CI 0.62-2.19), deep vein thrombosis (OR 1.25; 95%CI 0.88-1.78), pulmonary embolism (OR 2.25; 95%CI 0.98-5.17), readmission rates (OR 1.07; 95%CI 0.88-1.30) and readmission causes were observed between two groups. However, the transfusion group had higher hospitalization charges than the non-transfusion group (72,239.89 vs 65,649.57 Chinese yuan [CNY], P < 0.001). This study found that allogeneic RBC transfusion in THA was not associated with the increased risk of complications and any-cause readmission. However, the currently restrictive transfusion policy should be continued because excessive blood transfusion may increase the socioeconomic burden.

Establishment of a national quality improvement process on oxygen delivery index during cardiopulmonary bypass.

Targeted oxygen delivery during cardiopulmonary bypass (CPB) has received significant attention due to its influence on patient outcomes, especially in mitigating acute kidney injury. While it has gained popularity in select institutions, there remains a gap in establishing it globally across multiple centers. The purpose of this investigation was to describe the development of a quality improvement process of targeted oxygen delivery during CPB across hospitals throughout the United States. A systematic approach to utilize oxygen delivery index (DO2i) as a key performance indicator within hospitals serviced by a national provider of perfusion services. The process included a review of the current literature on DO2i, which yielded a target nadir value (272mL/min/m2) and an area under the curve (DO2i272AUC) cut off of 632. All data is displayed on a dashboard with results categorized across multiple levels from system-wide to individual clinician performance. From January 2020 through December 2022, DO2i data from 91 hospitals and 11,165 coronary artery bypass graft procedures were collected. During this period the monthly proportion of DO2i measurements above the target nadir DO2i272 ranged from 60.5% to 78.4% with a mean+/-SD of 70.8 +/- 4.2%. Binary logistic regression for the first 7months following monthly DO2i performance reporting has shown a statistically significant positive linear trend in the probability of achieving the target DO2i272 (p < .001), with a crude increase of approximately 7.8% for DO2i272AUC, and a 73.8% success rate (p < .001). A survey was sent to all individuals measuring oxygen delivery during CPB to assess why a target DO2i272 could not be reached. The two most common responses were an 'inability to improve CPB flow rates' and 'restrictive allogeneic red blood cell transfusion policies'. This study demonstrates that targeting a minimum level of oxygen delivery can serve as a key performance indicator during CPB using a structured quality improvement process.

Impact of Blood Transfusion on Postoperative Infection and Hospital Stay after Isolated Coronary Artery Bypass Surgery

Objective: The blood transfusion during cardiac surgeries has been demonstrated to be increased in length of hospital stay. The aim of current study was to characterize the post-operative complication. Methodology: A descriptive study was conducted at Cardiac Centre Bahawalpur from 1st February 2020 to 30th March, 2021 all patients were divided into two groups. who underwent cardiac surgery during this period Group A (No blood transfusion). Group B (low transfusion 1-2 units) Results: A total of 176 patients, 122 (69.3%) were male and 54 (30.7%) female. in our study there were 1(1%) in Group A while 5(6.6%) in Group B were found with post-operative infection with statistically significant p-value 0.049. Similarly, hospital stay in group A was 5.8 ± 1.3 while in Group B was 6.9 ± 0.3 showing insignificant p-value 0.067. Conclusion: A restrictive transfusion policy while considering RCC transfusion seems more useful and patients who require blood should receive the number of transfusions as minimum as possible. Keywords: RCC Red Cell Concentrates Transfusion, CABG Cardiac Artery Bypass Graft, LOH Length of Hospital Stay, restrictive blood transfusion.

1586P Improving the management of anaemia in cancer patients receiving chemotherapy: ESMO clinical practice guidelines in action

Anaemia affects up to two-thirds of cancer patients during chemotherapy. It is associated with impaired quality of life and worse overall survival, but is significantly under-treated. 35% of these patients have underlying functional iron deficiency (FID). ESMO guidelines recommend haematinic monitoring and consideration of intravenous iron and erythropoiesis-stimulating agents (ESAs) to reduce red blood cell (RBC) transfusions. Studies have shown that liberal rather than restrictive transfusion policies are associated with negative outcomes in patients with and without cancer. However, evidence from a recent European survey of clinical practice among Oncologists shows that UK practice still relies heavily on RBC transfusions with minimal use of transfusion-sparing agents. A pre-intervention audit was performed of all solid tumour patients who started chemotherapy during September and October 2019 at University Hospital Southampton. Electronic patient records were interrogated to identify how anaemia was treated over the following six months. Results were interpreted against the following audit standard: ESMO Clinical Practice Guidelines - Management of Anaemia and Iron Deficiency. This was followed by a series of interventions including a new anaemia treatment protocol based on the ESMO algorithm, and education sessions for all prescribers. An identical post-intervention audit was then performed of all patients who started chemotherapy during March and April 2021. Table: 1586PPre-interventionPost-interventionTotal patients108106Iron status assessed (%)1.937.5Patients prescribed darbepoetin if Hb≤100g/L (%)330.8Total IV iron doses given112Total RBC units given4427Anaemic patients given ≥1 RBC transfusion (%)26.820.8RBC units per anaemic patient0.790.38 Open table in a new tab Our ‘real world’ data has shown that even with a limited improvement in guideline adherence, using ESAs and correcting FID anaemia can significantly reduce RBC transfusions. For patients this means less time spent in hospital, and less exposure to adverse outcomes of RBC transfusions. This change in practice was also cost-efficient for our centre, with extrapolated annual savings of €24,000 and 180 hours of treatment time for the chemotherapy unit.

Incorporation of Blood and Fluid Management Within an Enhanced Recovery after Surgery Protocol in Complex Spine Surgery.

retrospective review. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary set of evidence-based interventions to reduce morbidity and accelerate postoperative recovery. Complex spine surgery carries high risks of perioperative blood loss, blood transfusion, and suboptimal fluid states. This study evaluates the efficacy of a perioperative fluid and blood management component comprised of a restrictive transfusion policy, goal directed fluid management, number of tranexamic acid (TXA) utilization, and autologous blood transfusion within our ERAS protocol for complex spine surgery. A retrospective review compared patients undergoing elective complex spine surgery prior to and following implementation of an ERAS protocol with intraoperative blood and fluid management. Outcomes included incidence of blood transfusion, estimated blood loss, intraoperative crystalloids administered, frequency of intraoperative TXA utilized, incidence of patients extubated within the operating room (OR), intensive care unit (ICU) admission, and hospital length of stay. Following implementation, the rate of blood transfusion decreased by 11.7%(P = .017) and average crystalloid infusion was reduced 680 mL per case(P < .001). Intraoperative blood loss decreased on average 342 mL per case(P = .001) and TXA use increased significantly by 25%(P < .001). Postoperative ICU admissions declined by 8.5%(P = .071); extubation within the OR increased by 13.3%(P = .005). This protocol presents a unique perspective with the inclusion of an interdisciplinary and comprehensive blood and fluid management protocol as an integral part of our ERAS pathway for complex spine surgery. These results indicate that a standardized approach is associated with reduced rates of blood transfusion and optimized fluid states which was correlated with decreased postoperative ICU admissions.

807 The Association between Blood Transfusion and Outcome in Hip Fracture Patients

Abstract Aim Hip Fractures are endemic in older adults across Europe, with potential increases in incidence expected as the population ages. Management of blood loss and anaemia is a mainstay of care for these patients, but there is still significant debate regarding balance between benefit and risk of liberal versus restrictive transfusion policies. Understanding the association between providing blood products and adverse healthcare outcomes in hip fracture patients is a key component in the transfusion decision-making process. Method This retrospective cohort study uses national audit data from the Scottish Hip Fracture Audit (SHFA) and the Scottish National Blood Transfusion Service (SNBTS) to examine the association between blood transfusion and important hip fracture process of care measures and healthcare outcomes. Results A total of 28 461 patient records were included for assessment across 19 acute hospitals. Blood transfusion during admission was associated with a small but statistically significant decrease in survival at both 30 and 60 days. Those receiving blood transfusion during admission were less likely to be mobilised by the end of the 1st post-operative day, less likely to have a length of stay below the average and had far lower probability of discharge. Conclusion This study found that blood transfusion is associated with poor healthcare outcomes following hip fracture, even when adjusted for potential confounding factors. This likely reflects the potential harm of perioperative anaemia rather than any direct impact from transfusion. Further work to reduce perioperative blood loss is therefore key to improving important hip fracture outcomes.

The effect of clinician education on blood transfusion practice in obstetrics: completing the audit cycle.

With blood products being alimited and expensive resource within the healthcare system, there is an ever-increasing emphasis on judicial and appropriate use. To evaluate whether implementing contemporary society recommendations on restrictive transfusion policies would reduce inappropriate use of red blood cell transfusions, by evaluating the effect of a staff educational campaign. An audit of peri-partum red cell concentrate (RCC) transfusion practice within a tertiary obstetric unit was undertaken, covering a 1-year period (2015), examining data related to transfusion prescribing practices. Subsequently, an educational programme was held for clinical and laboratory staff which aimed to bring practice in line with society guidelines. A repeat audit covering another 1-year period (2018) was undertaken. The number of RCC units of transfused reduced by 49% between 2015 and 2018 (426 to 218). The number of patients receiving transfusion dropped from 166 in 2018 (1.8% of births) to 119 in 2015 (1.5% of births). Among stable patients who were transfused, the proportion receiving a single unit increased from 6.9 to 53.9%. (p < 0.001). Haematological reassessment between units rose from 13.8 to 80.4% (p < 0.001). Written consent documentation improved (68% in 2018 vs. 38% in 2015) (p < 0.001). The implementation of guidelines has resulted in substantial reduction in RCC transfusions between 2015 and 2018. Fewer women received a blood transfusion, and those who did received fewer units. There is a higher proportion of patients being reassessed between units and receiving single unit transfusions. Recording of consent has improved.

Transfusion policy in pediatric extracorporeal membrane oxygenation patients: Less could be more.

To evaluate a restrictive transfusion policy of red blood cells (RBC) and platelets in pediatric patients submitted to extracorporeal membrane oxygenation (ECMO). Retrospective descriptive study of pediatric patients supported with ECMO, from January 2010 to December 2019. Hemoglobin, platelet, lactate and mixed venous oxygen saturation (SvO2) values of each patient while on ECMO, were collected. Transfusion efficiency and tissue oxygenation were statistically evaluated comparing pre-transfusion hemoglobin, lactate and SvO2 with post-transfusion values. Ranges of hemoglobin and platelets were established, and the number of transfusions registered. The bleeding complications and outcome were documented. Of a total of 1016 hemoglobin values, the mean value before transfusion was 8.6g/dl. Hemoglobin and SvO2 increased significantly post-transfusion. Red blood cell transfusion varied with hemoglobin values: when hemoglobin value was less than 7g/dl, 89% (41/46) were transfused but just 23% (181/794) when greater or equal to 7g/dl. In the presence of active bleeding, the frequency of RBC transfusion increased from 32% to 62%, with hemoglobin between 7g/dl and 8g/dl.The mean value for platelet transfusion was 32 x 109/L. Thirty-eight (43%) platelet values between 20 x 109/L and 30x109/L, and 31 (40%) between 30 x 109/L and 40 x 109/L led to platelet transfusion; between 40 x 109/L and 50 x 109/L, only 7 (9%) prompted platelet transfusion.Comparing the 2010-2015 to 2016-2019 periods there was a decrease in RBC and platelet transfusion threshold with similar survival (p = .528). Survival to discharge was 68%. Using a restrictive RBC and platelet transfusion policy was safe and allowed a good outcome in this case series. The presence of active bleeding was an important decision factor when hemoglobin was above 7g/dl and platelets were above 30 x 109/L.

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.

The prognostic role of in-hospital transfusion of fresh frozen plasma in patients with cholangiocarcinoma undergoing curative-intent liver surgery

IntroductionMajor hepatectomy for perihilar and intrahepatic cholangiocarcinoma (CCA) is often associated with a significant intraoperative blood loss and the requirement for perioperative transfusion of blood products. The aim of this study was to investigate the oncological impact of fresh frozen plasma (FFP) transfusion during hospitalization in patients undergoing hepatectomy for CCA as adverse effects have been described in other malignancies. Material and methodsPatients undergoing hepatectomy for CCA from 2010 to 2019 at a single institution were eligible for this study. Survival analysis was carried out according to Kaplan-Meier and the associations of cancer-specific (CSS) and recurrence-free survival (RFS) with in-hospital application of FFP and other clinico-pathological characteristics were assessed using Cox regression models. Perioperatively deceased patients were excluded from the analysis. ResultsA total of 219 CCA patients were included in this survival analysis of which 53.0% (116/219) received FFP during hospitalization. Patients receiving in-hospital FFP showed a median CCS of 33 months (3-year-CSS = 46%, 5-year-CSS = 29%) compared to 83 months (3-year-CSS = 55%, 5-year-CSS = 53%) in patients who did not receive in-hospital FFP (p = 0.006 log rank). Further, in-hospital FFP was identified as an independent predictor of oncological outcome in multivariable analysis (CSS: HR = 1.71, p = 0.016; RFS: HR = 1.89, p = 0.003). ConclusionIn a large European cohort of patients, in-hospital transfusion of FFP was identified as a novel independent prognostic marker in CCA patients undergoing curative-intent liver surgery. A restrictive transfusion policy is therefore recommended to improve long-term outcome in these patients.

Could Transfusion be Restricted for Acute Promyelocytic Leukemia in the Era of Diffetentiating Agents?

BACKGROUNDWith the advent of differentiating agents (DA) like all-trans-retinoic-acid (ATRA), and arsenic trioxide (ATO), acute promyelocytic leukemia (APL) has become one of the best prognostic type of acute myeloid leukemia (AML) even in the under-developed countries. In Myanmar, APL is recognized as a common form of AML and managing APL in the resource limited setting particularly for aggressive transfusion support according to current guidelines is difficult and therefore transfusion requirement of APL treated in our center were analyzed with an aim to find evidence for restrictive transfusion policy. MATHODSCases of APL complicated by disseminated intravascular coagulation (DIC) treated during November 2014 to April 2017 were retrospectively reviewed in this study. All cases were treated with combined ATRA and ATO and conventional chemotherapy was added in high risk patients and those who developed rapid rise in white cell counts. Recommended target platelet count of 30-50 x 109/L and fibrinogen level of 100-150 mg/dl were maintained only for WHO grade 3 to 4 bleeding while the rest were transfused with platelet target of 20 x 109/L and fixed dose of FFP 2 -4 units per day until bleeding subsided. Prophylactic platelet was given for counts below 10 x 109/L. RESULTSAmong 33 APL admitted during two and half year's period, 29 presented with evidence of DIC, of them 4 had already developed intracerebral haemorrhage at presentation and died within 24 hours. In remaining molecularly confirmed 25 patients with APL, 14 males and 11 females, with median age of 28 years (range 12 -58) with initial performance status of 3 to 4 in 8 cases (32%) were classified as low, intermediate and high risk in 1 (4%), 13 (52%) and 11 (44%) cases respectively. Presenting blood counts were median hemoglobin - 5.9 mg/dl (3.2 - 10.6), median white cell count 7.23 x 109/L (0.43 - 110.8) and median platelet count 29 x 109/L (2 - 121). Regarding coagulation profile median PT - 15.6 second (9.9 - 21), median APTT - 28.4 second (20 - 46), median fibrinogen 160 mg/dl (82 - 900) and median D-Dimer - 8700 ng/ml (1917 - 19166). Median lowest platelet was 6 x 109/L (2 - 37) and median days of platelet count less than 10 x 109/L and less than 20 x 109/L were 4 days (0 - 10) and 8 days (2 - 26) respectively. Median number blood products transfused were of 6 units (3 - 12) of red cell, 10 units (6 - 15) of platelets and 10 unit (4 - 24) of FFP in total for each patient. Most bleeding and DIC subsided within first week and there were no haemorrhagic death during induction. CONCLUSIONRestricted transfusion policy may be possible in APL provided close monitoring of clinical and laboratory parameters and transfusion of blood products are tailored according to the risk and clinical condition. DisclosuresNo relevant conflicts of interest to declare.

78 Adherence to national transfusion guidelines by benign gynecologic surgeons at an academic, tertiary-care women’s hospital

Strong evidence supports the benefits of restrictive blood transfusion policies in non-cardiac surgery and national guidelines were adapted nearly a decade ago to recommend changes such as restrictive hemoglobin (hgb) thresholds and single unit transfusion. Whether these changes have modified transfusion practices in benign gynecologic surgery remains unclear as rates of perioperative transfusion remain high compared to other surgical specialties. We aimed to describe perioperative transfusion practices in benign gynecologic surgery at an academic, tertiary care women’s hospital in order to assess adherence to national guidelines.

Association of anemia and transfusions with outcome after subarachnoid hemorrhage

IntroductionThe benefits of correcting anemia using red blood cell transfusion (RBCT) after subarachnoid hemorrhage (SAH) are controversial. We aimed to evaluate the role of anemia and RBCT on neurological outcome after SAH using a restrictive transfusion policy. ObjectiveWe reviewed our institutional database of adult patients admitted to the Department of Intensive Care (ICU) after non-traumatic SAH over a 5-year period. We recorded hemoglobin (Hb) levels daily for a maximum of 20 days, as well as the use of RBCT. Unfavorable neurological outcome (UO) was defined as a Glasgow Outcome Score of 1–3 at 3 months. ResultsAmong 270 eligible patients, UO was observed in 40% of them. Patients with UO had lower Hb over time and received RBCT more frequently than others (15/109, 14% vs. 6/161, 4% - p < 0.01). Pre-RBCT median Hb values were similar in UO and FO patients (6.9 [6.6–7.1] vs. 7.3 [6.3–8.1] g/dL – p = 0.21). The optimal discriminative Hb threshold for UO was 9 g/dL. In a multivariable analysis, neither anemia nor RBCT were independently associated with UO. ConclusionIn this retrospective single center study using a restrictive strategy of RBCT in SAH patients was not associated with worse outcome in 3 months.

Efekti uvođenja Type&amp;Screen sistema na racionalno korišćenje transfuzije

Introduction: The number of blood donors at the global level has decreased primarily due to ethical and age-related changes in the structure of the planet's population. In addition, there is over ordering of blood for surgical patients. Accordingly, there is a need for rationalizing the testing i.e. reducing the number of cross-matchings and decrease in the use of blood. A type and screen (T&amp;S) upon admission is sufficient for most patients. Determination of ABO blood group and Rh type, and screens for clinically significant alloantibodies is denoted as type and screen (T&amp;S). Aim: Comparison of pharmaco-economic effect using transfusion indices on the number of performed cross-matches and the amount of packed red blood cells issued. Material and Methods: The authors present the comparison between the year 2010 before the introduction of the Type and Screen (T&amp;S) system and the year 2019 when the T&amp;S system and restrictive policy in transfusion practice, were introduced. Data for 2010 were collected from written transfusion protocols of the clinic, and for 2019 were obtained from the hospital information system (Heliant) and written transfusion protocols. The difference between two groups of data was examine with Chi-square test and Fisher exact test, with the reliability level set at p&lt;0.05. Results: With the introduction of the T&amp;S system, the number of cross-matches was reduced from 0.63 to 0.49 and the number of blood units was reduced from 0.21 to 0.11 per hospitalized patient, which at the level of one clinic represents a significant pharmacoeconomic contribution of approximately 50%. In our study, after processing T&amp;S in ordering of blood, the indices (CTR, %T, TI) failed to improve. Despite of unsatisfactory transfusion indices, the application of restrictive indication policies in accordance with national and international guidelines has led to highly significant reduction in the consumption of total blood from 3243 to 1867 blood units. The BOQ as an overall assessment of the results after the introduction of the T&amp;S procedure indicated improvement. Conclusions: The introduction of validation in blood transfusion indirectly draws the attention of prescribing physicians to take into account the significance of blood therapy. The effects of the introduction of the T&amp;S method and restrictive transfusion policy are savings in blood consumption, decreased number of patients tested, a significant reduction in used blood units, and the number of performed cross-matches, despite the increased number of patients.

Perioperative changes in hemoglobin levels during major hepatopancreatic surgery in transfused and non-transfused patients.

Background:Several studies have shown that restrictive transfusion policies are safe. However, in clinical practice, transfusion policies seem to be inappropriate. In order to assist in decision-making concerning red blood cell transfusions, we determined perioperative hemoglobin (Hb) levels during major pancreatic and hepatic operations.Methods:Patients who underwent major pancreatic or hepatic resections between 2002 and 2011 were classified into the transfused (TF+) and non-transfused (TF) groups. The perioperative Hb values of these patients were evaluated at six points in time.Results:The study included 1596 patients, of which 785 underwent pancreatoduodenectomy, 79 total pancreatectomy, and 732 partial hepatectomy. Similar perioperative changes in Hb levels were seen in all patients regardless of whether they received a blood transfusion. In patients undergoing pancreatoduodenectomy and total pancreatectomy, the median of the lowest measured hemoglobin values was 89.2 g/L and in partial hepatectomy patients 92.6 g/L, and these were assumed to be the trigger points for red blood cell transfusion.Conclusions:Despite guidelines on blood transfusion thresholds, restrictive blood transfusion policies were not observed during our study period. After major pancreatic and hepatic surgery, Hb levels recovered without transfusions. This should encourage clinicians to obey the restrictive blood transfusion policies after major hepatopancreatic surgery.

Unnecessary Blood Transfusion Prolongs Length of Hospital Stay of Patients Who Undergo Free Fibular Flap Reconstruction of Mandibulofacial Defects: A Propensity Score–Matched Study

Blood transfusion is usually a common clinical practice in flap transfer surgery because of its invasive hemorrhagic nature. Although intraoperative restrictive transfusion policy was suggested in vascularized fibular flap reconstruction, its clinical evidence was still insufficient. Therefore, our study aimed to investigate the influence of intraoperative blood transfusion on length of stay (LOS) after vascularized fibular flap reconstruction. Patients who underwent vascularized fibular flap reconstruction of mandibulofacial defects between 2012 and 2018 were reviewed. Univariate and multivariate analyses were performed to identify factors that influenced LOS. The identified factors and other perioperative factors that may influence transfusion decision were included in propensity score matching to explore the independent impact of intraoperative blood transfusion on LOS. About 375 patients were included, and the median LOS was 14.00 (12.00, 19.00) days in our study. Multivariate analysis suggested that duration of surgery, fluid infusion speed for more than 24hours on operative day, intraoperative blood transfusion, and postoperative complication were associated with prolonged LOS (P<.05). Propensity score matching was performed, and the difference of LOS between the matched transfused and nontransfused group was statistically significant (15.00 [12.75, 20.00] vs 14.00 [11.75, 16.25]; P<.001). The comparison between the matched and unmatched transfused patients indicated that the former has less radiotherapy history, blood loss, and higher preoperative hemoglobin (P≤.001). Intraoperative blood transfusion is independently associated with prolonged LOS in patients without preoperative anemia, radiotherapy history, or intraoperative massive hemorrhage who undergo vascularized fibular flap reconstruction. Efforts should be made to avoid unnecessary intraoperative blood transfusion, and our results support consideration of a restrictive transfusion policy in these patients.

Vox Sanguinis International Forum on Hospital Transfusion Services' Response to COVID‐19: Responses

Question 1Demographics:a. Beer Yaakov, Israel.b. Large academic medical center.c. 956 beds.d. 9034 RBC units issued in 2019, approximately 9000.e. 4831 confirmed SARS‐CoV‐2 cases and 17 deaths (March 31, 2020, 12:40 pm, data from the Israeli Ministry of Health).f. 9,136,000 inhabitants.g. The spread of SARS‐CoV‐2 in Israel is still increasing, but as of yesterday the rate of increase is declining sharply (from almost 30% of samples tested per day at the peak to 12% yesterday).

The best strategy for red blood cell transfusion in severe burn patients, restrictive or liberal: A randomized controlled trial

IntroductionAlthough blood transfusion is common in burns, data are lacking in appropriate transfusion thresholds. It has been reported that a restrictive blood transfusion policy decreases blood utilization and improves outcomes in critically ill adults, but the impact of a restrictive blood transfusion policy in burn patients is unclear. We decided to investigate the outcome of decreasing the blood transfusion threshold. Material and methodsEighty patients with TBSA > 20% who met our inclusion criteria were included. They were randomly divided into control and intervention groups. The intervention group received packed cells only when Hemoglobin declined to less than 8 g/dL at routine laboratory evaluations. While the control group received packed-cell when hemoglobin was declined to less than 10 g/dl. The total number of the received packed cell before, during and after any surgical procedure was recorded. The outcome was measured by the evaluation of the infection rate and other complications. ResultThe mean hemoglobin level before transfusion was 7.7 ± 0.4 g/dL in the restrictive group and 8.8 ± 0.7 g/dL in the liberal group. The mean number of RBC unit transfusion per patient in the restrictive group was significantly lower than the traditional group (3.28 ± 2.2 units vs. 5.9 ± 3.7 units) (p-value = 0.006). The total number of RBC transfused units varied significantly between the two groups (p-value = 0.014). The number of transfused RBC units outside the operation room showed a significant difference between groups (restrictive: 2.8 ± 1.4 units vs. liberal: 4.4 ± 2.6 units) (p = 0.004). We did not find any significant difference in mortality rate or other outcome measures between groups. ConclusionApplying the restrictive transfusion strategy in thermal burn patients who are highly prone to all kinds of infection, does not adversely impact the patient outcome, and results in significant cost savings to the institution and lower rate of infection. We conclude that the restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications. Clinical Trial Registration ReferenceIRCT20190209042660N1.