Restrictive Transfusion Policy Research Articles

Transfusion after acute upper gastrointestinal haemorrhage

In The Lancet, Vipul Jairath and colleagues1 report on a feasibility trial of restrictive versus liberal blood transfusion in acute upper gastrointestinal haemorrhage. Six UK hospitals were randomly assigned to either a restrictive (transfusion when haemoglobin concentration fell below 80 g/L; 403 patients enrolled) or liberal (transfusion when haemoglobin concentration fell below 100 g/L; 533 patients enrolled) red blood cell transfusion policy for patients with acute upper gastrointestinal bleeding.

Implementation of a clinical decision support system improves compliance with restrictive transfusion policies in hematology patients.

There is increasing evidence for restrictive red blood cell (RBC) transfusion but compliance with recommended transfusion triggers is variable. A clinical decision support system (CDSS) has been found to reduce unnecessary transfusion in some clinical settings when physicians are advised they are noncompliant with the current guidelines. The objective was to assess the impact of a CDSS for blood product ordering in patients with hematologic disease. All platelet (PLT) and RBC transfusions were identified in hematology patients in three periods: before (baseline), immediately after (CDSS1), and 7 months after implementation of CDSS for blood ordering (CDSS2). Compliance with the recommended transfusion triggers was monitored for all orders made by CDSS or non-CDSS methods during each period. Ninety-seven patients with a variety of hematologic diagnoses received 502 RBC and 572 PLT transfusions during the three periods with no significant difference in 1) the mean number of transfusions per patient, 2) the proportion of patients transfused, 3) posttransfusion hemoglobin (Hb), and 4) pre- and posttransfusion PLT count, although mean pretransfusion Hb decreased. The proportion of noncompliant RBC and PLT transfusion requests improved from baseline to CDSS2 (69.0% to 43.4% p ≤ 0.005 for RBCs; and 41.9% to 31.2%, p = 0.16 for PLT) when all orders were compared, although this improvement was not significant at the 5% level for PLTs. The introduction of CDSS for blood product ordering supported by education and physician feedback in the hematology setting had an immediate impact on improving compliance with guidelines for restrictive transfusion practice.

Improving red blood cell orders, utilization, and management with point‐of‐care clinical decision support

The computerized order for red blood cell (RBC) transfusion within our electronic health record was redesigned with integrated clinical decision support (CDS) to reinforce our restrictive transfusion policy. These changes encouraged 1-unit (1U) RBC orders, clarified hemoglobin (Hb) transfusion triggers, and discouraged unnecessary orders. This study assessed whether these changes resulted in durable effects on provider practices. The study compared three 1-year subperiods from August 2011 to August 2014, with each year corresponding to a historical control period, preintervention and postintervention years. This study analyzed ratios of 1U versus 2-unit (2U) orders and the absolute rate of RBC orders, units charged, Hb transfusion triggers, repeat transfusion orders, and selected clinical indications both institution-wide and across several subpopulations. Our institution-wide ratio of 1U versus 2U orders increased from 0.50 to 1.20 (p < 0.0001) in the pre- to postintervention subperiods, respectively. The number of units charged per day decreased from 15.68 to 13.53 (p < 0.001), while rates of initial and repeat orders remained stable. Proportion of clinical indications used and mean Hb triggers demonstrated generally positive results. The changes observed between the pre- and postintervention years were far greater than changes between historical control versus preintervention years, reinforcing attribution of results to computerized physician order entry changes. Use of computerized orders and CDS encouraged a restrictive transfusion policy, which was highly successful in changing provider practices. We also succeeded in decreasing mean Hb triggers and overall utilization of RBCs. These findings persisted across many subpopulations.

Blood management in total hip replacement: an analysis of factors associated with allogenic blood transfusion.

The aim of this study was to audit the blood transfusion practice throughout the Epworth Healthcare Hospitals for patients undergoing primary total hip replacement (THR). We determined if blood-saving techniques were having an impact on the risk of allogenic blood transfusion and which patients were at risk of receiving allogenic blood transfusion. This study uses a retrospective audit of 787 patients who had undergone primary THR surgery at three Melbourne hospitals: Epworth Richmond, Epworth Eastern and Epworth Freemasons in 2010. Patient demographics, transfusion requirements and blood-conserving techniques were recorded. One hundred and eighty (23%) patients received allogenic blood transfusion and 18 (2.3%) patients received autologous blood transfusion. On multivariate analysis, preoperative anaemia (odds ratio (OR) 4.7, P < 0.0001), female gender (OR 3.1, P < 0.0001) and patient age (OR 1.07 per year of age increase, P < 0.0001) were shown to be significantly associated with higher risk of allogenic blood transfusion. Use of spinal anaesthetic was found to be associated with lower risk of transfusion (OR 0.6, P = 0.0180) compared with general anaesthetic alone. Cell saver, acute normovolaemic haemodilution and re-infusion drain tube usage did not have a significant impact on reducing the risk of allogenic blood transfusion. Identification of patients at risk of blood transfusion, correction of preoperative anaemia and a restrictive transfusion policy are important factors to consider in effective perioperative blood management.

Comparison of a restrictive versus liberal red cell transfusion policy for patients with myelodysplasia, aplastic anaemia, and other congenital bone marrow failure disorders.

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the efficacy and safety of a restrictive versus liberal red cell transfusion strategy for patients with long-term bone marrow failure. These include myelodysplasia, acquired aplastic anaemia, and other inherited bone marrow failure disorders.

The impact of electronic decision support and electronic remote blood issue on transfusion practice.

To assess the impact on transfusion practice of a two-stage electronic intervention: the introduction of a decision support system (DSS) followed by the addition of electronic remote blood issue (ERBI). With increasing evidence to show the benefit of restrictive transfusion policies, it is important to ascertain which interventions can increase clinician compliance with their implementation. A DSS provides patient-specific recommendations to clinicians. ERBI reduces delays in acquiring blood and may alter the transfusion behaviour of clinicians. All electronically requested blood transfusions administered outside of surgical theatres or recovery were identified in an orthopaedic hospital. These were divided into three time periods corresponding to pre-intervention, the successive introduction of DSS alone and DSS with ERBI. Pre- and post-transfusion haemoglobin (Hb) concentration levels, and the number of units ordered and transfused were recorded. A total of 204 transfusions for 92 patients were assessed; 38 of 85 (45%) transfusions in the first time period were compliant. This did not significantly change after introduction of the DSS, but with DSS and ERBI together significantly increased to 39 of 60 (65%) (P < 0·05). Mean pre-transfusion Hb reduced from 8·24 g dl(-1) in the first time period to 7·67 g dl(-1) in the third (P < 0·0001). There was no significant change in overall blood usage, although ERBI significantly reduced the amount of unused blood orders from 70 to 25%. Electronic DSS was not sufficient to change practice in the form implemented in this study. ERBI can contribute to significant improvements in blood usage as well as the efficiency of blood provision.

Significant reduction in red blood cell transfusions in a general hospital after successful implementation of a restrictive transfusion policy supported by prospective computerized order auditing

Our hospital transfusion policy was recently revised to recommend single-unit red blood cell transfusion (RBC TXN) for nonbleeding inpatients when the hemoglobin (Hb) level is not more than 7 g/dL. Our computerized provider order entry system was reconfigured to provide real-time decision support using prospective computerized order auditing based on the most recent Hb level and to remove the single-click ordering option for 2-unit RBC TXNs to enhance compliance. This study was undertaken to assess the impact of these changes on hospital transfusion practice. This study analyzed the total number of transfusion events, proportion of single and 2-unit transfusions and the Hb transfusion trigger in the preimplementation period (October 2011-March 2012) compared to the postimplementation period (October 2012-March 2013). In the postimplementation period the total number of RBC units transfused/1000 patient-days decreased from 60.8 to 44.2 (p < 0.0001). The proportion of 2-unit TXNs decreased from 47% to 15% (p < 0.0001). We also observed significant decreases in pretransfusion Hb triggers. Implementation of restrictive transfusion policy supported by prospective computerized order auditing has resulted in significantly decreased RBC utilization at our institution.

Acute variceal haemorrhage: Practice guidelines and real-life management

Variceal haemorrhage is a life-threatening event in the course f cirrhosis of the liver. In the 1970s and 1980s, the short term (30 ays to 6 weeks) mortality for variceal bleeding was in the order f 40–50%, with 6-weeks rebleeding rates of over 30%. In subseuent years, great progress has been made in the management f this medical emergency; such progress has been made possile by improvements in general supportive care as well as in the pecific management of variceal bleeding, such as the introduction f emergency endoscopic treatments (first sclerotherapy and subequently rubber band ligation), the early use of vasoactive drugs vasopressin, terlipressin, somatostatin, and octreotide), the adopion of antibiotic prophylaxis and of restrictive transfusion policies, nd the availability of emergency transjugular intrahepatic portoystemic shunt (TIPS) for patients failing (or at high risk for failure f) first line therapies. Indeed, progressive decrease over the years f rebleeding and mortality rates after variceal haemorrhage has een reported from several countries. As an example, in a nationide study from Sweden [1] the survival of patients hospitalized for esophageal varices increased steadily and significantly between 969 and 2002. The Authors attributed the improvement in surival to the “improved acute treatment and secondary prophylaxis f the hospitalized patients with varices”. Similar results have been eported in the United Kingdom, France, the United States and enmark. In 1990, the scientific evidence concerning the diagnosis nd management of variceal haemorrhage was critically evaluated y a faculty including several world experts in the field in a consenus workshop that took place in Baveno, Italy. Recommendations or clinical practice based on the conclusions of the workshop (aka he Baveno recommendations) were published in the Journal of epatology. Since then, the Baveno recommendations have been pdated in consensus workshops held every 5 years, to incorpoate the new evidence as soon as it was published. The most recent aveno workshop (Baveno V) took place in 2010 [2]. The Baveno ecommendations are widely accepted, and in subsequent years nspired the publications of similar guidelines by scientific societies

Perioperative anemia management in colorectal cancer patients: A pragmatic approach

Anemia, usually due to iron deficiency, is highly prevalent among patients with colorectal cancer. Inflammatory cytokines lead to iron restricted erythropoiesis further decreasing iron availability and impairing iron utilization. Preoperative anemia predicts for decreased survival. Allogeneic blood transfusion is widely used to correct anemia and is associated with poorer surgical outcomes, increased post-operative nosocomial infections, longer hospital stays, increased rates of cancer recurrence and perioperative venous thromboembolism. Infections are more likely to occur in those with low preoperative serum ferritin level compared to those with normal levels. A multidisciplinary, multimodal, individualized strategy, collectively termed Patient Blood Management, minimizes or eliminates allogeneic blood transfusion. This includes restrictive transfusion policy, thromboprophylaxis and anemia management to improve outcomes. Normalization of preoperative hemoglobin levels is a World Health Organization recommendation. Iron repletion should be routinely ordered when indicated. Oral iron is poorly tolerated with low adherence based on published evidence. Intravenous iron is safe and effective but is frequently avoided due to misinformation and misinterpretation concerning the incidence and clinical nature of minor infusion reactions. Serious adverse events with intravenous iron are extremely rare. Newer formulations allow complete replacement dosing in 15-60 min markedly facilitating care. Erythropoiesis stimulating agents may improve response rates. A multidisciplinary, multimodal, individualized strategy, collectively termed Patient Blood Management used to minimize or eliminate allogeneic blood transfusion is indicated to improve outcomes.

Compliance rates and outcomes associated with a restrictive transfusion policy in gynecologic oncology patients

ObjectivesBlood products are scarce but essential medical resources. Initially transfusions showed increased perioperative complications, prolonged hospitalizations, and higher mortality. Recently developed restrictive transfusion policies have not shown those adverse affects in critically ill patients. Hospitals adopted these policies to guide blood product administration. The objective of this study is to determine compliance with a restrictive transfusion policy in gynecologic oncology patients. MethodsA retrospective chart review of gynecologic oncology patients undergoing transfusion with packed red blood cells (pRBCs) from 12/2008 to 9/2011 was performed. Cancer type and stage, surgical procedure, hemoglobin values, pRBC transfusions, intraoperative blood loss, and postoperative complications were collected. Each transfusion was classified as compliant or noncompliant. ResultsA total of 582 patients requiring 2,276 blood transfusions were identified. The mean age was 55.9years. Ovarian and endometrial cancers were the most common malignancies. Gynecologic oncologists were 81.1% compliant with the restrictive transfusion policy; 59.0% of transfusions were secondary to exceptions. Noncompliant transfusions were commonly given on the day of surgery when intraoperative blood loss was <1500cc and for asymptomatic anemia. Only 64.7% of the transfusions were ordered in single unit increments. There was no significant difference in postoperative infections, thrombotic events, and mortality between compliant and noncompliant transfusions. ConclusionThe majority of gynecologic oncology patients receive transfusions compliant with the restrictive transfusion policy. Morbidity and mortality are not increased with a restrictive transfusion policy. Efforts to improve compliance should focus on limiting transfusions when the hemoglobin is ≥7g/dL and transfusing in single pRBCs unit increments.

Safety and effects of two red blood cell transfusion strategies in pediatric cardiac surgery patients: a randomized controlled trial

To investigate the safety and effects of a restrictive red blood cell (RBC) transfusion strategy in pediatric cardiac surgery patients. Randomized controlled trial. Pediatric ICU in an academic tertiary care center, Leiden University Medical Center, Leiden, The Netherlands. One hundred seven patients with non-cyanotic congenital heart defects between 6 weeks and 6 years of age. One hundred three patients underwent corrective surgery on cardiopulmonary bypass. Prior to surgery patients were randomly assigned to one of two groups with specific RBC transfusion thresholds: Hb 10.8 g/dl (6.8 mmol/l) and Hb 8.0 g/dl (5.0 mmol/l). Length of stay in hospital (primary outcome), length of stay in PICU, duration of ventilation (secondary outcome), incidence of adverse events and complications related to randomization (intention to treat analysis). In the restrictive transfusion group, mean volume of transfused RBC was 186 (±70) ml per patient and in the liberal transfusion group 258 (±87) ml per patient, (95% CI 40.6-104.6), p < 0.001. Length of hospital stay was shorter in patients with a restrictive RBC transfusion strategy: median 8 (IQR 7-11) vs. 9 (IQR 7-14) days, p = 0.047. All other outcome measures and incidence of adverse effects were equal in both RBC transfusion groups. Cost of blood products for the liberal transfusion group was 438.35 (±203.39) vs. 316.27 (±189.96) euros (95% CI 46.61-197.51) per patient in the restrictive transfusion group, p = 0.002. For patients with a non-cyanotic congenital heart defect undergoing elective cardiac surgery, a restrictive RBC transfusion policy (threshold of Hb 8.0 g/dl) during the entire perioperative period is safe, leads to a shorter hospital stay and is less expensive.

Randomised trial of blood transfusion versus a restrictive transfusion policy after hip fracture surgery

BackgroundDebate exists as to what should be the transfusion threshold for patients with anaemia after hip fracture surgery. MethodsA total of 200 patients aged 60 years and above with a haemoglobin level of between 8.0 and 9.5gdl−1 after hip fracture surgery were randomised to receive a transfusion to raise the haemoglobin to at least 10.0gdl−1 or not to have a transfusion unless definite symptoms of anaemia became apparent. Patients were followed up for 1 year. ResultsThere was no statistically significant difference in the outcomes of mortality, hospital stay, regain of mobility or complications between the two groups. ConclusionsThis study confirms other recent research studies which found that reducing the transfusion threshold to 8.0gdl−1 appears to be a safe practice for this group of patients.

Restrictive vs Liberal Blood Transfusion for Acute Upper Gastrointestinal Bleeding: Rationale and Protocol for a Cluster Randomized Feasibility Trial

Acute upper gastrointestinal bleeding (AUGIB) is the commonest reason for hospitalization with hemorrhage in the UK and the leading indication for transfusion of red blood cells (RBCs). Observational studies suggest an association between more liberal RBC transfusion and adverse patient outcomes, and a recent randomised trial reported increased further bleeding and mortality with a liberal transfusion policy. TRIGGER (Transfusion in Gastrointestinal Bleeding) is a pragmatic, cluster randomized trial which aims to evaluate the feasibility and safety of implementing a restrictive versus liberal RBC transfusion policy in adult patients admitted with AUGIB. The trial will take place in 6 UK hospitals, and each centre will be randomly allocated to a transfusion policy. Clinicians throughout each hospital will manage all eligible patients according to the transfusion policy for the 6-month trial recruitment period. In the restrictive centers, patients become eligible for RBC transfusion when their hemoglobin is < 8 g/dL. In the liberal centers patients become eligible for transfusion once their hemoglobin is < 10 g/dL. All clinicians will have the discretion to transfuse outside of the policy but will be asked to document the reasons for doing so. Feasibility outcome measures include protocol adherence, recruitment rate, and evidence of selection bias. Clinical outcome measures include further bleeding, mortality, thromboembolic events, and infections. Quality of life will be measured using the EuroQol EQ-5D at day 28, and the costs associated with hospitalization for AUGIB in the UK will be estimated. Consent will be sought from participants or their representatives according to patient capacity for use of routine hospital data and day 28 follow up. The study has ethical approval for conduct in England and Scotland. Results will be analysed according to a pre-defined statistical analysis plan and disseminated in peer reviewed publications to relevant stakeholders. The results of this study will inform the feasibility and design of a phase III randomized trial.

The impact of a restrictive transfusion trigger on post-operative complication rate and well-being following elective orthopaedic surgery: a post-hoc analysis of a randomised study.

Peri-operative red blood cell transfusions have been associated with post-operative complications in patients undergoing elective orthopaedic hip or knee replacement surgery. We performed a post-hoc analysis of data extracted from a randomised study on transfusion triggers using pre-storage leucocyte-depleted red blood cells. Patients who were assigned to the most restrictive transfusion policy ("restrictive group") were compared with patients who were assigned to the most liberal policy ("liberal group"). End-points were red blood cell use, hospital stay, haemoglobin levels, post-operative complications and quality of life scores. Of 603 patients, 26.4% patients in the restrictive group and 39.1% in the liberal group were transfused (P =0.001). The rate of post-operative infections was lower, although not statistically significantly so, in the restrictive group than in the liberal group (5.4% vs. 10.2%, respectively) as was the rate of respiratory complications (1.7% vs. 4.9%, respectively), whereas hospital stay, cardiovascular complications and mortality rate were not different in the two groups. Quality of life scores were not associated with type of transfusion policy, the number of red blood cell transfusions or the transfusion status. A restrictive transfusion protocol was not associated with worse outcome and resulted in a lower transfusion rate compared to the liberal policy. Well-being (quality of life) was not associated with transfusion policy or with red blood cell transfusions.

Update on the transfusion in gastrointestinal bleeding (TRIGGER) trial: statistical analysis plan for a cluster-randomised feasibility trial

BackgroundPrevious research has suggested an association between more liberal red blood cell (RBC) transfusion and greater risk of further bleeding and mortality following acute upper gastrointestinal bleeding (AUGIB).Methods and designThe Transfusion in Gastrointestinal Bleeding (TRIGGER) trial is a pragmatic cluster-randomised feasibility trial which aims to evaluate the feasibility of implementing a restrictive vs. liberal RBC transfusion policy for adult patients admitted to hospital with AUGIB in the UK. This trial will help to inform the design and methodology of a phase III trial. The protocol for TRIGGER has been published in Transfusion Medicine Reviews. Recruitment began in September 2012 and was completed in March 2013. This update presents the statistical analysis plan, detailing how analysis of the TRIGGER trial will be performed. It is hoped that prospective publication of the full statistical analysis plan will increase transparency and give readers a clear overview of how TRIGGER will be analysed.Trial registrationISRCTN85757829

Changing Transfusion Practice in Total Hip Arthroplasty: Observational Study of the Reduction of Blood Use Over 6 Years

Patients undergoing primary total hip arthroplasty (THA) have historically been over-transfused. In a district general hospital setting, the authors observed a significant downward trend in blood transfusion requirements in these patients over 6 years after a change in transfusion policy. The purpose of this study was to retrospectively analyze the change in transfusion practice and present the results of the restrictive transfusion policy. All patients undergoing primary THA between January 2003 and December 2008 were identified from hospital records. Pre- and postoperative hemoglobin levels, transfusion trigger hemoglobin, blood transfusion requirements, patient age and sex, 30-day mortality, and length of stay data were analyzed for all patients. A total of 1169 primary THAs were performed. Annual allogeneic blood transfusion requirements reduced progressively from 151 units in 2003 to 90 units in 2008 despite an increase in the number of patients undergoing THA. During this period, the proportion of patients transfused decreased from 35% to 17%. A reduction of mean transfusion trigger hemoglobin from 79 to 73 g/L was observed over the study period. No patient experienced any significant complications as a result of undertransfusion. The authors' institution has steadily restricted the use of blood transfusion in patients undergoing THA to those symptomatic of anemia. Increasing confidence among medical and nursing staff that reduced postoperative hemoglobin levels can be safely tolerated has resulted in a 55% reduction in blood transfusion in patients undergoing THA with no other change of practice.

The appropriateness of blood transfusion following primary total hip replacement

A significant proportion of all red cell transfusions are given to patients undergoing elective orthopaedic surgery. Concern over transfusion safety and cost, coupled with evidence showing that restrictive transfusion policies benefit patients, prompted us to audit our blood prescribing practice at Gloucestershire Hospitals NHS Foundation Trust in order to assess the appropriateness of every transfusion episode following elective primary total hip replacement. All patients undergoing a primary total hip replacement in our department over a six-month period were included in the study. Data were collected retrospectively using case note examination and transfusion service data. Standards were dictated by the British Orthopaedic Association guidelines on blood conservation in elective orthopaedic surgery. Twenty-seven per cent of patients (39/143) were transfused. Forty-six per cent of these (18/39) were transfused inappropriately and twenty-three per cent (9/39) appropriately. Thirteen per cent (5/39) had a valid indication for transfusion but were over-transfused and in eighteen per cent (7/39) the quality of documentation did not allow an assessment to be made. Fifty-two per cent of patients who had surgical drains (29/56) were transfused. Reaudit following staff education and amendments to the local transfusion policy did not demonstrate a reduction in transfusion rates. This audit showed that significant potential exists for reducing transfusion rates based on optimising prescribing practice alone. It also demonstrated that changing local practice based on audit data can be challenging.

Impact of transfusion policy on acute coronary syndrome after major vascular reconstruction

ObjectivesTo investigate the impact of a restrictive transfusion approach, as indicated by accepting a perioperative hemoglobin (Hb) level as low as 8 g/dL, on the incidence of acute coronary syndrome (ACS) and mortality after major vascular reconstruction. MethodsUsing a case-control design, 45 patients who underwent vascular reconstruction and developed postoperative ACS were compared with 135 patients treated with similar procedures who did not suffer ACS postoperatively. ResultsA history of CAD was more often present in the ACS group (16% vs 56%) and was an independent predictor of ACS (odds ratio [OR] = 6.62; confidence interval [CI], 3.16–13.88; P < .001) and postoperative death (OR = 5.08; CI, 2.0–12.85; P = .001). Postoperative (Hb) levels as low as 8 g/dL were well tolerated and had no impact on the occurrence of ACS (OR = .61; CI, 0.29–1.26; P = .181) or death (OR = 1.33; CI, 0.52–3.43; P = .547). The presence of CAD for a given Hb level did not increase the odds of either ACS (OR = 3.43; CI, .75–15.6; P = .112) or death (OR = 2.02; CI, .5–19.55; P = .543). ConclusionsA restrictive transfusion policy is justified in patients undergoing major vascular reconstruction, even in the presence of appropriately managed cad.

Outcomes following early red blood cell transfusion in acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding (AUGIB) accounts for 14% of RBC units transfused in the UK. In exsanguinating AUGIB the value of RBC transfusion is self evident, but in less severe bleeding its value is less obvious. To examine the relationship between early RBC transfusion, re-bleeding and mortality following AUGIB, which is one of the most common indications for red blood cell (RBC) transfusion. Data were collected on 4441 AUGIB patients presenting to UK hospitals. The relationship between early RBC transfusion, re-bleeding and death was examined using logistic regression. 44% were transfused RBCs within 12 hours of admission. In patients transfused with an initial haemoglobin of <8 g/dl, re-bleeding occurred in 23% and mortality was 13% compared with a re-bleeding rate of 15%, and mortality of 13% in those not transfused. In patients transfused with haemoglobin >8 g/dl, re-bleeding occurred in 24% and mortality was 11% compared with a re-bleeding rate of 6.7%, and mortality of 4.3% in those not transfused. After adjusting for Rockall score and initial haemoglobin, early transfusion was associated with a two-fold increased risk of re-bleeding (Odds ratio 2.26, 95% CI 1.76-2.90) and a 28% increase in mortality (Odds ratio 1.28, 95% CI 0.94-1.74). Early RBC transfusion in AUGIB was associated with a two-fold increased risk of re-bleeding and an increase in mortality, although the latter was not statistically significant. Although these findings could be due to residual confounding, they indicate that a randomized comparison of restrictive and liberal transfusion policies in AUGIB is urgently required.

Risk Factors for Surgical Site Infection After Cardiac Surgery in Children

We sought to identify risk factors for surgical site infections (SSI) in children undergoing cardiac surgery. A matched case-control study was conducted in the Children's Hospital Boston Cardiovascular Program. Surgical site infections were identified for 3 years (2004 to 2006). We identified two randomly selected control patients who underwent cardiac surgery within 7 days of each index case. Univariate and multivariate conditional logistic regression analyses were used to identify risk factors for SSI. In a secondary analysis, risk factors for organ space SSI (mediastinitis) were sought. Secondary analyses were also conducted using only those variables known preoperatively. Seventy-two SSI and 144 controls were included. Independent risk factors for any type of SSI were age younger than 1 year (adjusted odds ratio, 2.28; 95% confidence interval, 1.18 to 4.39) and duration of cardiopulmonary bypass greater than 105 minutes (adjusted odds ratio, 1.92; 95% confidence interval, 1.02 to 3.62). Independent risk factors for organ space SSI were aortic cross-clamp time greater than 85 minutes (adjusted odds ratio, 5.61; 95% confidence interval, 1.06 to 29.67) and postoperative exposure to at least three separate red blood cell transfusions (adjusted odds ratio, 7.87; 95% confidence interval, 1.63 to 37.92). When only those potential risk factors known preoperatively were considered, age younger than 1 year independently predicted the subsequent development of any type of SSI, and preoperative hospitalization independently predicted the subsequent development of organ space SSI. Younger patients undergoing longer surgical procedures and those requiring more postoperative blood transfusions are at greatest risk for SSI. Additional preventive strategies, including restrictive blood transfusion policies, warrant further investigation.