Restrictive Transfusion Strategy Research Articles

The restrictive red blood cell transfusion strategy for critically injured patients: RESTRIC trial

The restrictive red blood cell transfusion strategy for critically injured patients: RESTRIC trial

Impact of restrictive platelet transfusion strategies on transfusion rates: A cohort study in very preterm infants.

Evidence supports a restrictive platelet transfusion threshold in preterm neonates. We aimed to describe the effect of implementing this threshold on transfusion rates. This retrospective observational cohort study included all very preterm infants (born <32 weeks' gestation) admitted to a neonatal intensive care unit between 2004 and 2022, divided into three epochs. Platelet transfusion thresholds changed from 30 × 109/L for stable neonates and 50 × 109/L for unstable neonates (January 2004 to December 2009) to 20 × 109/L for stable neonates and 50 × 109/L for unstable neonates (January 2010 to June 2019) to 25 × 109/L for non-bleeding neonates and 50 × 109/L for neonates with major bleeding (July 2019 to July 2022). The primary outcome was the percentage of transfused neonates in each epoch. Secondary outcomes included the median number of transfusions per neonate, the percentage of transfusions given above 25 or 50 × 109/L, and major bleeding and mortality rates. The percentage of neonates transfused was 12.2% (115/939), 5.8% (96/1660), and 4.8% (25/525) in Epoch I, II, and III, respectively (p < .001), a relative reduction of 61%. The median number of transfusions per transfused neonate was 2.0 (interquartile range [IQR]: 1.0-3.0) in Epoch I, and 1.0 (IQR: 1.0-2.0) in subsequent Epochs (p = .04). The percentage of infants receiving at least one transfusion above 50 × 109/L in Epoch I, II, and III was 51.3% (59/115), 17.7% (17/96), and 20.0% (5/25; p < .001). Mortality and bleeding rates did not significantly differ between epochs. Implementation of restrictive platelet guidelines led to reduction of the rate and number of platelet transfusions.

Clinical outcomes in critically ill children on extracorporeal membrane oxygenation with severe thrombocytopenia

Introduction As international guidelines suggest keeping the platelet count between 50 and 100 × 109 cells/L in children on extracorporeal membrane oxygenation (ECMO), platelet transfusions are administered to two-thirds of ECMO days, and up to 70% of these patients still bleed. We aim to describe outcomes in critically ill children who develop severe thrombocytopenia on ECMO. Methods Single-center retrospective study, enrolling critically ill children on ECMO admitted at Children’s Memorial Hermann, TX, between 1/2018 and 12/2022, with at least one platelet count below 50 × 109 cells/L (severe thrombocytopenia). Platelet counts were measured four times a day. We report platelet transfusion, bleeding, hemolysis, and clotting events within 6 h after transfusion, as well as ECMO duration and mortality. Results We enrolled 54 patients representing 337 ECMO days and 1190 platelet counts. Median weight was 3.7 kg and 54% were male. Severe thrombocytopenia was observed in 56% of platelet counts. Severe thrombocytopenia was not associated with bleeding in the subsequent 6 h (18% vs 20%, p = .95), but was associated with more frequent platelet transfusions (18% vs 11%, p = .001). There was no correlation between time spent with severe thrombocytopenia and the duration of ECMO (R2 = 0.03). While the time spent with severe thrombocytopenia was not associated with on-ECMO mortality rate ( p = .36), there was an association with in-hospital mortality rate ( p = .003). Conclusions Our results indicate a restrictive platelet transfusion strategy is not associated with higher proportions of subsequent bleeding, duration of ECMO, or on-ECMO mortality rate. Multicenter studies are needed to evaluate further the appropriateness of this strategy.

A survey on perioperative red blood cell transfusion trigger strategies for pediatric patients in the Nordic countries.

Transfusion of red blood cells (RBC) to rapidly increase hemoglobin levels have been associated with increased risks and worse outcomes in critically ill children. The international TAXI consensus from 2018 (pediatric critical care transfusion and anemia expertise initiative) recommended restrictive RBC transfusion strategies in pediatric patients. To elucidate physicians perioperative RBC transfusion trigger strategies for pediatric patients in the Nordic countries and to investigate what factors influence the decision to transfuse this group of patients. An electronic web-based survey designed by the TransfUsion triggers in Pediatric perioperAtive Care (TUPAC) initiative including six different clinical scenarios was sent to anesthesiologist treating pediatric patients at university hospitals in the Nordic countries on February 1, 2023 and closed May 1, 2023. The study had a response rate of 67.7% (180 responders out of 266 contacted). Median hemoglobin thresholds triggering RBC transfusions were 7.0 [IQR, 7.0-7.3] g/dL in a stable young child (1-year-old), 7.0 [IQR, 7.0-7.0] g/dL in the stable older child (5-year-old), 8.5 [IQR, 8.0-9.0] g/dL in the older child with cardiac disease, 9.0 [IQR, 8.0-10.0] g/dL the older child with traumatic brain injury, 8.0 [IQR, 7.3-9.0] g/dL in stabilized older child with septic shock and 8.0 [IQR, 7.0-9.0] g/dL in the older child with active but non-life-threatening bleeding. Apart from specific hemoglobin level, RBC transfusions were mostly triggered by high lactate level (74.2%), increasing heart rate (68.0%), prolonged capillary refill time (48.3%), and lowered blood pressure (47.8%). No statistical difference was found between the Nordic countries, work experience, or enrollment in a pediatric anesthesia fellowship program regarding RBC transfusion strategies. Anesthesiologists in the Nordic countries report restrictive perioperative RBC transfusion strategies for children that are mostly in agreement with the international TAXI recommendations. However, RBC transfusions strategies were modified to be guided by more liberal trigger levels when pediatric patients presented with severe comorbidity such as severe sepsis, septic shock, and non-life-threatening bleeding.

Red blood cell transfusion in neurocritical patients: a systematic review and meta-analysis

BackgroundAnemia can lead to secondary brain damage by reducing arterial oxygen content and brain oxygen supply. Patients with acute brain injury have impaired self-regulation. Brain hypoxia may also occur even in mild anemia. Red blood cell (RBC) transfusion is associated with increased postoperative complications, poor neurological recovery, and mortality in critically ill neurologic patients. Balancing the risks of anemia and red blood cell transfusion-associated adverse effects is challenging in neurocritical settings.MethodsWe searched the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE (PubMed) from inception to January 31, 2024. We included all randomized controlled trials (RCTs) assessing liberal versus restrictive RBC transfusion strategies in neurocritical patients. We included all relevant studies published in English. The primary outcome was mortality at intensive care unit (ICU), discharge, and six months.ResultsOf 5195 records retrieved, 84 full-text articles were reviewed, and five eligible studies were included. There was no significant difference between the restrictive and liberal transfusion groups in ICU mortality (RR: 2.53, 95% CI: 0.53 to 12.13), in-hospital mortality (RR: 2.34, 95% CI: 0.50 to 11.00), mortality at six months (RR: 1.42, 95% CI: 0.42 to 4.78) and long-term mortality (RR: 1.22, 95% CI: 0.64 to 2.33). The occurrence of neurological adverse events and most major non-neurological complications was similar in the two groups. The incidence of deep venous thrombosis was lower in the restrictive strategy group (RR: 0.41, 95% CI: 0.18 to 0.91).ConclusionsDue to the small sample size of current studies, the evidence is insufficiently robust to confirm definitive conclusions for neurocritical patients. Therefore, further investigation is encouraged to define appropriate RBC transfusion thresholds in the neurocritical setting.

Adherence to a restrictive red blood cell transfusion strategy in critically ill patients: An observational study.

Randomized controlled trials relatively consistently show that restrictive red blood cell (RBC) transfusion strategies are safe and associated with similar outcomes compared to liberal transfusion strategies in critically ill patients. Based on these data, the general threshold for RBC transfusion was changed to 70 g/L at a 9-bed tertiary level intensive care unit in September 2020. Implementation measures included lectures, webinars and feedback during clinical practice. The aim of this study was to investigate how implementation of a restrictive transfusion strategy influenced RBC usage, haemoglobin trigger levels and adherence to prescribed trigger levels. In this registry-based, observational study, critically ill adult patients without massive bleeding were included and divided into a pre-cohort, with admissions prior to the change of transfusion strategy, and a post-cohort, with admissions following the change of transfusion strategy. These cohorts were compared regarding key RBC transfusion-related variables. In total 5626 admissions were included in the analyses (pre-cohort n = 4373, post-cohort n = 1253). The median volume (interquartile range, IQR) of RBC transfusions per 100 admission days, in the pre-cohort was 6120 (4110-8110) mL versus 3010 (2890-4970) mL in the post-cohort (p < .001). This corresponds to an estimated median saving of 1128 € per 100 admission days after a restrictive RBC transfusion strategy was implemented. In total, 26% of the admissions in the pre-cohort and 19% in the post-cohort (p < .001) received RBC transfusion(s) during days 0-10. Both median (IQR) prescribed trigger levels (determined by intensivist) and actual haemoglobin trigger levels (i.e., levels prior to actual administration of transfusion) were higher in the pre- versus post-cohort (90 [80-100] vs. 80 [72-90] g/L, p < .001 and 89 [82-96] g/L vs. 83 [79-94], p < .001, respectively). Percentage of days without compliance with the prescribed transfusion trigger was higher in the pre-cohort than in the post-cohort (23% vs. 14%, p < .001). Sensitivity analyses, excluding patients with traumatic brain injury, ischemic heart disease and COVID-19 demonstrated similar results. Implementation of a restrictive transfusion trigger in a critical care setting resulted in lasting decreased RBC transfusion use and costs, decreased prescribed and actual haemoglobin trigger levels and improved adherence to prescribed haemoglobin trigger levels.

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

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

Restrictive vs Liberal Blood Transfusions for Patients with Acute Myocardial Infarction and Anaemia by Heart Failure Status: An RCT Subgroup Analysis

BackgroundRed blood cell transfusion can cause fluid overload. We evaluated the interaction between heart failure (HF) at baseline and transfusion strategy on outcomes in acute myocardial infarction (AMI). MethodsWe used data from the randomized REALITY trial (https://www.clinicaltrials.gov/study/NCT02648113), comparing restrictive versus liberal transfusion strategies in patients with AMI and anaemia. HF was defined as history of HF or Killip class > 1 at randomization. Primary outcome was major adverse cardiovascular events (MACE: composite of all-cause death, non-recurrent AMI, stroke, or emergency revascularization prompted by ischaemia) at 30 days. ResultsAmong 658 randomized patients, 311 (47.3%) had HF. HF patients had higher rates of MACE at 30 days and 1 year, and higher rates of non-fatal new-onset HF. There was no interaction between HF and effect of randomized assignment on the primary outcome or non-fatal new-onset HF. A liberal transfusion strategy was associated with increased all-cause death at 30 days and at 1 year in HF patients (Pinteraction = 0.009 and P = 0.049, respectively). The main numerical difference in cause of death between restrictive and liberal strategies was death by HF at 30 days (4 vs 11). ConclusionsHF is frequent in AMI patients with anaemia and is associated with higher risk of MACE (including all-cause death) and non-fatal new-onset HF. While there was no interaction of HF with effect of transfusion strategy on MACE, a liberal transfusion strategy was associated with higher all-cause death that appears driven by a higher risk of early death due to HF.

Blood Product Transfusions for Children in the Perioperative Period and for Critically Ill Children.

Approximately 1% to 2% of all hospitalized children receive a transfusion of blood products, in Germany as in other countries. High-quality scientific evidence on transfusions in children is scarce. The available evidence is discussed in this review. This review is based on publications on blood product transfusions in children that were retrieved by a literature search, including clinical studies, international guideline recommendations, the recommendations of the German cross-sectional guideline, and results of other recent, relevant publications. A restrictive transfusion strategy is recommended for all children, including those who are critically ill. Randomized controlled trials have shown that a restrictive strategy for erythrocyte concentrate transfusion in the intensive care unit is safe for children, including neonates. No robust data are available to enable the definition of a suitable threshold for the intraoperative administration of red blood cell concentrates in children undergoing extracardiac surgery. On the basis of studies from pediatric intensive care units, transfusions for hemodynamically stable children with a hemoglobin concentration of more than 7 g/dL are recommended only in exceptional cases. Therapeutic plasma is not recommended as volume replacement, except in massive transfusion. Platelet concentrate transfusions are indicated in case of active hemorrhage, and only rarely for prophylaxis. There is a broad lack of evidence from randomized controlled trials concerning the indications for transfusions in children. A restrictive transfusion strategy, which has been found safe in the intensive-care setting, is favored by the guidelines in the perioperative setting as well. Further studies are needed to evaluate transfusion triggers and indications for all types of blood products, especially therapeutic plasma. Until more evidence is available, physicians should be aware of what the current evidence supports, and blood products should be given restrictively, and not prophylactically.

Association of initial lactate levels and red blood cell transfusion strategy with outcomes after severe trauma: a post hoc analysis of the RESTRIC trial

BackgroundThe appropriateness of a restrictive transfusion strategy for those with active bleeding after traumatic injury remains uncertain. Given the association between tissue hypoxia and lactate levels, we hypothesized that the optimal transfusion strategy may differ based on lactate levels. This post hoc analysis of the RESTRIC trial sought to investigate the association between transfusion strategies and patient outcomes based on initial lactate levels.MethodsWe performed a post hoc analysis of the RESTRIC trial, a cluster-randomized, crossover, non-inferiority multicenter trials, comparing a restrictive and liberal red blood cell transfusion strategy for adult trauma patients at risk of major bleeding. This was conducted during the initial phase of trauma resuscitation; from emergency department arrival up to 7 days after hospital admission or intensive care unit (ICU) discharge. Patients were grouped by lactate levels at emergency department arrival: low (< 2.5 mmol/L), middle (≥ 2.5 and < 4.0 mmol/L), and high (≥ 4.0 mmol/L). We compared 28 days mortality and ICU-free and ventilator-free days using multiple linear regression among groups.ResultsOf the 422 RESTRIC trial participants, 396 were analyzed, with low (n = 131), middle (n = 113), and high (n = 152) lactate. Across all lactate groups, 28 days mortality was similar between strategies. However, in the low lactate group, the restrictive approach correlated with more ICU-free (β coefficient 3.16; 95% CI 0.45 to 5.86) and ventilator-free days (β coefficient 2.72; 95% CI 0.18 to 5.26) compared to the liberal strategy. These findings persisted even after excluding patients with severe traumatic brain injury.ConclusionsOur results suggest that restrictive transfusion strategy might not have a significant impact on 28-day survival rates, regardless of lactate levels. However, the liberal transfusion strategy may lead to shorter ICU- and ventilator-free days for patients with low initial blood lactate levels.

Is restrictive transfusion sufficient in colorectal cancer surgery? A retrospective study before and during the COVID-19 pandemic in Korea.

Blood transfusion is one of the most common procedures used to treat anemia in colorectal surgery. Despite controversy regarding the adverse effects of blood products, surgeons have maintained standards for administering blood transfusions. However, this trend was restrictive during the COVID-19 pandemic because of a shortage of blood products. In this study, we conducted an analysis to investigate whether the restriction of blood transfusions affected postoperative surgical outcomes. Medical records of 318 patients who underwent surgery for colon and rectal cancer at Ewha Womans University Mokdong Hospital between June 2018 and March 2022 were reviewed retrospectively. The surgical outcomes between the liberal and restrictive transfusion strategies in pre- and post-COVID-19 groups were analyzed. In univariate analysis, postoperative transfusion was associated with infectious complications (odds ratio [OR], 1.705; 95% confidence interval [CI], 1.015-2.865; P=0.044). However, postoperative transfusion was not an independent risk factor for the development of infectious complications in multivariate analysis (OR, 1.305; 95% CI, 0.749-2.274; P=0.348). In subgroup analysis, there was no significant association between infectious complications and the hemoglobin threshold level for the administration of a transfusion (OR, 1.249; 95% CI, 0.928-1.682; P=0.142). During colorectal surgery, the decision to perform a blood transfusion is an important step in ensuring favorable surgical outcomes. According to the results of this study, restrictive transfusion is sufficient for favorable surgical outcomes compared with liberal transfusion. Therefore, modification of guidelines is suggested to minimize unnecessary transfusion-related side effects and prevent the overuse of blood products.

Anemia and Optimal Transfusion Thresholds in Brain-Injured Patients: A Narrative Review of the Literature.

Anemia is a highly prevalent condition that may compromise oxygen delivery to vital organs, especially among the critically ill. Although current evidence supports the adoption of a restrictive transfusion strategy and threshold among the nonbleeding critically ill patient, it remains unclear whether this practice should apply to the brain-injured patient, given the predisposition to cerebral ischemia in this patient population, in which even nonprofound anemia may exert a detrimental effect on clinical outcomes. The purpose of this review is to provide an overview of the pathophysiological changes related to impaired cerebral oxygenation in the brain-injured patient and to present the available evidence on the effect of anemia and varying transfusion thresholds on the clinical outcomes of patients with acute brain injury.

Restrictive Versus Liberal Red Blood Cell Transfusion Strategies for Patients with Hematologic Malignancies Receiving Intensive Chemotherapy

Background: It is estimated that one-quarter to one-half of people diagnosed with hematologic malignancies experience anemia and red blood cell (RBC) transfusion plays an essential supportive role in their management. There are different strategies for RBC transfusions to treat anemia. A restrictive transfusion strategy seeks to maintain a lower hemoglobin level (usually between 70 g/L to 90 g/L with a trigger for transfusion when the hemoglobin drops below 70 g/L), whereas a liberal transfusion strategy aims to maintain a higher hemoglobin (usually between 100 g/L to 120 g/L, with a threshold for transfusion when hemoglobin drops below 100 g/L). The most effective and safest strategy is unknown in people with hematological malignancies. Objectives: To determine the efficacy and safety of a restrictive versus liberal RBC transfusion strategies for people diagnosed with hematological malignancies treated with intensive chemotherapy, radiotherapy, or both, with or without a hematopoietic stem cell transplant (HSCT). Methods: Review was completed using Cochrane standard methodological procedures. We included randomized controlled trials RCTs and prospective non-randomized studies NRS that evaluated a liberal compared with a restrictive RBC transfusion strategy in children or adults with malignant hematological disorders receiving intensive chemotherapy/radiotherapy or undergoing HSCT. We searched for RCTs and NRS in MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and eight other databases and three trial registries to 21 March 2023. For dichotomous outcomes such as mortality, results were presented as a risk ratio (RR) with 95% confidence interval (CI) to compare restrictive versus liberal transfusion strategies. For continuous outcomes using the same scale, we assessed the mean difference (MD) with 95% CI. Where outcome measures were heterogenous, a narrative synthesis was used. Review Manager Web was used to meta-analyze the data. GRADE rating methodology was used for the overall certainty of evidence from included studies. Main Results: Nine studies were included: eight RCTs and one NRS. 644 participants were included in analyses from six completed RCTs (n=560) and one completed NRS (n=84). Two ongoing RCTs consisting of 294 participants (260 adult and 34 pediatric) are pending inclusion. One completed RCT included children receiving HSCT (n=6) and five RCTs only included adults (n=239 with acute leukemia receiving chemotherapy and n=315 with a hematological malignancy receiving HSCT). The restrictive strategies varied from 70 g/L to 80 g/L and liberal strategies from 80 g/L to 120 g/L. A restrictive strategy was found to result in a reduction in the number of RBC units per participant compared to a liberal strategy (Four studies; 457 participants; MD: -2.39, 95%CI -3.38 to -1.39, P = &amp;lt;0.00001). No difference was seen in bleeding between strategies although there was high concern for bias in included trials. Effects were reported in the summary of findings tables for RCTs (Table 1) which included results from adults only to reduce indirectness as a result of limited information from the single published pediatric RCT which was terminated early. Overall, a restrictive RBC transfusion strategy may result in little to no difference in the risk of death at 31 to 100 days compared to a liberal transfusion strategy (three studies; 382 participants; RR 0.74, 95% CI 0.13 to 4.09, P= 0.73; I 2=28%; low-certainty evidence). Two outcomes (mortality at 31 to 100 days and clinically significant bleeding) were reported from the one NRS (Table 2). The evidence is very uncertain whether there is a difference in mortality and clinically significant bleeding between the transfusion strategies based on the very low-certainty evidence. Conclusions: A restrictive transfusion strategy demonstrated a reduction in RBC usage, while there may be no impact on mortality. Definite conclusions are challenging given the relatively few studies with low numbers of included participants, concern for bias, heterogeneity of intervention and outcome reporting and overall certainty of evidence. There is a need for larger and methodologically better designed and executed studies. There is insufficient evidence to answer this review's primary outcome. Further RCTs are required overall, particularly trials inclusive of pediatric participants.

Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia

BackgroundA strategy of administering a transfusion only when the hemoglobin level falls below 7 or 8 g per deciliter has been widely adopted. However, patients with acute myocardial infarction may benefit from a higher hemoglobin level.MethodsIn this phase 3, interventional trial, we randomly assigned patients with myocardial infarction and a hemoglobin level of less than 10 g per deciliter to a restrictive transfusion strategy (hemoglobin cutoff for transfusion, 7 or 8 g per deciliter) or a liberal transfusion strategy (hemoglobin cutoff, <10 g per deciliter). The primary outcome was a composite of myocardial infarction or death at 30 days.ResultsA total of 3504 patients were included in the primary analysis. The mean (±SD) number of red-cell units that were transfused was 0.7±1.6 in the restrictive-strategy group and 2.5±2.3 in the liberal-strategy group. The mean hemoglobin level was 1.3 to 1.6 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group on days 1 to 3 after randomization. A primary-outcome event occurred in 295 of 1749 patients (16.9%) in the restrictive-strategy group and in 255 of 1755 patients (14.5%) in the liberal-strategy group (risk ratio modeled with multiple imputation for incomplete follow-up, 1.15; 95% confidence interval [CI], 0.99 to 1.34; P=0.07). Death occurred in 9.9% of the patients with the restrictive strategyand in 8.3% of the patients with the liberal strategy (risk ratio, 1.19; 95% CI, 0.96 to 1.47); myocardial infarction occurred in 8.5% and 7.2% of the patients, respectively (risk ratio, 1.19; 95% CI, 0.94 to 1.49).ConclusionsIn patients with acute myocardial infarction and anemia, a liberal transfusion strategy did not significantly reduce the risk of recurrent myocardial infarction or death at 30 days. However, potential harms of a restrictive transfusion strategy cannot be excluded. (Funded by the National Heart, Lung, and Blood Institute and others; MINT ClinicalTrials.gov number, NCT02981407.)

Impact of transfusion on platelet aggregation and biomarkers in myocardial infarction patients with anemia: an ancillary study of the randomized REALITY trial

Abstract Importance Higher rates of thrombotic events have been reported in patients with myocardial infarction (MI) requiring blood transfusion. The impact of transfusion strategies on biomarkers of thrombosis and inflammation is still unknown. Objective Compare the impact of a liberal vs a restrictive transfusion strategy in anemic MI patients on P2Y12 mediated platelet reactivity and biomarkers of thrombosis and inflammation. Design and Setting: Prespecified ancillary study of the multicentric randomized REALITY trial, performed in 6 French centers between February 2018 and September 2019 (Figure). Patients randomized to a liberal (hemoglobin ≤10g/dL) or a restrictive (hemoglobin ≤8g/dL) transfusion strategy had platelet reactivity measured at baseline and after randomization. Participants: One hundred anemic acute MI patients from the REALITY trial (666 randomized patients). Measurements: Measurements of platelet reactivity included a centralized blinded VASP-PRI assay and PRU measured locally using encrypted VerifyNow assay. Biomarkers of thrombosis (P-selectin, PAI-1, vWF) and inflammation (TNF-α) were also measured. The primary endpoint was the change in the VASP-PRI (difference from baseline and post randomization) between the two randomized groups. Results Among 100 patients included (n=50 in each group), the most frequent P2Y12 inhibitors used was clopidogrel (48%) while 16% of the patients did not receive any P2Y12 inhibitors. Transfused patients received on average 2.4±1.6 units of packed red blood cells. We found no differences between groups in change in P2Y12-mediated platelet aggregation before and after randomization, measured either by the VASP PRI (difference 4.3%; 95% CI (-5.4% to 14.1%)) or by the PRU (difference 23.5; 95% CI (-20.8 to 67.8)). Similar results were found in transfused patients (n=71) regardless of the randomized group, VASP PRI (difference 1.6%; 95% CI (-6.7% to 10.0%)) or PRU (difference -17.6; 95% CI (-41.0 to 5.7)). We did not find an impact of transfusion strategy or transfusion itself in the levels of P-selectin, PAI-1, vWF and TNF-α. Conclusion and Relevance A liberal or a restrictive transfusion strategy does not impact platelet reactivity and biomarkers in MI patients with anemia, supporting the lack of clinically relevant difference in thrombotic risk between both strategies.

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

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

The impact of anemia and blood transfusion on mortality after open abdominal surgery in the elderly

BackgroundMajor abdominal surgery is associated with considerable mortality in the elderly. Anemia has been linked to increased mortality in other types of surgery, such as hip and cardiac surgery. This study aimed to assess the impact of preoperative anemia on mortality in the elderly undergoing major abdominal surgery, and how allogeneic red cell blood transfusion influences mortality in these patients.Materials and methodsWe conducted a single-center, register-based retrospective study on patients, who were aged beyond 60 years and underwent one of 81 open abdominal surgical procedures. Patients operated on during the period from January 1, 2000, to May 31, 2013, were consecutively identified in the Danish National Patient Registry. Plasma hemoglobin was measured within 30 days prior to surgery and the primary endpoint was 30-day postoperative mortality. Information about patient transfusions from the hospital blood bank was available from 1998 to 2010.ResultsA total of 3199 patients were included of whom 85% underwent emergency surgery. The total mortality after 30 days was 20%. The median preoperative hemoglobin value of survivors was 7.7 mmol/L vs 6.9 mmol/L in those who died. The difference in hemoglobin values, between those who survived or died, decreased from the pre- to the post-operative phase. The 30-day postoperative mortality was 28%, 20%, and 12% in patients with a preoperative hemoglobin level in the lower, median, and upper quartile respectively. Transfusion therapy was associated with higher postoperative mortality, except in patients with very low hemoglobin values.ConclusionPreoperative anemia has a clear association with surgically related mortality. The distribution of hemoglobin values in patients with a fatal outcome differs significantly from that of survivors. Red cell transfusion is associated with increased mortality, except in patients with very low hemoglobin values which supports recent guidelines suggesting a restrictive transfusion strategy.

Using blood wisely in oncology patients: An institutional experience implementing Choosing Wisely Canada restrictive transfusion practices.

382 Background: Using Blood Wisely is a national Choosing Wisely Canada (CWC) initiative that challenges hospitals to benchmark themselves on evidence-informed restrictive transfusion strategies, with the aim to decrease inappropriate red blood cell (RBC) transfusions in Canada. We previously assessed transfusion practices among oncology patients at BC Cancer Vancouver during a 12-month period. Here we present the results of a second audit, after implementation of quality improvement (QI) interventions. Methods: BC Cancer Vancouver RBC transfusion records were obtained for the periods of October 2019-September 2020 and April 2021-March 2022. The percentage of transfusions that were single-unit or for hemoglobin (Hg) ≤80 g/L were measured to assess adherence to CWC targets of ≥65% and ≥80%, respectively, for these metrics. QI interventions were implemented after the first audit, including staff education (grand rounds presentation, sitewide email bulletin) and direct engagement of ordering physicians by nursing staff. Uni- and multivariate analyses were used to test associations between patient characteristics and transfusion outcomes. Results: Single-unit transfusions increased from 41% in inpatients (49/120) and 12% in outpatients (69/586) in the first audit, to 86% (126/146) in inpatients ( P&lt;0.001) and 34% (170/495) in outpatients ( P&lt;0.001) in the second audit. Transfusions for Hg ≤80 g/L increased from 79% (95/120) in inpatients and 66% (384/586) in outpatients, to 93% (136/146) in inpatients ( P=0.001) and 78% (384/495) in outpatients ( P&lt;0.001). Patient factors associated with restrictive transfusion practices included inpatient status and having a hematological malignancy. Conclusions: In the face of fluctuating RBC shortages, interventions aimed at high-use populations like oncology patients are crucial to reducing transfusion overuse. Through education and prescriber engagement, we successfully reduced the rate of inappropriate RBC transfusions at our institution and achieved the status of a designated Using Blood Wisely Hospital.[Table: see text]

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

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

Impact of transfusion strategy on platelet aggregation and biomarkers in myocardial infarction patients with anemia.

Higher rates of thrombotic events have been reported in myocardial infarction (MI) patients requiring blood transfusion. The impact of blood transfusion strategy on thrombosis and inflammation is still unknown. To compare the impact of a liberal vs. a restrictive transfusion strategy on P2Y12 platelet reactivity and biomarkers in the multicentric randomized REALITY trial. Patients randomized to a liberal (hemoglobin≤10g/dL) or a restrictive (hemoglobin≤8g/dL) transfusion strategy had VASP-PRI platelet reactivity measured centrally in a blinded fashion and platelet reactivity unit (PRU) measured locally using encrypted VerifyNow; at baseline and after randomization. Biomarkers of thrombosis (P-selectin, PAI-1, vWF) and inflammation (TNF-α) were also measured. The primary endpoint was the change in the VASP-PRI (difference from baseline and post randomization) between the randomized groups. A total of 100 patients randomized were included in this study (n=50 in each group). Transfused patients received on average 2.4±1.6 units of blood. We found no differences in change of the VASP PRI (difference 1.2% 95% CI (-10.3-12.7%)) or by the PRU (difference 13.0 95% CI (-21.8-47.8)) before and after randomization in both randomized groups. Similar results were found in transfused patients (n=71) regardless of the randomized group, VASP PRI (difference 1.7%; 95% CI (-9.5-1.7%)) or PRU (difference 27.0; 95% CI (-45.0-0.0)). We did not find an impact of transfusion strategy or transfusion itself in the levels of P-selectin, PAI-1, vWF, and TNF-α. In this study, we found no impact of a liberal vs. a restrictive transfusion strategy on platelet reactivity and biomarkers in MI patients with anemia. A conclusion that should be tempered due to missing patients with exploitable biological data that has affected our power to show a difference.