Restrictive Transfusion Trigger Research Articles

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.

Clinical Issues-October 2022.

Verifying patient identity before blood product administration Key words: patient identification, patient verification, blood transfusion, blood management, wristband. Surgical site infection risk with allogeneic blood administration Key words: patient blood management, restrictive transfusion triggers, allogeneic blood products, intraoperative blood salvage, surgical site infection. Information on topical thrombin Key words: hemostatic agents, licensed biological product, hemostasis, bovine thrombin, human thrombin. Safe use of topical thrombin Key words: severe adverse events, hemostatic agents, accidental injection, accidental intravascular uptake, product labeling.

Transfusion practice in the bleeding critically ill: An international online survey-The TRACE-2 survey.

BackgroundTransfusion is very common in the intensive care unit (ICU), but practice is highly variable, as has recently been shown in non‐bleeding critically ill patients practices survey. Bleeding patients in ICU require different blood products across a range of specific patient categories. We hypothesize that a large variety in transfusion practice exists in bleeding patients.Study design and methodsAn international online survey was performed among physicians working in the ICU. Transfusion practice in massively and non‐massively bleeding patients was examined, including transfusion ratios, thresholds, and the presence of transfusion guidelines.ResultsSix hundred eleven respondents filled in the survey of which 401 could be analyzed, representing 64 countries. Among the respondents, 52% had a massive transfusion protocol (MTP) available at their ICU. In massively bleeding patients, 46% of the respondents used fixed transfusion component ratios. Of those who used fixed blood ratios, the 1:1:1 ratio (red blood cell [RBC] concentrates: plasma: platelet concentrates) was most commonly used (33%). The presence of an MTP was associated with a more frequent use of fixed ratios (p < .001). For RBC transfusion in the general non‐massively bleeding ICU population, a hemoglobin (Hb) threshold of 7.0[7.0–7.3] g/dl was reported. In the general ICU population, a platelet count threshold of 50[26–50] × 109/L was applied.DiscussionHalf of the centers had no massive transfusion protocol available. Transfusion practice in massively bleeding critically ill patients is highly variable and driven by the presence of an MTP. In the general non‐massively bleeding ICU population restrictive transfusion triggers were chosen.

Restrictive versus liberal transfusion in patients with diabetes undergoing cardiac surgery: An open-label, randomized, blinded outcome evaluation trial.

To characterize the association between diabetes and transfusion and clinical outcomes in cardiac surgery, and to evaluate whether restrictive transfusion thresholds are harmful in these patients. The multinational, open-label, randomized controlled TRICS-III trial assessed a restrictive transfusion strategy (haemoglobin [Hb] transfusion threshold <75 g/L) compared with a liberal strategy (Hb <95 g/L for operating room or intensive care unit; or <85 g/L for ward) in patients undergoing cardiac surgery on cardiopulmonary bypass with a moderate-to-high risk of death (EuroSCORE ≥6). Diabetes status was collected preoperatively. The primary composite outcome was all-cause death, stroke, myocardial infarction, and new-onset renal failure requiring dialysis at 6months. Secondary outcomes included components of the composite outcome at 6 months, and transfusion and clinical outcomes at 28 days. Of the 5092 patients analysed, 1396 (27.4%) had diabetes (restrictive, n=679; liberal, n=717). Patients with diabetes had more cardiovascular disease than patients without diabetes. Neither the presence of diabetes (OR [95% CI] 1.10 [0.93-1.31]) nor the restrictive strategy increased the risk for the primary composite outcome (diabetes OR [95% CI] 1.04 [0.68-1.59] vs. no diabetes OR 1.02 [0.85-1.22]; Pinteraction =.92). In patients with versus without diabetes, a restrictive transfusion strategy was more effective at reducing red blood cell transfusion (diabetes OR [95% CI] 0.28 [0.21-0.36]; no diabetes OR [95% CI] 0.40 [0.35-0.47]; Pinteraction =.04). The presence of diabetes did not modify the effect of a restrictive transfusion strategy on the primary composite outcome, but improved its efficacy on red cell transfusion. Restrictive transfusion triggers are safe and effective in patients with diabetes undergoing cardiac surgery.

BLOOD TRANSFUSION REQUIREMENTS IN CARDIAC SURGERY

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

Perioperative Patient Blood Management: common risk, common tasks, common responsibility

Human red blood cell concentrate and platelet suspension are unstable preparations, therefore, they are not part of the international pharmaceutical market for biological and economic reasons. Consequently, they cannot be replaced by external sources. Human allogeneic erythrocyte and platelet preparations should therefore be considered as part of the common national wealth. The amount of transfused red blood cell concentrate has been declining in countries with advanced health systems in recent years. The changes were initially driven by the spread of the concept and practice of liberal and restrictive transfusion triggers. A complex, thoughtful system of perioperative blood utilization, the Patient Blood Management has later emerged, and a paradigm shift in the delivery of life-threatening perioperative bleeding has developed. At the same time, clinical practitioners are facing a new challenge of reducing willingness to donate blood worldwide. The rationalization of the use of human red blood cell concentrate and platelet suspension is essential in Hungary. As a health care measure, the currently rigidly earmarked financial resources available for allogeneic preparations and stable factor concentrates for the treatment of life-threatening haemorrhages need to be changed to be interoperable. The perioperative blood use could additionally be reduced by the widespread dissemination of the Patient Blood Management requiring complex coordinated educational interdisciplinary and logistical work. Orv Hetil. 2020; 161(37): 1545-1553.

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).

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

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

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

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

Effects of a More Restrictive Transfusion Trigger in Trauma Patients

Since the Transfusion Requirements in Critical Care trial, studies have shown that acutely ill patients can drift as a low as 5 g/dL. This study reviews a transfusion trigger change to 6.5 g/dL, which we hypothesize will conserve resources and improve quality of care. This is a retrospective chart review at an urban Level I trauma center from January through December 2015 after our trauma service changed the transfusion trigger from 7 to 6.5 g/dL. Outcomes in patients before (TT7) and after (TT6.5) the change in transfusion threshold were then compared. One hundred thirty-one discrete patients were included in this trial, with 285 instances of a hemoglobin of 7 g/dL or less and 178 transfusions. Seventy-two patients were before the change in threshold and 59 after. There was no change in length of hospital stay, ICU stay, ventilator days, mortality, and organ system failure after change in the transfusion threshold. After initiation of a more conservative threshold, 72 units of blood were saved. Decreased transfusion threshold was associated with no worse outcomes associated with decreased resource utilization.

The Effect on Blood Use after Adopting Single-Unit Policy and Restrictive Transfusion Trigger in a Hematology Unit: The Ensure Study

IntroductionRed blood cell (RBC) transfusion is a frequently performed medical procedure. But it is not without risk. Evidence suggests that restrictive transfusion is safe and effectively lessens the demand for blood components. Nevertheless, there exist considerable variations in transfusion practice among different centers. The hematology unit of Princess Margaret Hospital, a secondary referral center providing inpatient services for patients with various haematological malignancies and autologous stem cell transplantation, adopted a two-phase patient blood management program to reduce the demand for blood transfusions. Firstly, single-unit policy was implemented in Feb 2015 to replace the original protocol of transfusing two units of RBC in every transfusion episode. Secondly, the hemoglobin (Hb) trigger for transfusion decreased from 8g/dL to 7g/dL in asymptomatic and hemodynamically stable patients without cardiovascular disease in Aug 2016. The impact of these strategies to blood use and patient outcomes is evaluated in the present study.MethodThe study periods included 01/01/2014 - 12/31/2014 (Period A), 04/01/2015 - 03/31/2016 (Period B) and 10/01/2016 - 09/30/2017 (Period C). All patients admitted to the center during the study periods were recruited. Demographic data, RBC consumption, length of hospital stay and all-cause inpatient mortality were retrieved from the electronic medical record system. The proportions of single-unit transfusion and the mean Hb level transfusion triggers in different periods were compared with analysis of variance for continuous variables and logistic regressions for categorical variables respectively. Blood use in different periods was expressed in terms of RBC unit transfused per patient-day of hospitalization, and compared by age and sex adjusted incidence rate ratios (IRRs) obtained from zero-inflation negative binomial regression. To study the length of stay, negative binomial regression was performed to determine the age and sex adjusted IRRs for days of hospitalization in different periods. Clustering of data was further adjusted by applying robust standard errors. Generalized estimating equation for logistic regression, controlling for age, sex, days of hospitalization and number of previous admissions, was applied to compare the inpatient mortality in different periods.ResultsA total of 815 patients were recruited in the study, and the total number of admissions was 1,836. The number of patients in Period A was 232 (median age: 61 [IQR 49-71] years, male 54.7%) with 580 admissions, in Period B was 258 (median age: 63 [IQR 49-71] years, male 53.1%) with 566 admissions, and in Period C was 325 (median age: 62 [IQR 52-70] years, male 57.8%) with 690 admissions. The number of transfusion episodes in Periods A to C was 721, 923 and 803 respectively. The proportion of single-unit transfusion increased from 21.8% in Period A to 81.8% in Periods B (p<0.001) and 79.8% in Period C (p<0.001) respectively. The mean transfusion trigger Hb levels were 7.2±1.1 g/dL and 7.2±0.9 g/dL in Periods A and B respectively, and decreased to 6.6±0.9 in Period C (p<0.001 and <0.001). The proportion of transfusions with trigger Hb level >7g/dL decreased from 64.8% and 67.1% in Periods A and B to 17.7% in Period C (p<0.001 and <0.001) (TABLE 1).The total number of RBC transfused in the center was 1,317 units, 1,116 units and 990 units in Periods A to C respectively. RBC transfusion rate per patient-day of hospitalization reduced by 23% in Period B (p<0.001) and by 37% in Period C (p<0.001) respectively. The median length of hospital stay [IQR] was 7 [5-14], 6 [4-16] and 6 [4-13] days in Periods A to C. The in-patient mortality rates were 7.1%, 7.9% and 8.7% in Periods A to C. There was no statistically significant difference in the length of stay and in-patient mortality between different periods (TABLE 2).ConclusionsOur patient blood management program shows that both single-unit policy and lower Hb transfusion trigger are effective measures to reduce RBC use in hematology patients, without compromising the length of stay and inpatient mortality. Subgroup analysis could determine if restrictive transfusion strategies are applicable to all patients. Prospective studies including the occurrence of transfusion incidents and cost-effectiveness as outcome variables are useful to confirm our findings and substantiate the practicability of patient blood management. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Variation in red cell transfusion decisions in the intensive care unit - a nationwide survey in the Netherlands.

Most guidelines recommend a restrictive transfusion trigger of 7 g/dl. It is unclear whether this resulted in more uniform transfusion practices. The primary objective was to uncover the extent of variation in transfusion decisions within four scenarios of critically ill patients among critical care physicians in the Netherlands. An online survey comprising four different hypothetical clinical scenarios was sent to all members of the Dutch Society of Intensive Care. The scenarios represented patients with acute myocardial infarction (Hb 8·5 g/dl), abdominal sepsis (Hb 7·1 g/dl), traumatic brain injury (TBI) (Hb 7·9 g/dl) and post-surgical complications (Hb 7·3 g/dl). The questions explored the decision whether or not to transfuse and a ranking of clinical characteristics playing the most important role in the transfusion decision. A total of 224 members (22%) participated in the study of whom 188 (84%) completed all questions. The percentages of respondents that decided to transfuse ranged from 25·9% in the scenario with TBI to 81·6% in the scenario with post-surgical complications. Most controversy was seen in the scenario with sepsis for which 43·2% decided to transfuse, whereas 56·8% decided not to. Haemoglobin level, diagnosis and haemodynamics were most important for the transfusion decision in all scenarios. Physicians decided differently on red-blood-cell transfusion given the clinical scenarios and weighed clinical characteristics differently in their transfusion decisions. These findings suggest there still is substantial variation in critical care transfusion practice.

Intravenous Tranexamic Acid Bolus plus Infusion Is Not More Effective than a Single Bolus in Primary Hip Arthroplasty: A Randomized Controlled Trial.

Preoperative administration of the antifibrinolytic agent tranexamic acid reduces bleeding in patients undergoing hip arthroplasty. Increased fibrinolytic activity is maintained throughout the first day postoperation. The objective of the study was to determine whether additional perioperative administration of tranexamic acid would further reduce blood loss. This prospective, double-blind, parallel-arm, randomized, superiority study was conducted in 168 patients undergoing unilateral primary hip arthroplasty. Patients received a preoperative intravenous bolus of 1 g of tranexamic acid followed by a continuous infusion of either tranexamic acid 1 g (bolus-plus-infusion group) or placebo (bolus group) for 8 h. The primary outcome was calculated perioperative blood loss up to day 5. Erythrocyte transfusion was implemented according to a restrictive transfusion trigger strategy. The mean perioperative blood loss was 919 ± 338 ml in the bolus-plus-infusion group (84 patients analyzed) and 888 ± 366 ml in the bolus group (83 patients analyzed); mean difference, 30 ml (95% CI, -77 to 137; P = 0.58). Within 6 weeks postsurgery, three patients in each group (3.6%) underwent erythrocyte transfusion and two patients in the bolus group experienced distal deep-vein thrombosis. A meta-analysis combining data from this study with those of five other trials showed no incremental efficacy of additional perioperative administration of tranexamic acid. A preoperative bolus of tranexamic acid, associated with a restrictive transfusion trigger strategy, resulted in low erythrocyte transfusion rates in patients undergoing hip arthroplasty. Supplementary perioperative administration of tranexamic acid did not achieve any further reduction in blood loss.

Preoperative management of colorectal cancer-induced iron deficiency anemia in clinical practice: data from a large observational cohort.

Preoperative anemia prevalence among colorectal cancer (CRC) patients is high and may adversely influence postoperative outcome. This study assesses the efficacy of a preoperative anemia managing protocol in CRC. This was a retrospective analysis of consecutive CRC resections at two Spanish centers (January 2012 to December 2013). Preoperative anemia was defined as a hemoglobin (Hb) level of less than 13 g/dL and treated with intravenous iron (IVI) or standard care (oral iron or no iron). Red blood cell transfusion (RBCT) requirements was the primary outcome variable. Postoperative infection rate and length of hospital stay (LOS) were secondary outcome variables. Patients were managed with a restrictive transfusion trigger (Hb < 8 g/dL). Infection was diagnosed clinically and confirmed by laboratory, microbiologic, and/or radiologic evidence. Overall, 322 of 571 patients (56%) presented with anemia: 232 received IVI and 90 standard care. There were differences in RBCT rate between no anemia and anemia (2% vs. 16%; p < 0.01), but not in postoperative infections (19% vs. 22%; p = NS) or LOS. Compared to those on standard care, anemic patients on IVI presented with lower Hb (10.8 g/dL vs. 12.0 g/dL; p < 0.001) at baseline, but similar Hb on day of surgery and Postoperative Day 30. There were no between-group differences in RBCT rates (16% vs. 17%; p = NS), but infection rates were lower among IVI-treated patients (18% vs. 29%; p < 0.05). No relevant IVI-related side effects were recorded. Compared to standard care, IVI was more effective in treating preoperative anemia in CRC patients and appeared to reduce infection rate, although it did not reduce postoperative RBCT.

No benefit of autologous transfusion drains in total knee arthroplasty.

Autologous blood transfusion drains are commonly used to reduce allogeneic blood transfusion rate after total knee arthroplasty. There is conflicting evidence as to whether autologous transfusion drains (ABT drains) were effective when restrictive transfusion triggers were used. The aim of our study was to ascertain where, as a part of a blood management protocol, autologous blood transfusion drains reduce the allogeneic blood transfusion rate after total knee arthroplasty. Two-hundred total knee arthroplasty patients were included in the prospective randomized controlled study. After implantation, a Redon drain without vacuum assistance (control, n=100) or an autologous blood transfusion drain (ABT group, n=100) was used. Demographic and operative data were collected. The blood loss, total blood loss, blood values and transfusion rate were documented. The blood loss in the drains was significantly increased for the ABT group (409 vs. 297ml, p<0.001). There was a non-significant trend towards a higher total blood loss for ABT patients (1844 vs. 1685ml, n.s.). The allogeneic blood transfusion rate was similar for both groups (8 vs. 9%, n.s.). Similarly, the number of transfused blood units was comparable between both groups (0.2U/patient vs. 0.17U/patient n.s.). In combination with restrictive blood transfusion triggers, ABT drains had no positive effect on the allogeneic blood transfusion rate. The blood loss in ABT drains was higher. As a consequence, the use of ABT drains was discontinued. I.

Practical Guidelines for Evaluating Transfusion Needs

It is estimated that ∼24 million units of blood products are administered annually in the United States, with ∼10% of all packed red blood cell transfusions used in orthopedic surgery. Protocols and guidelines for the administration of blood vary widely among orthopedic practices and hospitals. Although transfusions can be lifesaving, their use carries substantial risks, from minor to life-threatening complications. Therefore, transfusions should be considered a last option when dealing with postoperative anemia. Blood conservation and taking steps to avoid postoperative anemia should be goals in orthopedic surgery. Creating a standardized approach to blood management is important to enhance outcomes and decrease transfusions and their attendant risks. This includes correcting preoperative anemia when possible and using techniques to minimize perioperative blood loss. Restrictive transfusion triggers have been shown to decrease the number of transfusions without compromising outcomes. Use of antifibrinolytic agents such as tranexamic acid has also decreased the need for transfusions. This article reviews current transfusion practices, including indications and contraindications, perioperative blood management techniques, transfusion complications, and safe transfusion thresholds for patients undergoing orthopedic surgery.

Single-unit transfusions and hemoglobin trigger: relative impact on red cell utilization.

Patient blood management (PBM) programs can reduce unnecessary transfusions, but the optimal methods used to achieve this effect are unclear. We tested the hypothesis that encouraging single-unit red blood cell (RBC) transfusions in stable patients would have a greater impact on blood use than compliance with a specific hemoglobin (Hb) transfusion trigger alone. We analyzed blood utilization data at three community hospitals without previous PBM efforts before and after implementing a PBM program. Data were analyzed at monthly intervals to determine the relative impact of a "Why give 2 when 1 will do?" campaign promoting single-unit RBC transfusions and simultaneous efforts to promote evidence-based Hb triggers of 7 or 8 g/dL. Univariate and multivariate analyses were used to identify independent effects of these two interventions on overall RBC utilization. Univariate analysis revealed that both the increase in single-unit transfusions (from 38.0% to 70.9%; p < 0.0001) and the decrease in RBC orders with an Hb trigger of at least 8 g/dL (from 45.7% to 25.0%; p < 0.0001) were associated with decreasing RBC utilization. Multivariate analysis showed that the increase in single-unit transfusions was an independent predictor of decreased RBC utilization, but the Hb triggers of both 7 and 8 g/dL were not. Overall, our PBM efforts decreased RBC utilization from 0.254 to 0.185 units/patient (27.2%) across all three hospitals (p = 0.0009). A campaign promoting single-unit RBC transfusions had a greater impact on RBC utilization than did encouraging a restrictive transfusion trigger.

Restrictive versus liberal blood transfusion in patients with coronary artery disease: a meta-analysis

Objectives: To compare clinical outcomes between restrictive versus liberal blood transfusion strategies in patients with coronary artery disease (CAD).Research design and methods: A literature search from January 1966 to May 2016 was performed in PubMed, EMBASE and Cochrane Library to find trials evaluating a restrictive hemoglobin transfusion trigger of ≤8 g/dL, compared with a more liberal trigger. Two study authors independently extracted data from the trials. The primary outcome was mortality and the secondary outcome was subsequent myocardial infarction. Relative risks (RRs) with their 95% confidence intervals (CIs) were assessed.Results: Six trials involving 133,058 participants were included in this study. Pooled results revealed no difference in mortality between the liberal transfusion and restrictive transfusions (RR = 1.17, 95% CI = 0.91–1.52, P = .22). Subgroup analysis revealed that a restrictive transfusion strategy was associated with a higher risk of in-hospital mortality (RR = 1.38, 95% CI = 1.15–1.67, P < .001) and 30 day mortality (RR = 1.21, 95% CI = 1.01–1.45, P = .03), compared with the liberal strategy. No significant difference was found between the liberal transfusion strategy and restrictive transfusion strategy in risk for subsequent myocardial infarction (RR = 1.09, 95% CI = 0.57–2.06, P = .80).Limitations: Limitations include (1) limited number of trials, especially those evaluating myocardial infarction, (2) observed heterogeneity, (3) confounding by indication and other inherent bias may exist.Conclusion: The findings suggest that restrictive blood transfusion was associated with higher in-hospital and 30 day mortality than liberal blood transfusion in CAD patients. The conclusions are mainly based on retrospective studies and should not be considered as recommendation before they are supported by randomized controlled trials.

The new German guideline on postpartum haemorrhage (PPH): essential aspects for coagulation and circulatory therapy

Worldwide, post-partum haemorrhage (PHH) remains one of the leading causes for maternal mortality. The German Society of Gynaecology and Obstetrics, the German Midwifes' Society, the German Society of Thrombosis and Haemostasis and the German Society of Anaesthesiology and Intensive Care updated the former guideline. The resulting recommendations are the results of a structured literature search and a formal consensus process and contain all aspects of PPH including diagnosis, causes, risk factors and therapy. Key aspect of the anaesthesiological and haemostatic therapies is the development of an interdisciplinary standard operating procedure containing medical options related to the bleeding's cause and severity as well as the surgical option. For suspected PPH, this guideline emphasizes clinical and laboratory-based diagnostics, as only those will enable an early identification of the bleeding's causes and the resulting causative therapy. Recommendations cover evidence-based application of uterotonics for atony as well as tranexamic acid, calcium, factor concentrates and blood products. Additionally, recommendations are given on the topics of cell salvage, controlled hypotension and restrictive transfusion triggers.

Management of bleeding in vascular surgery

Management of acute coagulopathy and blood loss during major vascular procedures poses a significant haemostatic challenge to anaesthetists. The acute coagulopathy is multifactorial in origin with tissue injury and hypotension as the precipitating factors, followed by dilution, hypothermia, acidemia, hyperfibrinolysis and systemic inflammatory response, all acting as a self-perpetuating spiral of events. The problem is confounded by the high prevalence of antithrombotic agent use in these patients and intraoperative heparin administration. Trials specifically examining bleeding management in vascular surgery are lacking, and much of the literature and guidelines are derived from studies on patients with trauma. In general, it is recommended to adopt permissive hypotension with a restrictive fluid strategy, using a combination of crystalloid and colloid solutions up to one litre during the initial resuscitation, after which blood products should be administered. A restrictive transfusion trigger for red cells remains the mainstay of treatment except for the high-risk patients, where the trigger should be individualized. Transfusion of blood components should be initiated by clinical evidence of coagulopathy such as diffuse microvascular bleeding, and then guided by either laboratory or point-of-care coagulation testing. Prophylactic antifibrinolytic use is recommended for all surgery where excessive bleeding is anticipated. Fibrinogen and prothrombin complex concentrates administration are recommended during massive transfusion, whereas rFVIIa should be reserved until all means have failed. While debates over the ideal resuscitative strategy continue, the approach to vascular haemostasis should be scientific, rational, and structured. As far as possible, therapy should be monitored and goal directed.