Risk Of Red Blood Cell Transfusion Research Articles

Association between selective serotonin reuptake inhibitors use and blood transfusion risk in older adults after hip fracture: a cohort study

BackgroundHip fracture is common and associated with high morbidity and mortality rates. Selective serotonin reuptake inhibitors (SSRIs) influence platelet hemostasis and might result in abnormal bleeding. This study aims to determine whether the use of SSRIs in older patients undergoing hip fracture surgery is associated with the risk of perioperative red blood cell (RBC) transfusion.MethodsWe conducted a retrospective observational study using prospectively collected data of patients aged 70 years and older admitted to a French geriatric perioperative ward for hip fracture between January 2012 and June 2021. The primary endpoint was the occurrence of RBC transfusion during hospitalization. Multivariate logistic regression was performed, with a sensitivity analysis according to co-prescriptions.ResultsOut of 1085 patients, 253 (23%) were male, mean age was 86 (± 6.2) years, and median Charlson Comorbidity Index was 7 (interquartile range [5–8]). 486 (45%) patients received perioperative RBC transfusion, with a median of 2 units (interquartile range [1–3]) transfused per patient postoperatively. After adjusting for age, sex, comorbidities, functional status, institutionalization, polypharmacy, antiplatelet therapy, fracture type, hemoglobin and albumin levels, the use of SSRIs was not associated with an increased risk of RBC transfusion (aOR 0.91, 95%CI 0.64–1.29, p = 0.59). We did not observe any association between concomitant use of SSRIs and anticoagulant or antiplatelet therapy and the risk of RBC transfusion.ConclusionsAmong older comorbid adults undergoing hip fracture surgery, the use of SSRIs was not associated with an increased risk of perioperative RBC transfusion.

Hospital policy of tranexamic acid to reduce transfusion in major non-cardiac surgery (TRACTION): protocol for a phase IV randomised controlled trial

IntroductionTranexamic acid (TXA) is an inexpensive and widely available medication that reduces blood loss and red blood cell (RBC) transfusion in cardiac and orthopaedic surgeries. While the use of TXA...

Development of a Risk Assessment Model for Predicting Red Blood Cell Transfusion in Neonatal Patients.

The goal was to develop a risk assessment model for predicting red blood cell (RBC) transfusion in neonatal patients to assist hospital blood supply departments in providing small portions of RBCs to those requiring RBC transfusion on time. Clinical information was collected from 1,201 children admitted to the neonatal unit. Clinical factors associated with predicting RBC transfusion were screened, and prediction models were developed using stepwise and multifactorial logistic regression analyses, followed by the evaluation of prediction models using receiver operating characteristic curves, calibration curves, and decision curve analysis (DCA). Overall, 81 neonatal patients were transfused with RBCs, and the variables of gestational age at birth, age < 1 month, receipt of mechanical ventilation, and infant anemia were included in the final prediction model. The area under the curve of the prediction model was 0.936 (0.921 - 0.949), which was significantly higher than that of the individual indicators of gestational age at birth, age at admission < 1 month, receipt of mechanical ventilation, and infant anemia (p < 0.001). DCA showed a standardized net benefit for the possible risk of infant RBC transfusion at 0.1 - 1.0. We developed a risk assessment model to predict the risk of RBC transfusion in neonatal patients that can effectively assess the risk of RBC transfusion in children.

Association of body mass index with perioperative blood transfusion and short-term clinical outcomes in patients undergoing isolated coronary artery bypass grafting

BackgroundFew studies have considered outcomes among low body mass index (BMI) cohorts undergoing coronary artery bypass grafting (CABG). This study aims to investigate the effects of low body weight on blood transfusion and perioperative outcomes in patients undergoing isolated CABG.MethodsThis retrospective study enrolled consecutive cases from a single-center between January 2008 and December 2018. Low body weight/underweight was defined as a BMI < 18.5 kg/m², while normal BMI was defined as 18.5 ≤ BMI < 24.0 kg/m². The primary endpoint was the perioperative red blood cell (RBC) transfusion rate. Secondary endpoints include platelet and plasma transfusion rates, transfusion volume for all blood components, hospital length of stay, and the occurrence of adverse events including prolonged mechanical ventilation, re-intubation, re-operation, acute kidney injury, and 30-day all-cause mortality.ResultsA total of 7,620 patients were included in this study. After 1:1 propensity score matching, 130 pairs were formed, with 61 pairs in the on-pump group and 69 pairs in the off-pump group. Baseline characteristics were comparable between the matched groups. Low body weight independently increased the risk of RBC transfusion (on-pump: OR = 3.837, 95% CI = 1.213–12.144, p = 0.022; off-pump: OR = 3.630, 95% CI = 1.875–5.313, p < 0.001). Moreover, within the on-pump group of the original cohort, BMI of < 18.5 kg/m² was independently correlated with increased risk of re-intubation (OR = 5.365, 95% CI = 1.159 to 24.833, p = 0.032), re-operation (OR = 4.650, 95% CI = 1.019 to 21.210, p = 0.047), and 30-day all-cause mortality (OR = 10.325, 95% CI = 2.011 to 53.020, p = 0.005).ConclusionBMI < 18.5 kg/m² was identified as an independent risk factor for increased perioperative RBC transfusion rate in patient underwent isolated CABG with or without CPB. Only on-pump underweight patients in the original cohort exhibited an increased risk for re-intubation, re-operation, and 30-day all-cause mortality. Physicians and healthcare systems should consider these findings to improve management for this population.

Development of a Novel Prediction Model for Red Blood Cell Transfusion Risk in Cardiac Surgery.

Cardiac surgery is a complex and invasive procedure that often requires blood transfusions to replace the blood lost during surgery. Blood products are a scarce and expensive resource. Therefore, it is essential to develop a standardized approach to determine the need for blood transfusions in cardiac surgery. The main objective of our study is to develop a simple prediction model for determining the risk of red blood cell transfusion in cardiac surgery. Retrospective cohorts of adult patients who underwent cardiac surgery between 2017 and 2019 were studied to identify hypothetical predictors of blood transfusion. Finally, a multivariable logistic regression model was developed to predict the risk of transfusion in cardiac surgery using the AUC and the Hosmer-Lemeshow goodness-of-fit test. We included 1234 patients who underwent cardiac surgery. Of the entire cohort, 875 patients underwent a cardiac procedure 69.4% [CI 95% (66.8%; 72.0%)]; 119 patients 9.6% [CI 95% (8.1%; 11.4%)] underwent a combined procedure, and 258 patients 20.9% [CI 95% (18.7; 23.2)] underwent other cardiac procedures. The median perioperative hemoglobin was 13.0 mg/dL IQR (11.7; 14.2). The factors associated with the risk of transfusion were age > 60 years OR 1.37 CI 95% (1.02; 1.83); sex female OR 1.67 CI 95% (1.24; 2.24); BMI > 30 OR 1.46 (1.10; 1.93); perioperative hemoglobin < 14 OR 2.11 to 51.41 and combined surgery OR 3.97 CI 95% (2.19; 7.17). The final model shows an AUC of 80.9% for the transfusion risk prediction [IC 95% (78.5-83.3%)]; p < 0.001]. We have developed a model with good discriminatory ability, which is more parsimonious and efficient than other models.

Prediction of red blood cell transfusion after orthopedic surgery using an interpretable machine learning framework

Postoperative red blood cell (RBC) transfusion is widely used during the perioperative period but is often associated with a high risk of infection and complications. However, prediction models for RBC transfusion in patients with orthopedic surgery have not yet been developed. We aimed to identify predictors and constructed prediction models for RBC transfusion after orthopedic surgery using interpretable machine learning algorithms. This retrospective cohort study reviewed a total of 59,605 patients undergoing orthopedic surgery from June 2013 to January 2019 across 7 tertiary hospitals in China. Patients were randomly split into training (80%) and test subsets (20%). The feature selection method of recursive feature elimination (RFE) was used to identify an optimal feature subset from thirty preoperative variables, and six machine learning algorithms were applied to develop prediction models. The Shapley Additive exPlanations (SHAP) value was employed to evaluate the contribution of each predictor towards the prediction of postoperative RBC transfusion. For simplicity of the clinical utility, a risk score system was further established using the top risk factors identified by machine learning models. Of the 59,605 patients with orthopedic surgery, 19,921 (33.40%) underwent postoperative RBC transfusion. The CatBoost model exhibited an AUC of 0.831 (95% CI: 0.824-0.836) on the test subset, which significantly outperformed five other prediction models. The risk of RBC transfusion was associated with old age (>60 years) and low RBC count (<4.0 × 1012/L) with clear threshold effects. Extremes of BMI, low albumin, prolonged activated partial thromboplastin time, repair and plastic operations on joint structures were additional top predictors for RBC transfusion. The risk score system derived from six risk factors performed well with an AUC of 0.801 (95% CI: 0.794-0.807) on the test subset. By applying an interpretable machine learning framework in a large-scale multicenter retrospective cohort, we identified novel modifiable risk factors and developed prediction models with good performance for postoperative RBC transfusion in patients undergoing orthopedic surgery. Our findings may allow more precise identification of high-risk patients for optimal control of risk factors and achieve personalized RBC transfusion for orthopedic patients.

Preoperative anaemia and red blood cell transfusion in patients with aneurysmal subarachnoid and intracerebral haemorrhage \u2014 a multicentre subanalysis of the German PBM Network Registry

PurposeAnaemia is common in patients presenting with aneurysmal subarachnoid (aSAH) and intracerebral haemorrhage (ICH). In surgical patients, anaemia was identified as an idenpendent risk factor for postoperative mortality, prolonged hospital length of stay (LOS) and increased risk of red blood cell (RBC) transfusion. This multicentre cohort observation study describes the incidence and effects of preoperative anaemia in this critical patient collective for a 10-year period.MethodsThis multicentre observational study included adult in-hospital surgical patients diagnosed with aSAH or ICH of 21 German hospitals (discharged from 1 January 2010 to 30 September 2020). Descriptive, univariate and multivariate analyses were performed to investigate the incidence and association of preoperative anaemia with RBC transfusion, in-hospital mortality and postoperative complications in patients with aSAH and ICH.ResultsA total of n = 9081 patients were analysed (aSAH n = 5008; ICH n = 4073). Preoperative anaemia was present at 28.3% in aSAH and 40.9% in ICH. RBC transfusion rates were 29.9% in aSAH and 29.3% in ICH. Multivariate analysis revealed that preoperative anaemia is associated with a higher risk for RBC transfusion (OR = 3.25 in aSAH, OR = 4.16 in ICH, p < 0.001), for in-hospital mortality (OR = 1.48 in aSAH, OR = 1.53 in ICH, p < 0.001) and for several postoperative complications.ConclusionsPreoperative anaemia is associated with increased RBC transfusion rates, in-hospital mortality and postoperative complications in patients with aSAH and ICH.Trial registrationClinicalTrials.gov, NCT02147795, https://clinicaltrials.gov/ct2/show/NCT02147795

Influence of Pretransplant Anemia on Red Blood Cell Transfusions in Myeloma Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation

Background and Objectives: Anemia during peripheral blood stem cells (PBSCs) transplant is considered a bad prognostic marker. The study aimed to determine whether pretransplant anemia influence peritransplant transfusion requirements in myeloma patients. Methods: Myeloma patients planned for PBSC transplant were stratified based on hemoglobin levels at time of mobilization, PBSC collection, and PBSC infusion. Univariate and multivariate analysis was performed to study the predictors for good mobilization, adequate CD34 yield by apheresis, and red blood cell (RBC) transfusion in the peritransplant period. Results: Of 67 patients, the prevalence of anemia at mobilization, PBSC collection, and PBSC infusion was 37%, 58%, and 70%, respectively. Eighty-five percent had good mobilization with peripheral blood CD34 count of 50 cells/μl (8–123) and 81% had adequate CD34 yield with first apheresis. Thirty-two percent patients received peritransplant RBC transfusion with the median of one unit (range: 0–5). Anemia on the day of infusion did influence the RBC transfusions in the peritransplant period (P = 0.03). Conclusion: One third of myeloma patients require RBC transfusion support in the peritransplant period. We identified pretransplant anemia neither influenced mobilization nor PBSC collection but increased the risk for RBC transfusion in the peritransplant period.

The occurrence and impact of blood transfusion in cardiogenic shock patients supported by an Impella device: a retrospective study

Abstract Background Cardiogenic shock (CS) patients are frequently supported by mechanical devices, such as the Impella. The use of these devices is associated with device-related complications, such as hemolysis and bleeding, which may necessitate blood transfusion. Blood transfusion has been associated with worse clinical outcome. Information on the occurrence and impact of blood transfusion in these patients is scarce. Purpose To assess the incidences of hemolysis, bleeding and red blood cell (RBC) transfusion in CS patients receiving Impella support, to identify patients at risk for RBC transfusion and to assess mortality in transfused and non-transfused patients. Methods We performed a single center retrospective cohort study between August 2006 and April 2019, collecting data on all patients supported by an Impella device (type 2.5, CP or 5.0) for more than 24 hours. Patient baseline characteristics, clinical course and outcomes were compared between patients transfused with RBCs and non-transfused patients. Multivariate logistic regression analysis was used to identify factors associated with RBC transfusion. Correlations between patient characteristics and the number of units of RBCs administered were tested using the Spearman's Rank correlation coefficient. Results We included 122 CS patients who received Impella support for longer than 24 hours. Seventy-eight percent was male and the median age was 60.0 years. Transfused patients had a longer support duration compared with non-transfused patients (respectively; 97 (52–173) hours versus 51 (39–76) hours, p&amp;lt;0.001). Of all included patients, 68% received RBC transfusion. Transfused patients received a median of 1.5 (0.6–2.8) units of RBCs per day. The incidence of hemolysis was 10% in transfused patients and 11% in non-transfused patients (p=NS). Bleeding occurred in 61% of the transfused patients and 11% of the non-transfused patients (p&amp;lt;0.001). Higher age, lower hemoglobin level prior to Impella implant and longer support duration increased the odds of receiving RBC transfusion. The 30-day mortality was similar in transfused and non-transfused patients, respectively 58% and 42% (p=NS) (Figure 1. Kaplan-Meier Curve showing 30-day mortality of transfused and non-transfused patients). Conclusion RBC transfusion was required in more than two-third of the CS patients who received Impella support for longer than 24 hours. Higher age, lower hemoglobin level prior to implant and longer support duration were independent risk factors for RBC transfusion. In contrast to previous studies, transfusion was not associated with 30-day mortality. Future research should focus on the effects of RBC transfusion on morbidity and mortality and investigate the optimal transfusion criteria and aims. Funding Acknowledgement Type of funding source: None

Evaluation of Transfusion Practices in Noncardiac Surgeries at High Risk for Red Blood Cell Transfusion: A Retrospective Cohort Study.

Perioperative bleeding is a major indication for red blood cell (RBC) transfusion, yet transfusion data in many major noncardiac surgeries are lacking and do not reflect recent blood conservation efforts. We aim to describe transfusion practices in noncardiac surgeries at high risk for RBC transfusion. We completed a retrospective cohort study to evaluate adult patients undergoing major noncardiac surgery at 5 Canadian hospitals between January 2014 and December 2016. We used Canadian Classification of Health Interventions procedure codes within the Discharge Abstract Database, which we linked to transfusion and laboratory databases. We studied all patients undergoing a major noncardiac surgery at ≥5% risk of perioperative RBC transfusion. For each surgery, we characterized the percentage of patients exposed to an RBC transfusion, the mean/median number of RBC units transfused, and platelet and plasma exposure. We identified 85 noncardiac surgeries with an RBC transfusion rate ≥5%, representing 25,607 patient admissions. The baseline RBC transfusion rate was 16%, ranging from 5% to 49% among individual surgeries. Of those transfused, the median (Q1, Q3) number of RBCs transfused was 2 U (1, 3 U); 39% received 1 U RBC, 36% received 2 U RBC, and 8% were transfused ≥5 U RBC. Platelet and plasma transfusions were overall low. In the era of blood conservation, we described transfusion practices in major noncardiac surgeries at high risk for RBC transfusion, which has implications for patient consent, preoperative surgical planning, and blood bank inventory management.

When to transfuse your acute care patient? A narrative review of the risk of anemia and red blood cell transfusion based on clinical trial outcomes.

This narrative review critically evaluates the evidence for risk of anemia and red blood cell (RBC) transfusion. For this purpose, it assesses large prospective randomized-controlled trials (RCTs) in medical, surgical, and critical care patient populations in which the impact of specific hemoglobin transfusion thresholds are compared. In these trials, the risks of anemia relative to those of RBC transfusion are assessed. The results of published systematic reviews and meta-analyses are also discussed. Lastly, recommendations for patient blood management and treatment of anemia are explored. The main conclusion of this review emphasizes that the decision to transfuse RBCs is complex and depends on the interaction between multiple factors including the balance between the risk of anemia and the risk of RBC transfusion, existing patient comorbidities, and medical and surgical exposures. The transfusion thresholds recommended by current guidelines vary for medical and surgical patient populations. Guidelines suggesting specific transfusion thresholds for different patient populations should be viewed as a starting point for making an informed decision about RBC transfusion. Alternatives to transfusion (i.e., patient blood management), biomarkers of anemia-induced tissue hypoxia, and transfusion alternatives should continue to be evaluated in large RCTs, with the goal of improving event-free survival in critically ill and perioperative patients.

Efficacy and Safety of Tranexamic Acid in Major Non-Cardiac Surgeries at High Risk for Transfusion: A Systematic Review and Meta-Analysis.

Tranexamic acid (TXA) reduces transfusion requirements in cardiac surgery and total hip and knee arthroplasty, where it has become standard of care. Our objective is to determine the efficacy and safety of TXA in other surgeries associated with a high risk for red blood cell (RBC) transfusion. We identified randomized controlled trials in Medline, Embase, CENTRAL, and CAB abstracts from inception to June 2019. We included trials evaluating intraoperative IV TXA in adult patients undergoing a non-cardiac and non-hip and knee arthroplasty surgeries at high-risk for RBC transfusion, defined as a baseline transfusion rate ≥5% in comparator arm. We assessed risk of bias using the Cochrane Risk of Bias tool. We used GRADE methodology to assess certainty of evidence. From 8565 citations identified, we included 69 unique trials, enrolling 6157 patients. TXA reduces both the proportion of patients transfused RBCs (relative risk (RR) 0.59; 95% confidence interval (CI) 0.48 to 0.72; low certainty evidence) and the volume of RBC transfused (MD -0.51 RBC units; 95%CI -0.13 to -0.9 units; low certainty evidence) when compared to placebo or usual care. TXA was not associated with differences in deep vein thrombosis, pulmonary embolism, all-cause mortality, hospital length of stay, need for re-operation due to hemorrhage, myocardial infarction, stroke or seizure. In patients undergoing a broad range of non-cardiac and non-hip and knee arthroplasty surgeries at high risk for RBC transfusion, perioperative TXA reduced exposure to RBC transfusion. No differences in thrombotic outcomes were identified; however, summary effect estimates were limited by lack of systemic screening and short duration of follow-up.

RISK FACTORS FOR BLOOD TRANSFUSION IN WOMEN UNDERGOING GYNAECOLOGICAL SURGERY

Objectives A common complication of surgery is peri-operative blood loss, which increases the likelihood of red blood cell (RBC) transfusion and its associated risks. The objective of this study was to identify demographic, medical, and surgical factors that may predict the need for RBC transfusion in patients undergoing benign gynaecological surgery. Methods We performed a retrospective cohort study of patients undergoing benign gynaecological surgery between April 1st 2016 to March 31st 2017 in a tertiary care hospital. Log binomial regression model was used to calculate risk ratios and adjusted risk ratios, while controlling for the effect of preoperative anaemia. Results Among the 988 patients included, 41 patients (4.1%) received an RBC transfusion and 185 (18.7%) had preoperative anemia. In the total cohort, mean haemoglobin was 126.19+/-15.43g/L, while itwas 104.39+/-21.59g/L among those who received RBC transfusion. Patients had an increased risk of requiring RBC transfusion if they had preoperative anemia (RR 8.37[95%CI 4.48-15.64]), abnormal uterine or vaginal bleeding (RR 2.47[95%CI 1.21-5.03]), underwent vaginal/hysteroscopic myomectomy (RR 6.28[95%CI 1.82-21.69]), or had a salpingectomy (RR 2.13[95%CI 1.01-4.48]). Risk of RBC transfusion was lower among patients with vaginal hysterectomy (RR 0.08[95%CI 0.01-0.57]) and prolapse repair (RR 0.06[95%CI 0.01-0.44]). After controlling for preoperative anemia, only vaginal/hysteroscopic myomectomy showed increased risk of requiring RBC transfusion (RR 3.36[95%CI 1.13-10.01]). Conclusions Preoperative anemia and vaginal/hysteroscopic myomectomy are important independent risk factors for predicting the need for increased RBC transfusion in the peri-operative period. Identifying risk factors can facilitate peri-operative management to minimize the need for transfusion.

Establishing a perinatal red blood cell transfusion risk evaluation model for obstetric patients: a retrospective cohort study

BACKGROUNDThe ability to predict risk factors for blood transfusion after postpartum hemorrhage could enhance the performance of lifesaving procedures in patients who experience postpartum hemorrhage. Therefore, this study aimed to evaluate these risk factors and create a scoring system for blood transfusion evaluations and risk in obstetric patients.STUDY DESIGN AND METHODSDiagnosis and blood transfusion data of 14,112 women who delivered between January 1, 2015, and December 31, 2015, were analyzed. A binary logistic regression model was used. We conducted univariate analyses of each risk factor as well as multivariable logistic regression analysis. Data of obstetric patients in 2016 validated the receiver operating characteristic curve. A risk prediction score was generated from the transfusion risk factor β‐coefficients in the multivariable logistic regression model.RESULTSIn total, 392 (2.94%) of 13,328 patients received transfusions. After multivariable adjustment, polyembryony, anemia, thrombocytopenia, preeclampsia, placenta previa, placental implantation, uterine scarring, uterine rupture, retained placenta, stillbirth, and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) were significantly associated with perinatal transfusion. Heart disease and hemophilia were not related to transfusion risk. The blood transfusion risk evaluation table was well calibrated.CONCLUSIONSOur retrospective analysis revealed that diagnoses including polyembryony, anemia, thrombocytopenia, preeclampsia, placenta previa, placenta implantation, uterine scarring, uterine rupture, retained placenta, stillbirth, and HELLP syndrome are significantly associated with perinatal transfusion and are risk factors for blood transfusion. The blood transfusion scoring system could be beneficial for evaluating blood transfusion risk.

The influence of ultrafiltration on red blood cell transfusion during cardiopulmonary bypass.

Ultrafiltration during cardiopulmonary bypass (CPB) reduces fluid overload and inflammatory mediators in open-heart surgery and is thought to reduce the risk of red blood cell (RBC) transfusion. We evaluated its effectiveness in reducing RBC transfusions in a large population undergoing cardiac surgery, among patients in general as well as by gender. We analyzed 40,650 propensity-matched adult cardiac surgery cases conducted over a 61-month period at 195 hospitals. We assessed the risk of intraoperative transfusion (⩾1 unit RBC) according to body surface area (BSA)-normalized ultrafiltration volume via mixed-effects binary logistic regression. Our statistical model controlled for 12 demographic and operative variables as well as for center level tendencies in ultrafiltration use and intraoperative RBC transfusion. In light of recent findings on gender and risk of transfusion, we also included an interaction effect between gender and ultrafiltration volume (UV). Ultrafiltration was associated with an increased crude rate of RBC transfusion (32.1% vs. 28.1%, p<0.001), but equivalent crude median hematocrit change from first in operating room to nadir on bypass (-11% in both groups, p = 0.133). After controlling for patient, operative and site-level characteristics, we found no statistically significant effect on transfusion rate by volume of ultrafiltrate removed nor did we find statistical support for any gender-specific effect of ultrafiltration. Ultrafiltration is not associated with a reduction of risk of RBC transfusion during cardiac surgery. The use of ultrafiltration as a method for reducing intraoperative RBC transfusion warrants further study.

Blood Loss Due to Laboratory Testing in Critical Care Patients: A Retrospective Cohort Study

Abstract Background: Anemia and red blood cell (RBC) transfusions occur frequently in intensive care unit (ICU) patients and are associated with morbidity and mortality. Observational data suggest that anemia (nadir hemoglobin ≤ 9 g/dL) in ICU patients is associated with an increased risk of death within 30 days (OR 1.54, 95% confidence interval [CI] 1.12-2.12). Although anemia in this population is likely multifactorial, phlebotomy for laboratory testing is substantial (up to 41 mL/day) and may be a modifiable contributor as only 10% of the blood collected is required for analysis. This study aims to (i) characterize the blood volume taken for laboratory testing in ICU patients, and (ii) explore the effect of blood taken for testing on rates of RBC transfusion and anemia in a contemporary cohort of ICU patients. Methods: We conducted a retrospective cohort study of consecutive adult patients, age ≥18 years, admitted to a medical-surgical ICU for ≥48 hours in Hamilton, Ontario between November 1, 2012 to October 1, 2015. We extracted data from previously validated administrative databases. The primary outcome was estimated volume of blood drawn for laboratory testing during index ICU admission calculated using the number of unique blood specimens drawn and known sampling tube volumes. Secondary outcomes included: incidence of severe anemia (hemoglobin ≤9 g/dL), discharge hemoglobin adjusted for RBC transfusion (1.0 g/dL subtracted for each RBC transfusion administered), proportion of patients receiving RBC transfusion, number of RBC units transfused per patient, duration of ICU admission and ICU mortality. Categorical data are reported as counts and proportions. Continuous data are reported as means with standard deviations (SD) or medians with interquartile range (IQR). Predictors of RBC transfusion were examined using Cox regression analysis. P-values &lt;0.05 were considered statistically significant. Results: We included 7,273 ICU patients. The median age was 66 years (IQR 54-76 years) and 40.8% of patients were female. Most responsible diagnosis was circulatory (33.3%), followed by injury/poisoning (15.9%), respiratory (12.8%), and gastrointestinal (9.2%). The ICU mortality rate was 13.8% and the median ICU length of stay was 5 days (IQR 3-10 days). On ICU admission, median hemoglobin value was 9.7 g/dL (IQR 8.2-11.6 g/dL) and 39.6% of patients had hemoglobin ≤ 9.0 g/dL. Median blood loss due to laboratory testing was 25 mL per patient per day (IQR 14-43 mL) and 213 mL per patient for the ICU admission (IQR 133-382 mL). On ICU discharge, median hemoglobin was 8.4 g/dL (IQR 5.8-10.5 g/dL), and 67.0% of patients had hemoglobin ≤ 9.0 g/dL while in ICU. After adjusting for RBC transfusions, the median decrease in hemoglobin from ICU admission to discharge was 1.2 g/dL (IQR 0-2.9 g/dL). RBC transfusions were administered to 47.5% of patients while in the ICU with 37.3% of these patients receiving 5 or more units. The median number of RBC units received in transfused patients was 3 (IQR 2-7). Additional blood drawn for laboratory testing of 150 mL from day 2 to day 7 of ICU admission (hazard ratio [HR] 2.3, 95%CI 2.1-2.5), hematologic diagnosis vs. other (HR 1.5, 95%CI 1.2-2.0), and RBC transfusion prior to ICU admission vs. none (HR 1.5, 95%CI 1.2-1.9) were associated with a higher risk of RBC transfusion in the ICU. Conclusions: Anemia and RBC transfusions are frequent in ICU patients with two-thirds of patients developing severe anemia (hemoglobin &lt;9.0 g/dL) and 47.5% receiving RBC transfusion, respectively. Our results suggest that blood loss for laboratory testing remains substantial in contemporary medical-surgical ICU patients and is associated with the need for RBC transfusion. Strategies to reduce blood loss from laboratory testing represent an area for further prospective investigation. Disclosures Siegal: BMS-Pfizer: Honoraria; Bayer: Honoraria; Portola Pharmaceuticals: Honoraria.

Treating Anemia in the Preanesthesia Assessment Clinic: Results of a Retrospective Evaluation

Perioperative anemia is challenging during hospital stay because anemia and red blood cell (RBC) transfusions are associated with an increased morbidity and mortality. With the implementation of patient blood management (PBM), a preanesthesia assessment clinic to screen and treat anemia before elective surgery was institutionalized at Muenster University Hospital, Germany. The main objective of this study was to evaluate the association between treating preoperative anemic patients with intravenous iron (IVI) and (primarily) presurgical hemoglobin levels and (secondarily) use of RBCs and mortality. Between April 1, 2014, and July 4, 2016, patients scheduled for elective surgery with a risk for RBC transfusions >10% in 2013 were screened for preoperative anemia and, if indicated, treated with IVI. Patients' data, time span between visit in the anesthesia/PBM clinic and surgery, demographic data, type of surgery, the difference of hemoglobin levels between visit and surgery, RBC transfusion, infectious-related International Classification of Disease codes during hospital stay, and 1-year survival were determined retrospectively by screening electronic data files. In addition, patients were interviewed about adverse events, health-related events, and infections via telephone 30, 90, and 365 days after visiting the anesthesia/PBM clinic. A total of 1101 patients were seen in the anesthesia/PBM clinic between days -28 and -1 (median [Q1-Q3], -3 days [-1, -9 days]) before elective surgery. Approximately 29% of patients presented with anemia, 46.8% of these anemic patients were treated with ferric carboxymaltose (500-1000 mg).In the primary analysis, hemoglobin levels at median were associated with a reduction between the visit in the anesthesia/PBM clinic and the surgery in all nonanemic patients on beginning of medical treatment (nonanemic patients at median -2.8 g/dL [-4, -0.9 g/dL], while anemic patients without IVI presented with median differences of -0.8 g/dL [-2, 0 g/dL] and anemic patients with IVI of 0 g/dL [-1.0, 0.5 g/dL]). Hemoglobin levels raised best at substitution 22-28 days before surgery (0.95 g/dL [-0.35, 1.18 g/dL]). Due to the selection criteria, transfusion rates were high in the cohort. Overall, there was no association between IVI treatment and the use of RBC transfusions (odds ratio for use of RBCs in anemic patients, no IVI versus IVI: 1.14; 95% confidence interval, 0.72-1.82). Patients treated with or without IVI presented a comparable range of International Classification of Disease codes related to infections. Telephone interviews indicated similar adverse events, health-related events, and infections. Cox regression analysis showed an association between anemia and reduced survival, regardless of IVI. An anemia clinic within the preanesthesia assessment clinic is a feasible and effective approach to treat preoperative anemia. The IVI supplementation was safe but was associated with decreased RBC transfusions in gynecology/obstetric patients only. The conclusions from this retrospective analysis have to be tested in prospective, controlled trials.

Bioelectrical Impedance Phase Angle—Predictor of Blood Transfusion in Cardiac Surgery

To determine whether bioelectrical impedance-derived phase angle (PA) can be a predictor of red blood cell (RBC) transfusion in patients undergoing cardiac surgery. An observational retrospective study of prospectively collected data. Single center, tertiary referral university hospital. The study sample comprised 642 adult patients undergoing elective cardiac surgery. Patient demographic and clinical variables were collected. The body composition of the patients was evaluated by bioelectrical impedance analysis (BIA) the day prior to surgery. The rates of postoperative RBC transfusion were recorded. Among the 642 patients (67.8% men, median age of 66 [range 59-73]) included in the present study, 210 (32.7%) received at least 1 RBC unit postoperatively. Hypertension, preoperative stroke, renal failure, preoperative hemoglobin and hematocrit values, BIA-derived PA, aortic crossclamp time, and cardiopulmonary bypass (CPB) time were associated with the risk of RBC transfusion in the univariate analysis, and were included in the final multivariate regression model. Preoperative stroke (odds ratio [OR] 0.394; 95% confidence interval [CI]: 0.183-0.848; p = 0.017), preoperative hemoglobin values (OR 0.943; 95% CI: 0.928-0.960; p < 0.001), PA <15th percentile (OR 2.326; 95% CI: 1.351-4.000; p = 0.002), and CPB time (OR 1.013; 95% CI: 1.008-1.018; p < 0.001) were identified as independent predictors of RBC transfusion. Several factors were identified to be associated significantly with postoperative RBC transfusion in patients undergoing cardiac surgery. Among the conventional predictors, the value of the BIA-derived PA was indicated as a potent prognostic tool.

Transfusion for Patients With Sepsis in 2018

Red blood cell transfusion (RBCT) threshold in patients with sepsis remains a matter of controversy. In this review, we report a summary of the benefits and risks of RBCT. We then focus on the latest studies addressing this controversy, including the randomized controlled trials dealing with the early goal-directed therapy, the randomized controlled trials comparing liberal versus restrictive transfusion strategies, and finally the cohort studies assessing the impact of RBCT. The conclusions of these studies no longer argue for a 10 g/dL (30% hematocrit) transfusion threshold during the early phase of septic shock. Similarly, following the initial stabilization, most septic patients can be managed with a restrictive transfusion strategy using a 7 g/dL hemoglobin threshold. A more liberal transfusion strategy should be adopted if patients are not stabilized or for patients at risk of bleeding, with myocardial ischemia, or oncohematologic patients with potential hemostasis disorders. Triggers of RBCT other than hemoglobin level, more related to macrocirculation or microcirculation failures, should be developed to decide RBCT in septic patients.

Positive impact of retrograde autologous priming in adult patients undergoing cardiac surgery: a randomized clinical trial

BackgroundAdult cardiac surgery with extracorporeal circulation is known to be associated with increased risk of blood transfusion leading to adverse outcomes. Procedures like retrograde autologous priming (RAP) may reduce these negative side effects. This randomized prospective study was initiated to assess whether RAP using specifically designed RAP bag (Terumo) has immediate effects on patient outcome.MethodsOne hundred eighteen adults undergoing elective CABG or elective aortic valve replacement were randomly assigned by a computer program into two groups: the RAP group (n = 54) in which the retrograde autologous priming was applied and the non-RAP (n = 64) group in which the same setting was used without the possibility to save priming volume. Patient demographics, preoperative characteristics and postoperative outcomes were analyzed for both groups.ResultsThe primary endpoint defined as rate of intraoperative blood transfusion was significantly reduced in the RAP-group (p = 0.04). The absolute risk reduction for RAP managed patients was 13.5 percent points. There were no significant differences in operation time and blood loss. No deaths and no myocardial infarctions were observed. The number of patients needed to treat to prevent at least one red blood cell transfusion was around 8 (NNT = 7.42).ConclusionsRetrograde autologous priming is a safe and less invasive procedure which achieves clear benefits for adult cardiac surgery patients. In the light of increasing red blood cell transfusion risks and costs and the wish of patients to avoid a transfusion implementation of retrograde autologous priming is an interesting option.Trial registrationGerman Clinical Trials Register ID: DRKS00013512, registered 04 December 2017.