Single-unit Red Blood Cell Research Articles

Single-Unit Transfusion Policy in Autologous Hematopoietic Stem Cell Transplantation: Less is Not Worse

Single-unit red blood cell (1-RBC) transfusion policy has shown to effectively reduce transfusion burden while maintaining comparable clinical outcomes in hematological patients compared to the classical double-unit policy. However, its effects specifically after autologous stem cell transplantation (ASCT) have not been previously studied. We aimed to evaluate the impact of the 1-RBC policy on transfusion burden in a homogeneous cohort of patients undergoing ASCT. We retrospectively compared the transfusion requirements and the clinical outcomes of 187 patients transplanted from May 2019 to December 2022 under a 1-RBC policy, with a historical cohort of 153 patients transplanted from January 2016 to April 2019 under a double-unit policy. The 1-RBC policy was associated with a 32% reduction in RBC utilization and lower number of RBC transfusions at day 30 after transplantation (median 2 versus 3 units; P < .0001), with an odds ratio of 0.49 in multivariate analysis (P = .03). However, the number of transfusion episodes remained similar (median of 2 in both arms; P = .34). No significant differences in length of stay, hemoglobin levels at discharge or 30‐day mortality were observed. In conclusion, transitioning to the 1-RBC represents a straightforward action in current practice that significantly reduces blood transfusions in patients undergoing ASCT, without negatively impacting clinical outcomes.

Effect of Red Blood Cell Transfusion on Central Venous-to-Arterial Carbon Dioxide Difference in Anemic Surgical Patients – A Pilot Study

Background: Biochemical markers for monitoring adequacy of cardiac output and tissue perfusion such as blood lactate and central venous oxygen saturation (ScvO2) are meanwhile well established in clinical routine. In addition, in recent years, the central venous-to-arterial carbon dioxide difference (dCO2) has been evaluated as a further marker, and studies meanwhile have demonstrated the validity of an increased dCO2 to identify capillary perfusion mismatches. However, results from animal studies suggest that dCO2 may be influenced by altered hemoglobin values during severe bleeding. It was the aim of our study to evaluate if dCO2 changes upon Red Blood Cell (RBC) transfusion in humans. Methods: Patients of the ongoing LIBERAL trial were prospectively evaluated. Participants were aged ≥70 years and scheduled for elective intermediate or high risk orthopedic or trauma surgery with the clinical need for invasive blood pressure monitoring and central venous catheterization. During surgery, drop of hemoglobin triggered administration of one single RBC unit, together with arterial and central venous blood analysis immediately before as well as after transfusion. Results: In total, 46 patients were analyzed. Baseline median hemoglobin before RBC transfusion was 8.35 (7.48–8.73)g/dl, while dCO2 was 6.2 (3.4–9.6)mmHg. According to Spearman correlation, there was a linear association between pre-transfusion dCO2 and ScvO2. Transfusion of one RBC unit resulted in a significant increase of median hemoglobin by 1.2 (0.7–1.63)g/dl (p&lt;0.0001), and hemoglobin increase was more pronounced when pre-transfusion hemoglobin was low, as evidenced by a significant negative association between both parameters (r=-0.61, p &lt;0.0001). Neither lactate nor ScvO2 nor dCO2 were significantly influenced by transfusion. When the whole cohort was divided according to pre-transfusion dCO2 levels using a cut-off value of 6 mmHg, median dCO2 decreased significantly more pronounced following RBC transfusion when pre-transfusion values were high (&gt;6 mmHg), compared to those patients with a pre-transfusion dCO2 below 6 mmHg. Conclusions: The results of our study suggest that crude dCO2 is not influenced by moderate hemoglobin increases in orthopedic and trauma surgery patients. However, including dCO2 into the decision whether to administer RBC or not may be an interesting reasonable approach for further investigations on the way towards more individualized transfusion regimens.

Mitochondrial oxygen tension in critically ill patients receiving red blood cell transfusions: a multicenter observational cohort study

PurposeCurrently, there is no marker of efficacy of red blood cell (RBC) transfusion. This study describes the impact of RBC transfusion on mitochondrial oxygen tension (mitoPO2) and mitochondrial oxygen consumption (mitoVO2) in critically ill patients with anemia.MethodsCritically ill patients with a hemoglobin concentration < 10 g/dL, for whom a single RBC unit had been ordered, were included. MitoPO2 was measured with the COMET device immediately before RBC transfusion, 0.5 h, 1 h, 3 h, and 24 h after RBC transfusion. MitoVO2 was calculated from dynamic mitoPO2 measurements during cessation of local oxygen supply.ResultsSixty-three patients participated, median age 64.0 (interquartile range (IQR) 52.3–72.8) years, median hemoglobin concentration before transfusion 7.4 (IQR 7.1–7.7) g/dL. Median mitoPO2 values were 55.0 (IQR 49.6–63.0) mmHg before RBC transfusion, 51.0 (IQR 41.5–61.2) directly after and 67.3 (IQR 41.6–83.7) at 24 h after RBC transfusion. Median mitoVO2 values were 3.3 (IQR 2.1–5.9) mmHg/s before RBC transfusion, 3.7 (IQR 2.0–5.1) mmHg/s directly after, and 3.1 (IQR 2.5–4.8) mmHg/s 24 h after RBC transfusion. In the higher Hb concentration group (> 7 g/dL), we saw a dissociation of the effect of RBC transfusion on mitoPO2 versus on mitoVO2 values. MitoPO2 and mitoVO2 values were not associated with commonly used parameters of tissue perfusion and oxygenation.ConclusionRBC transfusion did not alter mitoPO2 and mitoVO2 in critically ill patients with anemia. MitoPO2 and mitoVO2 values were not notably associated with Hb concentrations, parameters of severity of illness and markers of tissue perfusion or oxygenation. Given the high baseline value, it cannot be excluded nor confirmed whether RBC can improve low mitoPO2.Trial registration number NCT03092297 (registered 27 March 2017)

Haemoglobin thresholds for transfusion: how are we doing in the era of Choosing Wisely? A retrospective cohort study.

Clinical practice guidelines and the Choosing Wisely initiative launched in 2012 recommend a haemoglobin (Hb) threshold of 70-80 g/lfor red blood cell (RBC) transfusions in stable hospitalised patients. Data on transfusion practices and their trends in medical inpatients are limited. To address this gap, we investigated transfusion practices and their trends in general internal medicine and other clinics. This retrospective cohort study analysed data from all hospitalisations with RBC transfusions at a Swiss university hospital between 2012 and 2019. We included all first transfusion episodes if pretransfusion Hb was available. The primary endpoint was mean pretransfusion Hb; secondary endpoints included potentially inadequate transfusions (i.e., transfusions at Hb ≥80 g/l) and receipt of a single RBC unit. Trends in mean pretransfusion Hb over time were estimated using generalised estimating equations, and risk factors for potentially inadequate transfusions were identified using multivariable adjusted generalised estimating equations models. Of 14,598 hospitalisations with RBC transfusions, 1980 (13.6%) were discharged from general internal medicine. From 2012 to 2019, mean pretransfusion Hb decreased from 74.0 g/l to 68.8 g/l in general internal medicine (mean annual decrease -0.76 g/l, 95% confidence interval [CI] -0.51 to -1.02) and from 78.2 g/l to 72.7 g/l in other clinics (mean annual decrease -0.69, 95% CI -0.62 to -0.77; p for interaction 0.53). The overall proportion of potentially inadequate transfusions was 17.8% in general internal medicine and 24.1% in other clinics (p <0.001) and decreased over the study period from 26.9% to 5.5% in general internal medicine and from 37.0% to 15.2% in other clinics. In contrast, the proportion of cases receiving a single RBC unit increased (39.5% to 81.4% in general internal medicine, 42.7% to 66.1% in other clinics). Older age (adjusted odds ratio [aOR] 1.45, 95% CI 1.32-1.58 for ≥65 vs <65 years), having surgery (aOR 1.24, 95% CI 1.14-1.36), acute haemorrhage (aOR 1.16, 95% CI 1.02-1.33), chronic heart failure (aOR 1.17, 95% CI 1.04-1.32), ischaemic heart diseases (aOR 1.27, 95% CI 1.15-1.41), chronic pulmonary diseases (aOR 1.24, 95% CI 1.08-1.42), malignancy (aOR 1.11, 95% CI 1.01-1.21), and rheumatic disease (aOR 1.27, 95% CI 1.01-1.59) were risk factors for potentially inadequate transfusions. More restrictive transfusion practices were adopted in general internal medicine and other clinics over time, suggesting that guideline recommendations and the Choosing Wisely initiative may have been increasingly followed. Interventions to reduce potentially inadequate transfusions should target providers who care for older patients and those with surgery or chronic cardiac and pulmonary diseases.

Incidence and Impact of a Single-Unit Red Blood Cell Transfusion: Analysis of The Society of Thoracic Surgeons Database 2010-2019

BackgroundAs the adverse effects of blood transfusions are better understood, recommendations support single-unit red blood cell (RBC) transfusions (SRBCT). However, an isolated SRBCT across the entire index admission suggests even the single unit may be avoidable. We sought to identify the characteristics of cardiac surgery patients receiving an isolated SRBCT and analyze the impact on outcomes. MethodsThe Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for the period between January 1, 2010, and December 31, 2019. Patients aged >18 years undergoing isolated coronary artery bypass grafting or isolated aortic valve replacement were included. A total of 2,151,430 encounters were analyzed. ResultsOf the 847,442 patients (39.3%) receiving any RBC transfusion during their index admission, 206,555 (24.4%) received only 1 unit. Propensity-matching analysis determined SRBCT patients were significantly older (67.26 vs 64.02 years; odds ratio [OR], 1.02; P < .001), female (39.1% vs 17.8%; OR, 1.57; P < .001), non-White (18.2% vs 13.1%; OR, 0.81; P < .001), and had a smaller body surface area (1.94 vs 2.07 m2; OR, 0.20; P < .001). They also had higher mortality (1.4% vs 1.0%, P < .001), stroke (1.7% vs 1.2%, P < .001), prolonged ventilation (6.4% vs 3.4%, P < .001), renal failure (1.8% vs 0.9%, P < .001), and reoperations (1.3% vs. 0.5%, P < .001) than patients who received 0 RBCs. ConclusionsSRBCT is a common occurrence in adult cardiac surgery. This low-volume transfusion is strongly associated with higher morbidity, even after controlling for preoperative risk factors.

Successful Collaboration of a Hospital Based Blood Center and Blood Bank during the Pandemic and Blood Shortage

Abstract Introduction/Objective At the beginning of the SARS-Co-V2 pandemic, many hospitals implemented mitigating strategies to preserve their blood supply in anticipation of a blood shortage. Our health system, Inova (IHS), which includes 5 hospitals supported by our hospital based blood services, was no different. During the pandemic we experienced a decline in donations and available blood products. In anticipation of this shortage, our institution mobilized the Patient Blood Management (PBM) initiative. A multidisciplinary review of transfusion criteria was performed across the system. This included enforcing single unit red blood cell (RBC) transfusions, partial RBC exchanges for sickle-cell disease, and reduction in plasma replacement volume during plasma exchanges for patients with thrombotic thrombocytopenic purpura (TTP). By implementing these strategies, patient outcomes were not impacted despite the constraints to our blood supply. Methods/Case Report IHS Executive leaders were identified to participate along with key stakeholders in the PBM committee meetings to ensure proper blood utilization for our patients. Clinical guidelines were updated within the physician order sets. Data was compiled with a focus on hemoglobin metrics along with the percentage of single unit transfusions. Collaborating with IHS Apheresis Services and our providers, we developed a strategy to reduce the number of blood products transfused. Results (if a Case Study enter NA) Although there was decline in donor blood collections during the pandemic due to significant concerns of SARS-CO-V2 exposure, the implementation of Patient Blood Management strategies at our institution proved to be beneficial for product management and resource allocation. Although there was a decline in the number of donations (6.5%) we were able to transfuse more patients. Conclusion The SARS-Co-V2 pandemic significantly reduced the blood inventory nationwide. By implementing a robust Patient Blood Management program, we were able to successfully utilize our blood inventory while maintaining transfusion practices that aligned with standards of care. The collaborative efforts between our hospital based blood center and the blood bank led to the optimal use of a reduced blood supply during the pandemic. Incorporating Patient Blood Management principles and safe implementation of novel treatment plans for certain apheresis patient population during the pandemic enabled our system to have more available blood products and care for more patients with improved patient outcomes.

The Effect of Sex-Mismatched Red Blood Cell Transfusion on Endothelial Cell Activation in Critically Ill Patients

Background: Observational studies suggest that sex-mismatched transfusion is associated with increased mortality. Mechanisms driving mortality are not known but may include endothelial activation. The aim of this study is to investigate the effects of sex-mismatched red blood cell (RBC) transfusions on endothelial cell activation markers in critically ill patients. Study Design and Methods: In patients admitted to the intensive care unit who received a single RBC unit, blood samples were drawn before (T₀), 1 h after (T₁), and 24 h after transfusion (T₂₄) for analysis of soluble syndecan-1, soluble intercellular adhesion molecule-1, soluble thrombomodulin (sTM), von Willebrand factor antigen, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNFα). Changes in the levels of these factors were compared between sex-matched and sex-mismatched groups. Results: Of 69 included patients, 32 patients were in the sex-matched and 37 patients were in the sex-mismatched group. Compared to baseline, sex-matched transfusion was associated with significant reduction in sTM level (p value = 0.03). Between-group comparison showed that levels of syndecan-1 and sTM were significantly higher in the sex-mismatched group compared to the sex-matched group at T₂₄ (p value = 0.04 and 0.01, respectively). Also, TNFα and IL-6 levels showed a statistically marginal significant increase compared to baseline in the sex-mismatched group at T₂₄ (p value = 0.06 and 0.05, respectively), but not in the sex-matched group. Discussion: Transfusion of a single sex-mismatched RBC unit was associated with higher syndecan-1 and sTM levels compared to transfusion of sex-matched RBC unit. These findings may suggest that sex-mismatched RBC transfusion is associated with endothelial activation.

Single-Unit Transfusion Is Non Inferior to Double Unit Transfusion in Patients with Hematological Disorders Receiving Allogeneic or Autologous Bone Marrow Transplant or Induction Chemotherapy for Acute Leukemia: The 1versus2 Prospective Multicentric Randomized Clinical Trial

IntroductionAnemia is a common complication of hematological chemotherapy for acute leukemia and following hematopoietic stem cell transplantation (HSCT). Exposure to allogeneic blood transfusions has been associated with unfavorable outcome in several studies in a non-surgical settings. Retrospective studies in hematological intensive unit have suggested that single red blood cell (RBC) unit transfusion policy may reduce the number of RBC used in comparison with a classical double RBC unit transfusion policy, without clinical impact. The aim of the study was to demonstrate that single RBC transfusion was non inferior to the standard double RBC transfusion arm in terms of severe complication or mortality for inpatient with hematological malignancies. Key secondary endpoint, was the comparison of the numbers of RBC units transfused in each arm.MethodIn a phase 3 multicenter randomized trial, 245 adults' patients with acute leukemia requiring intensive chemotherapy or patients receiving autologous or allogeneic HSCT were randomly assigned (1:1) to receive either single RBC unit (1 RBC arm, n=125) per transfusion or double RBC (2 RBC arm, n=120) per transfusion when hemoglobin level was below 8g/dL.The primary composite endpoint was the percentage of patients who developed a grade ≥3 complications defined as stroke, transient ischemic attack, acute coronary syndrome, heart failure, elevated troponin level, intensive care unit transfer, death, new pulmonary infiltrates, and/or transfusion-related infections during hospital stays. The secondary endpoint was the number of red cell units transfused per patient per hospital stay. The primary endpoint was compared between groups by non-inferiority analysis for the proportion risk difference using Farrington-Manning method with a non-inferiority margin of 0.1, in ITT dataset.ResultsHematological disease were as followed: AML (59%), ALL (13.1%), Lymphoma (16.4%), others (11.5%). The median age was 55 years. Baseline characteristics were well balanced between the 2 arms (Figure 1A). A total of 981 and 592 transfusions have been necessary in the 1 RBC arm and 2 RBC arm, respectively. The median of RBC unit per transfusion was 1(1-1) and 2(2-2) in the 1 RBC and 2 RBC arm, respectively. The mean pre transfusion hemoglobin level was 7.49 +/- 0.83 g/dL in the 1 RBC arm and 7.46 +/- 0.67 g/dL in the 2 RBC arm (p=0.275). Hemoglobin level at discharge was 9.35 +/-1.14 g/dL in the 1 RBC arm and 9.58 +/-1.13 g/dL in the 2 RBC arm (p=0.118).The median (IQR) of red-cell units transfused per patient was 7 (4-12) in the single arm and 8 (4-12) in the double arm (p=0.65). The median number of platelet transfusion event was 7 (3.5-11.5) in the 1 RBC arm and 7 (3-13) in the 2 RBC arm (p=0.69). The median (IQR) number of red cell unit transfused per cycle and per day was 7 (3-9) and 0.28 (0.17-0.37) in the 1RBC arm and 6 (4-10) and 0.27 (0.20-0.38) in the 2 RBC arm (p=0.61 and p=0.47).The predefined non-inferiority criteria was achieved with 28 patients developing a serious complication in the 1 CGR arm (22.4%) and 28 patients in the 2 RBC arm (23.3%) (Risk difference 0.009; 95% Confidence interval [-0.0791- 0.0978] (Figure 1B).Conclusion: Single RBC transfusion policy is non inferior to double RBC transfusion policy in hematological intensive care unit for patient receiving a bone marrow transplant or intensive chemotherapy. Single RBC unit transfusion can be used safely in daily clinical practice. The single RBC transfusion policy does not reduce the number of RBC transfusion. [Display omitted] DisclosuresJardin: Genexpath: Patents & Royalties: The author is a potential inventor on a patent application for the LymphoSign, which has been licensed for by Genexpath Patents & Royalties. .

Implementation of a patient blood management program based on a low-income country-adapted clinical decision support system

IntroductionPatient blood management (PBM) programs are associated with better patient outcomes, a reduced number of transfusions and cost-savings The Clinical Decision Support (CDS) systems are valuable tools in this process, but their availability is limited in developing countries This study assesses the feasibility and effectiveness of an adapted CDS system for low-income countries. MethodsThis was a prospective study of the PBM program implementation, in a 200-bed tertiary hospital, between February 2019 and May 2020. Outcome measures were red blood cell (RBC), fresh frozen plasma (FFP) and platelet unit transfusions, the transfusion of a single unit of red blood cells and an RBC adequacy index (RAI). ResultsComparing the post-PBM program era with the pre-PBM system era, there was a decrease in red blood cell transfusions (p=0.05), with an increase in single unit red blood cell transfusions (p=0.005) and RAI (p<0.001). ConclusionsThe PBM programs, including electronic transfusion guidelines with pre-transfusion medical auditing, was associated with improved transfusion practices and reduced product acquisition-related costs.

A Retrospective Study of Single-Unit Transfusion in a Tertiary Care Center of Southern India

Background and Objectives: Single-unit transfusions continue to be a widespread transfusion practice. Single-unit red blood cell (RBC) transfusions were treated with substantial denunciation in the past but recently have been reviewed as to whether it is acceptable or could be acceptable. This study was undertaken to observe the overall profile of the patients receiving the single-unit transfusion and analyze the possible rationale of such transfusion. Methods: This was a retrospective record-based study conducted in multispecialty tertiary level care teaching hospital over a period of 1 year from January to December 2017. Variables included were age, gender, diagnosis, indication for transfusion, pre- and post-hemoglobin, additional modality of treatment received including other blood components and length of hospital stay. Qualitative variables were described as number and percentages, and quantitative variables as number, mean, and standard deviation. Results: During the study, 50,880 blood components were issued out of which, packed RBCs (PRBCs) accounted to 19760. Twenty-four percent (4742 units) of the total blood units were transfused as single unit of PRBC. 52.1% of these single-unit transfusions were carried out by the surgical specialties. Conclusion: Single-unit transfusions are more common in medical specialties probably due to the chronic nature of the diseases. However, even in surgical specialties, especially those striving toward reducing blood usage and the ones operating in more of an elective setting, single-unit transfusions were higher.

Liberal transfusion strategy to prevent mortality and anaemia-associated, ischaemic events in elderly non-cardiac surgical patients \u2013 the study design of the LIBERAL-Trial

BackgroundPerioperative anaemia leads to impaired oxygen supply with a risk of vital organ ischaemia. In healthy and fit individuals, anaemia can be compensated by several mechanisms. Elderly patients, however, have less compensatory mechanisms because of multiple co-morbidities and age-related decline of functional reserves. The purpose of the study is to evaluate whether elderly surgical patients may benefit from a liberal red blood cell (RBC) transfusion strategy compared to a restrictive transfusion strategy.MethodsThe LIBERAL Trial is a prospective, randomized, multicentre, controlled clinical phase IV trial randomising 2470 elderly (≥ 70 years) patients undergoing intermediate- or high-risk non-cardiac surgery. Registered patients will be randomised only if Haemoglobin (Hb) reaches ≤9 g/dl during surgery or within 3 days after surgery either to the LIBERAL group (transfusion of a single RBC unit when Hb ≤ 9 g/dl with a target range for the post-transfusion Hb level of 9–10.5 g/dl) or the RESTRICTIVE group (transfusion of a single RBC unit when Hb ≤ 7.5 g/dl with a target range for the post-transfusion Hb level of 7.5–9 g/dl). The intervention per patient will be followed until hospital discharge or up to 30 days after surgery, whichever occurs first. The primary efficacy outcome is defined as a composite of all-cause mortality, acute myocardial infarction, acute ischaemic stroke, acute kidney injury (stage III), acute mesenteric ischaemia and acute peripheral vascular ischaemia within 90 days after surgery. Infections requiring iv antibiotics with re-hospitalisation are assessed as important secondary endpoint. The primary endpoint will be analysed by logistic regression adjusting for age, cancer surgery (y/n), type of surgery (intermediate- or high-risk), and incorporating centres as random effect.DiscussionThe LIBERAL-Trial will evaluate whether a liberal transfusion strategy reduces the occurrence of major adverse events after non-cardiac surgery in the geriatric population compared to a restrictive strategy within 90 days after surgery.Trial registrationClinicalTrials.gov (identifier: NCT03369210).

Macrophage Recycling of Red Blood Cells and Iron Following Transfusion

Red blood cells (RBCs) destined for transfusion can be refrigerator stored for up to 42 days prior to transfusion. During this ex vivo storage period, RBCs are progressively damaged in a process that is termed the RBC storage lesion. The end result of this storage lesion is that with longer durations of storage prior to transfusion, an increased number of storage-damaged RBCs are cleared from the circulation via extravascular hemolysis. Studies in mice, dogs, and humans suggest that transfusion of older, stored RBCs, but not fresh RBCs, produce acute elevations in circulating markers of extravascular hemolysis (e.g., indirect bilirubin and transferrin saturation). Furthermore, hepcidin is induced in humans approximately 4-6 hours after transfusion and likely results in the return to baseline serum iron levels by 20-hours following transfusion. This is associated with a concomitant rise in serum ferritin levels, suggesting that hepcidin-induced degradation of ferroportin results in intracellular storage of iron within macrophages. Furthermore, the rate at which the macrophages release iron can be greater than the capacity of circulating transferrin to handle that iron, resulting in production of non-transferrin-bound iron. This pathogenic form of iron may be a cause of adverse effects in transfusion recipients. Indeed, in animal models, iron availability is associated with increased morbidity and mortality from infectious challenges with certain bacteria. A human study comparing transfusion of a single unit of RBCs following 1, 2, 3, 4, 5, or 6 weeks of storage suggests that the RBC storage lesion does not develop linearly and is only capable of inducing non-transferrin-bound iron production in healthy adult recipients following 5-6 weeks of storage. However, this relationship may differ in critically-ill populations. Furthermore, there is significant variability among blood donors in their RBC quality following storage. There are likely to be both genetic and environmental causes to this variability. Some of these causes may be donor glucose-6-phosphate dehydrogenase status, iron status, and/or dietary lipid content. In addition, in animal models, the clearance of a bolus of storage-damaged RBCs is associated with a pro-inflammatory cytokine response. Although this has yet to be demonstrated in studies using healthy adult human volunteers, studies in pediatric patient populations suggest that RBC transfusions may be associated with a pro-inflammatory response in this vulnerable population. The precise mechanism of inflammation following transfusion, and its clinical implications, has yet to be resolved. Finally, recent randomized clinical trials suggest that there are no clinical outcome differences when patients are randomized to receiving transfusions of fresh RBCs as opposed to the standard of care. Perhaps the RBC storage lesion has no clinical consequences to the transfusion recipient. However, these studies were not powered nor designed to test the effects of transfusion of RBCs during the final week of storage, in which studies suggest the effects would be most striking. Furthermore, many of the recipients in these studies already suffered from baseline hemolysis (e.g., from cardiac pump induced hemolysis, malaria, and sickle cell disease). It is unlikely that the added hemolysis from a transfusion of older RBCs would have a clinical impact given the level of baseline hemolysis from other causes observed in these patient populations. Thus, whether there are pathophysiologic consequences to the clearance of storage-damaged RBCs is still debatable. DisclosuresNo relevant conflicts of interest to declare.

The administration of blood components: a British Society for Haematology Guideline.

The administration of blood components: a British Society for Haematology Guideline.

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.

Single Unit Red Blood Cell Transfusion Is a Safe and Effective Alternative to Double Unit Transfusion in Hematologic Malignancies

▪IntroductionBlood products are a valuable resource associated with infectious and immunological adverse effects, hence the ongoing efforts for blood conservation. Evidence supports the use of restrictive Hemoglobin (Hb) triggers as safe and effective. Nevertheless, transfusion practice remains based largely on physician preference. The use of single-unit (SU) rather than double-unit (DU) transfusions per transfusion episode may be another strategy. Scant retrospective data from the 1960's discarded this idea as being ineffective in treating anemia.A recent European study demonstrated that using a SU transfusion protocol led to a 25% reduction in red blood cell usage amongst patients with hematologic malignancies(Berger et al; Haematologica, 2012). There have been no comparative studies done in the US population outside the orthopedic population which yielded similar benefit (Ma et al; Transfusion Medicine, 2005).Clinical Decision Support Systems (CDSS) are protocols shown to be effective in standardizing practice. At our academic institution, a CDSS was initiated for admissions to the Malignant Hematology and Transplantation Service. From September 2014, a protocol amendment prompted providers to order SU red blood cells (RBCs) for transfusion for Hb <8. Herein, we report the adherence to CDSS, and the differences in RBC utilization and patient outcomes one year before (DU-gp) and one year after (SU-gp) implementation of this protocol.MethodsRetrospective chart review was performed on all adult patients admitted to the Malignant Hematology and Transplantation Service who received routine RBC transfusions from 9/1/2013- 8/31/2014 (DU-gp) and 9/1/2014 to 8/31/2015 (SU-gp). Patients with active bleeding were excluded. The primary endpoint for this study was median RBC units transfused per admission. Analysis was limited to RBC products only. Chi-square test and t-test were used in the data analysis for categorical variables and continuous variables, respectively. A mixed model was used for repeated measurements.Results147 patients in 201 admissions in DU-gp and 126 patients in 170 admissions in SU-gp were analyzed. Baseline characteristics are presented in Table 1 with no significant differences noted between groups. Excellent adherence to the CDSS protocol was noted in both the DU (97%) and SU (92%) groups. Baseline admission Hb was similar, but Hb at discharge was significantly higher in DU-gp 9.4 g/dL vs 8.8 g/dL in SU-gp (P=0.005).The median number of transfusion episodes (each time RBC orders were placed) per admission in the DU-gp and SU-gp was 2 (range, 1-16) and 3 (range, 1-27), respectively (P<0.001). The corresponding median number of RBC units given per admission was 4 (range, 1-29) and 3 (range, 1-44), respectively (P=0.02). Overall, a 29% reduction in RBC utilization was noted in SU-gp (731 units) compared to DU-gp (1031 units). No difference was noted in 30-day mortality and readmissions, outpatient transfusion requirements or transfusion reactions between the 2 groups (Table 2).ConclusionsOur data show that implementing a CDSS, transfusing single-unit RBCs instead of double-units for Hb < 8g/dL had an excellent adherence, highlighting the feasibility of such a strategy. It is noteworthy that although patients required more transfusion encounters, the overall RBC utilization fell by 29%. Single-unit RBC transfusion was safe, efficacious and significantly reduced the RBC utilization per admission. Prospective data is required to confirm our results as well as assess the potential cost-benefit advantage with single-unit RBC transfusions. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Single-unit transfusions in the obstetric setting: a qualitative study.

The rate of obstetric blood transfusion is increasing, and there is hospital variation in its use. Recent Australian guidelines recommend a restrictive transfusion strategy in maternity patients who are not actively bleeding and advocate single-unit red blood cell (RBC) transfusions followed by clinical reassessment to determine the need for further transfusion. The aim of this study was to identify factors influencing single RBC unit use when initiating transfusion in a postpartum woman with noncritical bleeding. A qualitative research study using semistructured interviews was conducted. Nine maternity hospitals were chosen to cover a range of clinical settings and obstetric transfusion rates in Australia. Interviews were conducted with the key decision makers in obstetric blood transfusion. Interviews were transcribed and coded, and themes were developed. One hundred twenty-five interviews were conducted, including 61 doctors' interviews among obstetric (n = 42) and hematology (n = 19) staff. Most doctors (54%) interviewed would initiate transfusion with 2 RBC units; and, of those who started with single-unit transfusions, most (63%) had practiced obstetrics for less than 5 years. Clinician and external factors influenced decision making. Important clinician factors included perceived utility or clinical need and education/experience. External factors included influence of colleagues, clinical context, availability of RBC units, and regulation mechanisms. The decision to use single-unit RBC transfusion varied between and within hospitals. Efforts to reduce exposure to blood in the obstetric setting via the number of units transfused may need to target perceptions regarding the utility of single units and lack of experience with this approach.

Patient Blood Management Implementation Strategies and Their Effect on Physicians' Risk Perception, Clinical Knowledge and Perioperative Practice - the Frankfurt Experience

Introduction: A multicomponent, evidence-based and interdisciplinary Patient Blood Management (PBM) program was introduced at the University Hospital Frankfurt in July 2013. The implementation strategy included practical and tactical components aimed to increase knowledge on the risks of preoperative anemia, to standardize hemotherapy, and to facilitate PBM components. Methods: This article analyzes barriers to PBM implementation and outlines a strategy to introduce and manifest PBM. The effects in Frankfurt were measured in a before and after questionnaire study distributed among groups of physicians immediately before and 1 year after PBM implementation. Results: 142 clinicians completed the questionnaire in July 2013 and 101 clinicians in August 2014. Absolute certainty that the treatment of preoperative anemia favorably influences morbidity and mortality rose from 25 to 37%. Transfusion behavior seems to have been affected: In 2014, 56% of clinicians stated that they clinically reassess the patient and analyze hemoglobin following each single red blood cell unit compared to only 38% stating this in 2013. Conclusion: These results show that our implementation strategy was effective in changing physicians' risk perception, attitude, and knowledge on PBM principles. Our experience highlights key success factors for the implementation of a comprehensive PBM program.

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

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

A pragmatic approach to embedding patient blood management in a tertiary hospital

We describe the implementation and impact of a patient blood management program (PBMP) in an Australian teaching hospital. A PBMP was introduced at a single tertiary care hospital in 2009 as a pilot for the Western Australian Health Department statewide PBMP. The first 3 years of interventions aimed to make effective use of preoperative clinics, manage perioperative anemia, improve perioperative hemostasis, reduce blood sample volumes, and implement restrictive transfusion triggers and a single-unit transfusion policy. Between 2008 and 2011, admissions to Fremantle Hospital and Health Services increased by 22%. Using 2008 as a reference year, the mean number of red blood cell (RBC) units per admission declined 26% by 2011. Use of fresh-frozen plasma and platelets showed 38 and 16% declines, respectively. Cryoprecipitate increased 7% over the 4-year period. For elective admissions between 2008 and 2011, the leading decline in RBC transfusion rate was seen in cardiothoracic surgery (27.5% to 12.8%). The proportion of single RBC unit use increased from 13% to 28% (p < 0.001), and the proportion of double units decreased from 48% to 37% (p < 0.001). This is the first tertiary hospital in Australia to establish a multidisciplinary multimodal PBMP. Interventions across disciplines resulted in decreased use of RBC units especially in orthopedic and cardiothoracic surgery. Continuing education and feedback to specialties will maintain the program, improve patient outcomes, and decrease the transfusion rate.

Transfusion indication RBC (PBM-02): Gap Analysis of a Joint Commission Patient Blood Management Performance Measure at a Community Hospital

BACKGROUND The Joint Commission accredits health care organisations in the USA as a prerequisite for licensure. In 2011, TJC published seven Patient Blood Management Performance Measures to improve the safety and quality of care. These Measures will provide hospital-specific information about clinical performance. MATERIALS AND METHODS Of the seven TJC PBM Performance Measures, we decided to evaluate PBM-02, Transfusion indication RBC, at our hospital. Blood transfusion orders were collected from May 2 to August 2, 2011 and the data analysed. RESULTS Of the 724 consecutive red blood cell transfusion orders, 694 (96%) documented both clinical indication and pre-transfusion haemoglobin/haematocrit results. The leading transfusion indication (47% of total) was high risk patients with pre-transfusion Hb of <9 g/dL. The majority (72%) of non-actively bleeding patients received a single unit of blood as recommended by our transfusion guidelines. However, 70% of these patients went on to receive additional units and 21% of the initial orders were placed for two or more units. Patients with active bleeding and special circumstances accounted for 17% and 4% of the transfusions, respectively. Our blood utilisation did not change by introducing the single-unit transfusion policy. DISCUSSION The majority (96%) of the transfusion orders met The Joint Commission criteria by providing both transfusion indication and pre-transfusion Hb and/or Hct values. Our transfusion guidelines recommend single-unit red blood cell transfusions with reassessment of the patient after each transfusion for need to receive more blood. Although most (72%) initial orders followed our transfusion guidelines, 70% of patients who received a single unit initially went on to receive more blood (some in excess of 10 units). Our objective data may be helpful in evaluating blood ordering practices at our hospital and in identifying specific clinical services for review.