Single-unit Transfusions Research Articles

How do we obtain and maintain patient blood management certification?

The creation of a patient blood management (PBM) certification program by The Joint Commission (TJC) and Association for the Advancement of Blood and Biotherapies (AABB) provides validation of an existing PBM program. A team of subject matter experts in PBM formed a working group to develop a structured approach to guide PBM programs through the PBM certification. Program challenges and metrics were reviewed. Initial steps to establishing PBM certification include a multidisciplinary working group and hospital administration buy-in. Development of policies and procedures individualized to the facility will standardize practice. An institutional transfusion committee can provide PBM oversight including enforcing compliance. Using resources such as TJC and AABB standards and tools including electronic medical records (EMR) can track and trend hospital PBM performance and identify improvement opportunities. A gap analysis tool helps implementation. Challenges might include maintaining a PBM program during a merger, slow responsiveness of information systems (IS) to requests, PBM education for both the Transfusion Safety Officer (TSO) and hospital staff with constant turnover. Available metrics from one hospital system showed good compliance with transfusion thresholds (average all products: 97.9%, 2019, 2020). In 2020, through educational efforts the cost savings were $124,856.70 compared to 2019. Regarding single unit transfusion of RBCs, this was 62.25% (2019), 63.75% (2020), 72.00% (2021), and surpassed the target goal of 60%. Obtaining PBM certification highlights the success of an institution's PBM program. Facilities that have achieved PBM certification have seen significant reductions in transfusions and considerable cost savings.

Single Plasma Unit Transfusions in Adults Are Either Unnecessary or Underdosed.

Previous studies of blood product use have shown higher inappropriate use of plasma compared with other products. Given typical weight-based dosing of plasma, we hypothesized that single plasma transfusions in adults would either be a nontherapeutic dose or outside clinical guidelines. A single-center, retrospective review of nonoperative, nonapheresis plasma use was conducted from January 2020 to April 2020. Plasma transfusions were reviewed for compliance with clinical guidelines formulated at our institution as well as national and society guidelines. During the study period, 313 units of plasma were transfused. Of these, 152 (48.6%) were given against institutional or national guidelines, 126 plasma units (40.3%) were transfused as single units, and 187 (59.7%) were given as part of multiple-unit transfusions. All single-unit plasma transfusions during the study period were either underdosed or outside clinical guidelines. Units transfused with an indication of "Other" were significantly more likely to be outside clinical guidelines. Nonoperative, nonapheresis plasma use is often outside clinical guidelines. Single-unit plasma transfusions in adults are a potential target for patient blood management programs seeking to minimize unnecessary plasma use.

Donor genetic and nongenetic factors affecting red blood cell transfusion effectiveness.

BACKGROUNDRBC transfusion effectiveness varies due to donor, component, and recipient factors. Prior studies identified characteristics associated with variation in hemoglobin increments following transfusion. We extended these observations, examining donor genetic and nongenetic factors affecting transfusion effectiveness.METHODSThis is a multicenter retrospective study of 46,705 patients and 102,043 evaluable RBC transfusions from 2013 to 2016 across 12 hospitals. Transfusion effectiveness was defined as hemoglobin, bilirubin, or creatinine increments following single RBC unit transfusion. Models incorporated a subset of donors with data on single nucleotide polymorphisms associated with osmotic and oxidative hemolysis in vitro. Mixed modeling accounting for repeated transfusion episodes identified predictors of transfusion effectiveness.RESULTSBlood donor (sex, Rh status, fingerstick hemoglobin, smoking), component (storage duration, γ irradiation, leukoreduction, apheresis collection, storage solution), and recipient (sex, BMI, race and ethnicity, age) characteristics were associated with hemoglobin and bilirubin, but not creatinine, increments following RBC transfusions. Increased storage duration was associated with increased bilirubin and decreased hemoglobin increments, suggestive of in vivo hemolysis following transfusion. Donor G6PD deficiency and polymorphisms in SEC14L4, HBA2, and MYO9B genes were associated with decreased hemoglobin increments. Donor G6PD deficiency and polymorphisms in SEC14L4 were associated with increased transfusion requirements in the subsequent 48 hours.CONCLUSIONDonor genetic and other factors, such as RBC storage duration, affect transfusion effectiveness as defined by decreased hemoglobin or increased bilirubin increments. Addressing these factors will provide a precision medicine approach to improve patient outcomes, particularly for chronically transfused RBC recipients, who would most benefit from more effective transfusion products.FUNDINGFunding was provided by HHSN 75N92019D00032, HHSN 75N92019D00034, 75N92019D00035, HHSN 75N92019D00036, and HHSN 75N92019D00037; R01HL126130; and the National Institute of Child Health and Human Development (NICHD).

Single-unit Versus Multiple-unit Transfusion in Hemodynamically Stable Postpartum Anemia: A Pragmatic Randomized Controlled Trial

(Am J Obstet Gynecol. 2021;224:84.e1–7) Postpartum anemia is often managed by postpartum transfusion, but there is limited data on the appropriate transfusion protocol for hemodynamically stable postpartum anemia. Transfusion carries risks of infectious disease transmission, alloantibody development, and transfusion-related acute lung injury, while undertransfusion can negatively affect postpartum healing, depression, and breastfeeding. Two units of packed red blood cells (pRBCs) for women with hemoglobin (Hb) level <7 g/dL has been common practice, but recent guidelines recommend a single unit of pRBCs. Studies have shown single-unit transfusion protocols do not increase morbidity, but no studies on the subject have been performed in the obstetric population. This study aimed to compare single-unit with multiple-unit transfusion protocols to treat hemodynamically stable postpartum anemia.

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. .

Using blood wisely in oncology patients: An institutional analysis of the Choosing Wisely Canada restrictive transfusion strategy guidelines.

10 Background: Numerous studies support the safety of single-unit red red blood cell (RBC) transfusions and restrictive pre-transfusion hemoglobin (Hg) thresholds (≤ 70-80 g/L) among diverse populations of hospitalized patients, including those with malignancies on myelosuppressive systemic therapy. Using Blood Wisely is a national Choosing Wisely Canada (CWC) initiative that challenges hospitals to benchmark themselves on evidence-informed restrictive transfusion strategies, with the aim to decrease inappropriate RBC transfusions in Canada. We assessed transfusion practices among oncology inpatients at BC Cancer Vancouver Centre as part of this initiative and performed an exploratory analysis among outpatients. Methods: BC Cancer Vancouver RBC transfusion records were obtained for the period of October 2019-September 2020. The percentage of single-unit transfusions and transfusions for Hg ≤ 80 g/L were measured, to assess adherence to CWC targets of ≥ 65% and ≥ 80%, respectively, for these metrics. Univariate analyses were used to compare treatment variables and transfusion outcomes. Results: During the 1-year audit period, 120 inpatient and 586 outpatient RBC transfusions occurred. For inpatient transfusions, 40.8% (n = 49) were single-unit and 79.2% (n = 95) were for Hg ≤ 80 g/L. For outpatient transfusions, 11.8% (n = 69) were single-unit and 65.7% (n = 304) were for Hg ≤ 80 g/L. Outpatients and patients with solid malignancies were more likely to receive multiple-unit transfusions, compared to inpatients (p < 0.001) and patients with hematological malignancies (p < 0.001), respectively. Patients with solid malignancies and those on active treatment were more likely to be transfused when Hg was > 80 g/L, compared to patients with hematological malignancies (p = 0.004) and those off treatment (p = 0.003), respectively. Multiple RBC units were more likely to transfused when the interval from pre-transfusion bloodwork to receipt of transfusion was > 3 days (p = 0.029). Conclusions: A high rate of inappropriate RBC transfusions are being ordered for oncology patients at our institution, in discordance with CWC restrictive transfusion strategy guidelines. Quality improvement interventions are planned to adopt best practices in transfusion medicine in this high-use population.[Table: see text]

78 Adherence to national transfusion guidelines by benign gynecologic surgeons at an academic, tertiary-care women’s hospital

Strong evidence supports the benefits of restrictive blood transfusion policies in non-cardiac surgery and national guidelines were adapted nearly a decade ago to recommend changes such as restrictive hemoglobin (hgb) thresholds and single unit transfusion. Whether these changes have modified transfusion practices in benign gynecologic surgery remains unclear as rates of perioperative transfusion remain high compared to other surgical specialties. We aimed to describe perioperative transfusion practices in benign gynecologic surgery at an academic, tertiary care women’s hospital in order to assess adherence to national guidelines.

Pooled platelet concentrates provide a small benefit over single-donor platelets for patients with platelet refractoriness of any etiology

BackgroundAt our institution, patients with platelet refractoriness (of any etiology) are sometimes switched from apheresis platelets to pooled platelets before human leukocyte antigen (HLA)-matched units become available.Study design and methodsSeven patients were analyzed. Platelet counts were available from 57 single-unit transfusions (26 pooled, 31 apheresis). A mixed linear effects model was used and significance was determined using a likelihood ratio test.ResultsWhen analyzed as the only fixed effect in the model, the use of pooled versus single-donor units and time from transfusion to post-transfusion blood sampling each showed a significant effect on platelet count increments. A mixed linear effect model including both factors showed that transfusing a pooled unit correlated with a 4500±2000/µL greater platelet count increment compared with a single-donor unit, and an increase in time from transfusion to post-transfusion blood sampling lowered the platelet count increment by 300±100/µL per hour.ConclusionA small but potentially clinically relevant benefit was observed in transfusing pooled random-donor platelets compared with single-donor units for patients with platelet refractoriness (of any etiology).

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.

TACO‐BEL‐3: a feasibility study and a retrospective audit of diuretics for patients receiving blood transfusion at ten hospitals

Transfusion-associated circulatory overload (TACO) is the leading cause of transfusion-related morbidity and mortality. A recently completed pilot trial randomized patients to pre-transfusion furosemide versus placebo but had a slower than expected enrollment rate. We sought to determine whether the lack of recruitment was due to a paucity of eligible patients or excessively restrictive eligibility criteria. At 10 sites, eligible patients were retrospectively identified by first screening blood bank databases over one month for all transfusion episodes meeting trial inclusion criteria, defined as non-surgical patients receiving single RBC unit transfusions. The age threshold was decreased from 65 to 50years. The first 10 patients meeting inclusion criteria then underwent detailed chart review for the exclusion criteria. The incidence of TACO and furosemide use was also recorded. At the 10 sites, 11969 red cell units were transfused over 1month and 1356 met the inclusion criteria. Of the 100 charts reviewed, 60 (60%) had no exclusion criteria. Active bleeding was the most common reason for ineligibility. There were 813 eligible transfusion episodes. Of the eligible patients, 17 (28·3%) had evidence of congestive heart failure, and furosemide was prescribed in 24 (40%). Despite the use of a lower age threshold, three cases of TACO were detected with an incidence of 3%. A large number of transfusion episodes met eligibility criteria. With a 3% incidence of TACO, 50% decrease through the use pre-transfusion furosemide and a target consent rate of 30%, a definitive trial of approximately 3000 patients could be completed within 1year.

Outcome of audit and education on blood transfusion practice in obstetrics setting

IntroductionAudit and education are essential pre-requisites in the review and update of blood transfusion practices. Although standard guidelines on appropriate utilization of blood components exists, erroneous use of blood components with no justification still continues. This study evaluates appropriateness of blood transfusion in obstetric settings and identifies key areas requiring educational intervention to improve blood transfusion practice toward the evidence-based at our hospital. MethodThis was a prospective observational study on the analysis of blood transfusion requisition forms for obstetric patients before and after educational intervention, performed in two Phases from September 2011 to August 2012 and October 2012 to September 2013. The appropriateness of blood utilization was assessed against the Royal College of Obstetricians and Gynecologists Guidelines for blood transfusion and Green-Top Guideline no. 47. Data required for the study were obtained from department records and statistical analysis was performed using the SPSS, version 20 (IBM, USA). ResultsThe total transfusion episodes were 214 in 51 patients and 181 in 43 patients in Phases 1 and 2, respectively. Fresh frozen plasma was the most misused blood component, next to whole blood in Phase 1. However, appropriate utilization of components, including cryoprecipitate (6.6%), reduction in whole blood (34.5–14.4%) and single unit transfusion (23.3–18.2%) were observed in Phase 2. Inappropriate use of blood components, namely, packed red blood cells and fresh frozen plasma dropped significantly (p<0.05) from 29.7% to 13.1% and 45.1% to 22.5%, respectively, with the exclusion of platelet concentrate (33.3–20.6%, p-value 0.414). ConclusionAudit and targeted education helped in optimizing transfusion practices in the obstetric setting.

Single-unit vs multiple-unit transfusion in hemodynamically stable postpartum anemia: a pragmatic randomized controlled trial

The American Academy of Blood Banks recommends single-unit red cell transfusion protocols across medicine to reduce transfusion complications and the use of a scarce resource. There are minimal data regarding single-unit protocols in obstetrics. We aimed to compare single-unit vs multiple-unit transfusion protocols for treatment of hemodynamically stable postpartum anemia. We performed a randomized trial comparing initial transfusion with 1 unit of packed red blood cells (single-unit protocol) to 2 units of packed red blood cells (multiple-unit protocol) from March 2018 to July 2019. Women who required transfusion >6 hours postpartum were approached for consent. Unstable vital signs, hemoglobin level <5 g/dL, hemoglobinopathy, and cardiomyopathy were exclusion criteria for enrollment. Hemoglobin assessment and standardized clinical evaluation were performed 4 to 6 hours posttransfusion; additional packed red blood cells were given if indicated. The primary outcome was total units transfused. Secondary outcomes included length of stay, endometritis, wound separation or infection, venous thromboembolism, and intensive care unit admission within 30 days postpartum. Breastfeeding, depression, maternal attachment, and fatigue scores were assessed at 4 to 9 weeks postpartum. A total of 66 women were required to detect a 20% reduction in units transfused with a single-unit protocol (power=80%; α=0.05). A total of 66 women were randomized (33 per arm). There were no differences between groups in demographic or clinical characteristics, including delivery mode, blood loss, and randomization hemoglobin levels. The mean number of units transfused was lower in the single-unit protocol than in the multiple-unit protocol (1.2 U vs 2.1 U; P<.001). Only 18.2% of women in the single-unit arm required additional packed red blood cells. At posttransfusion assessment, women in the single-unit arm had lower hemoglobin levels (7.8 g/dL vs 8.7 g/dL; P<.001), but there were no differences in vital signs or symptoms between groups. There were also no differences in length of stay, 30-day complications, or 4 to 9 week postpartum outcomes. In women with hemodynamically stable postpartum anemia, a single-unit protocol avoided a second unit of packed red blood cells in >80% of women without significant impact on morbidity. Our work supports the use of single-unit initial transfusion in this population.

P004: The impact of transfusion guideline on emergency physician transfusion orders

Introduction: Blood transfusions continue to be a critical intervention in patients presenting to emergency departments (ED). Improved understanding of the adverse events associated with transfusions has led to new research to inform and delineate transfusion guidelines. The Nova Scotia Guideline for Blood Component Utilization in Adults and Pediatrics was implemented in June 2017 to reflect current best practice in transfusion medicine. The guideline includes a lowering of the hemoglobin threshold from 80 g/L to 70 g/L for transfusion initiation, to be used in conjunction with the patient's hemodynamic assessment before and after transfusions. Our study aims to augment understanding of transfusion guideline adherence and ED physician transfusing practices at the Halifax Infirmary Emergency Department in Nova Scotia. Methods: A retrospective chart review was conducted on one third of all ED visits involving red-cell transfusions for one year prior to and one year following the guideline implementation. A total of 350 charts were reviewed. The primary data abstracted for the initial transfusion, and subsequent transfusion if applicable, from each reviewed chart included clinical and laboratory data reflective of the transfusion guideline. Based on these data, the transfusion event was classified one of three ways: indicated based on hemoglobin level, indicated based on patient's symptomatic presentation, or unable to determine if transfusion indicated based on charting. Results: The year before guideline implementation, the total number of transfusions initiated at a hemoglobin of between 71-80 was 31 of 146 total transfusions. This number dropped by 23.6% to 22 of 136 in the year following guideline implementation. The number of single-unit transfusions increased by 28.0% from 47 of 146 in the year prior to 56 of 136 in the year after guideline implementation. The initial indication for transfusion being unable to be determined based on charting provided increased by 120%. The indication for subsequent transfusions being unable to be determined based on charting increased by 1500% (P &lt; 0.05). Conclusion: These data suggest that implementing transfusion guidelines effectively reduced the number of transfusions given in the ED setting and increased the number of single-unit transfusions administered. However, the data also suggest the need for better education around transfusion indications and proper documentation clearly outlining the rationale behind the decision to transfuse.

Patient Blood Management en artroplastia primaria de cadera y rodilla. Encuesta entre los investigadores del estudio POWER.2

BackgroundImplementation of Patient Blood Management programs remain variable in Europe, and even in centres with well-established PBM programs variability exists in transfusion practices. Objectives and methodsWe conducted a survey in order to assess current practice in perioperative Patient Blood Management in patients undergoing total hip and knee replacement among researchers involved in POWER.2 Study in Spain (an observational prospective study evaluating enhanced recovery pathways in orthopaedic surgery). ResultsA total of 322 responses were obtained (37.8%). Half of responders check Haemoglobin levels in patients at least 4 weeks before surgery; 35% treat all anaemic patients, although 99.7% consider detection and treatment of preoperative anaemia could influence the postoperative outcomes. Lack of infrastructure (76%) and lack of time (51%) are the main stated reasons not to treat anaemic patients. Iron status is routinely checked by 19% before surgery, and 36% evaluate it solely in the anaemic patient. Hb<9.9 g/dl is the threshold to delay surgery for 61% of clinicians, and 22% would consider transfusing preoperatively clinically stable patients without active bleeding. The threshold to transfuse patients without cardiovascular disease is 8 g/dl for 43%, and 7 g/dl for 34% of the responders; 75% of clinicians consider they use “restrictive thresholds”, and 90% follow the single unit transfusion policy. ConclusionsThe results of our survey show variability in clinical practice in Patient Blood Management in major orthopaedic surgery, despite being the surgery with the greatest tradition in these programs.

Study of blood component therapy in a tertiary level care hospital in Ghaziabad

Introduction: Pregnancy and labour present with many complications, which result in extra blood loss causing hemodynamic instability. This leads to a need of blood transfusion in the day-to-day practice of obstetrics. In a low resource country like India it becomes necessary to titrate the use of Blood components. With this in background we aim to study the usage of blood components in obstetrics in our hospital. Methodology: It was an Observational cross sectional study. All obstetric patients who were transfused with blood components in the Department Of Obstetrics and Gynaecology in the hospital from January 2018 - September 2019 were recruited in the study. The indications, components transfused and indications of single unit transfusion were noted. Results: Transfusion rate was found to be 3.1%. Anaemia and postpartum haemorrhage were the major causes for blood and blood product transfusion. Single unit transfusion was 55.1%. Anaemia in pregnancy was the major indication of single unit PRBC transfusion. Conclusion: There must be a focus on reduction of unnecessary transfusions especially in conditions, which can be managed effectively by other means. Keywords: Blood Transfusion in obstetrics, Single unit transfusion, Blood components, Active management of third stage of labour

261: SMaRTBlood: randomized, controlled trial of Single- versus Multiple-unit Red cell Transfusion for non-acute postpartum anemia

The American Academy of Blood Banks recommends single-unit red cell transfusion protocols across medicine to reduce complications and use of a scarce resource, without evidence specific to obstetrics. We aimed to compare a single- vs. multiple-unit transfusion protocol for non-acute postpartum anemia. We performed a randomized trial comparing initial transfusion with 1 unit of packed red blood cells [pRBCs] (single-unit protocol) to 2 units of pRBCs (multiple-unit protocol) from 3/2018-7/2019. Women >6 hours from delivery determined to require transfusion were approached for consent. Unstable vital signs, hemoglobin(Hb)< 5g/dL, hemoglobinopathy, and cardiomyopathy were enrollment exclusions. Block randomization occurred 1:1. Post-transfusion, a 4-6 hour Hb and standardized clinical evaluation were performed; additional pRBCs were then given if indicated. Breastfeeding, depression, maternal attachment, and fatigue scores were assessed at 4-9 weeks postpartum. The primary outcome was total units transfused. 66 women were required to detect a 20% reduction in units transfused with a single-unit protocol (power=80%; α=0.05). 66 women were randomized (33/arm). There were no differences between groups in demographic or clinical characteristics, including delivery mode, blood loss, and randomization Hb. Mean number of units transfused was lower in the single- compared to the multiple-unit protocol (1.2u vs. 2.1u, p< 0.001). Only 18.2% of women in the single-unit arm required additional pRBCs (Figure). At post-transfusion assessment, women in the single-unit arm had lower Hb (7.8g/dL vs. 8.7g/dL, p< 0.001), but there were no differences in vital signs or symptoms between groups. There were also no differences in length of stay, 30-day complications, or 4-9 week postpartum outcomes (Table). With a single-unit protocol, a second unit of pRBCs can be avoided in >80% of postpartum women requiring non-acute transfusion without significant impact on short-term or post-discharge morbidity. Our work supports single-unit initial transfusion as standard of care in this population.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Effect of donor, component, and recipient characteristics on hemoglobin increments following red blood cell transfusion

AbstractSignificant research has focused individually on blood donors, product preparation and storage, and optimal transfusion practice. To better understand the interplay between these factors on measures of red blood cell (RBC) transfusion efficacy, we conducted a linked analysis of blood donor and component data with patients who received single-unit RBC transfusions between 2008 and 2016. Hemoglobin levels before and after RBC transfusions and at 24- and 48-hour intervals after transfusion were analyzed. Generalized estimating equation linear regression models were fit to examine hemoglobin increments after RBC transfusion adjusting for donor and recipient demographic characteristics, collection method, additive solution, gamma irradiation, and storage duration. We linked data on 23 194 transfusion recipients who received one or more single-unit RBC transfusions (n = 38 019 units) to donor demographic and component characteristics. Donor and recipient sex, Rh-D status, collection method, gamma irradiation, recipient age and body mass index, and pretransfusion hemoglobin levels were significant predictors of hemoglobin increments in univariate and multivariable analyses (P < .01). For hemoglobin increments 24 hours after transfusion, the coefficient of determination for the generalized estimating equation models was 0.25, with an estimated correlation between actual and predicted values of 0.5. Collectively, blood donor demographic characteristics, collection and processing methods, and recipient characteristics accounted for significant variation in hemoglobin increments related to RBC transfusion. Multivariable modeling allows the prediction of changes in hemoglobin using donor-, component-, and patient-level characteristics. Accounting for these factors will be critical for future analyses of donor and component factors, including genetic polymorphisms, on posttransfusion increments and other patient outcomes.

Proceedings of the Food and Drug Administration public workshop on pathogen reduction technologies for blood safety 2018 (Commentary, p. 3026).

On November 29, 2018, experts in the field of infectious diseases, pathogen reduction technologies (PRTs) and other participants from blood centers, academia, and industry gathered at the Food and Drug Administration (FDA) White Oak Campus in Silver Spring, Maryland, for a 2‐day public workshop entitled “Pathogen Reduction Technologies for Blood Safety.” The workshop opened with welcome remarks from Dr. Nicole Verdun, Director, Office of Blood Research and Review (OBRR), Center for Biologics Evaluation and Research (CBER), FDA, followed by introductory remarks from Dr. Peter Marks, Director, CBER, FDA. The first day of the workshop focused on blood‐borne infectious agents and their impact on blood safety, experiences of the American Red Cross, and other blood establishments in implementing FDA‐approved pathogen inactivation (PI) technology for plasma and platelets (PLTs) in the United States and novel PRTs under consideration for whole blood (WB) and red blood cells (RBCs). The second day opened with welcome remarks from Dr. Chintamani Atreya, Associate Director for Research, OBRR, CBER, FDA. The focus was on emerging innovations relevant to PRTs and potential alternatives to PRTs. The workshop concluded with remarks on insights for future research and development in this area for blood and blood product safety from infectious agents. A brief introduction of each session by the session moderator followed by a summary of the speaker presentation as submitted by the moderator and speaker are reported here.

Single versus double-unit transfusion: Safety and efficacy for patients with hematologic malignancies.

Although hemoglobin thresholds for red blood cell (RBC) transfusion have decreased, double-unit RBC transfusion practices persist. We studied the effects switching from predominantly double-unit to single-unit RBC transfusions had on utilization and clinical outcomes for malignant hematology patients. Retrospective chart review compared malignant hematology patients before and after implementing single-unit RBC transfusion policy. Hemoglobin threshold was 8.0g/dL for both groups. RBC utilization metrics included number of RBC units transfused, RBC units transfused per admission, and number of transfusion episodes. Clinical outcomes included length of stay, 30-day mortality, and outpatient RBC transfusion 30-days post-discharge. Baseline hemoglobin was similar in both groups. The single-unit group was transfused with fewer RBC units per admission (5.1 vs 4.5, P=0.01) than the double-unit group, but had more transfusion episodes per admission (4.1 vs 2.7, P<0.001). After implementing single-unit policy, a 29% reduction in RBC utilization was observed. Mean hemoglobin at discharge was lower in the single-unit group (8.9 vs 9.5g/dL, P=0.005). No significant differences in length of stay or 30-day mortality were observed. Transfusing malignant hematology patients with single RBC units is safe and efficacious. Electronic provider order systems facilitating RBC transfusion requests provide excellent adherence to transfusion policy.

Perioperative blood transfusion has a dose-dependent relationship with disease recurrence and survival in patients with non–small cell lung cancer

ObjectivePerioperative blood transfusions have been implicated in decreased overall survival (OS) and disease-free survival (DFS) after resection for non–small cell lung cancer (NSCLC). We investigated the effects of single- and multiple-unit blood transfusions on OS, DFS, and recurrence after anatomic pulmonary resection. MethodsFrom January 1, 2000, to June 30, 2016, 5709 consecutive patients underwent pulmonary resection for NSCLC at our institution. Exclusion criteria were stage IIIB-IV disease, incomplete resections, ill-defined histologic subtypes, and nonanatomic wedge resections. For the 0 versus single-unit analysis, propensity scores were calculated from a logistic regression model that predicted the probability of patients receiving a single-unit transfusion. The resulting matching weights were incorporated into Cox models for OS, DFS, and cumulative incidence of recurrence, to compare no versus single-unit blood transfusion. We determined whether increasing numbers of blood transfusions influenced survival or recurrence using multivariable Cox models. ResultsApproximately 10% of patients received perioperative blood transfusion (median follow-up, 7.46 years [25th-75th percentile, 3.98-11.8]). There was no difference in OS, DFS, or cumulative incidence of recurrence between patients receiving no transfusion and those receiving single-unit transfusion (P > .05). However, a dose–response relationship was observed, demonstrating worse OS (overall P < .001), DFS (overall P < .001), and recurrence (overall P = .010) with increasing units of blood transfused. ConclusionsAlthough a single-unit blood transfusion did not affect survival in patients undergoing resection for NSCLC, greater unit perioperative blood transfusions were associated with significantly decreased long-term outcomes in a dose-dependent manner, suggesting avoidance or minimization of transfusions could improve long-term survival after lung resection.