Transfusion Guidelines Research Articles

Safe and Effective Implementation of a Red Blood Cell (RBC) Transfusion Hemoglobin (Hb) Threshold of 7 g/Dl on an Inpatient Stem Cell Transplant Unit: A Single Institution Experience

Introduction: Patient Blood Management (PBM) is an evidence-based, multidisciplinary approach designed to avoid unnecessary transfusions, optimize hemostasis, and minimize blood loss to improve patient outcomes. Our Blood and Marrow Transplant (BMT) program, in collaboration with our PBM program, changed the Hb guidelines for RBC transfusions to 7g/dL in the fall of 2015 for all patients without acute bleeding or cardiac history on our inpatient transplant floor. This study aimed to assess the compliance with the guideline and the impact of the change on allogeneic patient outcomes (readmission within 30 days and mortality).Methods: Data was extracted from our Electronic Medical Record and our transplant outcomes REDCAP database for an 18 month period before and after we changed the guidelines, 1/2014-6/2015 (pre) and 1/2016-6/2017 (post). Only RBC transfusions on the stem cell transplant unit were included. The main outcomes analyzed were a) all-cause mortality (at 100 days, 180 days and 365 days post-transplant) and b) hospital readmission (at days 1-7 and days 8-30 post discharge). Statistical analysis included Fisher's exact test and Wilcoxon rank-sum for non-parametric data. Univariate followed by multivariable stepwise logistic regression was performed for generating adjusted odds ratios (adjOR) for various outcomes. Testing for interaction and multi-collinearity was performed at each step of the model building. A two-sided p-value of <0.05 was the threshold for significance. Statistics were performed using Stata 14 and SAS 9.4.2.Results: During the time periods studied, 293 patients received an allogeneic stem cell transplant (pre=153, post=140): females n=134, 46%; median (IQR) age 57 years (46-64); Karnofsky performance status 90 (80-90); transplant hospital length of stay 18 days (15-25). The most common reasons for transplant were AML (n=144, 49%), MDS/Myeloproliferative Disease (n=44, 15%), NHL (n=39, 13%), and ALL (n=30, 10%). The most common types of transplant were haplo/cord (n=113, 39%), MUD (n=94, 32%) and MRD (n=80, 27%). In the pre and post periods, 883/1147 (77%) and 186/775 (24%) RBC transfusions were at a Hb>=7g/dL, respectively, (p<0.0001) (Figure 1A). In the pre-period 141 (92%) and the post-period 117 (84%) patients were transfused with RBCs (p=0.03) (Figure 1B). The all-cause mortality at 100, 180 and 365 days w n=31 (10.6%), n=58 (19.8%) and n=102 (34.8%) respectively. Among the ever-transfused subjects, all-cause re-admission rates at 1-7 days post discharge were n=69 (26.2%) and at day 8-30 were n=77 (29.3%). After adjusting for age, gender, ASBMT risk classification, Karnofsky score, relapse status, underlying cardiac disease and acute GVHD; there was no difference in adjOR (+/- 95% confidence intervals) for all-cause post-transplant mortality and re-admission at specified time points between the two time periods compared (Figure 1C).Conclusion: A RBC transfusion Hb threshold of 7 g/dL can be effectively implemented on an inpatient stem cell transplant unit, avoids RBC exposure in a significant percent of patients, and does not lead to increased all-cause post-transplant mortality or readmissions within one month. [Display omitted] DisclosuresRossi:Celgene: Consultancy; Thrassos: Consultancy. Lee:Clinipace: Consultancy; Baxalta: Consultancy; Amgen: Consultancy; Alexion Pharmaceuticals: Consultancy.

B-RhD-Positive Blood Group Appears Relatively Less Susceptible to Anemia in Sickle Cell Disease Pregnant Women

▪Background: Sickle cell disease in pregnancy accounts for 0.14-0.2% of pregnant women seen in Antenatal clinic in Niger Delta Nigeria.1,2Chronic anemia in SCD during pregnancy could lead to a cascade of maternal and fetal complications. The aim of this study is to assess the various types of ABO blood groups of pregnant SCD women at booking and the severity of anemia. The outcome of this study will help in making recommendations of ABO blood types most suitable to improve the quality of life of SCD patients. This may contribute to guidelines for safe blood transfusion in SCD.Methodology: This was a-ten-year retrospective study of all registered SCD pregnant women seen at the antenatal clinic of Braithwaite Memorial Specialist Hospital (BMSH) Port Harcourt (January 2004- December 2013). Data on gestational age, Hemoglobin (Hb) electrophoretic pattern, Hb concentration and blood group were obtained at booking clinic. Data were analysed using Epi-info version 7.02 by WHO, Geneva Switzerland and CDC, USA.Result: A total of 52 Hb SS pregnant women were seen during the study period. The average booking trimester was the 2nd trimester. 94.2 % (49) were anemic (<11.0 g/dl)3 while 5.8% (3) were non anemic (≥ 11 g/dl). 27.0%, 9.6% and 61.5% were A, B and O rhesus D positive blood groups respectively. No AB blood group was recorded from this study [Table 1]. The O rhesus D positive blood group was significantly more prone to anemia [30 (61.2%)] than other ABO blood groups (X2=50.37; 0.001) [Table 2]. 20% (1/5) of B rhesus D positive and 6.3% (2/32) of O rhesus D positive patients were non-anemic. All A rhesus D positive blood were anemic. The highest prevalence of A rhesus D positive blood group (37.5%) was in 2nd trimester, that of B (20%) and O (66.7%) rhesus D positive blood groups were in 1st and 3rd trimesters respectively [Figure 1].Conclusion: Although most SCD pregnant women in this region are O rhesus D positive blood groups, B rhesus D positive blood group patients appear to be less susceptible to anemia. There is need to carry out more elaborate study on this group of blood.

Sickle Cell Disease and the Adherence to Guidelines for Use of Blood Transfusions

▪Background:An expert panel convened by the NHLBI in 2014 provided guidelines and indications for blood transfusions in patients with sickle cell disease (SCD). These recommendations were to help conserve the use of blood transfusions in SCD in order to reduce the complications of iron overload, transmission of blood-borne pathogens and development of alloantibodies. We retrospectively reviewed the charts of SCD patients who received blood during inpatient admissions and evaluated the indications for transfusions in this population.Methods:The hospital database was screened for admissions of patients with the diagnosis of SCD (HbSS, HbSβ0, HbSβ+, HbSC) who were billed for a blood transfusion between 8/1/2015 to 8/31/2016. All patients were >18 years of age. Each chart was reviewed individually to assess the clinical setting and reasons for transfusion. The following parameters were documented: age, sex, length of hospital stay (LOS), hemoglobin (Hgb) at time of transfusion, baseline Hgb, reticulocyte count, total bilirubin, number of units transfused, documented reason for transfusion, immediate reaction to transfusion, presence of alloantibodies and ferritin level. We defined the infusion of blood as a transfused event which included single or multiple units of blood. We excluded transfusions given for acute bleeding.Results:There were a total of 200 decisions to transfuse blood for 87 patients between 8/1/2015 to 8/31/2016. 72% of the patients had HbSS disease. HbSB0, HbSB+, HbSC, and unknown genotype constituted 14%, 19%, 6% and 7% of the cohort, respectively. Mean age was 30.6 years and 76% were female. A total of 434 units were transfused. The most common reasons for transfusion that deviated from guidelines were uncomplicated pain crises and a fall in Hgb (> 2g/dl, >1.5 g/dl) which accounted for 65.5% (n = 237 units) of the transfusion events (Pain 27%, Hgb drop > 2 gm 20.5% and Hgb drop > 1.5 gm 17.5%). The most common indicated guideline reasons for transfusion were symptomatic anemia and acute chest syndrome and only accounted for 12.5% and 10%, respectively of transfusions in this cohort. The mean Hgb at which patients were transfused was 6.6 g/dl, with a median value of 6.5 g/dl. The mean Hgb of those transfused for drop in hemoglobin and symptomatic anemia were 5.9 g/dl and 5.7 g/dl, respectively. The mean level of ferritin in this cohort was 2483. 15/87(17%) of patients had allo-antibodies. There was a 2% occurrence of immediate allergic blood transfusion reaction. The average LOS for all patients was 9.0 days. The average LOS for patient who received blood for uncomplicated pain or drop in Hgb was 8.9 days.Conclusion:In this group of patients with SCD, the majority of the inpatient transfusions were not indicated by national guidelines. Only 34.5% of transfusion events met expert panel recommendations. There was significant iron overload and development of allo-antibodies noted in our cohort. It is possible that there was a lack of documentation of symptoms due to anemia in those who received blood for a drop in hemoglobin. Regardless, there appears to be a significant number of unnecessary transfusions in SCD patients. We plan to develop and implement an educational program for care providers as to increase adherence to guidelines for transfusions in SCD. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Doctors' practice and attitudes towards red blood cell transfusion at Mthatha Regional Hospital, Eastern Cape, South Africa: A mixed methods study.

BackgroundUnnecessary blood transfusion exposes recipients to potential harms.AimThe aim of this study was to describe blood transfusion practice and explore doctors’ attitudes towards transfusion.SettingA hospital providing level 1 and 2 services.MethodsA mixed-methods study design was used. In the cross-sectional descriptive component, a sample was taken from patients transfused over a 2-month period. Blood use was categorised as for medical anaemia or haemorrhage, and appropriate or not. The qualitative component comprised a purposeful sample for focus group and individual semi-structured interviews.ResultsOf 239 patients sampled, 62% were transfused for medical anaemia and 38% for haemorrhage. In the medical anaemia group, compliance with age-appropriate transfusion thresholds was 69%. In medical anaemia and haemorrhage, 114 (77%) and 85 (93.4%) of recipients had orders for ≥ 2 red blood cell (RBC) units, respectively. In adults ≥ 18 years old with medical anaemia, 47.1% of orders would have resulted in a haemoglobin (Hb) > 8 g/dL. Six doctors participated in focus group and eleven in individual interviews. There was a lack of awareness of institutional transfusion guidelines, disagreement on appropriate RBC transfusion thresholds and comments that more than one RBC unit should always be transfused. Factors informing decisions to transfuse included advice from senior colleagues, relieving symptoms of anaemia and high product costs.ConclusionMost orders were for two or more units. In medical anaemia, doctors’ compliance with RBC transfusion thresholds was reasonable; however, almost half of the orders would have resulted in overtransfusion. The attitudes of doctors sampled suggest that their transfusion practice is influenced more by institutional values than formal guidelines.

Viscoelastic tests in liver disease: where do we stand now?

Hemostasis is a complex physiological process based on the balance between pro-coagulant and anticoagulant systems to avoid pathological bleeding or thrombosis. The changes in standard coagulation tests in liver disease were assumed to reflect an acquired bleeding disorder, and cirrhotic patients were considered naturally anticoagulated. In the light of the new evidence, the theory of rebalanced hemostasis replaced the old concept. According to this model, the hemostatic alteration leads to a unique balance between pro-coagulant, anticoagulant, and fibrinolytic systems. But the balance is fragile and may prone to bleeding or thrombosis depending on various risk factors. The standard coagulation tests [INR (international normalized ratio), platelet count and fibrinogen] only explore parts of the hemostasis, not offering an entire image of the process. Rotational thromboelastometry (ROTEM) and thromboelastography (TEG) are both point of care viscoelastic tests (VET) that provide real-time and dynamic information about the entire hemostasis process, including clot initiation (thrombin generation), clot kinetics, clot strength, and clot stability (lysis). Despite prolonged PT/INR (international normalized ratio of prothrombin time) and low platelet counts, VET is within the normal range in many patients with both acute and chronic liver disease. However, bleeding remains the dominant clinical issue in patients with liver diseases, especially when invasive interventions are required. VET has been shown to asses more appropriately the risk of bleeding than conventional laboratory tests, leading to decrial use of blood products transfusion. Inappropriate clotting is common but often subtle and may be challenging to predict even with the help of VET. Although VET has shown its benefit, more studies are needed to establish cut-off values for TEG and ROTEM in these populations and standardization of transfusion guidelines before invasive interventions in cirrhotic patients/orthotopic liver transplantation.

Blood transfusion and venous thromboembolism trends and risk factors in primary and aseptic revision total hip and knee arthroplasties: A nationwide investigation of 736,061 cases

BackgroundOver the last years, new transfusion guidelines and pharmaceuticals have been introduced in primary and revision total hip and knee arthroplasty (P-THA, P-TKA, R-THA, R-TKA). In the US, a substantial decrease in transfusions has been observed in recent years. Little data exists on the subject in Europe. In this context we aimed to analyze: (1) Is there also a significant decrease in blood transfusion for these procedures in Germany? (2) Which patient and hospital related factors are associated with the risk of blood transfusion? (3) Is there a trend in complications, especially venous thromboembolism and stroke events that can be linked to tranexamic acid use? HypothesisThere is a significant trend in decreasing blood transfusions in hip and knee arthroplasty. MethodsUsing nationwide healthcare insurance data for inpatient hospital treatment, 736,061 cases treated between January 2011 and December 2017 were included (318,997 P-THAs, 43,780 R-THAs, 338,641 P-TKAs, 34,643 R-TKAs). Multivariable logistic regression was used to model the odds of transfusion as a function of the year of surgery. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated. ResultsIn each cohort the odds of transfusion decreased over time (2017 vs. 2011 (reference): P-THA: OR 0.42 (95%CI: 0.39–0.45), P-TKA: OR 0.41 (95%CI: 0.37–0.46), R-THA: OR 0.52 (95%CI: 0.47–0.58), R-TKA: OR 0.53 (95%CI: 0.46–0.61). Patient-related risk factors for blood transfusion included older age, female gender, lower Body Mass Index, comorbidities such as renal failure, cardiac arrhythmia, congestive heart failure, valvular disease, coagulopathy, depression, and antithrombotic medication prior to surgery. Venous thromboembolism or stroke events did not increase over the study period. DiscussionThe incidence of blood transfusions in primary and revision TKA and THA decreased over the study period. This may be due to new transfusion guidelines and the introduction of novel pharmaceuticals such as tranexamic acid. A further improved patient blood management and a focus on vulnerable patient groups might lead to a further future reduction of transfusions, especially in R-THA. Level of EvidenceIII; comparative observational study.

Context-Responsive Anticoagulation Reduces Complications in Pediatric Extracorporeal Membrane Oxygenation.

Purpose: We sought to determine the impact of a comprehensive, context-responsive anticoagulation and transfusion guideline on bleeding and thrombotic complication rates and blood product utilization during extracorporeal membrane oxygenation (ECMO).Design: Single-center, observational pre- and post-implementation cohort study.Setting: Academic pediatric hospital.Patients: Patients in the PICU, CICU, and NICU receiving ECMO support.Interventions: Program-wide implementation of a context-responsive anticoagulation and transfusion guideline.Measurements: Pre-implementation subjects consisted of all patients receiving ECMO between January 1 and December 31, 2012, and underwent retrospective chart review. Post-implementation subjects consisted of all ECMO patients between September 1, 2013, and December 31, 2014, and underwent prospective data collection. Data collection included standard demographic and admission data, ECMO technical specifications, non-ECMO therapies, coagulation parameters, and blood product administration. A novel grading scale was used to define hemorrhagic complications (major, intermediate, and minor) and major thromboembolic complications.Main Results: Seventy-six ECMO patients were identified: 31 during the pre-implementation period and 45 in the post-implementation period. The overall observed mortality was 33% with no difference between groups. Compared to pre-implementation, the post-implementation group experienced fewer major hemorrhagic and major thrombotic complications and less severe hemorrhagic complications and received less RBC transfusion volume per kg.Conclusions: Use of a context-responsive anticoagulation and transfusion guideline was associated with a reduction in hemorrhagic and thrombotic complications and reduced RBC transfusion requirements. Further evaluation of guideline content, compliance, performance, and sustainability is needed.

Transfusion Strategies for Pediatric Cardiac Surgery: A Meta-Analysis and Trial Sequential Analysis.

This study aimed to compare the effects of restrictive and liberal red blood cell (RBC) transfusion strategies on pediatric patients undergoing cardiac surgery, including cyanotic and non-cyanotic children. A literature search of the MEDLINE, EMBASE, PubMed, and the Cochrane Library database was conducted. Meta-analyses were carried out comparing restrictive and liberal transfusion strategies. Subgroup analyses were performed based on the basis of cyanotic status. Five randomized controlled trials with a total of 497 children were included. There was no significant difference in the risk of in-hospital mortality between the two transfusion strategies (risk ratio 1.21; 95% confidence interval 0.49 to 2.99; P = 0.68). The trial sequential analysis suggested that the current meta-analysis had an absence of evidence for in-hospital mortality, and the data were insufficient. Moreover, no significant differences existed between groups in terms of risk of infection, blood loss, duration of mechanical ventilation, pediatric intensive care unit (PICU) stay duration, or hospital stay duration. Cyanotic children treated with a liberal transfusion strategy had a shorter ventilator duration, but the transfusion strategy did not affect in-hospital mortality, infection, hospital stay, or PICU stay duration. On the basis of the available data, our analysis indicates that a liberal transfusion strategy did not lead to a better outcomes, but the data are extremely sparse, which highlights the need for clearer transfusion guidelines specific to this specific population.Trial registration number CRD42018102283.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00246-021-02644-8.

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.

Severe bleeding in the ICU.

Severe bleeding events, which require blood transfusions, are a challenge faced by many critical care physicians on a daily basis. Current transfusion guidelines generally recommend rather strict transfusion thresholds and strategies, which can appear opposing to a patient in need for urgent transfusion at first sight. Moreover, applied guidelines are lacking evidence and specificity for the typical ICU patient population and its comorbidities. Transfusion decisions, which are pivotal for clinical outcome, are often unsatisfactorily based on hemoglobin levels only. Recent publications generally support previous studies that a strict transfusion regimen is superior to a liberal one for the majority of cases. Newly developed and easily feasible techniques are currently in clinical trials and have the potential to become a valuable supplementation to hemoglobin-guided decision-making. In addition to the choice of the ideal transfusion strategy, physiological status and comorbidities were found to have a major impact on the outcome of severe bleedings in the ICU. The body of evidence for ICU-specific transfusion guidelines is scarce. Critical care physicians should properly evaluate their patient's comorbidities and consider extended point-of-care testing for transfusion decisions in indistinct anemic situations. A strict transfusion strategy should, however, be applied whenever possible.

Mortality Due to Severe Malarial Anemia is Associated with Thrombocytopenia and Mitigated by Restoration of Platelet Counts Following Whole Blood Transfusion: A Retrospective Observational Study

Background: Severe malaria due to Plasmodium falciparum is the leading parasitic cause of death in children worldwide, and severe malarial anemia (SMA) is the most common clinical presentation. The evidence in support of current transfusion guidelines for patients with SMA is limited. Methods: We conducted a retrospective cohort study of 911 hospitalized children with SMA in a holoendemic region of Zambia to examine the association of whole blood transfusion with in-hospital survival. Data were analyzed in adjusted logistic regression models using multiple imputation for missing data. Findings: The median age of patients was 24 months (interquartile range 16-30) and overall case fatality was 16%. Blood transfusion was associated with 35% reduced odds of death in children with SMA (odds ratio 0·65, 95% CI 0·52-0·81, p=0·002) corresponding to a number-needed-to-treat (NNT) of 14 patients. Children with SMA complicated by thrombocytopenia were more likely to benefit from transfusion than those without thrombocytopenia (NNT=5), and thrombocytopenia influenced the association between respiratory distress and death. Time-in-storage of whole blood was negatively associated with survival and with the post-transfusion rise in the platelet count but was not associated with the post-transfusion change in the hemoglobin concentration. Interpretation: Whole blood given to pediatric patients with SMA was associated with improved survival, mainly among those with thrombocytopenia who received fresh whole blood. The shelf life of whole blood may need to be reconsidered in this context. These findings point to a potential clinical role for platelet-directed transfusion strategies in the management of severe malaria, which can be further assessed in prospective studies, and underline the challenges of maintaining reliable blood donation networks in areas of high malaria transmission. Funding: National Institutes of Health, Johns Hopkins Malaria Research Institute, Bloomberg Philanthropies, Burroughs Wellcome Fund and the American Society of Tropical Medicine and Hygiene. Declaration of Interest: The authors declare no conflicts of interest. Ethical Approval: The study was approved in the United States by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board, and by the Tropical Disease Research Centre Ethics Review Committee in Ndola, Zambia.

Transfusion practices in a large cohort of hospitalized children.

While previous studies have described the use of blood components in subsets of children, such as the critically ill, little is known about transfusion practices in hospitalized children across all departments and diagnostic categories. We sought to describe the utilization of red blood cell, platelet, plasma, and cryoprecipitate transfusions across hospital settings and diagnostic categories in a large cohort of hospitalized children. The public datasets from 11 US academic and community hospitals that participated in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) were accessed. All nonbirth inpatient encounters of children 0-18 years of age from 2013 to 2016 were included. 61,770 inpatient encounters from 41,943 unique patients were analyzed. Nine percent of encounters involved the transfusion of at least one blood component. RBC transfusions were most common (7.5%), followed by platelets (3.9%), plasma (2.5%), and cryoprecipitate (0.9%). Children undergoing cardiopulmonary bypass were most likely to be transfused. For the entire cohort, the median (interquartile range) pretransfusion laboratory values were as follows: hemoglobin, 7.9 g/dl (7.1-10.4 g/dl); platelet count, 27 × 109 cells/L (14-54 × 109 cells/L); and international normalized ratio was 1.6 (1.4-2.0). Recipient age differences were observed in the frequency of RBC irradiation (95% in infants, 67% in children, p < .001) and storage duration of RBC transfusions (median storage duration of 12 [8-17] days in infants and 20 [12-29] days in children, p < .001). Based on a cohort of patients from 2013 to 2016, the transfusion of blood components is relatively common in the care of hospitalized children. The frequency of transfusion across all pediatric hospital settings, especially in children undergoing cardiopulmonary bypass, highlights the opportunities for the development of institutional transfusion guidelines and patient blood management initiatives.

Optimizing transfusion management of multiple myeloma patients receiving daratumumab-based regimens.

Daratumumab, a human anti-CD38 monoclonal antibody used to treat multiple myeloma, interferes with pretransfusion testing and can mask alloantibodies. Incidence of alloimmunization in patients on daratumumab has not been well characterized, and optimal transfusion guidelines regarding prophylactic antigen matching, accounting for both patient safety and efficiency, have not been well established for these patients. Records of patients who received daratumumab between January 1, 2014 and July 2, 2019 were reviewed. Daratumumab interference with pretransfusion testing was managed by testing with reagent red blood cells (RBCs) treated with 0.2M dithiothreitol. When daratumumab was present during antibody testing, patients were transfused with RBC units prophylactically matched for D, C, c, E, e, and K antigens per hospital policy. Out of 90 patients identified, 52 received a total of 638 RBC transfusions (average of 12.3units per patient, SD 17.2, range 1-105, median 5 among those transfused). Alloantibodies existing before daratumumab initiation were identified in seven patients. No new alloantibodies were detected in any patients after starting daratumumab treatment. The incidence of alloimmunization in patients receiving daratumumab is low. Whether this is due to the effect of daratumumab, underlying pathophysiology, or other factors, is unknown. Because these patients require a large number of RBC transfusions overall and have little observed alloimmunization, phenotype matching (beyond RhD) may be unnecessary. Since the use of dithiothreitol cannot rule out the presence of anti-K, we recommend transfusion of ABO-compatible units, prophylactically matched for the D and K antigens only.

1002 Calcium administration in Major haemorrhage Protocol

Abstract Introduction Calcium gluconate is an essential part of the major haemorrhage protocol (MHP). It minimizes the exacerbation of transfusion coagulopathies due to the citrate preservative. As fifty percent of trauma patients present with hypocalcaemia prior to transfusion, the risk is pertinent. Given the importance of the issue, surprisingly current guidelines remain sparse. We analysed the percentage of patients who received calcium and their hypocalcaemia incidence. Method A Retrospective review of red traumas during June to August 2019. The frequency of MHP and the patient’s ionised plasma calcium levels on VBG (1.15-1.26mmol/L) were identified. Our standard stated 100% of MHP should receive calcium. A massive transfusion was defined as 10 red blood cells units in 24 hours or 4 blood products within 30mins. Results 27 red traumas were accepted to audit, MHP was activated in 85%. Out of these 75% received calcium and on average after 6.4 units of blood products. The incidence of ionised hypocalcaemia in all MHP patients was 67%. Conclusions We identified a standard that supplementary calcium should be supplemented in all MHPs. Hypocalcaemia was more frequency than our research stipulated. Improvement needs to be made to meet standards. We recommend incorporation of Calcium gluconate into major haemorrhage pack and transfusion guidelines.

Sickle cell disease and the adherence to guidelines for the use of blood transfusions in Duhok, Kurdistan, Iraq

Background and objective: One of the important health problems in Duhok city, Iraqi Kurdistan Region, is sickle cell disease. Blood transfusion remains a significant therapeutic intervention in patients with sickle cell disease that reduces complications related to vaso-occlusions. This study aimed to assess compliance to guidelines for the use of blood transfusionsin Duhok, Kurdistan, Iraq. Methods: This is a cross-sectional study that included 135 patients with sickle cell disease registered at Jeen center of pediatric hematological diseases in Duhok, Kurdistan, Iraq. Between April 1st and July 31st, 2019, 205 medical visits of sickle cell disease were registered. Every patient was evaluated to record the clinical setting and explanations behind visiting and indications for transfusion. Results: Of 135 patients,65.9% had sickle cell anemia (HbSS disease), 33.3% had sickle beta thalassemia, and one patient (0.7%) had Sickle/D disease. A total of 205 medical visits of sickle cell disease were registered with 84 blood transfusion decisions. The most common indicated guideline reasons for transfusion were symptomatic anemia and acute hemolytic crisis with a drop of hemoglobin &gt;2 g/dl below steady state hemoglobin and severe painful crisis only accounted for 38.1%. Conclusion: In this study of patients with sickle cell disease, most blood transfusions were not indicated according to the transfusion guidelines (British Committee for Standards in Haematology – BCSH, 2017). Keywords: Transfusion guidelines for sickle cell disease (BCSH 2017); Sickle cell disease; Iraq.

Assessment of recipients' characteristics, transfusion appropriateness, and utilization pattern of blood and blood products in Jimma Medical Center, Jimma, Ethiopia.

BackgroundAs blood transfusion remains life-saving and is being frequently prescribed, a greater number of its practice is unnecessary or inappropriate. This important clinical intervention is reported as one of the five overused medical treatments, with gross over-ordering and whole blood transfusions as the sole component being common in developing countries. Study of recipient’s demographics, clinical conditions, appropriate blood utilization, and continuous clinical audits for quality assurance and service improvement plan are important factors to this practice. This study was designed to assess the recipient’s characteristics, blood type distributions, appropriateness of blood transfusion, and utilization practice of the big medical center.MethodsInstitution based cross-sectional study was conducted from February 1 to June 30, 2018. Data were collected using a structured data collection format prepared for this study. All transfusion prescriptions were followed from requisition up to completion. Patient’s age, sex, requesting departments, hemodynamics, number and component of units requested and issued, and units transfused were collected. Transfusion appropriateness was assessed by a criterion-based method while blood utilization was calculated.ResultsA total of 545 units of blood for 425 patients were cross-matched of the 809 units of total blood prescribed. The mean and median age of transfused individuals was found to be 27.47 ±15.28 years and 26 years respectively, and 65.4% females most in reproductive age groups. O and A Rhesus-positive blood types were the two major blood groups observed. Overall 82.1% of transfusions were appropriate; while only 27.8% of patients received appropriate components as 96.5% of individuals received a whole blood transfusion. Significant blood utilization was recorded with a C/T ratio of 1.05, TP% of 100%, and TI of 1.23.ConclusionMuch of the transfusion recipients were relatively young aged and females, most in the reproductive age group. Although whole blood was used as a sole component, significant blood transfusion utilization and appropriateness were recorded; while appropriate component transfusion was recorded to be significantly low. Local transfusion guidelines and appropriate component preparation and utilization are required to improve the sub-optimal blood component transfusion practice.

Study of Appropriateness of FFP transfusions in a tertiary care centre

Introduction: Blood transfusion is an essential part of modern health. Indiscriminate use of blood components is on the rise due to easy availability of sophisticated blood banking services. The aim of this study was to evaluate appropriate usage of Fresh frozen plasma (FFP). Materials and Methods: This study was conducted in a tertiary care centre. A total of 4236 blood request forms were analyzed in this study over a period of 12 months out of which 8.2% (n=349) were for FFP. Number of units requested were noted and appropriateness of requested transfusions was assessed according to the National guidelines on transfusion. Results: A total of 4236 blood request forms were analyzed in this study, out of which 8.2% (n=349) were for FFP. Out of these 349 FFP requests, 53.9% (n=188) requests were considered appropriate, 29.8% (n=104) were considered inappropriate and 16.3% (n=57) requests could not be assessed since PTINR values were not available. Out of the 29.8% inappropriate transfusions, in 13.8% (n=48) transfusion was appropriate but number of units transfused were inappropriate and in 16% (n=56) transfusion was considered inappropriate. Conclusion: This indicates that significant number of inappropriate transfusions were noted. This issue has to be addressed and inappropriate transfusions should be avoided. This can be achieved by regular CME programmes, educational visits to various departments and development of hospital transfusion guidelines which has to be agreed and followed by clinicians. Keywords: Transfusion, Appropriateness, FFP.

Peripartum considerations in sickle cell disease.

Pregnancy exacerbates sickle cell disease (SCD) and is associated with increased frequency and severity of complications resulting in high levels of maternal and fetal morbidity and mortality. We review recent recommendations for managing SCD in pregnancy. An updated pathobiological model of SCD now attributes the clinical picture to a vicious cycle of four major cellular disturbances. Management decisions should be guided by an understanding of this upgraded model. Red cell transfusions are a key therapeutic intervention used in managing several acute and chronic complications. Transfusion however has significant drawbacks. The American Society of Hematology recently published transfusion guidelines to support care providers. Patients should be managed by a multidisciplinary and experienced team. The perioperative episode is a recognized period of disease exacerbation and informed anesthetic management can contribute to improved patient outcomes.

Neurologic Outcomes in Neonates Following the Introduction of a Restrictive Transfusion Guideline

Objective: To evaluate the neurodevelopmental outcomes of very low birthweight (VLBW) infants before and after the introduction of a restrictive transfusion guideline. Study design: This is a large retrospective study comparing neurodevelopmental outcomes before and after a restrictive transfusion guideline (RTG) was established for VLBW infants admitted to a large single neonatal intensive care unit (NICU). Bayley-III scores obtained from routine NICU follow up appointments at pediatric neurodevelopmental clinics were evaluated. The mean age of obtaining the Bayley-III score was 20.3 months with a standard deviation of +/- 5.2 months. Results: Neurodevelopmental outcomes measured by Bayley-III scores, were similar for cognitive, language, and motor testing in the RTG versus LTG groups. In addition, the subcategories for normal, mild delay, moderate delay and severely delayed were also similar. Conclusion: RTG is safe in the neonatal VLBW population. RTG when compared to liberal transfusion guideline (LTG) is associated with similar neurodevelopmental outcomes as defined by Bayley-III scores.

Diacetylene-Based Colorimetric Radiation Sensors for the Detection and Measurement of γ Radiation during Blood Irradiation.

Blood and its cellular components are irradiated by ionizing radiation before transfusion to prevent the proliferation of viable T lymphocytes which cause transfusion associated-graft versus host disease. The immunodeficient patients undergoing chemotherapy for various malignancies are at risk of this disease. The international guidelines for blood transfusion recommend a minimum radiation exposure of 25 Gray (Gy) to the midplane of the blood bag, while a minimum dose of 15 Gy and a maximum dose of 50 Gy should be given to each portion of the blood bag. Therefore, precise dosimetry of the blood irradiator is essential to ensure the adequate irradiation of the blood components. The paper presents the fabrication of diacetylene-based colorimetric film dosimeters for the verification of irradiated doses. The diacetylene analogues are synthesized by tailoring them with different amide-based headgroups followed by their coating to develop colorimetric film dosimeters. Among all the synthesized diacetylene analogues, aminofluorene-substituted diacetylene exhibits the most significant color transition from white to blue color at a minimum γ radiation dose of 5 Gy. The quantitative study of color change is performed by the digitization of the scanned images of film dosimeters. The digital image processing of the developed film dosimeters facilitates rapid dose measurement which enables their facile implementation and promising application in routine blood irradiator dosimetry.