Transfusion Practice Research Articles

Hemoglobin-oxygen affinity changes in neonatal blood transfusions: RBC selection insights.

Despite preterm newborns often requiring blood transfusions, we have an incomplete understanding of the impact of adult packed red blood cell (pRBC) transfusions on fetal red blood cell (RBC) oxygen affinity. We investigated the influence of adult pRBC on oxygen binding in fetal RBCs obtained from the umbilical cord of preterm newborns. This included exploring the influence of the biological age of adult pRBCs on the oxygen affinity of fetal blood. Cord blood samples from preterm infants were titrated with young (Y-RBC) and old (O-RBC) adult pRBCs using an in vitro transfusion model. Parameters, including oxygen affinity (p50), hemoglobin variants, and red blood cell indices, were measured. The titration of cord blood with adult pRBCs (n = 19) resulted in a concentration-dependent decrease in p50, indicating an increased oxygen affinity. Hemoglobin variant analysis revealed a shift in composition, with a decrease in fetal hemoglobin (HbF) and an increase in adult hemoglobin (HbA) following titration. The impact of biological age was evident, as O-RBCs had a more pronounced effect on p50 values compared to Y-RBCs. Understanding the physiologic implications of transfusing preterm infants with adult pRBCs is important for optimizing transfusion practices in newborns. In an in vitro model, titrating adult pRBC into fetal blood significantly affects oxygen binding Oxygen affinity of fetal blood is significantly increased after titration of adult pRBC. Compared to older RBC subpopulations of adult pRBC, oxygen-binding properties of younger RBC subpopulations of adult pRBC more closely approximate the oxygen affinity of fetal blood. This work highlights the importance of investigating the influence of adult pRBC transfusion on fetal RBC oxygen binding. This may have implications for morbidities in the newborn period related to oxygen physiology.

Comparative Analysis of Blood Transfusion Accuracy and Hemolysis Rate of Transfusion Cartridge Set Between Conventional Infusion Pumps and Cylinder-Type Infusion Pumps

Background: Infusion pumps are critical in delivering fluids, including medications and blood products, in controlled amounts. However, conventional pumps can cause hemolysis and other issues such as flow variations and infection risks, especially during blood transfusions. To address these limitations, a novel cylinder-type infusion pump, the Anyfusion H-100, was developed, which includes a specialized blood transfusion cartridge set that combines syringe and peristaltic infusion methods. This study evaluates the accuracy and hemolysis rates of the Anyfusion H-100 compared to conventional pumps, aiming to confirm its viability as a safe and effective medical device for blood transfusions. Methods: This study evaluated six different infusion rates (10–180 cc/hr) and conducted 57 transfusion trials, 20 of which used a 1:1 blood–saline dilution. Blood transfusion accuracy was measured using research-grade packed red blood cells, and hemolysis rates were assessed before and after transfusion by chi-square tests and independent sample t-tests. Results: Anyfusion demonstrated an average transfusion error rate of 3.77%, compared to 4.00% for the Terufusion, with no statistically significant difference in hemolysis rates (p = 0.697). Bland–Altman plots confirmed their equivalent performance, with hemolysis rates of 0.566 ± 0.095% for Anyfusion and 0.518 ± 0.126% for Terufusion. Conclusions: Anyfusion provides an accurate and reliable blood transfusion performance comparable to that of Terufusion, with no significant difference in hemolysis rates; its integration of syringe and infusion methods shows a potential for safer and more efficient transfusion practices, especially in pediatric and emergency settings.

Transfusion-Related Acute Lung Injury

Transfusion-Related Acute Lung Injury is one of the most vital forthcoming risks that need to be addressed, assessed, diagnosed and treated. Blood transfusion save lives, but the side effects of transfusion can be really adverse and concerning. Blood transfusion helps the patient recover from severe blood loss that might lead to severe complications like cardiogenic or hypovolemic shock. Over the years, the health care industry is working on reducing the possible risk and complications of blood transfusion. Worldwide trainings are provided on safe blood transfusion practices. Blood banks are verified with legal authority and inspections are done every now and then. Transfusion-Related Acute Lung Injury is the upcoming concerning issue that needs to be familiar with all health care workers especially nurses since they are the one who keep a close monitoring of patient during the blood transfusion process. Furthermore intervention can be planned accordingly to help manage Transfusion-Related Acute Lung Injury better and treat the symptoms as soon as possible.

A 6-month Review of O pRBC Utilization in Non-O Blood Type Patients in a Level 1 Trauma Center

Abstract Introduction/Objective Using O pRBCs for non-O patients for acute events is not unusual in a level 1 trauma hospital. However, we occasionally utilize this blood type to meet the needs of our patients that are not acutely bleeding. In this study, we evaluated the utilization of O units in non-O patients to improve our transfusion practices. Methods/Case Report We reviewed the indications of the O pRBCs transfused to non-O patients from October 2023 to March 2024. We evaluated the number of units used in acute events such as massive transfusion protocol (MTP), acute blood loss, sickle cell disease (SCD) patients in crises, bleeding associated with surgery and in patients with symptomatic anemia. Results (if a Case Study enter NA) There were 258 O pRBCs transfused to non-O blood type from October 2023 to March 2024. 135(52%) of these units were used for bleeding patients, of which 91%(124/135) were used for acute events. Most of the units utilized for acute hemorrhage had activated MTP (92%, 89/124) due to trauma (88%, 78/89). Only 12%(31/258) were used by SCD patients, with a little over half of these units being used acutely and the rest used prophylactically. About 69% of the 16 units used in surgery were due to bleeding. Lastly, 76 units (29%) were used for symptomatic anemia patients with 45% of these units transfused for anemia of prematurity. Conclusion In a level 1 trauma hospital, advocating for conserving O units is crucial to ensure enough units are available for trauma. As anticipated, acute bleeding was found to be the leading cause for patients with non-O blood types to receive O pRBCs. Notably, the prevalence of using O units for acute and prophylactic transfusion is relatively the same for SCD patients and phenotypically matching the Rh and Kell systems likely plays a role.

Patient Blood Management in 2023: a Nationwide Survey of Anesthesiologists in Romania following the 2018 Guidelines.

In 2018, Romania established national guidelines for patient blood management (PBM), endorsed by the Romanian Society of Anesthesia and Intensive Care (SRATI) and approved by the Ministry of Health. These guidelines emphasize managing anemia, coagulation issues, and the cautious use of allogeneic transfusions to improve patient outcomes. A national survey was conducted among Romanian anesthesiologists to assess PBM guideline adoption. It included 38 questions addressing PBM strategies, resources, transfusion practices, and barriers to implementation. The survey was distributed via email to the SRATI database. Out of 512 professionals who opened the survey, 74% had adopted some PBM measures, and 97% recognized PBM's efficacy in improving outcomes. However, only 33% of anesthesiologists worked in hospitals with formal PBM groups, and 39% had attended PBM-related educational events. Preoperative anemia management was inconsistent, with only 33.5% routinely treating anemia. Access to diagnostic and therapeutic tools was limited; transferrin saturation testing was available in 27% of cases, and erythropoietin was used in 24%. Despite these limitations, 72% of respondents treated anemia with intravenous iron. The main challenges to implementation included insufficient time for pre-surgical assessments, lack of standardized procedures, and difficulties in surgeon-anesthetist collaboration. The survey highlights the need for systemic improvements in PBM adoption. Recommendations include enhancing organizational structures, standardizing protocols, and improving interdisciplinary collaboration to boost PBM implementation in Romania. While progress has been made, a national program with dedicated funding and auditing could facilitate widespread PBM integration into clinical practice.

Should viscoelastic testing be a standard point-of-care test on all intensive care units?

Viscoelastic tests (VETs) have transformed assessment of haemostasis and transfusion practices in trauma, cardiac and liver transplantation centres. Impaired haemostasis is a common problem on the general intensive care unit (ICU), but routine use of VETs is rare. We have accordingly reviewed the evidence to determine whether there is evidence to support the use of VETs as a standard point of care test on all ICUs in assessing and managing patients. The benefits of using VETs in the management of major haemorrhage, namely faster identification of a coagulopathy, in particular early detection of fibrinolysis, and reduced transfusion requirements for blood products have been seen in the general ICU. Validation of treatments algorithms is now required to standardise practice. There is also emerging evidence to support the use of VETs to guide urgent treatment decisions in patients with a coagulopathy or in patients taking anti-coagulants or anti-platelet therapies. We recommend that departments independently review the feasibility of setting up a viscoelastic point of care service which considers the applicability to their patient cohort, the financial cost and the personnel required.

A 6-month Review of pRBC Transfusion Practices in a Tertiary Institution in Brooklyn, NY

Abstract Introduction/Objective Many factors are considered when managing hospital blood inventory. Because demographics and types of services vary per institution, a conscious effort to survey the prevalence of different blood types is necessary to make better predictions of inventory adequacy and decrease inappropriate use of O pRBC units. Methods/Case Report We reviewed the transfused pRBC units between October 2023 and March 2024 to determine the number of patients receiving ABO-type specific units and the number of D+ patients receiving D- units. Results (if a Case Study enter NA) After review, the patient population was found to be approximately 80% African Americans. Most of our patients were D+ with a monthly average of 224 patients. In contrast, we served 15 D- patients per month (PPM). Between 21-33% of D+ patients received D- units. O blood type was the most common, with an average of 224 PPM, followed by A blood type at 57 PPM and B blood type at 51 PPM. Since we see an average of 10 AB blood type patients monthly, it wasn’t surprising that they all received non-type specific units. Noteworthy is the significant proportion of A and B blood type patients receiving ABO type-specific units, ranging from 74-85% for A blood type and 70-90% for B blood type. Conclusion Our institution’s commitment to hemovigilance and conservation of O units is evident in the relatively high percentage of patients receiving ABO-type specific units. It is worth noting that we are a tertiary institution mainly serving the African American population. This creates a unique need to maintain adequate O units for emergency transfusion and increase the possibility of using O units to meet our sickle cell disease patients’ needs. Given that our demographics are primarily D+, some of our D- units were utilized in D+ patients. By adhering to our transfusion protocol and surveying our patients’ ABO and D blood types, we can anticipate our inventory needs and help prevent future O pRBC shortages.

Can clinical guidelines reduce variation in transfusion practice? A pre-post study of blood transfusions during cardiac surgery.

Previously published studies have consistently identified significant variation in red blood cell (RBC) transfusions during cardiac surgery. Clinical guidelines can be effective at improving the average quality of care; however, their impact on variation in practice is rarely studied. Herein, we estimated how variation in RBC use across cardiac surgeons changed after the publication of national patient blood management guidelines. We performed a pre-post study estimating change in variation in RBC transfusions across 80 cardiac surgeons in 29 hospitals using a national cardiac surgery registry. Variation across surgeons was estimated using fixed-effects regressions controlling for surgery and patient characteristics and an empirical Bayes shrinkage to adjust for sampling error. RBC use was measured by three metrics-the total number of units transfused, the proportion of patients transfused and the number of units transfused, conditional on receiving RBC. The primary analysis utilized 35,761 elective cardiac surgeries performed between March 2009 and February 2015 and identified a 24.5% reduction (p < 0.0001) in mean total units transfused accompanied by a 37.2% reduction (p = 0.040) in the variation across surgeons. The reduction in mean total units was driven by both the proportion of patients transfused and the number of units transfused, conditional on receiving RBC, while the reduction in variation was only driven by the latter. In our study of RBC transfusions across cardiac surgeons, the surgeons who used more RBC in the pre-guideline period experienced larger reductions in RBC use after the guidelines were published.

Blood transfusion in pediatric intracranial tumor surgery

BackgroundPediatric central nervous system tumors are the most common solid tumors in children and leading cause of cancer-related morbidity and mortality. Various factors may influence the practice of blood transfusion during this tumor diagnosis. The primary aim of this study was to determine the factors that may influence intraoperative blood transfusion in pediatric patients undergoing surgery for intracranial tumors and to predict patients who may require blood transfusion.MethodsA retrospective study was performed in all pediatric patients younger than 15 years who underwent craniotomy for brain tumor removal from January 2018 to December 2023 in our institution. Preoperative, intraoperative and postoperative data were collected from medical and store anesthesia records. The predictors of intraoperative blood transfusion were determined using multivariate logistic regression.ResultsA total of 138 patients were enrolled in the study, of whom 62 (44.9%) required intraoperative blood transfusion. In multivariate regression analysis age < 4 years and operating time > 490 min were determined as independent variables in terms of need for intraoperative blood transfusion. It was determined that the need for transfusion was higher in patient who were operated on urgently and patients with comorbidities (p = 0.023, p = 0.005).ConclusionIn conclusion, the findings obtained in this study suggest that age and surgical duration are independent risk factors for intraoperative blood transfusion in pediatric patients undergoing surgery for intracranial tumors. Particularly, in younger patients and prolonged surgeries, closer monitoring and awareness may enhance early detection, leading to the prevention of complications.

Physician perspectives about the diagnosis and management of acute chest syndrome.

Acute chest syndrome (ACS) is the leading cause of mortality, accounting for 25% of all deaths among individuals with sickle cell disease (SCD). There is a lack of evidence-based laboratory and clinical risk stratification guidelines for the diagnosis and management of ACS. To better understand physician practices for the management of ACS in the United States, we created an ACS Working Group including hematology and transfusion medicine physicians from four different SCD treatment centers in the United States. The working group created a physician survey that included physician demographics and ACS diagnostic criteria that they had to rate. The survey also included three case scenarios to assess physician attitudes about the management of ACS. Management options included supportive and preventive strategies in addition to transfusion therapy options. Out of 455 physicians who received the survey, 195 responded (response rate = 43%). The respondents were primarily hematology/oncology physicians. The responses showed wide variability among physicians in how diagnostic criteria for ACS are used and how physicians risk-stratify ACS patients in their practice. The responses also reflected variability in the use of transfusions for ACS. Based on our results, we conclude that ACS is diagnosed and managed inconsistently among expert physicians, especially in their transfusion practices due to a lack of consensus on risk stratification criteria. Our data suggest an urgent need for well-designed prospective studies to provide evidence-based guidelines and minimize management variability among physicians who care for individuals with SCD and ACS.

Evaluation of the analytical performance of four different manufacturer's reagent red blood cells in antibody detection and identification.

The detection/identification of clinically significant antibodies to red cell antigens form the foundation for safe transfusion practices. This study aimed to evaluate the diagnostic performance of commercially available 0.8% reagent red blood cells (RRBCs) in Australia. 166 patient-derived plasma samples with a positive indirect antiglobulin test (IAT) were tested using column agglutination technology (CAT) with Immulab, Bio-Rad, Grifols and QuidelOrtho screening and identification RRBCs with the respective manufacturer's proprietary CAT system. False-negative antibody screening and identification results were obtained with Bio-Rad (3/61), Grifols (14/68) and Quidel-Ortho (3/59) RRBCs when tested with the respective manufacturer's proprietary CAT system. Zero false-negative results were observed with Immulab RRBCs when tested with samples across all platforms. The sensitivity of the RRBCs used in this study were calculated to be 95.83% (95%CI 88.30-99.13%) for Bio-Rad RRBCs, 82.50% (95%CI 72.38-90.09%) for Grifols RRBCs and 95.65% (95%CI 87.82-99.09%) for QuidelOrtho RRBCs. The sensitivity of Immulab RRBCs were stratified based on performance in the 3 CAT platforms: Bio-Rad CAT (100%, 95%CI 95.01-100%), Grifols CAT (100%, 95%CI 95.49-100%) and QuidelOrtho CAT (100%, 95%CI 94.79-100%). RRBCs used in antibody detection and identification vary in diagnostic performance and should therefore be carefully considered before being implemented in routine patient testing.

Transfusion Practice Patterns in Cancer Patients with Anemia: A Retrospective Study from a Single Oncology Center in Najran, Saudi Arabia

Background: Recent studies support the safety of restrictive pretransfusion hemoglobulin thresholds (≤7-8 g/dL) for adult cancer patients on chemotherapy. However, the restrictive transfusion strategies role in decreasing inappropriate red blood cell (RBC) transfusion practice in Saudi Arabia is not yet understood. This study aims to evaluate transfusion practices among oncologic patients at Najran Oncologic Center, Saudi Arabia. Materials and Methods: A retrospective chart review study between January 1, 2020, and December 31, 2022, involving 59 adult cancer patients presented to King Khaled Hospital in Najran, Saudi Arabia. Clinical variables for prescribing RBC transfusions based on liberal (&gt; 7 g/dL) or restricted (Hb &lt; 7 g/dL) baseline hemoglobin levels and number of transfused RBCs were investigated in univariate analysis. Results: The mean age was 65.0 ±10.2 years, and most cases were male (n=40, 67.8%). The common primary tumor location was colorectal cancers (n=27, 45.8%), and most cases were in metastatic stages (n=44, 74.6%). The majority of cases (n=36, 61.0%) had severe anemia (Hb &lt; 7 g/dL) at admission. The mean number of RBC units received was 4.9 ±2.4 RBC. Variables associated with restricted prescribing RBC transfusions were male gender (OR: 3.21; 95% CI: 1.05-10.33, p= 0.044), high ECOG-PS status (OR: 2.95; 95% CI: 1.01-9.03, p=0.048), cardiac disease history (OR: 2.05; 95% CI: 0.69-6.44, p= 0.009), and platinum-based chemotherapy (OR: 233.33; 95% CI: 33.12-5054.45, p &lt;0.001). However, survival status was higher among patients with restrictive strategy (OR: 0.25; 95% CI: 0.08-0.73, p= 0.025). Factors associated with an increased number of transfused RBCs were male gender (OR:1.43; 95% CI: 1.07-1.93, p= 0.012), platinum-based chemotherapy (OR:1.55; 95% CI: 1.18-2.15, p= 0.004), history of bleeding (OR: 1.31, 95% CI: 1.02-1.73, p= 0.032), and history of cardiac disease (OR: 1.31 (1.02-1.73; p= 0.002). Conclusion: The study concluded that factors like male gender, platinum-based chemotherapy, bleeding history, and concurrent cardiac disease were associated with an increased number of RBC transfusions. In addition to that, we found a clear adherence to the clinical practice guidelines among the transfused patients. The study suggests an etiology-based approach to cancer-related anemia and transfusions, enabling clinicians to plan safe, targeted therapy and improve patients’ quality of life by synchronizing chemotherapy efficacy.

Exploring the Intersection of Blood Transfusion and Same-Day Computed Tomography Imaging: An Overview of Clinical Risks and Practices.

The use of transfusions, whether involving whole blood or specific blood components, is essential for managing various clinical conditions. Many cases are acute, often requiring post-transfusion imaging evaluation. While there is no absolute contraindication for chest imaging following blood transfusion, it should be approached cautiously. We conducted a comprehensive search across multiple databases and registries. Research studies were limited to full-text original articles, reviews, and case reports published in English, involved human subjects, and focused on the interplay between blood transfusions and contrast-enhanced imaging. Scientific analyses were excluded if they did not focus on transfusion practices in the context of imaging or failed to address issues such as hemoglobin thresholds, transfusion reactions, or the clinical implications of contrast agents. Our research fills this gap by emphasizing the need for a cautious, multidisciplinary approach to post-transfusion computed tomography (CT) scans, especially in the presence of contrast agents. This study calls for increased awareness of the heightened risk of complications, such as autoimmune hemolysis, when both procedures are performed together. New insights from our research recommend individualized assessments and close patient monitoring when combining these interventions. Nevertheless, patients need to be hemodynamically and clinically stable before undergoing CT. Discussions. Symptoms that develop within the first 24 h post-transfusion are classified as secondary post-transfusion reactions unless proven otherwise. The prevalence of side effects from same-day CT scans and blood transfusions is challenging to quantify, as few studies focus on this combination. Transfusions and contrast-enhanced CT scans share overlapping adverse reactions and carry significant risks. Acute hemolytic red blood cell transfusion reactions are among the most frequent side effects, with a prevalence of 1:12,000-38,000. Conclusion. Our study contributes new insights to the literature by filling the gap concerning the interplay between transfusions and contrast media, paving the way for more informed clinical protocols to enhance patient safety.

Impact of introduction of point-of-care viscoelastic testing on transfusion practice in major obstetric haemorrhage

Impact of introduction of point-of-care viscoelastic testing on transfusion practice in major obstetric haemorrhage

Correlation of the Transfusion Camp knowledge assessment test with clinical transfusion practice.

It is uncertain how transfusion knowledge translates to practice. The purpose of the study was to determine if higher scores on a validated Transfusion Camp knowledge assessment test were associated with transfusion order appropriateness. Eligible participants included postgraduate trainees and faculty physicians who had prescribed at least four transfusion orders in the preceding 6 months at two hospitals. Participant data and knowledge were collected using a web-based questionnaire with a validated Transfusion Camp knowledge assessment tool. The most recent 4-10 consecutive transfusion orders per prescriber were independently dually adjudicated for appropriateness based on published criteria. The primary outcome was the correlation between the score on six questions on red blood cells (RBCs), platelets (PLTs), and plasma from the validated test and the percentage order appropriateness. Generalized linear regression was conducted to determine if factors (sex, specialty, participation in Transfusion Camp, previous transfusion education, self-rated knowledge) were associated with appropriate orders. Seventy-four participants (45 trainees, 29 faculty; 31 females, 43 males) completed the test. Median score was 66.7% (interquartile range [IQR]: 50.0, 83.3) for six questions on RBCs, PLTs, and plasma transfusions. Of 546 transfusion orders adjudicated, appropriateness was 90.7% (95% confidence interval [CI]: 87.9%-93.0%). The correlation between prescriber test scores and order appropriateness was very weak (r = -.08). In multivariable analysis, female prescribers (p = .02) and beginner (vs. intermediate) self-rated knowledge (p = .01) were associated with higher transfusion appropriateness. Transfusion knowledge test scores did not correlate with order appropriateness. Factors other than knowledge are key to understanding how to improve appropriate blood use.

Where Do We Stand in Blood Transfusion Practices: Insights From the First Clinical Audit From Khyber Pakhtunkhwa, Pakistan

Where Do We Stand in Blood Transfusion Practices: Insights From the First Clinical Audit From Khyber Pakhtunkhwa, Pakistan

Hemoglobin-based transfusion strategies for cardiovascular and other diseases: restrictive, liberal, or neither?

AbstractA “restrictive” red blood cell transfusion threshold, a hemoglobin concentration <7 to 8 g/dL, has long been recommended for most hospitalized patients including anemic patients with stable cardiovascular disease (CVD). Although no threshold recommendation is given for acute coronary syndromes (ACSs), recent evidence suggests that “liberal” rather than “restrictive” transfusion strategies are associated with significantly improved safety for hospitalized patients with stable CVD and/or ACS. This finding suggests that previously available data were misinterpreted. Conclusions drawn from earlier transfusion trigger trials have been confounded by unintentional trial design and analysis flaws that have contributed to erroneous recommendations regarding the safety of a restrictive threshold. Subsequently, these conclusions have been incorporated into widely accepted guidelines and clinical practice. Management with a restrictive vs liberal transfusion strategy (<10 g/dL) increases the risk of new-onset ACS in patients with CVD by ∼2%. We estimate that since 2019, using hospital databases and a recent meta-analysis, this practice may have resulted in ∼700 excess ACS events per year in orthopedic surgical patients. Given these findings, transfusion practices in other clinical conditions, particularly those derived from similar transfusion trigger trials, should be questioned. Restrictive and liberal transfusion policies merit a general reconsideration. Rather than a single numerical transfusion trigger, transfusion therapy should be personalized. Consideration of an individual patient’s age, clinical status, and comorbidities is integral to transfusing. To avoid making similar errors, future trials of transfusion therapy should determine common practices before study inception and incorporate them as a usual-care “control” comparator arm into the trial design. Such studies should more reliably improve current transfusion practice.

Red Blood Cell Transfusion in European Neonatal Intensive Care Units, 2022 to 2023

Red blood cell (RBC) transfusions are frequently administered to preterm infants born before 32 weeks of gestation in the neonatal intensive care unit (NICU). Two randomized clinical trials (Effects of Transfusion Thresholds on Neurocognitive Outcomes of Extremely Low-Birth-Weight Infants [ETTNO] and Transfusion of Prematures [TOP]) found that liberal RBC transfusion thresholds are nonsuperior to restrictive thresholds, but the extent to which these results have been integrated into clinical practice since publication in 2020 is unknown. To describe neonatal RBC transfusion practice in Europe. This international prospective observational cohort study collected data between September 1, 2022, and August 31, 2023, with a 6-week observation period per center, from 64 NICUs in 22 European countries. Participants included 1143 preterm infants born before 32 weeks of gestation. Admission to the NICU. Study outcome measures included RBC transfusion prevalence rates, cumulative incidence, indications, pretransfusion hemoglobin (Hb) levels, volumes, and transfusion rates, Hb increment, and adverse effects of RBC transfusion. A total of 1143 preterm infants were included (641 male [56.1%]; median gestational age at birth, 28 weeks plus 2 days [IQR, 26 weeks plus 2 days to 30 weeks plus 2 days]; median birth weight, 1030 [IQR, 780-1350] g), of whom 396 received 1 or more RBC transfusions, totaling 903 transfusions. Overall RBC transfusion prevalence rate during postnatal days 1 to 28 was 3.4 transfusion days per 100 admission days, with considerable variation across countries, only partly explained by patient mix. By day 28, 36.5% (95% CI, 31.6%-41.5%) of infants had received at least 1 transfusion. Most transfusions were given based on a defined Hb threshold (748 [82.8%]). Hemoglobin levels before transfusions indicated for threshold were below the restrictive thresholds set by ETTNO in 324 of 729 transfusions (44.4%) and TOP in 265 of 729 (36.4%). Conversely, they were between restrictive and liberal thresholds in 352 (48.3%) and 409 (56.1%) transfusions, respectively, and above liberal thresholds in 53 (7.3%) and 55 (7.5%) transfusions, respectively. Most transfusions given based on threshold had volumes of 15 mL/kg (470 of 738 [63.7%]) and were administered over 3 hours (400 of 738 [54.2%]), but there was substantial variation in dose and duration. In this cohort study of very preterm infants, most transfusions indicated for threshold were given for pretransfusion Hb levels above restrictive transfusion thresholds evaluated in recent trials. These results underline the need to optimize practices and for implementation research to support uptake of evidence.

Challenges in reliable preoperative blood ordering: A qualitative interview study.

Presurgical blood orders are important for patient safety during surgery, but excess orders can be costly to patients and the healthcare system. We aimed to assess clinician perceptions on the presurgical blood ordering process and perceived barriers to reliable decision-making. This descriptive qualitative study was conducted at a single large academic medical center. Semi-structured interviews were conducted with surgeons, anesthesiologists, nurse anesthetists, nurse practitioners working in preoperative assessment clinics, and transfusion medicine physicians to assess perceptions of current blood ordering processes. Interview responses were analyzed using an inductive open coding approach followed by thematic analysis. Twenty-three clinicians were interviewed. Clinicians felt that the current blood ordering process was frequently inconsistent. One contributor was a lack of information on surgical transfusion risk, related to lack of experience in ordering clinicians, insufficient communication between stakeholders, high turnover in academic settings, and lack of awareness of the maximum surgical blood ordering schedule. Other contributors included differing opinions about the benefits and harms of over- and under-preparing blood products, leading to variation in transfusion risk thresholds between clinicians, and disagreement about the safety of emergency-release blood. Several barriers to reliable decision-making for presurgical blood orders exist. Future efforts to improve ordering consistency may benefit from improved information sharing between stakeholders and education on safe transfusion practices.

Estimation of gestational age-specific reference intervals for coagulation assays in a neonatal intensive care unit using real-world data

BackgroundInterpretation of coagulation testing in neonates currently relies on reference intervals (RIs) defined from older patient cohorts. Direct RI studies are difficult, but indirect estimation may allow us to infer normative neonatal distributions from routinely collected clinical data. ObjectiveAssess the utility of indirect reference interval methods in estimating coagulation reference intervals in critically ill neonates. MethodsWe analyzed first-in-life coagulation testing results from all patients admitted to a level IV neonatal intensive care unit between January 1, 2018, and January 1, 2024. Results obtained after transfusion of any blood product were excluded. Indirect RIs were estimated across gestational age groups using refineR and compared with currently reported intervals for patients less than 1 year of age. ResultsProthrombin times (PTs) and international normalized ratios (INRs) were available for 1128 neonates, while activated partial thromboplastin times (APTTs) were available for 790 neonates. The indirect RI was 10 to 25 seconds in preterm, 10 to 22 seconds in term, and 10 to 24 seconds in all neonates for PT; 0.7 to 2.1 in preterm, 0.8 to 1.8 in term, and 0.8 to 1.9 in all neonates for INR; and 25 to 68 seconds in preterm, 25 to 58 seconds in term, and 25 to 62 seconds in all neonates for APTT. Compared with our current intervals, the indirect RIs would flag 58% fewer PT, 43% fewer INR, and 17% fewer APTT results as abnormal. ConclusionIndirectly estimated RIs in neonates admitted to intensive care show substantial divergence from current, first-year-of-life RIs, leading to an abundance of abnormal flags. The associations between these flags and provider behavior, transfusion practice, or clinical outcomes are areas of future exploration.