Transfusion Ratio Research Articles

Second Place Award: Tranexamic acid and intrathecal morphine are synergistic in reducing transfusion requirements in pediatric posterior spinal fusion

Background: Previous studies demonstrated that the independent use of both tranexamic acid (TXA) and intrathecal morphine (ITM) reduced transfusion requirements in scoliosis patients undergoing posterior spinal fusion (PSF). This study examined the combined effects of TXA and ITM on transfusion requirements in pediatric patients undergoing PSF. Methods: A retrospective review of consecutive patients treated with PSF at a single institution was performed. Patients with a minimum of 10 vertebral levels of fusion and PSF with segmental instrumentation were included. Transfusion records were reviewed during surgery and 7 days postoperatively. Patients were divided into four treatment groups for comparison: 1. No TXA, No ITM; 2. Only TXA; 3. Only ITM and 4. TXA and ITM. Multivariate regression analysis, Student t-test, and chi-squared test were used to determine significance. Results: Five hundred and ninety-four patients met inclusion criteria; 63% (376/594) were female, average age: 14.6 yr (range 8.0-24.3 yr) and average 13 levels fused (10-18 levels). Fifty-three percent (316/594) received packed red blood cell (PRBC) transfusion. Patients receiving the TXA and ITM combination had 72% lower odds ratio of transfusion (P<0.001, OR 0.28, CI 0.14-0.56). Patients did not have lower odds ratio of transfusion when receiving TXA alone (P=0.32, OR 0.65, CI 0.28-1.53) or ITM alone (P=0.09, OR 0.55, CI 0.28-1.09). Similar results were seen when patients were analyzed separately by diagnosis (idiopathic vs. nonidiopathic). Conclusions: The combination of TXA and ITM was associated with 72% reduction in odds ratio of PRBC transfusion in pediatric patients undergoing PSF, an effect seen in both idiopathic and nonidiopathic scoliosis when analyzed separately.

Clinical practice guideline adherence during Operation Inherent Resolve.

The Joint Trauma System (JTS) clinical practice guidelines (CPGs) contributed to the decrease in battlefield mortality over the past 15 years. However, it is unknown to what degree the guidelines are being followed in current military operations. A retrospective review was performed of all patients treated at three separate US Army Role II facilities during the first 10 months of Operation Inherent Resolve in Iraq. Charts were reviewed for patient demographics, clinical care, and outcomes. Charts were also reviewed for compliance with JTS CPGs and Tactical Combat Casualty Care recommendations. A total of 114 trauma patients were treated during the time period. The mean age was 26.9 ± 10.1 years, 90% were males, and 96% were host nation patients. The most common mechanisms of injury were blast (49%) and gunshot (42%). Records were compliant with documenting a complete set of vitals in 58% and a pain score in 50% of patients. Recommendations for treatment of hypothermia were followed for 97% of patients. Tranexamic acid was given outside guidelines for 6% of patients, and for 40%, it was not determined if the guidelines were followed. Recommendations for initial resuscitative fluid were followed for 41% of patients. Recommendations for antibiotic prophylaxis were followed for 40% of intra-abdominal and 73% of soft tissue injuries. Recommendations for tetanus prophylaxis were followed for 90% of patients. Deep vein thrombosis prophylaxis was given to 32% of patients and contraindicated in 27%. The recommended transfusion ratio was followed for 56% of massive transfusion patients. Recommendations for calcium administration were followed for 40% of patients. When composite scores were created for individual surgeons, there was significant variability between surgeons with regard to adherence to guidelines. There is significant deviation in the adherence to the CPGs. Epidemiologic study, level IV.

Any changes in recent massive transfusion practices in a tertiary level institution?

Background & objectivesA previous review of transfusion practices in our institution between 1998 and 2008 showed a trend of high ratios of red cells (RC) to plasma (FFP) and platelets to RC towards the later years of review period. The aim of the study was to further evaluate transfusion practices in the form of blood product usage and outcomes following massive transfusion (MT) MethodsAll adult patients with critical bleeding who received a MT (defined as ≥10 units of RC in 24h) in 2008 and between January 2010 and December 2014 were identified. Blood and blood products transfused, in-hospital mortality, 24h and 90-day mortality were analysed for the period 2010–2014. Blood and blood product usage, massive transfusion protocol (MTP) activation and use of ROTEM between 2008 and 2014 were compared. ResultsA total of 190 MT including surgical (52.1%), gastro-intestinal bleeding (25.3%), trauma (11.6%) and obstetric haemorrhage (5.8%) episodes were identified between 2010 and 2014. The overall in-hospital mortality was 26.7% with a significant difference in 24h (p=0.04) and 90-day mortality (p=0.02) between diagnostic groups. Comparing 2008 (n=33) and 2014 (n=23), there was no significant difference in median RC, FFP and platelet units, cryoprecipitate doses and RC:FFP ratio; however there was an increase in number of patients who used cryoprecipitate (54.5% vs 87%, p=0.01). ConclusionAligned with haemostatic resuscitation, the trend continues in the form of increased use of plasma and higher RC:FFP transfusion ratios including an increase in number of patients receiving cryoprecipitate.

An Analysis of Blood Utilization for Stem Cell Transplant Patients in a Tertiary Care Hospital

Background and ObjectiveHaematopoietic stem cell transplant is a potentially curative treatment option in various benign and malignant haematological diseases. Patients undergoing stem cell transplant procedure require blood transfusion on a daily basis. Currently, there is paucity of data from developing countries on transfusion practices. This audit was undertaken to determine the consumption of packed red blood cells (PRBCs) transfusion in the bone marrow transplant unit of the Aga Khan University Hospital.Subjects and MethodsA retrospective audit was conducted for packed red cell transfusion ordering practice over a period from June 2014~June 2015. All consecutive patients, admitted for stem cell transplant procedure for various underlying diseases were included. Outcome measures used in this study were (i) cross match to transfusion (C: T) ratio and (ii) transfusion trigger.ResultsDuring the study period, n=25 patients underwent haematopoietic stem cell transplant. There were n=19 males and n=6 females. One patient was less than 15 years of age while rests were adults. Median age±SD was 26.5±14.5 years (12~54 years). The underlying diagnosis included Aplastic anemia (n=8), Thalassemia major (n=3), Multiple Myeloma (n=4), Acute leukemia (n=5), Hodgkin’s lymphoma (n=4), PRCA (n=1). Grand total consumption of PRBCs during the study period was 204 while 258 products were crossmatch. The C:T ratio was 1.26. The transfusion trigger was Hb level of less than 8 gms/dl.ConclusionThe results of our BMT unit indicate that the C:T ratio and transfusion trigger is comparable to the international benchmark.

Prognostic effect of different blood transfusion ratios in trauma patients with massive transfusion

Objective To evaluate the prognostic effect of different ratios of fresh frozen plasma (FFP) to packed red blood cells (PRBC) in massively transfused trauma patients. Methods A retrospective cohort study was conducted for 210 trauma patients who received more than 10 units of PRBC during the initial 24 hours from January 2007 to June 2015. The patients were divided into four groups: Group A(PRBC ∶FFP≤1, n=41), Group B (1 2, n=76). At 24 hours after admission, blood transfusion amount, blood transfusion ratios, post-transfusion adverse reactions (allergy, non-hemolytic febrile transfusion reaction, hemolysis, congestive heart failure, pulmonary edema, etc) and coagulation changes [hemoglobin (Hb), platelet count (PC), prothrombin time(PT), activated partial thromboplastin time(APTT), international normalized ratio (INR), etc] were compared among groups. Prognostic markers including sequential organ failure assessment(SOFA), hospital stay, ICU stay, 30-day mortality and causes of death were also evaluated. Results Use of PRBC was decreased significantly in Group A than in other groups (P 0.05). The coagulation indices (PT, APTT and INR) in Groups A and B were significantly decreased compared to Group D after transfusion (P 0.05). Group D was associated with higher SOFA and higher 30-day mortality than other groups(P 0.05). Meanwhile, ratio of patients died of massive hemorrhage in Group D was also higher than other groups (P<0.01). Kaplan-Meier survival analysis showed the survival interval was the shortest in Group D, while the longest in Group B and C. Conclusions Modest transfusion ratios(1. 5<PRBC ∶FFP≤2)within 24 hours can substantially improve outcomes in trauma patients. Aggressive ratios may improve coagulation indices and reduce use of PRBC, with no more benefit to the outcomes. Key words: Blood component transfusion; Wounds and injuries; Prognosis

Erythropoietin for cancer-associated malignant anemia: A meta-analysis.

The present study aimed to evaluate the effectiveness of erythropoietin (EPO) for improving cancer-associated malignant anemia. A search was performed for randomized clinical trials, conducted according to the Cochrane manual, using electronic databases including PubMed, EMBASE, the Cochrane Library and ClinicalTrails.gov up to 15 August 2015. A total of 6 eligible studies from 5 articles enrolling a total of 453 patients were entered into the current meta-analysis. Upon EPO treatment, there were significant differences in the change in hemoglobin (HB) levels compared with the placebo at short-term follow-up [mean difference (MD)=0.66; 95% confidence interval (CI), 0.14-1.18; I2=Not applicable; P=0.01) and long-term follow-up (MD=0.10; 95% CI, 0.02-0.18; I2=Not applicable; P=0.01) under the random effects model. For changes in hematocrit (HCT) compared with the placebo, the results revealed there were significant differences at short-term follow-up (MD=2.47; 95% CI, 0.75-4.19; I2=Not applicable; P=0.005) and long-term follow-up (MD=7.60; 95% CI, 6.15-9.05; I2=Not applicable; P<0.00001) under the random effects model. Compared with the placebo in short-term follow-up under the fixed effects model with homogeneity, the result was a significant difference for the transfusion ratio [relative risk (RR)=0.81; 95% CI, 0.67- 0.97; I2=34%; P=0.02) and the transfusion requirements (MD=-0.45; 95% CI, -0.92, 0.03; I2=6%; P=0.07). Funnel plots did not detect any publication bias. These results suggest that EPO was beneficial to alleviate cancer-associated anemia and improve survival outcomes for patients with cancer.

Hysterectomy and Peri-operative Blood Transfusion: Identifying Modifiable Risk Factors [31H

INTRODUCTION: Blood loss and subsequent blood transfusion is a common complication in benign gynecologic surgery that has been understudied. The purpose of this study is to identify risk factors associated with peri-operative blood transfusion and highlight those that are modifiable for abdominal and vaginal hysterectomy. METHODS: Using a retrospective study design between 1/1/2008 and 4/30/2014, 562 of 667 hysterectomies were included. Hysterectomies performed peripartum or for cancer were excluded. Risk factors examined include race, pre-operative hemoglobin, body mass index (BMI), surgical route, and uterine size. Comparisons between subgroups were performed using Chi-square or Wilcoxon test. Blood transfusion rate, odds ratio (OR) of transfusion and its 95% confidence interval (CI) were reported. Multiple logistic regression was used to identify potential risk factors for peri-operative blood transfusion. RESULTS: The overall transfusion rate was 13.3% (75/562) and differed for abdominal versus vaginal hysterectomy (18.0% vs. 6.8% P &lt; .001). Pre-operative hemoglobin less than 10.6 g/dL versus greater than or equal to 13.1 g/dL had five times the odds of transfusion (95% CI 2.4-13.5). Uterus size greater than 470 gm versus less than or equal to 108 gm had fourfold odds of transfusion (95% CI 1.5-14.3). African Americans had twice the odds of transfusion (95% CI 1.2-4.5), despite controlling for increased uterus size and lower hemoglobin. There was no statistically significant association between BMI and transfusion. CONCLUSION: This study identified lower pre-operative hemoglobin, larger uterus size, and African American race as three important risk factors. Prior to hysterectomy, hemoglobin should be optimized above 13.1 g/dL, especially for patients with large uteri and African Americans.

The effects of a data driven maximum surgical blood ordering schedule on preoperative blood ordering practices

ABSTRACTObjectives: The maximum surgical blood ordering schedule (MSBOS) provides guidelines for pre-operative pre-transfusion testing for elective surgical procedures. This study compared blood ordering and utilization during the period when the MSBOS was created by achieving consensus between the blood bank and the various surgical specialties, and after the introduction of an MSBOS created by using department-specific red blood cell (RBC) transfusion data (data driven MSBOS, dMSBOS).Methods: The dMSBOS was created by analyzing 12 months of RBC transfusion data for each procedure across a regional health system. Pre-transfusion testing and the RBC crossmatch:transfusion (C:T) ratios at 8 of the hospitals were compared between the 12 month period before the dMSBOS was introduced, and the 15 months after its introduction.Results: There were significant reductions in the median monthly number of type and screens not associated with RBC crossmatches (10 714–10 061; p < 0.0001) and the median number of type and screens associated with RBC crossmatches (10 127–9 349; p = 0.0014) on surgical patients after dMSBOS implementation. There were significant decreases in the median number of monthly RBC units crossmatched (2 981–2 444; p < 0.0001) and transfused (890–791; p < 0.0001) to surgical patients after implementing the dMSBOS. The overall system-wide C:T ratio trended down after dMSBOS implementation (from 3.34 to 3.17, p = 0.067).Discussion: Crossmatching fewer RBC units facilitates more efficient management of the blood bank’s inventory.Conclusion: The dMSBOS was effective in reducing the extent of unnecessary pre-transfusion testing before surgery and reduced the number of RBCs that were crossmatched for specific patients.

Improvement of Treatment Outcomes after Implementation of a Massive Transfusion Protocol: A Level I Trauma Center Experience

We assessed the effectiveness of the implementation of an institutional massive transfusion protocol (MTP) for resuscitation with a 1:1:1 transfusion ratio of packed red blood cell (PRBC), fresh frozen plasma, and platelet units. In a Level I trauma center database, all trauma admissions (2004-2012) that received massive transfusions (≥10 units PRBCs in the first 24 hours) were reviewed retrospectively. Demographic data, transfusion ratios, and outcomes were compared before (PRE) and after (POST) MTP implementation in May 2008. Age, sex, and mechanism of injury were similar between 239 PRE and 208 POST trauma patients requiring massive transfusion. Transfusion ratios of fresh frozen plasma:PRBC and platelet:PRBC increased after MTP implementation. Among survivors, MTP implementation shortened hospital length of stay from 31 to 26 days (P = 0.04) and intensive care unit length of stay from 31 to 26 days (P = 0.02). Linear regression identified treatment after (versus before) implementation of MTP as an independent predictor of decreased ventilator days after adjusting for age, Glasgow Coma Scale, and chest Abbreviated Injury Score (P < 0.0001). Modest improvement in ratios likely does not account for all significant improvements in outcomes. Implementing a standardized protocol likely impacts automation, efficiency, and/or timeliness of product delivery.

99 - Lenalidomide Plus Decitabine Treatment in a Del5Q Patient with RAEB-1 and Response in the Dependency to Transfusion and Blast Ratio

99 - Lenalidomide Plus Decitabine Treatment in a Del5Q Patient with RAEB-1 and Response in the Dependency to Transfusion and Blast Ratio

Blood transfusion practices in a tertiary care center in Northern India.

BACKGROUND:Blood transfusion plays vital roles in the medical and surgical practice. To achieve optimum use of blood, transfusion has to be appropriate and judicious consuming minimal resources and manpower.OBJECTIVE:To evaluate the pattern of blood transfusion requests and utilization with the aim of determining transfusion practice.MATERIALS AND METHODS:Blood request forms and cross-match worksheets at the blood bank were analyzed over a 6-month period. Numbers of requisitions, blood units cross-matched, issued out, transfused, and nontransfused were calculated. Nonusage probability (NUP) and the cross-match to transfusion ratio (CTR) for each clinical unit were computed.RESULTS:Two thousand two hundred and sixty-eight units of blood were cross-matched for 1487 patient's transfusion requests, out of which only 1455 (64.2%) were transfused giving a total CTR of 1.6 for the hospital. The CTR for the various clinical units were: Obstetrics and gynecology (O and G) 2.7, surgery 2.1, orthopedics 1.9, medicine 1.1, pediatrics 1, and oncology 1.CONCLUSIONS:The overall CTR (1.6) of the hospital was within the optimal range except for the O and G and surgery department which were having very high NUP and CTR indicating their suboptimal transfusion practices. Introducing revised transfusion guidelines, maximum surgical blood ordering schedule and type, screen, save, and abbreviated cross-match method can help toward adequate requisition and utilization of blood thereby reducing wastage of resources, time, and manpower.

Association Between Ratio of Fresh Frozen Plasma to Red Blood Cells During Massive Transfusion and Survival Among Patients Without Traumatic Injury

Hemostatic resuscitation has been shown to be beneficial for patients with trauma, but there is little evidence that it is equally beneficial for bleeding patients without trauma. The practice of a high transfusion ratio of fresh frozen plasma (FFP) to red blood cells (RBCs) has spread to other surgical and medical fields. To identify whether ratio-based resuscitation in patients without trauma is associated with improved survival. This study is a retrospective review of all massive transfusions provided in an urban academic hospital from January 1, 2009, through December 31, 2012. Massive transfusion was defined as the transfusion of at least 10 U of RBCs in the first 24 hours after a patient's admission to the operating room, emergency department, or intensive care unit. All patients who received massive transfusions within the study period and survived more than 30 minutes after hospital arrival were counted (n=865). Patients were grouped into those with trauma and those without trauma. Sources of data included the Research Patient Data Registry, patients' medical records, and blood bank records. All data collection occurred between April 26, 2013, and April 26, 2015. Data analysis took place from April 27, 2015, and June 22, 2016. Examination of FFP:RBC transfusion ratios for patients without trauma. There were 865 massive transfusion events that occurred within 4 years, transfusing 16 569 U of RBCs, 13 933 U of FFP, 5228 U of cryoprecipitate, and 22 635 U of platelets. Most of these transfusions were received by patients without trauma (767 [88.7%]), by men (582 [67.3%]), and for intraoperative bleeding (544 [62.9%]). The FFP:RBC ratios of survivors and nonsurvivors were nearly identical: the ratio for survivors was 1:1.5 (interquartile range [IQR], 1:1.1-1:2.2) and for nonsurvivors was 1:1.4 (IQR, 1:1.1-1:1.9; P = .43). Among the 767 patients without trauma, there was no difference in the adjusted odds ratio (aOR) for 30-day mortality when comparing the high FFP:RBC ratio vs the low FFP:RBC ratio subgroups (aOR, 1.10; 95% CI, 0.72-1.70; P = .65). In vascular surgery, the aOR for death favored the high FFP:RBC ratio subgroup (aOR, 0.16; 95% CI, 0.03-0.79; P = .02). However, in general surgery and medicine, the aOR for death favored the low FFP:RBC ratio subgroup; general surgery: aOR, 4.27 (95% CI, 1.28-14.22; P = .02); medicine: aOR, 8.48 (95% CI, 1.50-47.75; P = .02). High FFP:RBC transfusion ratios are applied mostly to patients without trauma, who account for nearly 90% of all massive transfusion events. Thirty-day survival was not significantly different in patients who received a high FFP:RBC ratio compared with those who received a low ratio.

Hemostatic Resuscitation in Peripartum Hysterectomy Pre- and Postmassive Transfusion Protocol Initiation.

Background Massive transfusion protocols (MTPs) have been examined in trauma. The exact ratio of packed red blood cells (PRBC) to other blood replacement components in hemostatic resuscitation in obstetrics has not been well defined. Objective The objective of this study was to evaluate hemostatic resuscitation in peripartum hysterectomy comparing pre- and postinstitution of a MTP. Study Design We conducted a retrospective, descriptive study of women undergoing peripartum hysterectomies from January 2002 to January 2015 who received ≥ 4 units of PRBC. Individuals were grouped into either a pre-MTP institution group or a post-MTP institution group. The post-MTP group was subdivided into those who had the protocol activated (MTP) versus not activated (no MTP). Primary outcomes were estimated blood loss (EBL) and need for blood product replacement. The secondary outcome was a composite of maternal morbidity, including need for mechanical ventilation, venous thromboembolism, pulmonary edema, acute kidney injury, and postpartum infection. A Mann-Whitney U test was used to compare continuous variables, and a chi-squared test was used for categorical variables with significance of p < 0.05. Results Of the 165 women who had a peripartum hysterectomy during the study period, 62 received four units or more of PRBC. No significant differences were noted in EBL or blood product replacement between the pre-MTP (n = 39) and post-MTP (n = 23) groups. Similarly, the MTP (n = 6) and no MTP (n = 17) subgroups showed no significant difference between EBL and overall blood product replacement. Significant differences were seen in transfusion of individual blood products, such as fresh frozen plasma (FFP) (MTP = 4, no MTP = 2; p = 0.02) and platelets (plts) (MTP = 6, no MTP = 0; p = 0.03). The use of high ratio replacement therapy for both plasma and plts was more common in the MTP group (FFP/PRBC ratio [MTP = 0.5, no MTP = 0.3; p = 0.02]; plts/PRBC ratio [MTP = 0.7, no MTP = 0; p = 0.03]). There were no differences in the secondary outcome between pre- and post-MTP or MTP and no MTP. Conclusion Initiation of the MTP did result in an increase in transfusion of FFP and plts intraoperatively. At our institution, the MTP is underutilized, but it appears that providers are more cognizant of the use of high transfusion ratios.

Damage control laparotomy utilization rates are highly variable among Level I trauma centers: Pragmatic, Randomized Optimal Platelet and Plasma Ratios findings.

Damage control laparotomy (DCL) is intended to limit deleterious effects from trauma-induced coagulopathy. DCL has been associated with mortality reduction, but may increase complications including sepsis, abscess, respiratory failure, hernia, and gastrointestinal fistula. We hypothesized that (1) DCL incidence would vary between institutions; (2) mortality rates would vary with DCL rates; (3) standard DCL criteria of pH, international normalized ratio, temperature and major intra-abdominal vascular injury would not adequately capture all patients. Trauma patients at 12 Level 1 North American trauma centers were randomized based on transfusion ratios as described in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial. We analyzed outcomes after emergent laparotomy using a mixed-effects logistic model comparing DCL versus definitive surgical management with random effect for study site. Primary outcomes were 24-hour and 30-day mortality. Three hundred twenty-nine patients underwent emergent laparotomy: 213 (65%) DCL and 116 (35%) definitive surgical management. DCL rates varied between institutions (33-83%), (p = 0.002). Median Injury Severity Score (ISS) was higher in the DCL group, 29 (interquartile range, 13-34) versus 21 (interquartile range, 22-41) (p < 0.001). Twenty-four-hour mortality was 19% with DCL versus 4% (p < 0.001); 30-day mortality was 28% with DCL versus 19% (p < 0.001). In a mixed-effects model, ISS and major intra-abdominal vascular injury were correlates of DCL (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02-1.07 and OR, 2.7; 95% CI, 1.4-5.2). DCL was not associated with 30-day mortality (OR, 2.33; 95% CI, 0.97-5.60). Correlates included ISS (OR, 1.06; 95% CI, 1.02-1.09), PRBCs in 24 hours (OR, 1.10; 95% CI, 1.03-1.18), and age (OR, 1.04; 95% CI, 1.01-1.06). No significant mortality difference was detected between institutions (p = 0.63). Sepsis and VAP occurred more frequently with DCL (p < 0.05). Eighty percent (135/213) of DCL patients met standard criteria. Although DCL utilization varied significantly between institutions, there was no significant mortality difference between centers. This finding suggests tempering DCL use may not decrease mortality, but could decrease related complications. Therapeutic study, level III.

Sickle cell disease and pregnancy outcomes: a study of the community-based hospital in a tribal block of Gujarat, India

BackgroundSickle cell disease (SCD) is a hereditary blood disorder prevalent in tribal regions of India. SCD can increase complications during pregnancy and in turn negatively influence pregnancy outcomes. This study reports the analysis of tribal maternal admissions in the community-based hospital of SEWA Rural (Kasturba Maternity Hospital) in Jhagadia block, Gujarat. The objective of the study is to compare the pregnancy outcomes among SCD, sickle cell trait and non-SCD admissions. This study also estimated the risk of adverse pregnancy outcomes for SCD admissions.MethodsThe data pertains to four and half years from March 2011 to September 2015. The total tribal maternal admissions were 14640, out of which 10519 admissions were deliveries. The admissions were classified as sickle cell disease, sickle cell trait and non-sickle cell disease. The selected pregnancy outcomes and maternal complications were abortion, stillbirth, Caesarean section, haemoglobin levels, blood transfusion, preterm pregnancy, newborn birth weight and other diagnosed morbidities (IUGR, PIH, eclampsia, preterm labour pain). The odds ratios for each risk factor were estimated for sickle cell patients. The odds ratios were adjusted for the respective years.ResultsOverall, 1.2% (131 out of 10519) of tribal delivery admissions was sickle cell admissions. Another 15.6% (1645 out of 10519) of tribal delivery admissions have sickle cell trait. The percentage of stillbirth was 9.9% among sickle cell delivery admission compared to 4.2% among non-sickle cell deliveries admissions. Among sickle cell deliveries, 70.2% were low birth weight compared to 43.8% of non-sickle cell patient. Similarly, almost half of the sickle cell deliveries needed the blood transfusion. The 45.0% of sickle cell delivery admissions were pre-term births, compared to 17.3% in non-SCD deliveries. The odds ratio of severe anaemia, stillbirth, blood transfusion, Caesarean section, and low birth weight was significantly higher for sickle cell admissions compared to non-sickle cell admissions.ConclusionsThe study exhibited that there is a high risk of adverse pregnancy outcomes for women with SCD. It may also be associated with the poor maternal and neonatal health in these tribal regions. Thus, the study advocates the need for better management of SCD in tribal Gujarat.

Arranging blood for elective thyroid surgeries: dilemma continues in the developing world

BackgroundCross matched blood is frequently ordered based on a subjective anticipation of blood loss for a procedure. Excessive blood arrangement and wastage overburdens the blood bank in terms of work load and storage of blood, increases cost of medical care and results in injudicious use of a limited resource. The aim of this short report is to assess the current practice for arranging cross matched blood in elective thyroid surgeries by comparing cross match to blood transfused ratio.FindingsMedical records for all patients from January 2009 to December 2014 undergoing thyroid surgery were retrieved and reviewed through electronic health information management system (HIMS). A total of 91 patients were included in the study, out of which 18 (19.7%) were male and 73 (80.2%) were female. A total of 107 units of blood were arranged and only 9 were transfused. 47 patients underwent a total thyroidectomy, while 44 underwent a hemithyroidectomy. The cross match to transfusion ratio came out to be 11.88.ConclusionsRoutine arrangement of cross matched blood is not required in elective thyroid surgeries. All institutions should have a maximum blood ordering schedule planned for elective procedures, and blood products should be arranged accordingly to avoid unnecessary cross matching.

Are we cross-matching too much blood for elective open abdominal aortic aneurysm repair?

Objectives:This study aims to identify current blood transfusion requirements in elective open abdominal aortic aneurysm repair and to compare this to an existing maximum surgical blood order schedule.Methods:We retrospectively identified patients who underwent elective open abdominal aortic aneurysm repair over a 40-month period in our institution. Pre-operative number of units cross-matched and the number of units actually transfused were identified. The cross-match to transfusion ratio was then calculated.Results:Blood transfusion at any time post-operatively was required in 23 (48.9%) cases. Patients needing an intra-operative blood transfusion had a median of 2 units. Of the pre-operative cross-matched units (123), only 43 were used, giving a cross-match to transfusion ratio of 2.86.Conclusion:Our current maximum surgical blood order schedule is poorly followed and a cross-match to transfusion ratio of 2.86 indicates we are cross-matching too many units for elective open abdominal aortic aneurysm repair. A carefully considered individualised management of blood products, with the requirement of at least a valid group and save sample, may be more appropriate.

Combined effect of therapeutic strategies for bleeding injury on early survival, transfusion needs and correction of coagulopathy.

The combined effects of balanced transfusion ratios and use of procoagulant and antifibrinolytic therapies on trauma-induced exsanguination are not known. The aim of this study was to investigate the combined effect of transfusion ratios, tranexamic acid and products containing fibrinogen on the outcome of injured patients with bleeding. A prospective multicentre observational study was performed in six level 1 trauma centres. Injured patients who received at least 4 units of red blood cells (RBCs) were analysed and divided into groups receiving a low (less than 1 : 1) or high (1 or more : 1) ratio of plasma or platelets to RBCs, and in receipt or not of tranexamic acid or fibrinogen products (fibrinogen concentrates or cryoprecipitate). Logistic regression models were used to assess the effect of transfusion strategies on the outcomes 'alive and free from massive transfusion' (at least 10 units of RBCs in 24 h) and early 'normalization of coagulopathy' (defined as an international normalized ratio of 1·2 or less). A total of 385 injured patients with ongoing bleeding were included in the study. Strategies that were independently associated with an increased number of patients alive and without massive transfusion were a high platelet to RBC ratio (odds ratio (OR) 2·67, 95 per cent c.i. 1·24 to 5·77; P = 0·012), a high plasma to RBC ratio (OR 2·07, 1·03 to 4·13; P = 0·040) and treatment with tranexamic acid (OR 2·71, 1·29 to 5·71; P = 0·009). No strategies were associated with correction of coagulopathy. A high platelet or plasma to RBC ratio, and use of tranexamic acid were associated with a decreased need for massive transfusion and increased survival in injured patients with bleeding. Early normalization of coagulopathy was not seen for any transfusion ratio, or for use of tranexamic acid or fibrinogen products.

Injury severity, sex, and transfusion volume, but not transfusion ratio, predict inflammatory complications after traumatic injury

BackgroundBlood component (packed red blood cells [PRBC], fresh frozen plasma [FFP], platelets [PLT]) ratios transfused in a 1:1:1 fashion are associated with survival after trauma; the relationship among blood component ratios and inflammatory complications after trauma is not fully understood. ObjectivesTo evaluate the relationship among blood component ratios (1:1 vs other for PRBC:FFP and PRBC:PLT) and inflammatory complications (primary outcome) in patients with major trauma. MethodsSecondary analysis of a multi-institution database (N = 1538). Survival methods were used to determine the relationship among blood component ratios and inflammatory complications. ResultsPatients were primarily male (68%), Caucasians (89%), aged 39 ± 14 years, involved in a motor vehicle collision (53%). Eighty-six percent of patients developed an inflammatory complication; 76% developed organ failure, 27% ventilator-associated pneumonia, and 24% acute respiratory distress syndrome. Injury severity, sex, and total PRBC transfusion volume, not blood component ratio, predicted inflammatory complications. ConclusionsIncreased understanding of factors associated with inflammation after trauma and PRBC transfusion is needed.

Massive blood loss in elective spinal and orthopedic surgery: Retrospective review of intraoperative transfusion strategy

ObjectiveTo evaluate the perioperative dynamics of hematologic changes and transfusion ratio in patients undergoing a major spinal surgery accompanied with massive bleeding defined as blood loss >5 liters. DesignRetrospective cohort study. SettingOperating room of a university-affiliated hospital. PatientsAdult patients who underwent elective neurosurgical, orthopedic, or combined spinal surgical procedure between 2008 and 2012. MethodsPatients who underwent a major spinal or orthopedic surgery and who experienced major bleeding (>5 L) during surgery were identified and selected for final analysis. The following information was analyzed: demographics, clinical diagnoses, hematologic parameters, estimated intraoperative blood loss, blood product transfusions, and survival 1 year after surgery. ResultsDuring the study period, 25 patients, who underwent 28 spinal procedures, experienced intraoperative blood loss >5 L. Mean patient age was 50.5 years and 56.4% were males. The majority of patients underwent procedures to manage spinal metastases. Median estimated intraoperative blood loss was 11.25 L (IQR 6.35-22 L) and median number of units (U) transfused was 24.5 U (IQR 14.0-32.5 U) of packed red blood cells (RBCs), 24.5 U (IQR 14.0-34.0 U) of fresh frozen plasma (FFP), and 4.5 U (IQR 3.0-11.5 U) of platelets (PLTs). The blood product transfusion ratio was 1 and 4 for RBC:FFP, and RBC:PLT, respectively. Hematocrit, hemoglobin, PLTs, partial thromboplastin, prothrombin time, INR, and, fibrinogen varied significantly throughout the procedures. However, acid-base status did not change significantly during surgery. Patients' survival at 1 year was 79.17%. ConclusionOur results indicate that a 1:1 RBC:FFP and 4:1 RBC:PLT transfusion ratio was associated with significant intraoperative variations in coagulation variables but stable intraoperative acid-base parameters. This transfusion ratio helped clinicians to achieve postoperative coagulation parameters not significantly different to those at baseline. Future studies should assess if more liberal transfusion strategies or point of care monitoring might be warranted in patients undergoing spinal surgery at risk of major blood loss.