Transfusion Registry Research Articles

Ultra-Massive Transfusion: Predictors of Occurrence and In-Hospital mortality From the Australian and New Zealand Massive Transfusion Registry (ANZ-MTR)

Few data exist on patient clinical characteristics, predictors of occurrence and short- and long-term outcomes of ultra-massive transfusion (UMT), defined as receiving 20 units or more of red blood cells (RBCs) within 48h. This study analyses UMT events from the Australian and New Zealand Massive Transfusion Registry (ANZ-MTR). The ANZ-MTR captured all patients at 29 participating sites receiving a massive transfusion (MT), defined as ≥5 units of RBCs within 4h. Of 9028 patients, 803 (8.9%) received an UMT. UMT patients were younger than other MT patients (median age 57y vs 62y; P < .001). In UMT and MT, males predominated (66.3% and 62.9%, respectively); and context was predominantly trauma (28.8% and 23%) and cardiothoracic surgery (CTS) (21.7% and 20.3%). Median RBC units received within 4h were 16 (UMT) and 6 (MT). In UMT, 4h FFP:RBC ratio (0.6 vs 0.4, P < .001), and 4h cryoprecipitate use (72.9% vs 39.9%, P < .001) were higher. Independent predictors of UMT (Odds Ratio; 95% CI) were age <60y (1.52; 1.28-1.79), baseline Hb >100g/L (1.31; 1.08-1.59), INR >1.5 (1.56; 1.24-1.96), and APTT >60s (4.49; 3.40-5.61). Predictors of in-hospital mortality in UMT included Charlson Comorbidity Index score ≥3 (11.20, 0.60 - 25.00) and bleeding context, with mortality less likely in liver transplant (0.07, 0.01-0.41) and more likely in vascular surgery (8.27, 1.54-72.85), compared with CTS. In-hospital mortality was higher in the UMT group compared with MT group (20.5% vs 44.2%, P < .001), however 5y survival following discharge was not significantly different between the groups (HR=0.87 [95%CI 0.64-1.18], P = .38). UMT patients are more commonly younger, with baseline coagulopathy, and have higher in-hospital mortality compared with MT. However, UMT is not futile: 55.8% survived to discharge, without significant difference in survival postdischarge between the groups.

A voluntary transfusion recipient registry in Korea as a database for blood group antibodies.

Several types of transfusion-related registries have been developed to improve patient outcomes and blood banks. In Korea, a transfusion program functioning as a blood group antibody database and a reference laboratory has been in operation since July 2013. This study was conducted to determine the current status of blood group antigens and antibodies in Korea and propose a model for registries in the field of transfusion medicine. Cases with unexpected red cell antibodies were registered online in the voluntary transfusion registry. Specific antigen-negative frequencies were calculated based on the recorded data. To determine the frequencies of RhCE antigens, data added via the Blood Information Sharing System were also analyzed. Data added to the registries between July 2013 and June 2022 were included in the analysis. Among 9,048 antibody cases registered from 29 hospitals, anti-E alone was identified most commonly, followed by anti-E and c, anti-C and e, anti-Lea, and anti-M (2,202, 1,792, 757, 618, and 383 cases, respectively). The frequencies of E-, E-c-, C-e-, Le(a-), and M- were 49.1%, 41.6%, 9.1%, 69.4%, and 21.8%, respectively. The distributions of antibodies and antigen frequencies were estimated through the transfusion registry. Antigen frequencies were calculated based on the results of antigen typing of red blood cell components performed at the time of issuing. The online transfusion registry serving as a blood group antibody database is useful for determining the frequencies of blood group antigens and antibodies.

A retrospective analysis of haemolytic reactions to intravenous immunoglobulin using data from the Transfusion-Transmitted Injuries Surveillance System (Ontario).

Haemolysis can occur following intravenous immunoglobulin (IVIG) infusion. Haemovigilance data were analysed using a novel approach for including two control groups with no haemolysis to IVIG. Objectives included a summary of all reactions to IVIG, rate estimates and analysis of haemolytic reactions including risk factors. Canadian haemovigilance data from Ontario (2013-2021), IVIG distribution and transfusion data from the blood supplier, and data from a large local transfusion registry were used. An 'other-reactions' control group included patients with IVIG reactions that were not haemolytic, and registry patients with no-reaction were the 'no-reaction controls'. Descriptive analysis and two logistic regression models for the different control groups were performed. One thousand one hundred and seventy reactions were included. Most common were febrile non haemolytic (26.1%), minor allergic (24.5%) and IVIG headache (15.3%) followed by haemolytic 10.9% (128/1170). Haemolytic reaction rates decreased over time: rates since 2020 estimated between 1.5 and 2.9/1000 kg IVIG used. The regression model for other-reaction controls identified two risk factors for haemolysis: non-O blood group recipients compared with group O recipients (p value = 0.0106) and IVIG dose per 10 g increase (OR 1.359; 95% CI 1.225-1.506). The model using no-reaction controls gave similar results and also showed no pre-medication was associated with a higher risk of haemolysis (OR 29.084; 95% CI 1.989-425.312). The frequency of haemolytic reactions has decreased over time. We confirmed non-O blood group recipients and IVIG dose as risk factors for haemolysis and raise the hypothesis that no pre-medication may increase the risk of haemolysis.

Critical peptic ulcer bleeding requiring massive blood transfusion: outcomes of 270 cases.

Critical peptic ulcer bleeding requiring massive transfusion is a gastroenterological emergency. Few data exist on management and outcomes. The Australian and New Zealand Massive Transfusion Registry collects comprehensive data on adult patients receiving massive transfusion across all bleeding contexts. To evaluate clinical factors, management (procedural interventions, transfusions) and outcomes after massive transfusion for critical peptic ulcer bleeding. Demographics, diagnosis, procedures and mortality data were available for 5482 massive transfusion cases from 23 hospitals. International Classification of Diseases 10th Edition, Australian Modification codes were used to determine peptic ulcer bleeding and the Australian Classification of Health Intervention for interventions (i.e. endoscopic, radiological, surgical). Peptic ulcer bleeding accounted for 270 (4.9%) of all in-hospital massive transfusion cases; 70% were male. Median number of red blood cell (RBC) units transfused was 7 (interquartile range, 6-10). Thirty-day mortality was 19.6%. Age (75 vs 67 years; P = 0.009) and Charlson Comorbidity Index (3 vs 1; P < 0.001) were higher in those who died. Highest 24-h international normalised ratio (1.5 vs 1.4; P < 0.001) and creatinine (118 μmol/L vs 96 μmol/L; P = 0.03) and nadir platelet count (86 × 109 /L vs 118 × 109 /L; P = 0.01) were also associated with 30-day mortality. There were no differences in mortality according to number of RBC, platelets or plasma units transfused, gastroscopy (with or without intervention), interventional radiology or surgery. One in five patients with critical peptic ulcer bleeding requiring massive transfusion died by 30 days. Mortality was associated with patient characteristics rather than clinical interventions (e.g. procedures, blood product transfusion).

Perioperative Anemia Management in Women Undergoing Gynecologic Procedures: A 10 Year Multisite Study

BackgroundPreoperative anemia is a known risk factor for adverse patient outcomes. In women undergoing gynecologic surgery, preoperative anemia is independently associated with increased 30-day mortality, surgical complications, and hospital re-admission. Women with abnormal uterine bleeding and women undergoing gynecologic surgery remain under-studied and over-transfused. Patient blood management (PBM) initiatives are emerging from growing awareness of adverse outcomes associated with preoperative anemia. PBM efforts involve optimizing red cell mass and limiting unnecessary red blood cell (RBC) transfusions, with the goal of improving outcomes. Iron deficiency is a common cause of anemia in women with gynecologic sources of blood loss, and early identification and repletion of iron stores is an important component of PBM. Our research evaluated perioperative RBC utilization and intravenous (IV) iron use in women undergoing gynecologic procedures at three large academic hospitals.MethodsThis retrospective cohort study used data from the Transfusion Registry for Utilization Surveillance and Tracking database, a multihospital database network in Ontario, Canada. Canadian Classification of Health Interventions codes were used to identify women aged 15 and older who underwent gynecologic surgery with a hospital admission between January 1, 2010 and December 31, 2019 at three academic hospitals. Patients undergoing gynecologic surgery with malignant and non-malignant conditions were included. Patients who were pregnant and immediately postpartum were excluded. Collected data included patient demographics, laboratory investigations, RBC utilization, IV iron use, hospital length of admission, intensive care unit (ICU) admission, and in-hospital mortality. Data was collected from 90 days prior to gynecologic surgery to 30 days post gynecologic surgery. Only the first gynecologic surgery per patient was included in the analysis. Patients with an underlying malignancy were analyzed separately from patients without a malignancy diagnosis.ResultsA total of 4,822 patients with a gynecologic surgery were identified during the study period, with 4,842 hospital admissions. 3,687 patients had a malignancy diagnosis.We identified that 27.3% of all gynecologic surgery patients were anemic (hemoglobin (Hb) <120 g/L) on preoperative bloodwork. In the malignancy group, 798 patients (21.6%) received at least 1 unit RBC in the perioperative period, with 2.9% transfused in the 90 days prior to surgery, 12.6% transfused on the day of surgery, and 13.0% transfused within 30 days post-surgery. Of the non-malignancy patients, 58 patients (5.1%) had at least 1 unit RBC in the perioperative period, with 0.8% transfused in the 90 days prior to surgery, 1.9% transfused on the day of surgery, and 3.4% transfused within 30 days post-surgery (Table 1).Only 0.6% of patients in the malignancy group and 0.4% of patients in the non-malignancy group received IV iron in the perioperative period.Patients with a preoperative Hb< 120 g/L had an increased rate of ICU admission and longer hospital admission compared to patients with a preoperative Hb > 120 g/L; adverse outcomes were higher in patients with Hb< 80 g/L (Table 2). A logistic regression model adjusting for baseline characteristics demonstrated an association between preoperative anemia and ICU admission compared to non-anemic patients: for Hb 80-120 g/L, odds ratio (OR) 1.53, 95% CI 1.27-1.85, P <.0001; for Hb<80 g/L, OR 2.81, 95% CI 1.45-5.46, P=.0022.There was no significant change in transfusion rates from 2010 to 2019 (Figure 1).ConclusionOur retrospective cohort study of women undergoing gynecologic surgery is consistent with the findings of previous studies demonstrating that preoperative anemia is associated with adverse clinical outcomes in this population. IV iron was under-utilized in our study cohort; increased use of IV iron may have reduced unnecessary perioperative transfusions. 1 in 6 women in our study were transfused in the perioperative period. The appropriateness of these transfusions and the potential for preventing RBC transfusion in this patient population warrant further investigation. In contrast to other surgical specialties, transfusion rates in the gynecologic surgery population have been static over the past decade, suggesting a need for further PBM initiatives in this group. [Display omitted] DisclosuresZeller: Canadian Blood Services: Consultancy, Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding; Canadian Insitutes of Health Research: Research Funding; American Society of Hematology: Honoraria.

Coagulopathy Is a Strong Independent Predictor Of In-Hospital Mortality Following Massive Transfusion: Initial Results From The Australian and New Zealand Massive Transfusion Registry (ANZ-MTR)

IntroductionIn trauma, the presence of coagulopathy with or without critical bleeding (CB) is associated with poorer outcomes. However in non-trauma patients, it is unknown what proportion of CB patients are coagulopathic. We aimed to characterise the presence of coagulopathy in a representative cohort of massive transfusion (MT) recipients and explore what factors, including coagulopathy, were associated with in-hospital mortality. MethodsThe Australian and New Zealand Massive Transfusion Registry (ANZ-MTR), established in 2011, collects information on CB in all clinical contexts. In the pilot phase, all adult CB patients who received a MT (defined as ≥5 units of red blood cells [RBC] in 4hrs) were identified at 9 Australian hospitals. Transfusion history, laboratory results and hospital administrative data were extracted. Coagulopathy was defined as INR >1.5 or aPTT >60 s using the most recent laboratory test results following the onset of MT (post-MT). The association between mortality and patient characteristics and therapy were explored using multiple logistic regression. ResultsA total of 1263 MT cases occurred in 1242 patients (1% had 2x MTs). Median age was 64 (IQR 49-76) years; 64% were male. The majority of cases of CB were surgical (total 55%) followed by GI bleeding (17%). Of the 1147 (91%) MT cases with an aPTT or INR result available post-MT, 37% (n=472) were coagulopathic. Of these, 44% (n=209) were also coagulopathic preceding the onset of MT (pre-MT). Of the total group, 474 (38%) had no recorded pre-MT coagulation results. Patient characteristics are presented in Table 1. Presence of coagulopathy post-MT was associated with surgical causes of CB, low post-MT Hb level, higher use of all fresh blood components, increased prothrombinex use and in-hospital mortality. Independent predictors of in-hospital mortality following multivariate logistic regression were coagulopathy (OR= 2.94; 95%CI=2.09-4.16, p<0.001), certain causes of CB including medical (mainly hem/onc & liver disease; OR= 4.63; 95%CI=1.85-11.60, p=0.001), vascular surgery (OR= 2.44; 95%CI=1.27-4.66, p=0.007), GI bleeding (OR= 2.12; 95%CI=1.31-3.43, p=0.002), liver surgery (OR= 0.40; 95%CI=0.18-0.90, p=0.03), age (OR= 1.02; 95%CI=1.01-1.03, p<0.001), and units of RBC (OR= 1.01; 95%CI=1.00-1.02, p=0.03) and cryo (OR= 1.02; 95%CI=1.00-1.03, p<0.001). ConclusionPresence of coagulopathy early in MT varied accordingly to clinical context, with surgical causes of CB having the highest rates of coagulopathy and obstetric haemorrhage the lowest. Coagulopathy remained a predictor of in-hospital mortality independent of the clinical context. Data generated by the Australian and New Zealand Massive Transfusion Registry, provides a unique opportunity to explore differences in the pathophysiology of CB across clinical settings and the management and outcomes of this diverse patient population. Disclosures:Zatta:CSL Behring: Research Funding. Andrianopoulos:Monash University: Consultancy, Honoraria. Phillips:CSL Behring: Research Funding. Isbister:Johnson & Johnson: Honoraria. Wood:CSL Behring: Research Funding.

No Association between Age of Transfused Red Cells and 30-Day Mortality in Massively Transfused Patients: Results from the Australian and New Zealand Massive Transfusion Registry

BackgroundClinical trials studying age of transfused red blood cells (RBCs) have found no evidence of benefit from transfusion of fresher RBCs. However, these studies have not included patients requiring massive transfusion for major bleeding, a patient population that may be more susceptible to adverse effects of the RBC storage lesion. Further, no clinical trials have specifically evaluated the safety of transfusing RBCs approaching expiry (30-42 days). We investigated the association between RBC storage time and 30-day mortality in a large cohort of massively transfused patients (5 RBCs within 4 hours, from any bleeding context).MethodsUsing 2007-2015 Australian/NZ Massive Transfusion Registry data from 25 hospitals linked with Australian and New Zealand National Death Index data, we modelled the association between storage time and 30-day mortality in massively transfused patients. Our logistic regression model adjusted for Charlson co-morbidity score, patient age, patient sex, number of RBC units transfused, and bleeding category (cardiothoracic, gastrointestinal, obstetric, surgical, trauma, vascular surgery, or other) with treating hospital as a random-effects grouping variable. Storage time was quantified as the mean storage time of all units each patient received for our primary analysis, and as a binary predictor indicating patients receiving only RBCs older than 30 days for our secondary analysis. As sensitivity analyses, we stratified patients by number of RBC units received and ran our model individually on each stratum containing more than 50 patients receiving equivalent numbers of RBCs in order to eliminate any confounding introduced by comparing patients receiving differing numbers of RBCs. In our stratified sensitivity analyses, in addition to mean storage time of RBC units received by each patient, we tested minimum and maximum storage times of transfused RBC units as predictors.Results4127 patients meeting the massive transfusion definition during the study period had RBC age available. Stratifying on number of RBC units transfused resulted in 19 strata containing more than 50 patients (those receiving 5,6,7,...23 RBC units), comprising 3641 patients (88% of study population). In the analysis of the entire cohort together, we found no significant association between mean storage duration and 30-day mortality (ORST=0.99 [95%CI: 0.98 to 1.01]; p=0.42) or patients transfused with only RBCs >30days old and 30-day mortality (ORST>30d=0.85 [95%CI: 0.52 to 1.37]; p=0.49). In our stratified sensitivity analyses, we found no association between mean storage time and 30-day mortality (OR for a 1-day increase in mean storage time [ORmeanST] range = 0.95 to 1.08 with p>0.05 for entire range). We likewise found no associations between maximum and minimum storage times and 30-day mortality (ORmaxST range = 0.93 to 1.05 with p>0.05 for all but one stratum; ORminST range = 0.94 to 1.04 with p>0.05 for all strata). For all three stratified sensitivity analyses, we observed no trend in ORST across the strata of patients receiving equivalent numbers of RBCs (figure 1 shows the stratified analysis with mean storage time as the predictor).ConclusionsWe found no association between storage time of transfused RBCs and 30-day mortality in a large cohort of massively transfused patients. Our findings were consistent both for the cohort as a whole and within strata of patients receiving equivalent numbers of RBC transfusions. Additionally, we observed no association when we modelled storage duration as maximum RBC age, minimum RBC age, or when we considered patients receiving only RBCs >30 days old. Our conclusions are consistent with recent large randomised trials which have not demonstrated mortality benefit from transfusing fresher RBCs. Differences in our findings and those of previous observational studies reporting correlations between storage time and mortality may be due to methodological differences: specifically, our stratified analysis eliminated the potential confounding effect of number of RBCs transfused, and we more accurately modelled the storage lesion as a continuous function by using mean storage age rather than comparing patients who received only RBCs above or below arbitrary storage time thresholds. In conclusion, we find no evidence that fresher blood leads to better clinical outcomes in massively transfused patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Age of red blood cells is not associated with in-hospital mortality in massively transfused patients.

Studies comparing mortality following massive transfusion (MT) with fresher versus longer-stored red blood cells (RBCs) have focused on trauma patients. The Australian and New Zealand Massive Transfusion Registry collects data on all adult MT cases (≥5 RBCs within 4 hours, any bleeding context, ≥18 years) at participating hospitals. Years 2007 to 2018 data from 29 hospitals were analyzed to quantify the association between mortality and RBC storage time in adult MT cases. We ran three logistic regression models separately on each of seven bleeding contexts, with in-hospital mortality as the outcome and, in turn, (1) mean storage time (STmean) quartiles, (2) proportion of RBCs ≥30 days old (propOLD), and (3) scalar age of blood index as predictors. A total of 8,685 adult MT cases involving transfusion of 126,622 RBCs were analyzed with Australian and New Zealand data analyzed separately. Mean storage times for these cases were (by quartile in ascending order) as follows: Australia, 12.5 days (range, 3.1-15.5 days), 17.7 (15.5-19.9), 22.3 (19.9-24.9), and 29.8 (24.9-41.7); New Zealand, 11.3 days (3.6-13.7), 15.3 (13.7-16.8), 18.7 (16.8-20.7), and 24.5 (20.7-35.6). The odds ratios comparing in-hospital mortality for each quartile with that of the control first quartile (freshest blood), proportion of longer-stored (≥30 days) RBCs, and scalar age of blood index were not statistically significant across all bleeding contexts. We find no correlation between in-hospital mortality and storage time of transfused RBCs in a large cohort of adult MT patients representing all bleeding contexts. These results are consistent with those of recent large multicenter trials. Epidemiologic, level III; Therapeutic, level IV.

Utilising red cell antigen genotyping and serological phenotyping in sickle cell disease patients to risk-stratify patients for alloimmunisation risk.

Alloimmunisation and haemolytic transfusion reactions (HTRs) can occur in patients with sickle cell disease (SCD) despite providing phenotype-matched red blood cell (RBC) transfusions. Variant RBC antigen gene alleles/polymorphisms can lead to discrepancies in serological phenotyping. We evaluated differences between RBC antigen genotyping and phenotyping methods and retrospectively assessed if partial antigen expression may lead to increased risk of alloimmunisation and HTRs in SCD patients at a tertiary centre in Canada. RBC antigen phenotyping and genotyping were performed by a reference laboratory on consenting SCD patients. Patient demographic, clinical and transfusion-related data were obtained from a local transfusion registry and chart review after research ethics board approval. A total of 106 SCD patients were enrolled, and 91% (n = 96) showed additional clinically relevant genotyping information when compared to serological phenotyping alone. FY*02N.01 (FY*B GATA-1) (n = 95; 90%) and RH variant alleles (n = 52, 49%; majority accompanied by FY*02N.01) were common, the latter with putative partial antigen expression in 25 patients. Variability in genotype-phenotype antigen prediction occurred mostly in the Rh system, notably with the e antigen (kappa: 0.17). Fifteen (14.2%) patients had a history of alloimmunisation, with five having HTR documented; no differences in clinical outcomes were found in patients with partial antigen expression. Genotype/extended-phenotype matching strategies may have prevented alloimmunisation events. We show a high frequency of variant alleles/polymorphisms in the SCD population, where genotyping may complement serological phenotyping. Genotyping SCD patients before transfusion may prevent alloimmunisation and HTRs, and knowledge of the FY*02N.01 variant allele increases feasibility of finding compatible blood.

Accuracy of Blood Transfusion Records in a Population-based Perinatal Data Registry.

Blood transfusion is frequently used as an indicator of severe maternal morbidity during pregnancy. However, few studies have examined its validity in population perinatal databases. We linked a perinatal database from British Columbia, Canada, with the province's Central Transfusion Registry for 2004-2015 deliveries. Using the Central Transfusion Registry records for red blood cell transfusion as the gold standard, we calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the perinatal database variable for red blood cell transfusion, overall and by transfusion risk factor status. We used multivariable logistic regression to examine whether outcome misclassification altered the odds ratios for different transfusion risk factors. Among 473,688 deliveries, 4,033 (8.5 per 1,000) had a red blood cell transfusion according to the Central Transfusion Registry. The sensitivity of the perinatal database transfusion variable was 72.3 [95% confidence interval (CI) = 72.2, 72.4]. Sensitivity differed according to the presence of many transfusion risk factors (e.g., 84.9% vs. 72.2% in deliveries with versus without uterine rupture). Odds ratios associated with some transfusion risk factors were exaggerated when the perinatal database transfusion variable was used to define the outcome instead of the Central Transfusion Registry variable, but 95% confidence intervals for these estimates overlapped. Blood transfusion was documented with reasonable sensitivity in this large population perinatal database. However, validity varied according to risk factor status. Our findings enable researchers to better account for outcome misclassification in studies of obstetrical transfusion risk factors.

Haematological features, transfusion management and outcomes of massive obstetric haemorrhage: findings from the Australian and New Zealand Massive Transfusion Registry

Massive obstetric haemorrhage (MOH) is a leading cause of maternal morbidity and mortality world-wide. Using the Australian and New Zealand Massive Transfusion Registry, we performed a bi-national cohort study of MOH defined as bleeding at ≥20weeks' gestation or postpartum requiring ≥5 red blood cells (RBC) units within 4h. Between 2008 and 2015, we identified 249 cases of MOH cases from 19 sites. Predominant causes of MOH were uterine atony (22%), placenta praevia (20%) and obstetric trauma (19%). Intensive care unit admission and/or hysterectomy occurred in 44% and 29% of cases, respectively. There were three deaths. Hypofibrinogenaemia (<2g/l) occurred in 52% of cases in the first 24h after massive transfusion commenced; of these cases, 74% received cryoprecipitate. Median values of other haemostatic tests were within accepted limits. Plasma, platelets or cryoprecipitate were transfused in 88%, 66% and 57% of cases, respectively. By multivariate regression, transfusion of ≥6 RBC units before the first cryoprecipitate (odds ratio [OR] 3·5, 95% CI: 1·7-7·2), placenta praevia (OR 7·2, 95% CI: 2·0-26·4) and emergency caesarean section (OR 4·9, 95% CI: 2·0-11·7) were independently associated with increased risk of hysterectomy. These findings confirm MOH as a major cause of maternal morbidity and mortality and indicate areas for practice improvement.

Clinical coding data algorithm to categorize type of gastrointestinal bleeding as a primary reason for massive transfusion: results from the Australian and New Zealand Massive Transfusion Registry

Management of major gastrointestinal bleeding (GIB) may require massive transfusion (MT), but limited data are available. Upper and lower GIB have different aetiologies, prognosis, bleeding patterns and outcomes. Better understanding of current transfusion management and outcomes in these patients is important. We sought to define and validate an algorithm based on clinical coding data to distinguish critical upper and lower GIB using data from the Australian and New Zealand Massive Transfusion Registry (ANZ-MTR). Australian and New Zealand Massive Transfusion Registry hospital-source data on adult patients receiving a MT (defined as ≥5 red cell units within 4h) for any bleeding context were used. An algorithm allocating ICD-10-AM codes into 'probable' or 'possible' causes of GIB was developed and applied to the ANZ-MTR. Source medical records of 69 randomly selected cases were independently reviewed to validate the algorithm. Of 5482 MT cases available from 25 hospitals, 716 (13%) were identified as GIB with 538/716 (75%) categorized 'probable' and 178/716 'possible' GIB. Upper and lower GIB causes of MT were identified for 455/538 (85%) and 76/538 (14%) 'probable' cases, respectively; 7/538 (1·3%) cases had both upper and lower GIB. Allocation by the algorithm into a 'probable' GIB category had a 95·7% (CI: 90-100%) positive predictive value when validated against source medical records. An algorithm based on ICD-10-AM codes can be used to accurately categorize patients with luminal GIB as the primary reason for MT, enabling further study of this critically unwell and resource-intensive cohort of patients.

The association between platelet transfusions and mortality in patients with critical illness.

Platelet (PLT) transfusions are frequently administered in the setting of critical illness but their clinical impacts remain unknown. This study examined the association between PLT transfusions and death in a large intensive care unit (ICU) patient population. Using a transfusion registry spanning 2008 to 2015, this study assessed effect of in-ICU PLT transfusions on ICU and in-hospital mortality using a stratified, time-dependent Cox proportional hazards model adjusted for illness severity, thrombocytopenia, and other confounders. Patients with known malignancy were excluded. Exposure to PLT transfusions were analyzed dichotomously (ever or never transfused) and continuously (number of transfusions). Medical, general surgery, and cardiac surgery subgroups were analyzed separately. Overall 32,842 adult patients were admitted to ICU, and 4927 patients received PLT transfusion(s). Crude in-ICU and in-hospital mortality were higher for PLT-transfused patients compared to nontransfused patients (9.2% vs. 6.7% and 12.3% vs. 9.3%, respectively). After confounders were adjusted for, PLT transfusions (ever vs. never) were not associated with increased mortality in ICU (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.60-1.02; p = 0.06) or in hospital (HR, 0.89; 95% CI, 0.68-1.09; p = 0.41). Continuous exposure analysis also showed no association between PLT transfusions and death. PLT transfusions have a protective effect on in-hospital mortality in the subgroup of general surgery patients (HR, 0.71; 95% CI, 0.51-0.99; p = 0.04; ever or never analysis). Platelet transfusions were not associated with increased risk of death in critically ill patients. Further studies are required to identify subgroups for which PLT transfusions may be beneficial.

Group O RBCs: where is universal donor blood being used

There have been recurrent shortages of group O blood due to insufficient inventory and use of group O blood in ABO non-identical recipients. We performed a 12-year retrospective study to determine utilization of group O Rh-positive and Rh-negative red blood cells (RBCs) by recipient ABO group. Reasons for transfusing group O blood to ABO non-identical recipients were also assessed. Utilization data from all group O Rh-positive and Rh-negative RBCs transfused at three academic hospitals between April 2002 and March 2014 were included. Data were extracted from Transfusion Registry for Utilization Surveillance and Tracking, a comprehensive database with inventory information on all blood products received at the hospitals. Extracted data included product type, ABO and Rh, final disposition (transfused, wasted, outdated), and demographic and clinical data on all patients admitted to hospital. Descriptive statistics were performed using sas 9.3. There were 314 968 RBC transfusions: 151 645 (48·1%) were group O, of which 138 136 (91·1%) RBC units were transfused to group O individuals. ABO non-identical recipients received 13 509 group O RBCs (8·9%). The percentage of group O RBCs transfused to ABO non-identical recipients by fiscal year varied from 7·8% to 11·1% with a steady increase from 2011 to 2013. Reasons for this included: trauma, outdating, outpatient usage and shortages. The practice of transfusing O RBCs to non-O individuals has been increasing. Specific hospital and blood supplier policies could be targeted to change practice, leading to a more sustainable group O red blood cell supply.

Descriptive characteristics and in-hospital mortality of critically bleeding patients requiring massive transfusion: results from the Australian and New Zealand Massive Transfusion Registry.

Critically bleeding patients requiring massive transfusion (MT) are clinically challenging, and limited data exist to support management decisions. This study describes patient characteristics, transfusion support and clinical outcomes from the Australian and New Zealand (NZ) Massive Transfusion Registry (ANZ-MTR). Retrospective, cohort study of all adult patients receiving MT (≥5 units red blood cells [RBC] in 4 h) at participating ANZ-MTR hospitals, 2011-2015. Mortality information was collected from the Australian National Death Index and NZ Ministry of Health. Associations between patient characteristics and outcomes were modelled using logistic regression. A total of 3560 MT cases were identified. For in-hospital deaths, cardiothoracic surgery was the most frequent bleeding context (24·5%) followed by trauma (18·3%). Age (OR = 1·03; 95% CI: 1·02-1·04), more comorbidities (OR = 1·14; 95% CI: 1·09-1·21), larger volume of RBC in first 24 h from MT onset (OR = 1·04; 95% CI: 1·02-1·06), higher platelet to RBC ratio at 4 h (OR = 2·76; 95% CI: 1·14-6·65) and higher activated partial thromboplastin time (OR = 1·02; 95% CI: 1·01-1·03) were associated with in-hospital mortality. Patients with more comorbidities, older age, traumatic or surgical bleeding or requiring more blood components had higher in-hospital mortality. These findings provide a basis to evaluate and monitor practice relating to optimal use of blood products, variation in transfusion practices and patient outcomes, and also enable benchmarking of hospital performance for management of MT in specific patient groups.

Cardiothoracic Surgery Patients Requiring Massive Transfusion: Initial Data From the Australian and New Zealand Massive Transfusion Registry (ANZ-MTR)

Purpose: To characterise cardiothoracic (CT) surgery patients requiring massive transfusion (MT) (5 units red blood cells (RBCs) in 4 h) in the ANZ-MTR. Methodology: The ANZ-MTR uses electronically stored data from hospital information systems. All consecutive CT surgery patients who received a MT between Apr 2011 - Sept 2015 at 22 hospitals were included. Survival to hospital discharge was obtained from hospital records. Overall mortality post-discharge was obtained from linkage to the National Death Index. Results: Of 4379 MTR patients, 861 (19.7%) underwent CT surgery; 664 (77.1%) cardiac, 169 (19.6%) thoracic vascular and 28 (3.3%) lung procedures. 442 (66.6%) of cardiac procedures were male with median [interquartile range] age 69 [59-77] years compared to 2680 (61.2%) males aged 63 [47-74] years in the MTR cohort. In cardiac procedures, total fresh frozen plasma: red blood cell ratio (FFP: RBC) for the episode of care was 0.6 [0.4-0.8] compared with 0.5 [0.3-0.8] the MTR cohort. 18.3% of cardiac procedures received prothrombinex compared with 11.0% in the MTR cohort. 461 (75.1%) cardiac patients survived to discharge compared with 72.7% of the MTR cohort. Overall cardiac patient survival post-discharge was 71.8% compared with 68.5% in the MTR cohort. Conclusion: Critically bleeding CT surgery patients in Australia and New Zealand comprise a large proportion of patients requiring MT. Future studies are needed to examine the optimal ratio of blood components (e.g. FFP: RBC) and other patient, procedural and transfusion factors which may influence outcomes in these patients.

The Effect of Platelet Transfusion on Death in the Intensive Care Unit

▪Background: Thrombocytopenia is a common complication of critical illness and an independent risk factor for death in the intensive care unit (ICU). Whether platelet transfusions modify the risk of death in critically ill patients is unknown.Methods: Adult patients admitted to ICU who received one or more platelet transfusion over a 10-year period (2006 - 2015) from 3 academic hospitals in Canada were analyzed from a blood transfusion registry. Oncology patients were excluded. Contemporaneous non-transfused ICU patients were used as controls. Data from the registry were validated by integrity checks with medical records and laboratory information systems. We estimated the effect of platelet transfusion on mortality in ICU adjusted for baseline and time-varying covariates including multi-organ dysfunction score (MODS) and severity of thrombocytopenia using a stratified cox proportional hazards model. Significance was set at p<0.05 for all analyses.Results: Of 43,234 non-oncology patients admitted to ICU, 5,621 (13.0%) received one or more platelet transfusion. Compared with non-transfused controls, transfused patients had lower platelet counts (median, 82 x109/L vs. 163 x109/L); were more often admitted after surgery (90.7% vs. 46.9%) especially cardiac surgery (86.8% of surgeries vs. 60.6%); and had higher unadjusted mortality (10.7% vs. 6.5%). Using regression analysis adjusted for covariates (nadir platelet count, red blood cell transfusion, need for hemodialysis) and stratified by age, baseline MODS score (available for 66.2% of patients) and need for invasive mechanical ventilation, platelet transfusions were associated with a lower risk of death in ICU [hazard ratio (HR)= 0.66; 95% confidence interval (CI), 0.46 - 0.96; p= 0.028; n= 26,404 with all available data]. A similar effect was observed in the subgroup of cardiac surgery patients (HR= 0.50; 95% CI, 0.26 - 0.98; p=0.044; n= 10,676) but not all surgical patients (HR = 0.73; 95% CI, 0.46 - 1.17; p= 0.188; n= 14,461).Conclusion:After adjusting for illness severity, thrombocytopenia and other confounders common among critically ill patients, platelet transfusions were associated with improved survival in the population of mostly cardiac surgery patients. This potential protective effect of platelet transfusions requires further evaluation in prospective studies. DisclosuresArnold:Novartis: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy; UCB: Consultancy; Amgen: Consultancy, Research Funding.

Improving outcomes for hospital patients with critical bleeding requiring massive transfusion: the Australian and New Zealand Massive Transfusion Registry study methodology.

BackgroundThe Australian and New Zealand (ANZ) Massive Transfusion (MT) Registry (MTR) has been established to improve the quality of care of patients with critical bleeding (CB) requiring MT (≥ 5 units red blood cells (RBC) over 4 h). The MTR is providing data to: (1) improve the evidence base for transfusion practice by systematically collecting data on transfusion practice and clinical outcomes; (2) monitor variations in practice and provide an opportunity for benchmarking, and feedback on practice/blood product use; (3) inform blood supply planning, inventory management and development of future clinical trials; and (4) measure and enhance translation of evidence into policy and patient blood management guidelines. The MTR commenced in 2011. At each participating site, all eligible patients aged ≥18 years with CB from any clinical context receiving MT are included using a waived consent model. Patient information and clinical coding, transfusion history, and laboratory test results are extracted for each patient’s hospital admission at the episode level.ResultsThirty-two hospitals have enrolled and 3566 MT patients have been identified across Australia and New Zealand between 2011 and 2015. The majority of CB contexts are surgical, followed by trauma and gastrointestinal haemorrhage. Validation studies have verified that the definition of MT used in the registry correctly identifies 94 % of CB events, and that the median time of transfusion for the majority of fresh products is the ‘product event issue time’ from the hospital blood bank plus 20 min. Data linkage between the MTR and mortality databases in Australia and New Zealand will allow comparisons of risk-adjusted mortality estimates across different bleeding contexts, and between countries. Data extracts will be examined to determine if there are differences in patient outcomes according to transfusion practice. The ratios of blood components (e.g. FFP:RBC) used in different types of critical bleeding will also be investigated.ConclusionsThe MTR is generating data with the potential to have an impact on management and policy decision-making in CB and MT and provide benchmarking and monitoring tools for immediate application.

Platelet Transfusion Practices in the ICU: Data From a Large Transfusion Registry

Platelet transfusions are commonly used in critically ill patients, but transfusion thresholds, count increments, and predictors of ineffectual transfusions remain unclear. This retrospective study included consecutive adult nononcology patients who received platelet transfusions in ICUs at three Canadian academic hospitals between 2006 and 2015. Data were collected from a validated transfusion database. We determined independent predictors of ineffectual platelet transfusions, defined as transfusions that raised platelet counts by< 5× 10(9)/L. Reasons for transfusion were adjudicated in a subgroup of patients who underwent transfusion despite normal platelet counts. We identified 7,320 ICU admissions (n= 7,073 patients) during which 15,879 platelet transfusions were administered. Most admissions (78.7%) were for cardiac surgery. Based on 5,700 analyzable transfusions, the median pretransfusion platelet count was 87×10(9)/L (interquartile range [IQR], 57-130). The pretransfusion platelet count was≥ 50× 10(9)/L and≥ 150× 10(9)/L for 79.6% and 17.8% of transfusions, respectively. Reasons for transfusion despite a normal platelet count were active bleeding or surgery in patients receiving antiplatelet agents or anticoagulants. The median platelet count increment was 23× 10(9)/L (IQR, 7-44), and 21.8%of transfusions were ineffectual. ABO incompatibility, sepsis, liver disease, and red cell and cryoprecipitate transfusions were associated with a poor platelet count increment. Platelet transfusions were commonly used in the ICU when platelet counts were≥ 50× 10(9)/L. One platelet transfusion increased platelet count by 23× 10(9)/L. One in five transfusions was ineffectual, and ABO incompatibility was identified as a modifiable risk factor. These data can help direct efforts to reduce platelet overuse and improve transfusion quality.

Red blood cell processing methods and in-hospital mortality: a transfusion registry cohort study

Quality of red blood cells (RBCs) varies depending on the method of processing the whole blood donation, and the method of processing might affect outcomes in patients transfused RBCs. We aimed to establish whether an association exists between in-hospital mortality and RBC processing method and duration of storage. We did a retrospective registry cohort study using data from three acute care hospitals in Hamilton, ON, Canada, and Canadian Blood Services over a 6-year period (2008-14). Adult patients (≥18 years) who were admitted to hospital and who received RBC transfusions were included in the study. All transfused RBCs were characterised by the method of processing (red cell filtered or whole blood filtered) and storage age (fresh 1-7 days, mid 8-35 days, and old 36-42 days). The primary outcome was in-hospital mortality. We used Cox proportional hazards regression with time-dependent stratification variables and fixed stratification variables, and controlled for patient covariates. Between April 1, 2008, and March 31, 2014, 91 065 RBC transfusions were given to 23 634 adults who were included in the analyses. When storage duration was included in the model, in-hospital mortality was significantly increased with fresh whole blood filtered units compared with the reference group of mid-age red cell filtered units (hazard ratio 2·19, 95% CI 1·09-4·42; p=0·033). Differences between other age and processing categories were not significant. The potential effect of whole blood processing methods on patient outcomes is worthy of further investigation, since adverse outcomes could be reduced by minor changes to blood processing methods and inventory management policies. Canadian Blood Services, Health Canada, and the Canadian Institutes of Health Research.