Transfusion Thresholds Research Articles

Analysis of platelet transfusion efficacy during extracorporeal membrane oxygenation (ECMO) treatment in pediatric patients post-cardiac surgery-a retrospective cohort study.

Postoperative extracorporeal membrane oxygenation (ECMO) may be necessary for pediatric patients following cardiac surgery, with associated risks of thrombocytopenia and bleeding. Prophylactic platelet transfusions are utilized to mitigate these risks, but the effectiveness of platelet transfusion cannot be reliably predicted. The aim of this study was to investigate the effect of platelet transfusion during postoperative treatment with ECMO in children undergoing cardiac surgery and to explore the optimal transfusion thresholds to reduce the number of platelet transfusions in patients and reduce the risk of death. We included in our study patients from the Pediatric Cardiac Surgery Department at the First Affiliated Hospital of Tsinghua University who underwent cardiac surgery and received ECMO treatment from January 1, 2019, to December 31, 2023, and received platelets transfusion at least once during the ECMO therapy. The platelet counts were determined both before and 24 hours posttransfusion of the platelet product. The corrected count increment (CCI) was calculated for the effectiveness estimation of platelet transfusion. The research subjects were divided into 3 groups based on the platelet count before transfusion (pretransfusion platelet count ≤30×109/L was the low-threshold group, pretransfusion count 31-50×109/L was the medium-threshold group, and ≥51×109/L was the high-threshold group) and the effective rates of each group were calculated. A total of 11 patients received 47 platelet transfusions, an average of 4.27 ± 1.67 per patient. According to the 24-hour postinfusion platelet (Plt) corrected critical control increase index (24-hour CCI) ≥4500, the infusion was considered to be effective, and ineffective when the CCI was <4500. Out of these, 22 transfusions (46.8%) proved effective, whereas 25 (53.2%) were deemed ineffective. The effective transfusion rates across the 3 groups were 69.2%, 50%, and 27.7%, respectively. The efficacy of platelet transfusion may be higher if a low threshold of platelet transfusion is chosen during ECMO treatment, on the premise of ensuring life safety.

Effect of four hemoglobin transfusion threshold strategies in patients with acute myocardial infarction and anemia: a target trial emulation using MINT trial data

Abstract Background The hemoglobin (Hgb) threshold at which red blood cell transfusion affords greatest benefit, without increasing transfusion-associated risks, is uncertain for patients with acute myocardial infarction (MI). The Myocardial Ischemia and Transfusion (MINT) trial recently showed a restrictive transfusion strategy (Hgb threshold &amp;lt;7-8g/dL) resulted in a 15% increased risk of 30-day all-cause death or recurrent MI (death/MI) compared with a liberal strategy (Hgb threshold &amp;lt;10g/dL) in 3,504 adults with acute MI and anemia. However, the transfusion effect at different Hgb thresholds remains uncertain. Purpose To better understand the gradient of effects from Hgb threshold transfusion triggers between 7g/dL and 10g/dL. We estimated the effects of four Hgb transfusion thresholds on 30-day death/MI and death in patients with acute MI and anemia. Methods We used data from the MINT trial and applied an innovative causal inference method, target trial emulation, to assess four Hgb thresholds. We emulated a hypothetical, 4-arm target trial of &amp;lt;10g/dL, &amp;lt;9g/dL, &amp;lt;8g/dL, and &amp;lt;7g/dL transfusion strategies in adults with acute MI and Hgb &amp;lt;10g/dL using a "cloning" procedure. The target trial protocol closely mirrored that of the MINT trial. We conducted a per-protocol analysis of the emulated target trial using censoring and inverse probability (IP) weighting; we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) by fitting pooled logistic regression models with a time-dependent intercept for time free of the outcomes. We estimated IP weighted Kaplan-Meier cumulative incidence curves under each strategy for 30-day outcomes. Results Of the MINT trial participants, 3,492 (99.7%) met eligibility criteria for the hypothetical target trial of four transfusion strategies. The unadjusted rate of 30-day death/MI was lowest in the &amp;lt;10g/dL strategy and highest in the &amp;lt;9g/dL strategy, and the rate of transfusions decreased monotonically as Hgb thresholds decreased. Relative to the &amp;lt;10g/dL strategy, the estimated HRs (95% CI) from the IP weighted model of 30-day death/MI were 1.07 (0.77-1.50) for the &amp;lt;9g/dL strategy, 1.14 (0.84-1.55) for the &amp;lt;8g/dL strategy, and 1.44 (0.99-2.09) for the &amp;lt;7g/dL strategy (Figure). A log-linear estimate over strategy thresholds between 7-10g/dL estimated a 1.12 (95% CI 1.00-1.27) times greater average risk of death/MI and a 1.12 (95% CI 0.92, 1.37) times greater average risk of death over 30 days for each 1g/dL decrease in the Hgb threshold. The IP weighted cumulative incidence curves showed similar increase in risk of death/MI as transfusion thresholds decreased throughout 30 days post-randomization. Conclusions Relative to a &amp;lt;10g/dL transfusion strategy, we estimated a progressively greater risk of 30-day death/MI as transfusion Hgb thresholds decreased within the range of 7-10g/dL. Targeting a Hgb concentration of 10g/dL in patients with a recent acute MI may avoid serious risks associated with anemia.Hazard ratios for 30-day death/MI

A liberal blood transfusion strategy is safe in patients with myocardial infarction, anemia, and heart failure: lessons from MINT

Abstract Background In patients with acute myocardial infarction (MI) and anemia, the Myocardial Ischemia and Transfusion (MINT) trial found a trend toward increased 30-day death or recurrent MI with a restrictive compared with a liberal blood transfusion strategy. Patients with and without heart failure (HF) may respond differently to blood transfusion. Purpose To characterize the effects of restrictive vs. liberal transfusion strategies on clinical outcomes in patients with MI and anemia with and without baseline HF. Methods In the MINT trial, 3504 patients with MI and hemoglobin &amp;lt;10 g/dL were randomized to restrictive (7-8 g/dL) or liberal (10 g/dL) transfusion thresholds. We compared outcomes between patients with and without baseline HF, defined as any history of HF, acute HF, or baseline left ventricular ejection fraction (LVEF) &amp;lt;45%. Outcomes included death or incident HF, death or recurrent MI, death, and incident HF, all at 30 days. Results Compared with patients without baseline HF (n=1633), patients with baseline HF (overall n=1871 (history of HF n=1066, acute HF n=780, LVEF &amp;lt;45% n= 1099) were older, more frequently male and Black, and had higher rates of prior PCI, diabetes, and hypertension. In the restrictive strategy, patients with and without baseline HF received an average of 0.63 and 0.80 units of blood and had a median LOS of 6 and 4 days, respectively. In the liberal strategy, patients with and without baseline HF received an average of 2.44 and 2.49 units of blood and had a median LOS of 5 and 4 days, respectively. Patients with baseline HF had higher rates of death or incident HF (18.0% vs. 10.0%, risk ratio [RR]=1.79 [95% confidence interval {CI} 1.50-2.13]), death or recurrent MI (17.6% vs. 13.5%, RR=1.31 [95% CI 1.12-1.53]), and death (10.5% vs. 7.5%, RR 1.41 [95% CI 1.14-1.75]). Among patients with baseline HF, a restrictive transfusion strategy resulted in a trend toward an increase in death or HF and death or MI compared with a liberal transfusion strategy (Table, Figure). Among patients without baseline HF, the risk of incident HF was lower with restrictive than with liberal transfusion strategy. Conclusions Among patients with MI and anemia, a restrictive transfusion strategy resulted in a greater increase in death or HF, death or MI, and death in patients with baseline HF than in patients without baseline HF. A liberal transfusion strategy is safe for patients with MI and anemia, including those with prior or acute HF.TableFigure

European practices on antithrombotic management during percutaneous mechanical circulatory support in adults: insights from an international survey

Abstract Background Bleeding and thrombotic complications remain a major concern in cardiogenic shock (CS) patients undergoing percutaneous mechanical circulatory support (pMCS) with veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and/or microaxial flow pumps like the Impella. Antithrombotic practices strongly determine the coagulopathic risk, but standardized protocols are lacking in this context. Purpose This survey outlines European practices on antithrombotic management in adults on pMCS for CS, making an initial effort to standardize practices, inform future trials, and enhance outcomes. Methods This online cross-sectional survey was distributed through digital newsletters and social media platforms by the Association of Acute Cardiovascular Care (ACVC) of the ESC and the European branch of the Extracorporeal Life Support Organization (EuroELSO). The survey was accessible from April 17th to May 23rd, 2023. The target population were European clinicians involved in care for adults on pMCS. Results We included 105 responses from 26 European countries. In 72.4% of the European respondents’ institutions, a standardized local anticoagulation protocol is present, with unfractionated heparin (UFH) being the predominantly used anticoagulant (Impella: 97.0%; V-A ECMO: 96.1%). Similarly, the purge solution during Impella support is most frequently UFH-based (84.1%). A bicarbonate-based purge solution (BBPS) as standard purge is reported by only 1.6%. UFH titration based on the activated partial thromboplastin time (APTT) alone is the most common practice either for Impella (43.1%) and for V-A ECMO (32.9%). A minority of 16.9% and 13.2% indicate relying on activated clotting time (ACT) for UFH-titration during Impella and V-A ECMO support, respectively. UFH-titration protocols are anti-Xa based for 12.3% (Impella) and 10.5% (V-A ECMO) of the respondents. An UFH anticoagulant protocol based on APTT and anti-Xa in parallel is the preferred option for 10.8% (Impella) and 14.5% (V-A ECMO) of the respondents. Anticoagulant targets for APTT, ACT and anti-Xa varied across institutions. The majority (83.8%) does not alter their anticoagulation management in case of combined Impella plus V-A ECMO-approach (ECMELLA). Typical thresholds for transfusion or administration of blood products without acute bleeding as indication vary substantially and are frequently not predefined. Following acute coronary syndrome without percutaneous coronary intervention (PCI), 54.0% and 42.7% administered dual antiplatelet therapy during Impella and V-A ECMO support, increasing to 93.7% and 84.0% after PCI. Conclusions Our survey validated the considerable variation in antithrombotic management in adults in CS on pMCS across European centres. There is a pressing demand for a standardized approach to antithrombotic management in this context to mitigate the impact of coagulopathic complications and, consequently, enhance outcomes.Figure 1.Figure 2.

Generalizability of SELECT to a contemporary cohort of cardiac surgical patients: analysis of the TRICS III Randomized Trial

Abstract Background The SELECT trial reported a significant reduction in cardiovascular (CV) outcomes with semaglutide amongst patients without diabetes who had pre-existing CV disease and a body-mass index (BMI) of 27 or greater. Patients undergoing cardiac surgery represent a high-risk subset of those with established CV disease, and may benefit from treatment with semaglutide. Purpose This study evaluated the generalizability of SELECT to a contemporary international cohort of cardiac surgical patients, and assessed whether differences between SELECT-eligible and non-eligible patients translated to altered risks of CV outcomes. Methods Present data was gathered from the TRICS III trial, a multicentre, randomized trial of restrictive versus liberal red-cell transfusion thresholds amongst 5243 cardiac surgical patients with a EuroSCORE I of ≥6. The proportion of cardiac surgical patients eligible for SELECT was determined by applying its selection criteria to the TRICS III cohort. Finally, baseline characteristics and outcomes stratified by SELECT eligibility were compared. Results A total of 4887 patients from the TRICS III cohort had available data for analysis, of which 452 (9.2%) were deemed to have been eligible for the SELECT trial. A comparison of baseline characteristics between SELECT-eligible and non-eligible patients are presented in Table 1; while SELECT-eligible patients were more likely to have preserved left ventricular function (71.7% vs. 61.0%), EuroSCORE I values were comparable between the two groups (7.8±2.1 vs. 7.9±1.9). The rate of a 3-point MACCE of Death, MI or stroke in the present cohort of SELECT-eligible patients undergoing cardiac surgery (16.6%) was numerically higher than those enrolled in SELECT receiving semaglutide (8.1%) or placebo (10.0%), despite the shorter follow-up (6 months vs. 39.8 months). Six month outcomes following cardiac surgery were similar regardless of SELECT eligibility (Figure 1); no difference in risk of outcomes was documented for the 3-point MACCE [SELECT Eligible vs. Non-eligible – 16.6% vs. 14.5%; OR 1.17 (0.9-1.53); P=0.24] and the TRICS III primary composite of Death, MI, Stroke, or New-Onset Renal Failure with Dialysis [17.0% vs. 17.0%; OR 1.0 (0.77-1.29); P=0.98]. There was a trend towards higher rates of MI at 6 months amongst SELECT-eligible patients, but this difference failed to reach statistical significance [8.5% vs. 6.3%; OR 2.0 (0.96-1.39); P=0.08). Conclusions In this large international cohort of contemporary cardiac surgical patients, nearly 10% would have met eligibility for SELECT. SELECT-eligible patients undergoing cardiac surgery in TRICS III had a numerically higher rate of MACCE than those enrolled in SELECT, highlighting the high risk nature of this patient subgroup. However, amongst SELECT-eligible and non-eligible patients undergoing cardiac surgery, no significant difference in CV outcomes was uncovered.

Changes in platelet transfusion thresholds utilized in the NICU since PlaNeT-2

Abstract Background Use of prophylactic platelet transfusions in the neonatal setting is a common practice due to concerns about bleeding despite evidence of a developmental mismatch with transfusion of adult platelets. The Platelets for Neonatal Transfusion-Study 2 (PlaNeT-2) published in January 2019 showed that using higher platelet thresholds (50 x 109/L) was associated with more adverse outcomes and no improvement in bleeding events compared to lower platelet thresholds (25 x 109/L). Following this trial, implementation of a lower threshold was provider dependent as there were no changes made to the neonatal intensive care unit (NICU) institutional policies. Our goal was to determine if there were any overall changes in individual clinical practice with thresholds used for platelet transfusions in our NICU and number of transfusions per patient. Methods Our center has a 52 bed level IV NICU that specializes in care for critical and/or preterm infants. We performed a retrospective review from 2017 to 2023 of patients admitted in the NICU who received platelet transfusion and had an available platelet count in the 12 hours prior to the transfusion. Results There were 272 platelet transfusions given to 107 unique NICU patients who had platelet counts available. There were 66 transfusions given to 32 patients pre-PlaNeT-2 (2017-2018) and 206 transfusions given to 75 patients post-PlaNeT-2 (2019-2023). The average platelet count pre-PLaNeT-2(2017 to 2018) was 43 x 109/L (SD±24 x 109/L) and post-PLaNeT-2 (2019 to 2023) was 36 x 109/L (SD±21 x 109/L, p=0.03). Prior to PLaNeT-2, 26% of platelet transfusions were for platelet counts ≤ 25 x 109/L and 35% were for platelet counts between 51 to 100x9/L. Post PLaNeT-2 the percentages changed to 35% and 21% respectively. The percentage of transfusions occurring for platelet counts between 26 to ≤50 x 109/L was 38% and 44%, respectively. The number of platelet transfusions per year did not decrease significantly after the PLaNeT-2 trial (average of 33/year versus 41/year, p=0.5). The number of transfusions per patient before and after PLaNeT-2 did not change (2.1 transfusions per patient versus 2.6 transfusions per patient, p=0.3). Conclusion Platelet thresholds utilized in our center decreased after the PLaNeT-2 trial with less transfusions occurring for platelet counts greater than 50 x 109/L. Although thresholds decreased, the number of transfusions per year and the number of transfusions per patient did not significantly change. Further studies are needed to understand changes in patient outcomes and platelet utilization in the NICU.

Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury

Blood transfusions are commonly administered to patients with acute brain injury. The optimal hemoglobin transfusion threshold is uncertain in this patient population. To assess the impact on neurological outcome of 2 different hemoglobin thresholds to guide red blood cell transfusions in patients with acute brain injury. Multicenter, phase 3, parallel-group, investigator-initiated, pragmatic, open-label randomized clinical trial conducted in 72 intensive care units across 22 countries. Eligible patients had traumatic brain injury, aneurysmal subarachnoid hemorrhage, or intracerebral hemorrhage; hemoglobin values below 9 g/dL within the first 10 days after injury; and an expected intensive care unit stay of at least 72 hours. Enrollment occurred between September 1, 2017, and December 31, 2022. The last day of follow-up was June 30, 2023. Eight hundred fifty patients were randomly assigned to undergo a liberal (transfusion triggered by hemoglobin <9 g/dL; n = 408) or a restrictive (transfusion triggered by hemoglobin <7 g/dL; n = 442) transfusion strategy over a 28-day period. The primary outcome was occurrence of an unfavorable neurological outcome, defined as a Glasgow Outcome Scale Extended score between 1 and 5, at 180 days following randomization. There were 14 prespecified serious adverse events, including occurrence of cerebral ischemia after randomization. Among 820 patients who completed the trial (mean age, 51 years; 376 [45.9%] women), 806 had available data on the primary outcome, 393 in the liberal strategy group and 413 in the restrictive strategy group. The liberal strategy group received a median of 2 (IQR, 1-3) units of blood, and the restrictive strategy group received a median of 0 (IQR, 0-1) units of blood, with an absolute mean difference of 1.0 unit (95% CI, 0.87-1.12 units). At 180 days after randomization, 246 patients (62.6%) in the liberal strategy group had an unfavorable neurological outcome compared with 300 patients (72.6%) in the restrictive strategy group (absolute difference, -10.0% [95% CI, -16.5% to -3.6%]; adjusted relative risk, 0.86 [95% CI, 0.79-0.94]; P = .002). The effect of the transfusion thresholds on neurological outcome at 180 days was consistent across prespecified subgroups. In the liberal strategy group, 35 (8.8%) of 397 patients had at least 1 cerebral ischemic event compared with 57 (13.5%) of 423 in the restrictive strategy group (relative risk, 0.65 [95% CI, 0.44-0.97]). Patients with acute brain injury and anemia randomized to a liberal transfusion strategy were less likely to have an unfavorable neurological outcome than those randomized to a restrictive strategy. ClinicalTrials.gov Identifier: NCT02968654.

Analysis of bleeding outcomes in patients with hypoproliferative thrombocytopenia in the A-TREAT clinical trial.

Despite prophylactic platelet transfusions, hypoproliferative thrombocytopenia is associated with bleeding; historical risk factors include hematocrit (HCT) 25%, activated partial thromboplastin time 30 s, international normalized ratio 1.2, and platelets 5000/μL. We performed a post hoc analysis of bleeding outcomes and risk factors in participants with hematologic malignancy and hypoproliferative thrombocytopenia enrolled in the American Trial to Evaluate Tranexamic Acid Therapy in Thrombocytopenia (A-TREAT) and randomized to receive either tranexamic acid (TXA) or placebo. World Health Organization (WHO) grade 2+ bleeding occurred in 46% of 330 participants, with no difference between the TXA (44%) and placebo (47%) groups (p = 0.66). Overall, the most common sites of bleeding were oronasal (18%), skin (17%), gastrointestinal (11%), and genitourinary (11%). Among participants of childbearing potential, 28% experienced vaginal bleeding. Platelets ≤5000/μL and HCT < 21% (after adjusting for severe thrombocytopenia) were independently associated with increased bleeding risk (HR 3.78, 95% CI 2.16-6.61; HR 2.67, 95% CI 1.35-5.27, respectively). Allogeneic stem cell transplant was associated with nonsignificant increased risk of bleeding versus chemotherapy alone (HR 1.34, 95% CI 0.94-1.91). The overall rate of WHO grade 2+ bleeding was similar to previous reports, albeit with lower rates of gastrointestinal bleeding. Vaginal bleeding was common in participants of childbearing potential. Platelets ≤5000/μL remained a risk factor for bleeding. Regardless of platelet count, bleeding risk increased with HCT < 21%, suggesting a red blood cell transfusion threshold above 21% should be considered to mitigate bleeding. More investigation is needed on strategies to reduce bleeding in this population.

Coagulation profiles and percentiles in neonates with hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia: A step toward more accurate transfusion thresholds.

In the literature, there are no studies about the transfusion threshold for neonates with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). In order to facilitate accurate interpretation of coagulation results in these neonates, we aimed to generate specific reference intervals in this specific population. This retrospective study included all HIE neonates admitted from 2014 to 2022 to undergo TH. All infants during TH underwent blood exams, including the coagulation profile. Our primary outcome was to assess the estimates of the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles for each parameter on admission (before transfusion). By the receiver operating characteristic (ROC) analysis, the area under the ROC curve (AUC) and the best cut-off point were used to evaluate the ability of the prothrombin time expressed as international normalized ratio (PT-INR) to predict the risk of any bleeding. A total of 143 infants were included in this study. On admission, the median fibrinogen value was 205mg/dL, prothrombin time 18.6seconds, PT-INR 1.50, activated partial thromboplastin time 38.3seconds, thrombin time 18.6seconds, antithrombin 57.0%. The optimal cut-off of PT-INR in predicting the risk of any bleeding was greater than 1.84 (AUC.623, p=.024). For the first time, we proposed the percentiles of coagulation parameters in our cohort of neonates with HIE. Furthermore, we found that a PT-INR greater than 1.84 can significantly predict the risk of any bleeding. Further studies are needed to determine if a restrictive versus a liberal transfusion approach can be equally safer for these high-risk infants.

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

Objective To evaluate the appropriateness of packed red blood cell (PRBC) transfusions across different departments of a tertiary care hospital. Methods This audit included 632 patients admitted to the major departments of Hayatabad Medical Complex, Peshawar, Pakistan, who received one or more PRBC transfusions from November 2023 till July 2024. Six categories were defined who had different characteristics and thresholds for PRBC transfusion according to the Association for the Advancement of Blood & Biotherapies Red Blood Cell Transfusion International Guidelines. The appropriateness of PRBC transfusions was evaluated by checking if the pre-transfusion hemoglobin (Hb) met the threshold as specified in the guidelines. The chi-square test was used to test the association between the appropriateness of PRBC transfusions and the gender, department, and category of the patient. The significance of the difference in the mean pre-transfusion Hb was determined using an independent samples t-test. Results The median age was 30 years (IQR: 23-48.75). The majority of the patients were female (n=430, 68%). Patients from the Department of Gynecology and Obstetrics (n=267, 42.2%) outnumbered those from other departments. The majority of PRBC transfusions were inappropriate (n=465, 73.6%). Most transfusions in female patients (83.3%), in the patients of the Department of Gynecology and Obstetrics (95.5%), and in patients in the general category (86.9%) were found inappropriate. In the case of inappropriate transfusion, the mean pre-transfusion Hb was significantly different among departments, with the highest (14.1 gm/dL) value documented in the Department of Gynecology and Obstetrics. Conclusion Female patients, patients in the Department of Gynecology and Obstetrics, and patients in the general category had the highest frequency of inappropriate PRBC transfusions.

Effect of Four Hemoglobin Transfusion Threshold Strategies in Patients With Acute Myocardial Infarction and Anemia : A Target Trial Emulation Using MINT Trial Data.

The optimal hemoglobin threshold to guide red blood cell (RBC) transfusion for patients with acute myocardial infarction (MI) and anemia is uncertain. To estimate the efficacy of 4 individual hemoglobin thresholds (<10 g/dL [<100 g/L], <9 g/dL [<90 g/L], <8 g/dL [<80 g/L], and <7 g/dL [<70 g/L]) to guide transfusion in patients with acute MI and anemia. Prespecified secondary analysis of the MINT (Myocardial Ischemia and Transfusion) trial using target trial emulation methods. (ClinicalTrials.gov: NCT02981407). 144 clinical sites in 6 countries. 3492 MINT trial participants with acute MI and a hemoglobin level below 10 g/dL. Four transfusion strategies to maintain patients' hemoglobin concentrations at or above thresholds of 10, 9, 8, or 7 g/dL. Protocol exceptions were permitted for specified adverse clinical events. Data from the MINT trial were leveraged to emulate 4 transfusion strategies and estimate per protocol effects on the composite outcome of 30-day death or recurrent MI (death/MI) and 30-day death using inverse probability weighting. The 30-day risk for death/MI was 14.8% (95% CI, 11.8% to 18.4%) for a <10-g/dL strategy, 15.1% (CI, 11.7% to 18.2%) for a <9-g/dL strategy, 15.9% (CI, 12.4% to 19.0%) for a <8-g/dL strategy, and 18.3% (CI, 14.6% to 22.0%) for a <7-g/dL strategy. Absolute risk differences and risk ratios relative to the <10-g/dL strategy for 30-day death/MI increased as thresholds decreased, although 95% CIs were wide. Findings were similar and imprecise for 30-day death. Unmeasured confounding may have persisted despite adjustment. The 30-day risks for death/MI and death among patients with acute MI and anemia seem to increase progressively with lower hemoglobin concentration thresholds for transfusion. However, the imprecision around estimates from this target trial analysis precludes definitive conclusions about individual hemoglobin thresholds. National Heart, Lung, and Blood Institute.

Relaxing Transfusion Thresholds for Patients With Myocardial Infarction: Findings From the MINT Trial.

Relaxing Transfusion Thresholds for Patients With Myocardial Infarction: Findings From the MINT Trial.

Impact of implementing stricter criteria for blood transfusion in patients with head and neck cancer undergoing free tissue transfer.

Recent literature studying the impact of blood transfusion on outcomes in patients with head and neck cancer (HNC) have shown that blood transfusions are associated with increased risk of death and higher wound infection rates. The purpose of this study was to implement a lower transfusion threshold while comparing outcomes of free flap patients following initiation of a new transfusion guideline. A retrospective study of all patients at a tertiary care academic center who underwent free tissue transfer after HNC resection between July 17, 2007 and June 7, 2021. Transfusion criteria were adjusted in 2014; the hematocrit threshold to transfuse was incrementally reduced from 30% in 2007 to 21% in 2017. The main outcomes of interest were overall survival (OS) and recurrence free survival (RFS). A total of 346 patients met the criteria for inclusion in the study. Groups 1 (less strict protocol - 30%) and 2 (stricter protocol - 21%) consisted of 171 and 175 patients, respectively. Fewer units of packed red cells were transfused per patient in group 2 (0.26 vs. 2.87 in group 1, p < .001). Group 1 was associated with worse OS (p = .01; hazard ratio [HR] = 1.7) and RFS (p < .001; HR = 2.5). Comparing only patients with SCC between the two groups also demonstrated poorer OS (p = .01; HR = 1.8) and RFS (p = .006; HR = 2.1) in group 1. In HNC patients undergoing free tissue transfer, stricter transfusion criteria with threshold hematocrit of 21% was associated with improved OS, RFS, and complication rates with no negative impact on free flap survival. Level IV.

Managing neonatal hyperbilirubinemia: An updated guideline.

More than 80% of newborn infants experience jaundice as a result of elevated bilirubin during the first few weeks after birth. In most cases, hyperbilirubinemia is physiologic, but persistent and extreme elevations can lead to serious long-term complications, such as kernicterus. To avoid these complications and help clinicians in the successful assessment, evaluation, and treatment of hyperbilirubinemia, the American Academy of Pediatrics updated its clinical practice guideline for neonatal hyperbilirubinemia. This article reviews the guideline and highlights significant updates, such as an elevation in the threshold for phototherapy and exchange transfusion, inclusion of gestational age, and removal of racially based norms.

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.

Comparison of liberal versus restrictive transfusion strategies after hip surgery in patients with coronary artery disease: a post hoc analysis of the FOCUS trial

BackgroundThere are no clear recommendations for optimal transfusion thresholds for patients with coronary artery disease who undergo noncardiac surgery. By comparing restrictive and liberal transfusion strategies for coronary artery disease combined with hip surgery, this study hopes to provide recommendations for transfusion strategies in this special population.MethodsA total of 805 patients from the FOCUS trial (Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair) with coronary artery disease combined with hip surgery were divided into two groups based on transfusion thresholds: restricted transfusion (a hemoglobin level of 8 g/deciliter) and liberal transfusion (a hemoglobin threshold of 10 g/deciliter). The primary outcome of this study was a composite endpoint including in-hospital death, myocardial infarction, unstable angina, and acute heart failure. The secondary endpoints included other in-hospital adverse events and 30- and 60-day follow-up events. Analyses were performed by intention to treat.ResultsExcept for the proportion of congestive heart failure patients, the baseline levels of the two groups were comparable. The median number of transfusion units in the liberal transfusion group was 2 units, and the median transfusion volume in the restricted transfusion group was 0 units. The primary outcome was not significantly different between the two groups (9.2% vs. 9.4%, p = 0.91). The incidence of in-hospital myocardial infarction events was lower in the liberal transfusion group than in the restricted transfusion group (3.2% vs. 6.2%) (OR = 0.51, P = 0.048). The remaining in-hospital endpoint events, except for myocardial infarction, were not significantly different between the two groups. The 30-day and 60-day endpoints of death and inability to walk independently were not significantly different between the two groups, with ORs (95% CI) of 1.00 (0.75–1.31) and 1.06 (0.80–1.41), respectively. We also found no interaction between transfusion strategies and factors such as age, sex, or multiple underlying comorbidities at the 60-day follow-up.ConclusionsThere was no significant difference in the in-hospital, 30-day or 60-day outcome endpoints between the two groups. However, this study demonstrated that a liberal transfusion strategy tends to reduce the incidence of in-hospital myocardial infarction events in patients with coronary artery disease combined with hip surgery compared to a restrictive transfusion strategy. More high-quality studies should be designed to investigate the optimal transfusion threshold in patients with coronary artery disease treated without cardiac surgery.

A Survey on the Management of Patients with Severe Traumatic Brain Injury During Pregnancy: The MAMA Study.

Trauma, including traumatic brain injury (TBI), is the leading cause of nonobstetric maternal mortality during pregnancy. Few data are available regarding the optimal management of pregnant patients with TBI, leading to a lack of dedicated guidelines. We performed an international survey to examine the management of severe TBI in pregnant patients, focusing on monitoring, therapy, and intensive care practices. This survey, endorsed by the World Society of Emergency Surgery, was composed of a questionnaire with 79 items divided into four sections: (1) general information (items 1-7), (2) management of the maternal-fetal unit (items 8-43), (3) management of intracranial hypertension (items 44-76), and (4) specific considerations (items 77-79). One hundred and twenty-two physicians from 110 centers in 35 countries responded. The main findings related to TBI care in pregnant patients included the following: (1) a lack of availability of a specific TBI protocol in pregnancy; (2) an increase in the utilization of magnetic resonance imaging as the primary neuroimaging tool; (3) higher hemoglobin thresholds for transfusion; and (4) a lower utilization of therapeutic hypothermia, neuromuscular blocking agents, and barbiturate coma. We also report large variability in the timing of cesarean section in pregnant patients with TBI (≥ 23weeks of gestation) needing an emergency craniotomy (simultaneously 23% vs. later cesarean section 50.8%). Great variability in the management of pregnant patients with severe TBI was identified worldwide from the results of our survey. These findings, highlighting the lack of robust evidence on this topic, will be helpful to stimulate future investigations and to promote educational efforts on this difficult scenario.

WP4.6 - Reducing Unnecessary Transfusion of Blood Products – A Quality Improvement Project in a General Surgical Department in a District General Hospital

Abstract Aims To audit adherence of transfusion of blood products against NICE guideline thresholds. To reduce unnecessary blood transfusions following departmental teaching sessions and installation of posters on surgical wards. Methods We retrospectively audited all patients receiving packed red cells transfusions consecutively across two consecutive four-month periods in a general surgery department. Departmental teaching sessions were held after the first audit cycle, supplemented by installation of posters including NICE guideline thresholds on surgical wards. The medical notes for each patient were assessed for pre-transfusion haemoglobin, indication for transfusion, and whether each transfusion was prescribed according to NICE guidelines. Results A total of 112 units of packed red blood cells in 42 patients and 133 units in 43 patients were transfused, respectively, before and after intervention. 45 units (40.2%) were prescribed according to NICE guidelines on first audit, improving to 67 units (50.4%) following intervention. 23 units of blood (20.5% of total) were transfused back-to-back inappropriately on first audit, reducing to 6 units (4.51% of total) after intervention. There were 2 self-limiting transfusion-related reactions (1.79%) on first audit, both in patients transfused above guidance thresholds, and no reactions following intervention. At a raw cost of approximately £135 per unit of donated blood, savings of £1830 were made over a four-month period (£5493pa), not including nursing and administration costs Conclusions Through simple local interventions and stricter adherence to transfusion thresholds, we reduced inappropriate above-threshold blood product transfusions in our hospital. This corresponded to a reduction in unnecessary blood-transfusion reactions and significant hospital savings.

Admission Hemoglobin Associated with Increased Mortality in Hip Fracture Surgical Patients: An Observational Study.

In hip fracture patients, who are mostly elderly, preexisting anemia can be worsened when combined with trauma and surgery. To this date, there is no unequivocal approach about transfusion thresholds. We analyzed hemoglobin (Hb) and hematocrit (Hct) levels at three time points in surgical patients with proximal femoral fractures (PFF) to see which levels were triggers for transfusions and whether transfusions were related to mortality after hospital discharge. A total of 956 patients were operated on from 1 January 2021 to 31 December 2022 at the University Hospital of Split and included in the study. There were more women (74%); 47% patients had admission Hb < 120 g/L. Transfusion was given preoperatively to 88, intraoperatively to 74 and postoperatively to 309 patients. Transfusion thresholds were as follows: Hb 84 g/L preoperatively, 99 intraoperatively and 83 postoperatively. After hospital discharge, 10.79% of patients died within the 1st month and 23% within 6 months. In the group of non-survivors, 60% of patients had admission Hb ≤ 117 g/L and the proportion of patients transfused preoperatively was two times higher. Preoperative transfusion thresholds could be set to higher levels for patients with surgically treated PFF. However, that could increase mortality even more. Further investigation is necessary.