Red blood cell transfusion: a clinical practice guideline from the AABB*

The ASH Choosing Wisely® campaign: five hematologic tests and treatments to question

Choosing Wisely® is a medical stewardship and quality improvement initiative led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the United States. The ASH is an active participant in the Choosing Wisely® project. Using an iterative process and an evidence-based method, ASH has identified 5 tests and treatments that in some circumstances are not well supported by evidence and which in certain cases involve a risk of adverse events and financial costs with low likelihood of benefit. The ASH Choosing Wisely® recommendations focus on avoiding liberal RBC transfusion, avoiding thrombophilia testing in adults in the setting of transient major thrombosis risk factors, avoiding inferior vena cava filter usage except in specified circumstances, avoiding the use of plasma or prothrombin complex concentrate in the nonemergent reversal of vitamin K antagonists, and limiting routine computed tomography surveillance after curative-intent treatment of non-Hodgkin lymphoma. We recommend that clinicians carefully consider anticipated benefits of the identified tests and treatments before performing them.

Transfusion guidelines: when to transfuse

Transfusion of blood and blood components has been a routine practice for more than half a century. The rationale supporting this practice is that replacement of blood loss should be beneficial for the patient. This assumption has constituted the underpinning of transfusion medicine for many decades. Only over the past 20 years, we have seen a more concerted effort to answer very basic questions regarding the value of transfusion therapy. An assessment of the value of transfusion based on well-designed and appropriately powered randomized, controlled trials is the first step in optimizing transfusion practices. Systematic reviews provide the second step by building the knowledge base necessary to assess the impact of transfusion practice on patient outcomes. The third step is the development of clinical practice guidelines, and this occurs when systematic reviews are interpreted by individuals with expertise in transfusion medicine. Such guidelines are typically supported by professional organizations and/or health authorities. Implementation of clinical practice guidelines can be challenging, especially in an area as heterogeneous as transfusion medicine. However, clinical practice guidelines are necessary for the practice of evidence-based medicine, which optimizes patient care and improves patient outcomes. This review focuses on clinical practice guidelines for transfusion of three blood components: RBCs, platelets and plasma. In addition, we provide the approach used to implement clinical practice guidelines at our own institution.

The ASH Choosing Wisely® campaign: five hematologic tests and treatments to question

Choosing Wisely® is a medical stewardship and quality improvement initiative led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the United States. The ASH is an active participant in the Choosing Wisely® project. Using an iterative process and an evidence-based method, ASH has identified 5 tests and treatments that in some circumstances are not well supported by evidence and which in certain cases involve a risk of adverse events and financial costs with low likelihood of benefit. The ASH Choosing Wisely® recommendations focus on avoiding liberal RBC transfusion, avoiding thrombophilia testing in adults in the setting of transient major thrombosis risk factors, avoiding inferior vena cava filter usage except in specified circumstances, avoiding the use of plasma or prothrombin complex concentrate in the nonemergent reversal of vitamin K antagonists, and limiting routine computed tomography surveillance after curative-intent treatment of non-Hodgkin lymphoma. We recommend that clinicians carefully consider anticipated benefits of the identified tests and treatments before performing them.

An Analysis of Methodologies That Can Be Used to Validate if a Perioperative Surgical Home Improves the Patient-centeredness, Evidence-based Practice, Quality, Safety, and Value of Patient Care

Approximately 80 million inpatient and outpatient surgeries are performed annually in the United States. Widely variable and fragmented perioperative care exposes these surgical patients to lapses in expected standard of care, increases the chance for operational mistakes and accidents, results in unnecessary and potentially detrimental care, needlessly drives up costs, and adversely affects the patient healthcare experience. The American Society of Anesthesiologists and other stakeholders have proposed a more comprehensive model of perioperative care, the Perioperative Surgical Home (PSH), to improve current care of surgical patients and to meet the future demands of increased volume, quality standards, and patient-centered care. To justify implementation of this new healthcare delivery model to surgical colleagues, administrators, and patients and maintain the integrity of evidenced-based practice, the nascent PSH model must be rigorously evaluated. This special article proposes comparative effectiveness research aims or objectives and an optimal study design for the novel PSH model.

Peri-operative management of older people undergoing surgery

Increasing numbers of older people are undergoing both emergency and elective surgery. However, they remain at increased risk of adverse outcome in comparison with younger patients. This may relate to the association of ageing with physiological deterioration, multi-morbidity and geriatric syndromes such as frailty, all of which are independent predictors of adverse post-operative outcome. Although there is an emerging evidence base for the identification and management of these predictors, this has not yet translated into routine clinical practice. Older patients undergoing surgery often receive sub-optimal care and surgical pathways are not well suited to complex older patients with multi-pathology. Evidence is emerging for alternative models of care that incorporate the evolving evidence base for optimal peri-operative management of the older surgical patient, including risk assessment and optimization. This article aims to provide a practical overview of the literature to all disciplines working in this field.

Anemia, bleeding, and blood transfusion in the intensive care unit: causes, risks, costs, and new strategies

The definition of anemia is controversial and varies with the sex, age, and ethnicity of the patient. Anemia afflicts half of hospitalized patients and most elderly hospitalized patients. Acute anemia in the operating room or intensive care unit is associated with increased morbidity as well as other adverse outcomes, including death. The risks of anemia are compounded by the added risks associated with transfusion of red blood cells, the most common treatment for severe anemia. The causes of anemia in hospitalized patients include iron deficiency, suppression of erythropoietin and iron transport, trauma, phlebotomy, coagulopathies, adverse effects of and reactions to medications, and stress-induced gastrointestinal bleeding. The types and causes of anemia and the increased health care utilization and costs associated with anemia and undetected internal bleeding are described. The potential benefits and risks associated with transfusion of red blood cells also are explored. Last, the strategies and new tools to help prevent anemia, allow earlier detection of internal bleeding, and avoid unnecessary blood transfusions are discussed.

Evidence review: periprocedural use of blood products

Blood product transfusion has not been subject to rigorous clinical study, and great practice variations exist. Of particular concern to hospitalists is the use of red blood cells, plasma, and platelets prior to invasive procedures to correct anemia or perceived bleeding risk. We summarize the known risks associated with periprocedural anemia, prolonged international normalized ratio (INR), and thrombocytopenia, as well as the effects of blood product administration on clinical outcomes. Clinical trial evidence argues for a restrictive red blood cell transfusion threshold (a hemoglobin level of 7-8 g/dL or symptomatic anemia) for most perioperative patients. There are no high-quality data to guide plasma and platelet transfusions around the time of procedures. Available data do not support the use of prothrombin time/INR to guide prophylactic administration of plasma, and there are scarce data to guide platelet use around the time of an invasive procedure. Therefore, we rely on current consensus expert opinion, which recommends administration of plasma in moderate- to high-risk procedures when INR is >1.5. We recommend platelet transfusion in low-risk procedures when platelet count is <20,000/μL, for average-risk procedures when platelet count is <50,000/μL, and for procedures involving the central nervous system when the platelet count is <100,000/μL.

Haemoglobin management in acute brain injury

PURPOSE OF REVIEW

Anaemia is common among patients in the neurocritical care unit (NCCU) and is thought to exacerbate brain injury. However, the optimal haemoglobin (Hgb) level still remains to be elucidated for traumatic brain injury (TBI), subarachnoid haemorrhage (SAH) and acute ischaemic stroke (AIS). This review outlines recent studies about anaemia and the effects of red blood cell transfusion (RBCT) on outcome in TBI, SAH and AIS patients admitted to the NCCU.

RECENT FINDINGS

Patients with severe SAH, AIS and TBI often develop anaemia and require RBCT. In general critical care, a restrictive RBCT strategy (Hgb ~7 g/dl) is preferable in patients without serious cardiac disease. In severe TBI, AIS and SAH, both anaemia and RBCT may negatively influence clinical outcome. However, the appropriate RBCT trigger remains unclear and there is great variance in how these patients are transfused. There is evidence from PET and microdialysis studies in humans that RBCT can favourably influence brain metabolism and oxygenation. This correction of hypoxia or altered metabolism rather than anaemia may be of greater importance.

SUMMARY

Results from general critical care should not be extrapolated to all patients with acute brain injury. Transfusion is not risk free, but RBCT use needs to be considered also in terms of potential benefit.

Hemostasis, coagulation abnormalities, and liver disease

Coagulopathy-related bleeding events are a major concern in the management of acute and chronic liver disease. The liver attempts to maintain a balance between procoagulant and anticoagulant factors, and providers struggle with poor prognostic indicators to manage bleeding and critical complications. Subtle changes in patient presentation that may require extensive provider-directed interventions, such as blood transfusions, intravenous fluid management, mitigating possible sepsis, and evaluating appropriate pharmacologic treatment, are discussed.

Blood transfusion in the perioperative period

Anemia is associated with perioperative mortality and morbidity. Since the presence of anemia and blood transfusion often go hand in hand, it can be difficult to separate the effects of anemia from the effects of perioperative transfusion. The role for blood transfusion in mitigating the mortality and morbidity associated with anemia is unclear. A restrictive transfusion strategy has been advocated for hemodynamically stable patients, as blood transfusion exposes the patient to both infectious and non-infectious complications. Further research is warranted in patients with the acute coronary syndrome, as there is insufficient evidence to make recommendations for this patient population. Additional multi-center randomized controlled trials need to be conducted in perioperative and critically ill patients with large enough sample sizes to examine differences in mortality and major complications between liberal and restrictive transfusion strategies. Further trials need to incorporate current practices in improved blood storage and leukoreduction techniques.

Improved blood utilization using real-time clinical decision support

BACKGROUND

We analyzed blood utilization at Stanford Hospital and Clinics after implementing real-time clinical decision support (CDS) and best practice alerts (BPAs) into physician order entry (POE) for blood transfusions.

STUDY DESIGN AND METHODS

A clinical effectiveness (CE) team developed consensus with a suggested transfusion threshold of a hemoglobin (Hb) level of 7 g/dL, or 8 g/dL for patients with acute coronary syndromes. The CDS was implemented in July 2010 and consisted of an interruptive BPA at POE, a link to relevant literature, and an "acknowledgment reason" for the blood order.

RESULTS

The percentage of blood ordered for patients whose most recent Hb level exceeded 8 g/dL ranged at baseline from 57% to 66%; from the education intervention by the CE team August 2009 to July 2010, the percentage decreased to a range of 52% to 56% (p = 0.01); and after implementation of CDS and BPA, by end of December 2010 the percentage of patients transfused outside the guidelines decreased to 35% (p = 0.02) and has subsequently remained below 30%. For the most recent interval, only 27% (767 of 2890) of transfusions occurred in patients outside guidelines. Comparing 2009 to 2012, despite an increase in annual case mix index from 1.952 to 2.026, total red blood cell (RBC) transfusions decreased by 7186 units, or 24%. The estimated net savings for RBC units (at $225/unit) in purchase costs for 2012 compared to 2009 was $1,616,750.

CONCLUSION

Real-time CDS has significantly improved blood utilization. This system of concurrent review can be used by health care institutions, quality departments, and transfusion services to reduce blood transfusions.

Potential cost saving of Epoetin alfa in elective hip or knee surgery due to reduction in blood transfusions and their side effects: a discrete-event simulation model

Objectives

Transfusion of allogeneic blood is still common in orthopedic surgery. This analysis evaluates from the perspective of a German hospital the potential cost savings of Epoetin alfa (EPO) compared to predonated autologous blood transfusions or to a nobloodconservationstrategy (allogeneic blood transfusion strategy)during elective hip and knee replacement surgery.

Methods

Individual patients (N = 50,000) were simulated based on data from controlled trials, the German DRG institute (InEK) and various publications and entered into a stochastic model (Monte-Carlo) of three treatment arms: EPO, preoperative autologous donation and nobloodconservationstrategy. All three strategies lead to a different risk for an allogeneic blood transfusion. The model focused on the costs and events of the three different procedures. The costs were obtained from clinical trial databases, the German DRG system, patient records and medical publications: transfusion (allogeneic red blood cells: €320/unit and autologous red blood cells: €250/unit), pneumonia treatment (€5,000), and length of stay (€300/day). Probabilistic sensitivity analyses were performed to determine which factors had an influence on the model's clinical and cost outcomes.

Results

At acquisition costs of €200/40,000 IU EPO is cost saving compared to autologous blood donation, and cost-effective compared to a nobloodconservationstrategy. The results were most sensitive to the cost of EPO, blood units and hospital days.

Conclusions

EPO might become an attractive blood conservation strategy for anemic patients at reasonable costs due to the reduction in allogeneic blood transfusions, in the modeled incidence of transfusion-associated pneumonia andthe prolongedlength of stay.

Retrospective evaluation of adverse transfusion reactions following blood product transfusion from a tertiary care hospital: A preliminary step towards hemovigilance

Background:

The goal of hemovigilance is to increase the safety and quality of blood transfusion. Identification of the adverse reactions will help in taking appropriate steps to reduce their incidence and make blood transfusion process as safe as possible.

Aims:

To determine the frequency and type of transfusion reactions (TRs) occurring in patients, reported to the blood bank at our institute.

Materials and Methods:

A retrospective review of all TRs reported to the blood bank at the All India Institute of Medical Sciences, between December 2007 and April 2012 was done. All the TRs were evaluated in the blood bank and classified using standard definitions.

Results:

During the study period a total of 380,658 bloods and blood components were issued by our blood bank. Out of the total 196 adverse reactions reported under the hemovigilance system, the most common type of reaction observed was allergic 55.1% (n = 108), followed by febrile non-hemolytic transfusion reaction (FNHTR) 35.7% (n = 70). Other less frequently observed reactions were Anaphylactoid reactions 5.1% (n = 10), Acute non-immune HTRs 2.6% (n = 5), Circulatory overload 0.5% (n = 1), Transfusion related acute lung injury 0.5% (n = 1), Delayed HTRs 0.5% (n = 1). Not a single case of bacterial contamination was observed.

Conclusion:

The frequency of TRs in our patients was found to be 0.05% (196 out of 380,658). This can be an underestimation of the true incidence because of under reporting. It should be the responsibility of the blood transfusion consultant to create awareness amongst their clinical counterpart about safe transfusion practices so that proper hemovigilance system can be achieved to provide better patient care.

Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value

BACKGROUND

In an effort to lead physicians in addressing the problem of overuse of medical tests and treatments, the American Board of Internal Medicine Foundation developed the Choosing Wisely campaign. The Society of Hospital Medicine (SHM) joined the initiative to highlight the need to critically appraise resource utilization in hospitals.

METHODS

The SHM employed a staged methodology to develop the adult Choosing Wisely list. This included surveys of the organization's leaders and general membership, a review of the literature, and Delphi panel voting.

RESULTS

The 5 recommendations that were subsequently approved by the SHM Board are: (1) Do not place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis). (2) Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for gastrointestinal complications. (3) Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms or active coronary disease, heart failure, or stroke. (4) Do not order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation. (5) Do not perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.

CONCLUSIONS

Hospitalists have many opportunities to impact overutilization of care. The adult hospital medicine Choosing Wisely recommendations offer an explicit starting point for eliminating waste in the hospital.

Patient-centered approach to ensuring appropriateness of care through blood management

BACKGROUND

Concerns have been raised about the safety and efficacy of blood transfusions. Blood products are in demand and a decreasing supply is projected, with resource conservation a global concern. A consultant group determined that the transfusion rate at Mease Countryside Hospital was higher than an average baseline.

METHODS

A process-improvement project was initiated using a multidisciplinary team approach to improve blood utilization and ensure appropriateness in transfusion practice. The foundation of this project was to create new guidelines for transfusion; provide detailed education, communication, reporting, and feedback; and develop criteria to ensure compliance.

RESULTS

The mean monthly usage of red blood cell units per 1000 inpatient discharges between April 2010 and October 2011 was 321.4 compared with 212.0 for the 5 months after implementation. The mean monthly number of patients transfused per 1000 inpatient discharges from April 2010 to October 2011 was 135.2 compared with 90.2 after implementation. In both cases, this reduction was found to be statistically significant at a 95% confidence level (P = 0.000 in both respects).

CONCLUSIONS

The success of this project was the result of careful planning and execution, administrative support, physician leadership, and teamwork. Blood management includes strategies to avoid inappropriate transfusions and proactively treat anemia. Anemia management should be based on the patient's symptoms, laboratory values, and clinical assessment. Treatment of anemia should encompass a patient-centered approach, with the aim of promoting patient safety and minimizing the risk from exposure to blood products.

Impact of erythropoietin on intensive care unit patients

Anemia is common in intensive care unit (ICU) patients. Red blood cell (RBC) transfusions are mainstays of their treatment and can be life-saving. Allogeneic blood components inherently bear risks of infection and immune reactions. Although these risks are rare in developed countries, recombinant human erythropoietin (rhEpo) and other erythropoiesis-stimulating agents (ESAs) have been considered alternative anti-anemia treatment options. As summarized herein, however, most of the clinical studies suggest that ESAs are not usually advisable in ICU patients unless approved indications exist (e.g., renal disease). First, ESAs act in a delayed way, inducing an increase in reticulocytes only after a lag of 3-4 days. Second, many critically ill patients present with ESA resistance as inflammatory mediators impair erythropoietic cell proliferation and iron availability. Third, the ESA doses used for treatment of ICU patients are very high. Fourth, ESAs are not legally approved for general use in ICU patients. Solely in distinct cases, such as Jehovah's Witnesses who refuse allogeneic blood transfusions due to religious beliefs, ESAs may be considered an exceptional therapy.

Consensus statement from the consensus conference on bilateral total knee arthroplasty group

BACKGROUND

Controversy exists regarding many aspects of decision making pertaining to same-day versus staged bilateral TKA (BTKAs), including patient selection, perioperative management decisions, and other important choices.

QUESTIONS/PURPOSES

In the absence of suitable randomized trials, we sought to determine areas of consensus among national experts on the following questions: (1) What are the comparative risks of same-day BTKAs compared with unilateral TKA (UTKA) and staged BTKAs? (2) Who should be considered an appropriate candidate for same-day BTKAs? (3) What constitutes appropriate workup and perioperative management for BTKAs? (4) What is the optimal time between procedures if same-day BTKAs are not deemed appropriate? (5) Are there orthopaedic or rehabilitation considerations for BTKAs that might outweigh medical contraindications?

METHODS

In the setting of a consensus conference of national experts in orthopaedic surgery, anesthesiology, perioperative medicine, and epidemiology, the major questions surrounding same-day BTKAs were addressed by using an extensive literature review and the modified Delphi process. The process concluded with a meeting of participants and formulation of consensus statements.

RESULTS

Eighty-one percent of participants agreed that BTKAs are more invasive and complex procedures associated with increased risk for perioperative adverse events compared with UTKA in an unselected group of patients. The consensus group agreed that physicians and hospitals should consider using more restrictive patient selection criteria and exclude those with a modified cardiac risk index greater than 3 to mitigate the potentially increased risk. The majority of the group agreed that perioperative assessment and management should reflect the higher level of acuity of same-day BTKAs. Eighty-one percent of participants agreed that if a patient is not deemed a candidate for same-day BTKAs, a second TKA should be scheduled no sooner than 3 months after the first. The entire group agreed that when there is a conflict between the orthopaedic need and the medical adequacy of same-day BTKAs, the medical concern for the patient's safety should prevail over the orthopaedic need.

CONCLUSIONS

Experts perceived that same-day BTKAs increase medical risk, and thus a systematic approach to the management of patients should be taken to minimize complications.

Delirium outcomes in a randomized trial of blood transfusion thresholds in hospitalized older adults with hip fracture

OBJECTIVES

To determine whether a higher blood transfusion threshold would prevent new or worsening delirium symptoms in the hospital after hip fracture surgery.

DESIGN

Ancillary study to a randomized clinical trial.

SETTING

Thirteen hospitals in the United States and Canada.

PARTICIPANTS

One hundred thirty-nine individuals hospitalized with hip fracture aged 50 and older (mean age 81.5 ± 9.1) with cardiovascular disease or risk factors and hemoglobin concentrations of less than 10 g/dL within 3 days of surgery recruited in an ancillary study of the Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair.

INTERVENTION

Individuals in the liberal treatment group received one unit of packed red blood cells and as much blood as needed to maintain hemoglobin concentrations at greater than 10 g/dL; those in the restrictive treatment group received transfusions if they developed symptoms of anemia or their hemoglobin fell below 8 g/dL.

MEASUREMENTS

Delirium assessments were performed before randomization and up to three times after randomization. The primary outcome was severity of delirium according to the Memorial Delirium Assessment Scale (MDAS). The secondary outcome was the presence or absence of delirium defined according to the Confusion Assessment Method (CAM).

RESULTS

The liberal group received a median two units of blood and the restrictive group zero units of blood. Hemoglobin concentration on Day 1 after randomization was 1.4 g/dL higher in the liberal group. Treatment groups did not differ significantly at any time point or over time on MDAS delirium severity (P = .28) or CAM delirium presence (P = .83).

CONCLUSION

Blood transfusion to maintain hemoglobin concentrations greater than 10 g/dL alone is unlikely to influence delirium severity or rate in individuals with hip fracture after surgery with a hemoglobin concentration less than 10 g/dL.

Association between surgical resident involvement and blood use in noncardiac surgery

BACKGROUND

Although there is significant variability in the rate of blood transfusion in surgical patients, the role of surgical skill as a determinant of blood use is unknown.

STUDY DESIGN AND METHODS

We examined the association between surgery resident participation and intraoperative blood transfusion, and 30-day mortality and complications, among 381,036 patients undergoing noncardiac surgery, adjusting for patient factors and procedure complexity.

RESULTS

Compared to attending surgeons working without a resident, cases in which the attendings worked with either Postgraduate Year (PGY) 3 to 4 resident or a PGY5 to 8 resident had a 56% (adjusted odds ratio [AOR], 1.56; 95% confidence interval [CI, 1.48-1.64) or a 78% (AOR, 1.78; 95% CI, 1.70-1.87) higher odds of receiving a blood transfusion, respectively. Involvement of surgical interns or junior residents (PGY1-2), whose role in the operative procedure is assumed to be limited, was associated with a 27% higher odds of receiving a blood transfusion (AOR, 1.27; 95% CI, 1.18-1.37). Overall, resident involvement was not associated with increased risk of 30-day mortality (AOR, 0.97; 95% CI, 0.91-1.04), but was associated with a slightly increased risk of complications (AOR, 1.13; 95% CI, 1.10-1.16).

CONCLUSION

Senior surgery resident participation in noncardiac surgery is associated with between a 56% to 78% higher risk of receiving a blood transfusion intraoperatively compared to attending surgeons working without a resident. Assuming that senior surgical trainees are performing critical parts of the operative procedure and are less skilled than attending surgeons, the findings from this exploratory study suggest that intraoperative blood transfusion may serve as an indirect measure of surgical technical quality.

Anemia in general medical inpatients prolongs length of stay and increases 30-day unplanned readmission rate

OBJECTIVES

Anemia, either chronic or newly developed in the hospital as a result of underlying disease and/or phlebotomy, is seen commonly among general medical inpatients, and its impact on the quality and efficiency of care is unknown.

METHODS

This study investigated the relation among hemoglobin level, length of stay, and 30-day unplanned readmission rates in a cohort of 314 general medical inpatients 18 years old and older admitted to a teaching hospital during a period of 4 months in a large urban academic medical center, using retrospective chart review of the electronic health record.

RESULTS

Anemia was common among this cohort of general medical inpatients (44.6%), and there was a statistically significant decrease in hemoglobin levels during their hospitalization. Anemic patients, as compared with nonanemic patients, had significantly longer mean and median length of stay. More important, the admission hemoglobin level and its change during hospitalization were significant predictors of increased length of stay. For every 1-U increase in admission hemoglobin level, the median length of stay was reduced by 0.5 days. For every 1-U increase in the level of hemoglobin change, the median length of stay was extended by 1.5 days. Likewise, the discharge hemoglobin level predicted the rate of 30-day unplanned readmission. For every 1-U decrease in discharge hemoglobin level, the readmission rate increased by nearly 4%. These relations remained after adjusting for common demographic and clinical variables, including age, sex, nutritional status, and number of comorbidities.

CONCLUSIONS

Anemia is common among general medical inpatients and adversely affects their length of stay and 30-day unplanned readmission rate.

S-nitrosylation therapy to improve oxygen delivery of banked blood

From the perspectives of disease transmission and sterility maintenance, the world's blood supplies are generally safe. However, in multiple clinical settings, red blood cell (RBC) transfusions are associated with adverse cardiovascular events and multiorgan injury. Because ∼85 million units of blood are administered worldwide each year, transfusion-related morbidity and mortality is a major public health concern. Blood undergoes multiple biochemical changes during storage, but the relevance of these changes to unfavorable outcomes is unclear. Banked blood shows reduced levels of S-nitrosohemoglobin (SNO-Hb), which in turn impairs the ability of stored RBCs to effect hypoxic vasodilation. We therefore reasoned that transfusion of SNO-Hb-deficient blood may exacerbate, rather than correct, impairments in tissue oxygenation, and that restoration of SNO-Hb levels would improve transfusion efficacy. Notably in mice, administration of banked RBCs decreased skeletal muscle pO2, but infusion of renitrosylated cells maintained tissue oxygenation. In rats, hemorrhage-induced reductions in muscle pO2 were corrected by SNO-Hb-repleted RBCs, but not by control, stored RBCs. In anemic awake sheep, stored renitrosylated, but not control RBCs, produced sustained improvements in O2 delivery; in anesthetized sheep, decrements in hemodynamic status, renal blood flow, and kidney function incurred following transfusion of banked blood were also prevented by renitrosylation. Collectively, our findings lend support to the idea that transfusions may be causally linked to ischemic events and suggest a simple approach to prevention (i.e., SNO-Hb repletion). If these data are replicated in clinical trials, renitrosylation therapy could have significant therapeutic impact on the care of millions of patients.

Erythropoietin-stimulated endothelial cells support erythroid cell differentiation of CD34(+) haematopoietic progenitors

BACKGROUND AND OBJECTIVES

Endothelial cells provide a unique medium for the proliferation and white lineage differentiation of haematopoietic progenitor cells (HPC). Whether this quality can be exploited to facilitate the differentiation of erythroid precursors is not yet known.

MATERIALS AND METHODS

Haematopoietic progenitor cells derived from cord blood were cultured for 3 weeks in erythropoietin-stimulated supernatants with (n = 6) or without cyclosporine A (CSA, n = 6). Cell count, phenotype and morphology were assessed on a weekly basis, and the haemoglobin content was analysed. These cultures were compared with erythroid differentiation induced by cytokines only (n = 6).

RESULTS

Endothelial supernatants combined with CSA led to equivalent numbers of CD71(+) erythroblasts after 1 week as cytokines only. The purity of glycophorin-positive, CD45-negative cells was higher in cells generated in endothelial supernatants than in cytokine-based media. Additional prostaglandin E2 induced a change from fetal to adult haemoglobin.

CONCLUSION

For the generation of erythroblasts from HPC, endothelial supernatants are a simple and cost-effective alternative to culture conditions based on cytokines.

Red blood cell transfusion in critically ill children (CME)

BACKGROUND

Red blood cell (RBC) transfusions are common in the pediatric intensive care unit (PICU). However, there are no recent data on transfusion practices in the PICU. Our objective was to determine transfusion practice in the PICU, to compare this practice with that observed 10 years earlier, and to estimate the compliance to the recommendation of a large randomized clinical trial, the Transfusion Requirements in Pediatric Intensive Care Unit (TRIPICU) study.

STUDY DESIGN AND METHODS

This was a single-center prospective observational study over a 1-year period. Information was abstracted from medical charts. Determinants of transfusion were searched for daily until the first transfusion in transfused cases or until PICU discharge in nontransfused cases. The justifications for transfusions were assessed using a questionnaire.

RESULTS

Of 913 consecutive admissions, 842 were included. At least one RBC transfusion was given in 144 patients (17.1%). The mean hemoglobin (Hb) level before the first transfusion was 77.3 ± 27.2 g/L. The determinants of a first transfusion event retained in the multivariate analysis were young age (<12 months), congenital cardiopathy, lowest Hb level of not more than 70 g/L, severity of illness, and some organ dysfunctions. The three most frequently quoted justifications for RBC transfusion were a low Hb level, intent to improve oxygen delivery, and hemodynamic instability. The main recommendation of the TRIPICU study was applied in 96.4% of the first transfusion events.

CONCLUSIONS

RBC transfusions are frequent in the PICU. Young age, congenital heart disease, low Hb level, severity of illness, and some organ dysfunctions are significant determinants of RBC transfusions in the PICU. Most first transfusion events were prescribed according to recent recommendations.

Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease

BACKGROUND

Prior trials suggest it is safe to defer transfusion at hemoglobin levels above 7 to 8 g/dL in most patients. Patients with acute coronary syndrome may benefit from higher hemoglobin levels.

METHODS

We performed a pilot trial in 110 patients with acute coronary syndrome or stable angina undergoing cardiac catheterization and a hemoglobin <10 g/dL. Patients in the liberal transfusion strategy received one or more units of blood to raise the hemoglobin level ≥10 g/dL. Patients in the restrictive transfusion strategy were permitted to receive blood for symptoms from anemia or for a hemoglobin <8 g/dL. The predefined primary outcome was the composite of death, myocardial infarction, or unscheduled revascularization 30 days post randomization.

RESULTS

Baseline characteristics were similar between groups except age (liberal, 67.3; restrictive, 74.3). The mean number of units transfused was 1.6 in the liberal group and 0.6 in the restrictive group. The primary outcome occurred in 6 patients (10.9%) in the liberal group and 14 (25.5%) in the restrictive group (risk difference = 15.0%; 95% confidence interval of difference 0.7% to 29.3%; P = .054 and adjusted for age P = .076). Death at 30 days was less frequent in liberal group (n = 1, 1.8%) compared to restrictive group (n = 7, 13.0%; P = .032).

CONCLUSIONS

The liberal transfusion strategy was associated with a trend for fewer major cardiac events and deaths than a more restrictive strategy. These results support the feasibility of and the need for a definitive trial.

Concepts of blood transfusion in adults

Recent progress has been made in the identification and implementation of best transfusion practices on the basis of evidence-based clinical trials, published clinical practice guidelines, and process improvements for blood use and clinical patient outcomes. However, substantial variability persists in transfusion outcomes for patients in some clinical settings--eg, patients undergoing cardiothoracic surgery. This variability could be the result of insufficient understanding of published guidelines; different recommendations of medical societies, including the specification of a haemoglobin concentration threshold to use as a transfusion trigger; the value of haemoglobin as a surrogate indicator for transfusion benefit, even though only changes in concentration and not absolute red cell mass of haemoglobin can be identified; and disagreement about the validity of the level 1 evidence for clinical practice guidelines. Nevertheless, institutional experience and national databases suggest that a restrictive blood transfusion approach is being increasingly implemented as best practice.

Transfusion requirements in septic shock (TRISS) trial - comparing the effects and safety of liberal versus restrictive red blood cell transfusion in septic shock patients in the ICU: protocol for a randomised controlled trial

BACKGROUND

Transfusion of red blood cells (RBC) is recommended in septic shock and the majority of these patients receive RBC transfusion in the intensive care unit (ICU). However, benefit and harm of RBCs have not been established in this group of high-risk patients.

METHODS/DESIGN

The Transfusion Requirements in Septic Shock (TRISS) trial is a multicenter trial with assessor-blinded outcome assessment, randomising 1,000 patients with septic shock in 30 Scandinavian ICUs to receive transfusion with pre-storage leuko-depleted RBC suspended in saline-adenine-glucose and mannitol (SAGM) at haemoglobin level (Hb) of 7 g/dl or 9 g/dl, stratified by the presence of haematological malignancy and centre. The primary outcome measure is 90-day mortality. Secondary outcome measures are organ failure, ischaemic events, severe adverse reactions (SARs: anaphylactic reaction, acute haemolytic reaction and transfusion-related circulatory overload, and acute lung injury) and mortality at 28 days, 6 months and 1 year.The sample size will enable us to detect a 9% absolute difference in 90-day mortality assuming a 45% event rate with a type 1 error rate of 5% and power of 80%. An interim analysis will be performed after 500 patients, and the Data Monitoring and Safety Committee will recommend the trial be stopped if a group difference in 90-day mortality with P ≤0.001 is present at this point.

DISCUSSION

The TRISS trial may bridge the gap between clinical practice and the lack of efficacy and safety data on RBC transfusion in septic shock patients. The effect of restrictive versus liberal RBC transfusion strategy on mortality, organ failure, ischaemic events and SARs will be evaluated.

Evaluation of preoperative and intraoperative red blood cell transfusion practices at Maputo Central Hospital, Mozambique

BACKGROUND

The purpose of this study was to evaluate preoperative and intraoperative blood transfusion practices in Hospital Central (Maputo, Mozambique) and estimate the number of potentially avoidable transfusions.

STUDY DESIGN AND METHODS

A retrospective cohort study was performed. Age, comorbidities, hemoglobin (Hb), the potential for blood loss, and units of red blood cell (RBC) transfusions were recorded. Preoperative transfusions were evaluated to determine whether they met criteria established by the Mozambican Ministry of Health as well as proposed guidelines based on more restrictive protocols. Avoidable blood transfusions were defined as those preoperative transfusions that were not indicated based on these guidelines. Multivariate logistic regression was used to identify factors that predicted transfusion.

RESULTS

A total of 205 patients (age range, 0.1-86 years) underwent surgery in the main operating room during the 2-week study period. Overall, 35 (17%) patients received 68 transfusions. Of these, 36 transfusions were given preoperatively and 32 were given intraoperatively. Thirty-six percent of preoperative transfusions were avoidable according to national guidelines. Ninety-two percent were avoidable using more restrictive guidelines. The primary predictors of preoperative blood transfusion were lower Hb (odds ratio [OR], 0.390/1 g/dL; p < 0.0001) and the potential for blood loss (OR, 3.73; p = 0.0410).

CONCLUSIONS

Adherence to existing Hb thresholds recommended by national blood transfusion guidelines could significantly reduce the number of transfusions and the association risk of transfusion-transmissible infections. Adoption of more restrictive guidelines is recommended to further improve blood transfusion utilization and further reduce the transmission risk of human immunodeficiency virus and hepatitis.

Kidney Disease: Improving Global Outcomes guidelines on anaemia management in chronic kidney disease: a European Renal Best Practice position statement

Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) group has produced comprehensive clinical practice guidelines for the management of anaemia in CKD patients. These guidelines addressed all of the important points related to anaemia management in CKD patients, including therapy with erythropoieis stimulating agents (ESA), iron therapy, ESA resistance and blood transfusion use. Because most guidelines were 'soft' rather than 'strong', and because global guidelines need to be adapted and implemented into the regional context where they are used, on behalf of the European Renal Best Practice Advisory Board some of its members, and other external experts in this field, who were not participants in the KDIGO guidelines group, were invited to participate in this anaemia working group to examine and comment on the KDIGO documents in this position paper. In this article, the group concentrated only on those guidelines which we considered worth amending or adapting. All guidelines not specifically mentioned are fully endorsed.

Effects of red blood cell transfusion on hemodynamic parameters: a prospective study in intensive care unit patients

Background

The aim of the study was to investigate the effect of red blood cell (RBC) transfusion on hemodynamic parameters including transpulmonary thermodilution (TPTD)-derived variables.

Methods

We compared hemodynamic parameters obtained before and after RBC transfusion (2 RBC units) in 34 intensive care unit (ICU) patients.

Results

Directly after RBC transfusion, we observed a significant increase in hematocrit (28 ± 3 vs. 22 ± 2%, p < 0.001), hemoglobin (9.4 ± 0.9 vs. 7.6 ± 0.8 g/dL, p < 0.001), arterial oxygen content (CaO₂) (12.2 ± 1.2 vs. 9.9 ± 1.0 mL/dL, p < 0.001), and oxygen delivery (DO₂) (1073 ± 369 vs. 934 ± 288 mL/min, p < 0.001) compared with baseline. Cardiac output (CO) (8.89 ± 3.06 vs. 9.42 ± 2.75 L/min, p = 0.020), cardiac index (CI) (4.53 ± 1.36 vs. 4.82 ± 1.21 L/min/m², p = 0.016), and heart rate (91 ± 16 vs. 95 ± 14 bpm, p = 0.007) were significantly lower following RBC transfusion while no significant change in stroke volume (SV) was observed. Mean arterial pressure (MAP) (median 87 vs. 78 mmHg, p < 0.001) and systemic vascular resistance index (SVRI) (median 1212 vs. 1103 dyn*s*cm^-5*m², p = 0.001) significantly increased directly after RBC transfusion. Global end-diastolic volume index (GEDVI), extravascular lung water index (EVLWI), and pulmonary vascular permeability index (PVPI) did not significantly change.

Conclusions

In ICU patients, the transfusion of 2 RBC units induces a significant decrease in CO and CI because of a significant decrease in heart rate (while SV remains unchanged). Despite the decrease in CO, DO₂ significantly increases because of a significant increase in CaO₂. In addition, RBC transfusion results in a significant increase in MAP and SVRI. No significant changes in TPTD-parameters reflecting cardiac preload (GEDVI), pulmonary edema (EVLWI), and pulmonary vascular permeability (PVPI) are observed following RBC transfusion.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?» All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: "Does this particular AABT reduce the transfusion rate or not?" All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

Best supportive care and therapeutic plasma exchange with or without eculizumab in Shiga-toxin-producing E. coli O104:H4 induced haemolytic-uraemic syndrome: an analysis of the German STEC-HUS registry

BACKGROUND

May 22nd marks the beginning of a Shiga-toxin-producing Escherichia coli (STEC) O104:H4 outbreak in Northern Germany. By its end on 27 July, it had claimed 53 deaths among 2987 STEC and 855 confirmed haemolytic-uraemic syndrome (HUS) cases.

METHODS

To describe short-term effectiveness of best supportive care (BSC), therapeutic plasma exchange (TPE) and TPE with eculizumab (TPE-Ecu) in 631 patients with suspected HUS treated in 84 hospitals in Germany, Sweden and the Netherlands using the web-based registry of the DGfN (online since 27 May).

RESULTS

Of 631 entries, 491 fulfilled the definition of HUS (median age 46 years; 71% females). The median (inter-quartile range) hospital stay was 22 (14-31) days. Two hundred and eighty-one (57%) patients underwent dialysis and 114 (23%) mechanical ventilation. Fifty-seven patients received BSC, 241 TPE and 193 TPE-Ecu. Treatment strategy was dependent on disease severity (laboratory signs of haemolysis, thrombocytopenia, peak creatinine level, need for dialysis, neurological symptoms, frequency of seizures) which was lower in BSC than in TPE and TPE-Ecu patients. At study endpoint (hospital discharge or death), the median creatinine was lower in BSC [1.1 mg/dL (0.9-1.3)] than in TPE [1.2 mg/dL (1.0-1.5), P < 0.05] and TPE-Ecu [1.4 mg/dL (1.0-2.2), P < 0.001], while need for dialysis was not different between BSC (0.0%, n = 0), TPE (3.7%; n = 9) and TPE-Ecu (4.7%, n = 9). Seizures were absent in BSC and rare in TPE (0.4%; n = 1) and TPE-Ecu (2.6%; n = 5) patients. Total hospital mortality in HUS patients was 4.1% (n = 20) and did not differ significantly between the TPE and TPE-Ecu groups.

CONCLUSIONS

Despite frequent renal impairment, advanced neurological disorders and severe respiratory failure, short-term outcome was better than expected when compared with previous reports. Within the limitations of a retrospective registry analysis, our data do not support the notion of a short-term benefit of Ecu in comparison to TPE alone in the treatment of STEC-HUS. A randomized trial comparing BSC, TPE and Ecu seems to be prudent and necessary prior to establishing new treatment guidelines for STEC-HUS.