Transfusion-related acute lung injury (TRALI)--an important, severe transfusion-related complication

Nomogram to Predict Intensive Care Following Gastrectomy for Gastric Cancer: A Useful Clinical Tool to Guide the Decision-Making of Intensive Care Unit Admission

BACKGROUND

We aimed to generate and validate a nomogram to predict patients most likely to require intensive care unit (ICU) admission following gastric cancer surgery to improve postoperative outcomes and optimize the allocation of medical resources.

METHODS

We retrospectively analyzed 3,468 patients who underwent gastrectomy for gastric cancer from January 2009 to June 2018. Here, 70.0% of the patients were randomly assigned to the training cohort, and 30.0% were assigned to the validation cohort. Least absolute shrinkage and selection operator (LASSO) method was performed to screen out risk factors for ICU-specific care using the training cohort. Then, based on the results of LASSO regression analysis, multivariable logistic regression analysis was performed to establish the prediction nomogram. The calibration and discrimination of the nomogram were evaluated in the training cohort and validated in the validation cohort. Finally, the clinical usefulness was determined by decision curve analysis (DCA).

RESULTS

Age, the American Society of Anesthesiologists (ASA) score, chronic pulmonary disease, heart disease, hypertension, combined organ resection, and preoperative and/or intraoperative blood transfusions were selected for the model. The concordance index (C-index) of the model was 0.843 in the training cohort and 0.831 in the validation cohort. The calibration curves of the ICU-specific care risk nomogram suggested great agreement in both training and validation cohorts. The DCA showed that the nomogram was clinically useful.

CONCLUSIONS

Age, ASA score, chronic pulmonary disease, heart disease, hypertension, combined organ resection, and preoperative and/or intraoperative blood transfusions were identified as risk factors for ICU-specific care after gastric surgery. A clinically friendly model was generated to identify those most likely to require intensive care.

Nomogram to predict postoperative infectious complications after surgery for colorectal cancer: a retrospective cohort study in China

Background

Postoperative infectious complications (ICs) after surgery for colorectal cancer (CRC) increase in-hospital deaths and decrease long-term survival. However, the methodology for IC preoperative and intraoperative risk assessment has not yet been established. We aimed to construct a risk model for IC after surgery for CRC.

Methods

Between January 2016 and June 2020, a total of 593 patients who underwent curative surgery for CRC in Chengdu Second People’s Hospital were enrolled. Preoperative and intraoperative factors were obtained retrospectively. The least absolute shrinkage and selection operator (LASSO) method was used to screen out risk factors for IC. Then, based on the results of LASSO regression analysis, multivariable logistic regression analysis was performed to establish the prediction model. Bootstraps with 300 resamples were performed for internal validation. The performance of the model was evaluated with its calibration and discrimination. The clinical usefulness was assessed by decision curve analysis (DCA).

Results

A total of 95 (16.0%) patients developed ICs after surgery for CRC. Chronic pulmonary diseases, diabetes mellitus, preoperative and/or intraoperative blood transfusion, and longer operation time were independent risk factors for IC. A prediction model was constructed based on these factors. The concordance index (C-index) of the model was 0.761. The calibration curve of the model suggested great agreement. DCA showed that the model was clinically useful.

Conclusion

Several risk factors for IC after surgery for CRC were identified. A prediction model generated by these risk factors may help in identifying patients who may benefit from perioperative optimization.

Distinct risk factors for early and late blood transfusion following pancreaticoduodenectomy

BACKGROUND

The International Study Group of Pancreatic Surgery (ISGPS) has defined two periods of postpancreatectomy hemorrhage, early (<24 h) and late (>24 h). A previously published Blood Usage Risk Score (BURS) aimed to predict early and late blood transfusion. The primary aim of this study was to define risk factors for early and late blood transfusion after pancreaticoduodenectomy. Secondary aims were to assess the predictive accuracy of the BURS.

METHODS

In this retrospective observational study, multivariable analyses were used to identify independent risk factors for both early and late blood transfusion. The predictive ability of the BURS was then assessed using a receiver operating characteristic (ROC) curve analysis.

RESULTS

Among 628 patients, 99 (15.8%) and 144 (22.9%) received early and late blood transfusion, respectively. Risk factors for blood transfusion differed between early and late periods. Preoperative anemia and venous resection were associated with early blood transfusion whilst Whipple's resection (as opposed to pylorus preserving pancreaticoduodenectomy), lack of biliary stent and a narrow pancreatic duct were predictors of late blood transfusion. The BURS was significantly predictive of early blood transfusion, albeit with a modest degree of accuracy (AUROC: 0.700, P < 0.001), but not of late blood transfusion (AUROC: 0.525, P = 0.360). Late blood transfusion was independently associated with increasing severity of postoperative pancreatic fistula (POPF) (OR: 1.85, 3.18 and 9.97 for biochemical, types B and C POPF, respectively, relative to no POPF).

CONCLUSIONS

Two largely different sets of variables are related to early and late blood transfusion following pancreaticoduodenectomy. The BURS was significantly associated with early, albeit with modest predictive accuracy, but not late blood transfusion. An understanding of POPF risk allows assessment of the need for late blood transfusion.

Nomogram to predict perioperative blood transfusion for hepatopancreaticobiliary and colorectal surgery

Background

Predictive tools assessing risk of transfusion have not been evaluated extensively among patients undergoing complex gastrointestinal surgery. In this study preoperative variables associated with blood transfusion were incorporated into a nomogram to predict transfusion following hepatopancreaticobiliary (HPB) or colorectal surgery.

Methods

A nomogram to predict receipt of perioperative transfusion was developed using a cohort of patients who underwent HPB or colorectal surgery between January 2009 and December 2014. The discriminatory ability of the nomogram was tested using the area under the receiver operating characteristic (ROC) curve and internal validation performed via bootstrap resampling.

Results

Among 4961 patients undergoing either a HPB (56·3 per cent) or colorectal (43·7 per cent) resection, a total of 1549 received at least 1 unit of packed red blood cells, giving a perioperative transfusion rate of 31·2 per cent. On multivariable analysis, age 65 years and over (odds ratio (OR) 1·52), race (versus white: black, OR 1·58; Asian, OR 1·86), preoperative haemoglobin 8·0 g/dl or less (versus over 12·0 g/dl: OR 26·79), preoperative international normalized ratio more than 1·2 (OR 2·44), Charlson co-morbidity index score over 3 (OR 1·86) and procedure type (versus colonic surgery: major hepatectomy, OR 1·71; other pancreatectomy, OR 2·12; rectal surgery, OR 1·39; duodenopancreatectomy, OR 2·65) were associated with a significantly higher risk of transfusion and were included in the nomogram. A nomogram was constructed to predict transfusion using these seven variables. Discrimination and calibration of the nomogram revealed good predictive abilities (area under ROC curve 0·756).

Conclusion

The nomogram predicted blood transfusion in major HPB and colorectal surgery.

Impact of Transfusion on Cancer Growth and Outcome

For many years, transfusion of allogeneic red blood cells, platelet concentrates, and plasma units has been part of the standard therapeutic arsenal used along the surgical and nonsurgical treatment of patients with malignancies. Although the benefits of these blood products are not a matter of debate in specific pathological conditions associated with life-threatening low blood cell counts or bleeding, increasing clinical evidence is nevertheless suggesting that deliberate transfusion of these blood components may actually lead to negative clinical outcomes by affecting patient’s immune defense, stimulating tumor growth, tethering, and dissemination. Rigorous preclinical and clinical studies are needed to dimension the clinical relevance, benefits, and risks of transfusion of blood components in cancer patients and understand the amplitude of problems. There is also a need to consider validating preparation methods of blood components for so far ignored biological markers, such as microparticles and biological response modifiers. Meanwhile, blood component transfusions should be regarded as a personalized medicine, taking into careful consideration the status and specificities of the patient, rather than as a routine hospital procedure.

Transfusion-related acute lung injury (TRALI): current concepts and misconceptions

Transfusion-related acute lung injury (TRALI) is the most common cause of serious morbidity and mortality due to hemotherapy. Although the pathogenesis has been related to the infusion of donor antibodies into the recipient, antibody negative TRALI has been reported. Changes in transfusion practices, especially the use of male-only plasma, have decreased the number of antibody-mediated cases and deaths; however, TRALI still occurs. The neutrophil appears to be the effector cell in TRALI and the pathophysiology is centered on neutrophil-mediated endothelial cell cytotoxicity resulting in capillary leak and ALI. This review will detail the pathophysiology of TRALI including recent pre-clinical data, provide insight into newer areas of research, and critically assess current practices to decrease it prevalence and to make transfusion safer.

Transfusion-related acute lung injury: a clinical challenge

Transfusion-related acute lung injury is a life-threatening clinical syndrome. In the last 3 years, it has become the leading cause of reported transfusion-related deaths in the United States. This syndrome is characterized by acute hypoxemia and noncardiogenic pulmonary edema directly linked in time to a blood transfusion. All types of blood products have been implicated in transfusion-related acute lung injury, but transfusion of plasma-containing products from multiparous women seems to carry the highest risk. The purpose of this article is to raise awareness of this syndrome for the critical care nurse. This article discusses the widely accepted clinical features of transfusion-related acute lung injury, its pathogenesis, differential diagnosis, and treatment.