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Brandenburg LS, Metzger MC, Poxleitner P, Voss PJ, Vach K, Hell J, Hasel K, Weingart JV, Schwarz SJ, Ermer MA. Effects of Red Blood Cell Transfusions on Distant Metastases of Oral Squamous Cell Carcinomas. Cancers (Basel) 2021; 14:cancers14010138. [PMID: 35008301 PMCID: PMC8750075 DOI: 10.3390/cancers14010138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Patients with distant metastasis of oral squamous cell carcinoma should be identified at an early stage of disease. In this study, we investigated if patients who received red blood cell transfusions are at risk for the development of distant metastasis. A positive correlation was found between RBC transfusion (HR = 2.42) and the occurrence of M+ in a multivariate regression model. Therefore, the administration of RBC can be considered as an independent prognostic factor and special attention should be paid to its detrimental effects in the perioperative management of OSCC patients. Abstract There is no consensus on the effect of red blood cell (RBC) transfusions on patients with oral squamous cell carcinoma (OSCC). The aim of this study was to investigate the association between RBC administration and the occurrence of distant metastases (M+) after surgical treatment of OSCC. All medical records of patients who underwent primary surgery for OSCC in our department (2003–2019) were analyzed retrospectively (n = 609). Chi and Cox regression models were used to analyze the influence of transfusion on the development of M+, and survival rates. Kaplan–Meier curves were used for graphical presentation. A multitude of patient-specific factors showed a statistical impact in univariate analysis (transfusion, age, gender, diabetes, pT, pN, L, V, Pn, G, UICC, adjuvant therapy, free microvascular transplant, preoperative hemoglobin level). Transfusion status and pN stage were the only variables that showed a significant correlation to M+ in the multivariate Cox model. The hazard ratios for the occurrence of M+ were 2.42 for RBC transfusions and 2.99 for pN+. Administration of RBC transfusions was identified as a significant prognostic parameter for the occurrence of distant metastases after surgical treatment of OSCC. Hence, the administration of RBC transfusions should be considered carefully in the perioperative management.
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Affiliation(s)
- Leonard Simon Brandenburg
- Department of Oral and Maxillofacial Surgery, Clinic, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany; (M.C.M.); (P.P.); (P.J.V.); (K.H.); (J.V.W.); (S.J.S.); (M.A.E.)
- Correspondence: ; Tel.: +49-761-270-49240
| | - Marc Christian Metzger
- Department of Oral and Maxillofacial Surgery, Clinic, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany; (M.C.M.); (P.P.); (P.J.V.); (K.H.); (J.V.W.); (S.J.S.); (M.A.E.)
| | - Philipp Poxleitner
- Department of Oral and Maxillofacial Surgery, Clinic, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany; (M.C.M.); (P.P.); (P.J.V.); (K.H.); (J.V.W.); (S.J.S.); (M.A.E.)
| | - Pit Jacob Voss
- Department of Oral and Maxillofacial Surgery, Clinic, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany; (M.C.M.); (P.P.); (P.J.V.); (K.H.); (J.V.W.); (S.J.S.); (M.A.E.)
| | - Kirstin Vach
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Zinkmattenstr. 6A, 79108 Freiburg, Germany;
| | - Johannes Hell
- Department of Anesthesiology and Critical Care, Clinic, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany;
| | - Konstantin Hasel
- Department of Oral and Maxillofacial Surgery, Clinic, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany; (M.C.M.); (P.P.); (P.J.V.); (K.H.); (J.V.W.); (S.J.S.); (M.A.E.)
| | - Julia Vera Weingart
- Department of Oral and Maxillofacial Surgery, Clinic, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany; (M.C.M.); (P.P.); (P.J.V.); (K.H.); (J.V.W.); (S.J.S.); (M.A.E.)
| | - Steffen Jochen Schwarz
- Department of Oral and Maxillofacial Surgery, Clinic, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany; (M.C.M.); (P.P.); (P.J.V.); (K.H.); (J.V.W.); (S.J.S.); (M.A.E.)
| | - Michael Andreas Ermer
- Department of Oral and Maxillofacial Surgery, Clinic, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany; (M.C.M.); (P.P.); (P.J.V.); (K.H.); (J.V.W.); (S.J.S.); (M.A.E.)
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Hahm KD, Jin SJ, Cho SS, Park J, Park H, Kim DH, Choi SS. Relationship of epidural patient-controlled analgesia with postoperative bleeding after unilateral total knee arthroplasty: a propensity score-matching analysis. Sci Rep 2021; 11:11284. [PMID: 34050250 PMCID: PMC8163755 DOI: 10.1038/s41598-021-90946-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/19/2021] [Indexed: 11/09/2022] Open
Abstract
Although epidural patient-controlled analgesia (PCA) to control postoperative pain after total knee arthroplasty (TKA), the relationship of epidural PCA with postoperative bleeding remains controversial. Therefore, we aimed to evaluate the effect of epidural and intravenous PCA on postoperative bleeding in patients undergoing unilateral TKA. Total of 2467 patients who underwent TKA were divided to intravenous PCA (n = 2339) or epidural PCA (n = 128) group. After 1:1 propensity score-matching, 212 patients were analyzed to assess the associations between the perioperative blood loss and epidural PCA between the groups. Mean postoperative blood loss was significantly greater in epidural PCA than in intravenous PCA (900.9 ± 369.1 mL vs. 737.8 ± 410.1 mL; P = 0.007). The incidence of red blood cell (RBC) administration (> 3 units) was significantly higher in epidural PCA than in intravenous PCA (30.2% vs. 16.0%; OR 2.5; 95% CI 1.201–5.205; P = 0.014). Epidural PCA may be strongly related to postoperative bleeding and the incidence of RBC transfusion of more than 3 units after unilateral TKA, as compared to intravenous PCA. Therefore, the use of epidural PCA may be carefully considered for postoperative pain management in TKA.
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Affiliation(s)
- Kyung-Don Hahm
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Seok-Joon Jin
- Department of Pain, Shinshinplus Clinic, Anyang-si, 14401, Korea
| | - Seong-Sik Cho
- Department of Occupational and Environmental Medicine, College of Medicine, Dong-A University, Busan, 49201, Korea
| | - Jihoon Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Han Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Koepsell S. Complications of Transfusion. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Brandenburg LS, Schwarz SJ, Weingart JV, Metzger MC, Fuessinger MA, Ermer MA. Do Red Blood Cell Transfusions Influence Long-Term Outcomes in Patients Undergoing Primary Surgery for Oral Squamous Cell Carcinoma? J Oral Maxillofac Surg 2021; 79:1570-1579. [PMID: 33675703 DOI: 10.1016/j.joms.2021.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/13/2021] [Accepted: 01/29/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE There is no consensus on the impact of red blood cell (RBC) transfusion on patients with oral squamous cell carcinoma (OSCC). The purpose of this study was to investigate the association between RBC transfusions and overall survival (OS) and tumor-free survival (TFS) after operative treatment of OSCC. METHODS In this retrospective cohort study, all patients treated with primary surgery between 2003 and 2017 because of OSCC were chart reviewed. The occurrence and amount of RBC transfusions (0; 1-3; >3 units) was correlated with OS and TFS by Kaplan-Meier survival and Cox regression analyses. Demographic, clinical, and pathological parameters were also evaluated in order to identify confounding factors. RESULTS Of 420 patients (243 [57.9%] male) with a mean age of 62.6 years, 67 (16.0%) received RBC transfusion. There were statistically significant (P < .01) differences in 5-year OS respectively TFS in transfused patients for the Kaplan-Meier survival analysis (0 units = 70.6%; [95% confidence interval {CI}: 65.0-75.4%] respectively 63.2% [95% CI: 57.4-68.4%], 1-3 units = 47.2% [95% CI: 29.4-63.1%] respectively 40.6% [95% CI: 24.6-55.95%] and >3 units = 48.9% [95% CI: 20.9-72.1%] respectively 30.5% [95% CI: 8.9-55.8%]). After multivariate adjustments for demographic, clinical, and pathological parameters, RBC transfusion could not be sustained as a significant prognostic factor in OS respectively TFS (1-3 units: hazard ratio = 1.5 [95% CI: 0.7-3.2] respectively 1.3 [95% CI: 0.7-2.6]; >3 units: hazard ratio = 1.2 [95% CI: 0.5 - 3.0] respectively 1.1 [95% CI: 0.5-2.4]). CONCLUSIONS Although RBC transfusion was not identified as a significant prognostic parameter in multivariate analysis, a clear trend for shorter OS and TFS for transfused patients in univariate and Kaplan-Meier survival analysis could be shown.
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Affiliation(s)
- Leonard Simon Brandenburg
- Resident Physician, Department of Oral and Maxillofacial Surgery, Albert-Ludwigs University Freiburg, Freiburg, Germany.
| | - Steffen Jochen Schwarz
- Senior Physician, Department of Oral and Maxillofacial Surgery, Albert-Ludwigs University Freiburg, Freiburg, Germany
| | - Julia Vera Weingart
- Resident Physician, Department of Oral and Maxillofacial Surgery, Albert-Ludwigs University Freiburg, Freiburg, Germany
| | - Marc Christian Metzger
- Senior Physician, Department of Oral and Maxillofacial Surgery, Albert-Ludwigs University Freiburg, Freiburg, Germany
| | - Marc Anton Fuessinger
- Resident Physician, Department of Oral and Maxillofacial Surgery, Albert-Ludwigs University Freiburg, Freiburg, Germany
| | - Michael Andreas Ermer
- Senior Physician, Department of Oral and Maxillofacial Surgery, Albert-Ludwigs University Freiburg, Freiburg, Germany
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Ward MM, Dasgupta A. Pre-operative withholding of infliximab and the risk of infections after major surgery in patients with rheumatoid arthritis. Rheumatology (Oxford) 2020; 59:3917-3926. [PMID: 32710102 DOI: 10.1093/rheumatology/keaa291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/04/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Withholding TNF inhibitors (TNFI) before surgery has been recommended due to concern for post-operative infection. We examined the risks of post-operative infections and mortality in patients with RA in relation to the pre-operative timing of infliximab infusion. METHODS In this population-based retrospective cohort study, we used US Medicare claims data from 2007 to 2015 to identify patients with RA who underwent coronary artery bypass grafting (CABG), aortic or vascular surgery, or bowel resection, and who were treated with infliximab in the 90 days prior to surgery. We examined associations between the timing of infusion and infections and mortality in the 30 days after surgery. We adjusted for the predicted probability of post-operative infection or death, demographic characteristics, use of MTX, post-operative blood transfusion and hospital volume. RESULTS We studied 712 patients with CABG, 244 patients with vascular surgery and 862 patients with bowel resections. Post-operative pneumonia occurred in 7.4-11.9%, urinary tract infection in 9.0-15.2%, surgical site infection in 3.2-18.9%, sepsis in 4.2-9.6% and death in 3.5-7.0% among surgery cohorts. There was no association between the time from last infliximab dose to surgery and the risk of post-operative infection or mortality in any surgical cohort. No subgroups were identified that had an increased risk of infection with more proximate use of infliximab. CONCLUSION Among elderly patients with RA, risks of infection and mortality after major surgery were not related to the pre-operative timing of infliximab infusion.
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Affiliation(s)
- Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Abhijit Dasgupta
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
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Bansal N, Kaur G, Garg S, Gombar S. Acute normovolemic hemodilution in major orthopedic surgery. J Clin Orthop Trauma 2020; 11:S844-S848. [PMID: 32999566 PMCID: PMC7503082 DOI: 10.1016/j.jcot.2020.06.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND With increasing concerns regarding the newer emerging pathogens, alternatives to allogeneic blood transfusion are being explored and acute normovolemic hemodilution (ANH) is one of them. METHODS A prospective study was conducted in patients aged 18-65 years with preoperative hemoglobin >12 g/dl undergoing total knee replacement or total hip replacement. Patients in whom hemodilution was performed were included in the ANH group whereas patients undergoing treatment as per the routine hospital protocol were included in the control group. RESULTS Preoperative hemoglobin was similar in both ANH and control groups (12.7 ± 0.7 vs 12.6 ± 0.6, p = 0.56). Allogeneic blood requirement was significantly less in the ANH group as compared to the control group (4 vs 15, p = 0.001). Postoperative complications were significantly lower in ANH group as compared to control group (7 vs 16, p = 0.01). CONCLUSIONS ANH can be an alternative approach to meet the need of safe blood especially in resource constrained countries, like India where risk of transfusion transmitted infections are still high and where there is high demand of blood and acute shortage of blood in hospitals.
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Affiliation(s)
- Naveen Bansal
- Department of Transfusion Medicine, Government Medical College Hospital, Chandigarh, India
- Corresponding author. Department of Lab Medicine, ESIC Model Hospital, Baddi, Himachal Pradesh, 173205, India.
| | - Gagandeep Kaur
- Department of Transfusion Medicine, Government Medical College Hospital, Chandigarh, India
| | - Sudhir Garg
- Department of Orthopedics, Government Medical College Hospital, Chandigarh, India
| | - Satinder Gombar
- Department of Anesthesiology, Government Medical College Hospital, Chandigarh, India
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Gao Y, Jin H, Tan H, Wang Y, Wu J, Wang Y, Zhang J, Yang Y, Tian W, Hou R. The role of extracellular vesicles from stored RBC units in B lymphocyte survival and plasma cell differentiation. J Leukoc Biol 2020; 108:1765-1776. [PMID: 32421907 DOI: 10.1002/jlb.1a0220-666r] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/22/2020] [Accepted: 03/28/2020] [Indexed: 12/21/2022] Open
Abstract
Extracellular vesicles (EVs) are small, double-membrane vesicles derived from erythrocytes, leukocytes, platelets, and cells of multiple tissues under physiologic or pathologic conditions. The role of EVs in stored RBC units is of great interest with respect to transfusion-related immunomodulation. The current study focuses on the quantity of EVs isolated from stored RBC units and their action on B cell-mediated immune responses. The in vitro experiment demonstrated that EVs exhibited a negative role in B cell survival, plasmacytic differentiation, and class switch recombination under LPS stimulation. Furthermore, LPS-induced antibody production was significantly decreased after EVs injection in vivo. Biochemical analysis revealed that EVs hampered the expression of Blimp-1 and IRF4 and the activation of NF-κB pathway in LPS-primed B cells. Overall, these data imply a vital role for EVs isolated from RBC units in B cell-mediated immune responses.
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Affiliation(s)
- Yuhan Gao
- Department of Blood Transfusion, Peking University People's Hospital, Beijing, China
| | - Haiqiang Jin
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Hui Tan
- Guangdong Innovation Platform of Translational Research for Cerebrovascular Diseases, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Yan Wang
- Department of Immunology, and Key Laboratory of Medical Immunology of Ministry of Public Health, Peking University Health Science Center, Beijing, China
| | - Jia Wu
- Department of Immunology, and Key Laboratory of Medical Immunology of Ministry of Public Health, Peking University Health Science Center, Beijing, China
| | - Yuqing Wang
- Department of Immunology, and Key Laboratory of Medical Immunology of Ministry of Public Health, Peking University Health Science Center, Beijing, China
| | - Jianhua Zhang
- Department of Blood Transfusion, Peking University People's Hospital, Beijing, China
| | - Ying Yang
- Department of Blood Transfusion, Peking University People's Hospital, Beijing, China
| | - Wenqin Tian
- Department of Blood Transfusion, Peking University People's Hospital, Beijing, China
| | - Ruiqin Hou
- Department of Blood Transfusion, Peking University People's Hospital, Beijing, China
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The Effect of Diagnostic Blood Loss on Anemia and Transfusion Among Postoperative Patients With Congenital Heart Disease in a Pediatric Intensive Care Unit. J Pediatr Nurs 2018; 38:62-67. [PMID: 29167083 DOI: 10.1016/j.pedn.2017.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/29/2017] [Accepted: 09/15/2017] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate whether diagnostic blood loss can lead to anemia and consequent blood transfusion among postoperative patients with congenital heart disease (CHD) in the pediatric intensive care unit (PICU). DESIGN AND METHODS This prospective observational study was conducted in a university-affiliated tertiary hospital between January and August 2016. CHD patients aged <12years, undergoing cardiac surgery, with a PICU stay >48h were included (n=205). Multivariate logistic regression analyses were used to determine the effect of diagnostic blood loss on anemia and transfusion. RESULTS The mean daily phlebotomy volume was 5.40±1.94mL/d during the PICU stay (adjusted for body weight, 0.63±0.36mL/kg/d). Daily volume/kg was associated with cyanotic CHD, Pediatric Risk of Mortality III score, and Pediatric Logistic Organ Dysfunction (PELOD)-2 score. In total, 101 (49.3%) patients presented with new or more severe anemia after admission to PICU, which was not associated with phlebotomy volume. Forty-one (20.0%) children received one or more RBC transfusions during their PICU stay. Multivariate analysis indicated that PELOD-2 score>5, new or more severe anemia, and daily volume/kg of phlebotomy >0.63mL/kg/d were significantly associated with transfusion after 48h of admission to PICU. CONCLUSIONS Our findings indicate that diagnostic blood loss is not related to postoperative anemia in children with CHD; however, this factor does correlate with blood transfusion, since it somewhat reflects the severity of illness. PRACTICE IMPLICATIONS Strategies should be applied to reduce diagnostic blood loss, as appropriate.
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Hong FS, Sieradzki N, Pollock C, Nasra F, Mo A, Willcox A, Churilov L, Ho WK, Smith C. Prevalence and causes of preoperative anaemia in elective major surgery patients. Intern Med J 2017; 47:1400-1404. [DOI: 10.1111/imj.13613] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 08/01/2017] [Accepted: 08/27/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Frank S. Hong
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
| | - Nicole Sieradzki
- Department of Anaesthesia; Austin Health; Melbourne Victoria Australia
| | - Claire Pollock
- Department of Anaesthesia; Austin Health; Melbourne Victoria Australia
| | - Faye Nasra
- Department of Anaesthesia; Austin Health; Melbourne Victoria Australia
| | - Allison Mo
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
| | - Abbey Willcox
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
| | - Leonid Churilov
- Statistics and Decision Analysis Academic Platform; Florey Institute of Neuroscience and Mental Health; Melbourne Victoria Australia
- School of Science; RMIT University; Melbourne Victoria Australia
| | - Wai Khoon Ho
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
| | - Carole Smith
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
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Abstract
OBJECTIVES To determine if topical vancomycin and tobramycin powder reduces the incidence of surgical site infection after pelvic ring and acetabulum fracture surgery. DESIGN Retrospective cohort study. SETTING University of Alabama at Birmingham, Academic Level I Trauma Center. PATIENTS/PARTICIPANTS Two hundred nineteen patients (140 meeting inclusion criteria) with pelvic and acetabular fractures who underwent open reduction and internal fixation from March 2012 to November 2013. INTERVENTION One gram vancomycin and 1.2 g tobramycin powder applied deep in the surgical wound of the treatment group. MAIN OUTCOME MEASUREMENTS Postoperative infection rate. RESULTS One hundred forty patients were included. Control group (n = 69) and treatment group (n = 71) were similar for sex, age, ethnicity, and body mass index. There was no difference between groups with regards to renal function postoperative day 2 (P = 0.24). The risk of infection was 14.5% and 4.2% (P = 0.04) for the control and treatment groups, respectively. No significant effect of antibiotic treatment was observed overall after adjusting for EBL (odds ratio 0.20, 95% confidence interval, 0.02-1.06). Of note, a nonsignificant 71% increase was observed among those with ≥1 L EBL (odds ratio 1.71, 95% confidence interval, 0.02-147.02). CONCLUSIONS Topical antibiotics possibly reduce the incidence of surgical site infection after open pelvic and acetabulum fixation without increasing risk of renal impairment. The protective effect of topical antibiotics may be limited to patients with minimal intraoperative blood loss. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Aquina CT, Blumberg N, Becerra AZ, Boscoe FP, Schymura MJ, Noyes K, Monson JRT, Fleming FJ. Association Among Blood Transfusion, Sepsis, and Decreased Long-term Survival After Colon Cancer Resection. Ann Surg 2017; 266:311-317. [PMID: 27631770 DOI: 10.1097/sla.0000000000001990] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To investigate the potential additive effects of blood transfusion and sepsis on colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival after colon cancer surgery. BACKGROUND Perioperative blood transfusions are associated with infectious complications and increased risk of cancer recurrence through systemic inflammatory effects. Furthermore, recent studies have suggested an association among sepsis, subsequent systemic inflammation, and adverse cardiovascular outcomes. However, no study has investigated the association among transfusion, sepsis, and disease-specific survival in postoperative patients. METHODS The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for stage I to III colon cancer resections from 2004 to 2011. Propensity-adjusted survival analyses assessed the association of perioperative allogeneic blood transfusion, sepsis, and 5-year colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival. RESULTS Among 24,230 patients, 29% received a transfusion and 4% developed sepsis. After risk adjustment, transfusion and sepsis were associated with worse colon cancer disease-specific survival [(+)transfusion: hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.09-1.30; (+)sepsis: HR 1.84, 95% CI 1.44-2.35; (+)transfusion/(+)sepsis: HR 2.27, 95% CI 1.87-2.76], cardiovascular disease-specific survival [(+)transfusion: HR 1.18, 95% CI 1.04-1.33; (+)sepsis: HR 1.63, 95% CI 1.14-2.31; (+)transfusion/(+)sepsis: HR 2.04, 95% CI 1.58-2.63], and overall survival [(+)transfusion: HR 1.21, 95% CI 1.14-1.29; (+)sepsis: HR 1.76, 95% CI 1.48-2.09; (+)transfusion/(+)sepsis: HR 2.36, 95% CI 2.07-2.68] relative to (-)transfusion/(-)sepsis. Additional analyses suggested an additive effect with those who both received a blood transfusion and developed sepsis having even worse survival. CONCLUSIONS Perioperative blood transfusions are associated with shorter survival, independent of sepsis, after colon cancer resection. However, receiving a transfusion and developing sepsis has an additive effect and is associated with even worse survival. Restrictive perioperative transfusion practices are a possible strategy to reduce sepsis rates and improve survival after colon cancer surgery.
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Affiliation(s)
- Christopher T Aquina
- *Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY †Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY ‡New York State Cancer Registry, New York State Department of Health, Albany, NY §Center for Colon and Rectal Surgery, Florida Hospital Medical Group, University of Central Florida College of Medicine, Orlando, FL
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Loftus TJ, Thomas RM, Murphy TW, Nguyen LL, Moore FA, Brakenridge SC, Efron PA, Mohr AM. The effects of red cell transfusion donor age on nosocomial infection among trauma patients. Am J Surg 2017; 214:672-676. [PMID: 28720216 DOI: 10.1016/j.amjsurg.2017.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 05/08/2017] [Accepted: 07/09/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND We hypothesized that packed red blood cell (PRBC) transfusions from older donors would be associated with fewer nosocomial infections among trauma patients. METHODS We performed a four-year retrospective analysis of 264 consecutive adult trauma patients who received ≥1 PRBC transfusion during admission. The capacity of donor age to predict nosocomial infection was assessed by logistic regression. RESULTS Thirty-three percent of all patients developed a nosocomial infection. Donor age was significantly higher among patients with nosocomial infection (40.3 vs. 37.6 years, p = 0.035), and the incidence of infection was directly proportional to donor age. The association between donor age and infection was strongest among recipients age ≥60 years, and was significant on multivariate regression for this cohort (OR 1.07 (95% CI 1.01-1.13), p = 0.024). CONCLUSIONS Among trauma patients receiving PRBC transfusions, blood from older donors may be associated with increased risk for nosocomial infection.
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Affiliation(s)
- Tyler J Loftus
- University of Florida Health Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Ryan M Thomas
- Malcom Randall Veterans Affairs Medical Center Department of Surgery, Gainesville, FL, USA.
| | - Travis W Murphy
- University of Florida Health Department of Emergency Medicine, Gainesville, FL, USA.
| | - Linda L Nguyen
- University of Florida Health College of Medicine, Gainesville, FL, USA.
| | - Frederick A Moore
- University of Florida Health Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Scott C Brakenridge
- University of Florida Health Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Philip A Efron
- University of Florida Health Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Alicia M Mohr
- University of Florida Health Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
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Almizraq RJ, Seghatchian J, Acker JP. Extracellular vesicles in transfusion-related immunomodulation and the role of blood component manufacturing. Transfus Apher Sci 2016; 55:281-291. [DOI: 10.1016/j.transci.2016.10.018] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Henke PK, Park YJ, Hans S, Bove P, Cuff R, Kazmers A, Schreiber T, Gurm HS, Grossman PM. The Association of Peri-Procedural Blood Transfusion with Morbidity and Mortality in Patients Undergoing Percutaneous Lower Extremity Vascular Interventions: Insights from BMC2 VIC. PLoS One 2016; 11:e0165796. [PMID: 27835656 PMCID: PMC5106007 DOI: 10.1371/journal.pone.0165796] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 10/18/2016] [Indexed: 01/28/2023] Open
Abstract
Objective To determine the predictors of periprocedural blood transfusion and the association of transfusion on outcomes in high risk patients undergoing endoluminal percutaneous vascular interventions (PVI) for peripheral arterial disease. Methods/Results Between 2010–2014 at 47 hospitals participating in a statewide quality registry, 4.2% (n = 985) of 23,273 patients received a periprocedural blood transfusion. Transfusion rates varied from 0 to 15% amongst the hospitals in the registry. Using multiple logistic regression, factors associated with increased transfusion included female gender (OR = 1.9; 95% CI: 1.6–2.1), low creatinine clearance (1.3; 1.1–1.6), pre-procedural anemia (4.7; 3.9–5.7), family history of CAD (1.2; 1.1–1.5), CHF (1.4; 1.2–1.6), COPD (1.2; 1.1–1.4), CVD or TIA (1.2; 1.1–1.4), renal failure CRD (1.5; 1.2–1.9), pre-procedural heparin use (1.8; 1.4–2.3), warfarin use (1.2; 1.0–1.5), critical limb ischemia (1.7; 1.5–2.1), aorta-iliac procedure (1.9; 1.5–2.5), below knee procedure (1.3; 1.1–1.5), urgent procedure (1.7; 1.3–2.2), and emergent procedure (8.3; 5.6–12.4). Using inverse weighted propensity matching to adjust for confounders, transfusion was a significant risk factor for death (15.4; 7.5–31), MI (67; 29–150), TIA/stroke (24; 8–73) and ARF (19; 6.2–57). A focused QI program was associated with a 28% decrease in administration of blood transfusion (p = 0.001) over 4 years. Conclusion In a large statewide PVI registry, post procedure transfusion was highly correlated with a specific set of clinical risk factors, and with in-hospital major morbidity and mortality. However, using a focused QI program, a significant reduction in transfusion is possible.
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Affiliation(s)
- Peter K. Henke
- Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
- * E-mail:
| | - Yeo Jung Park
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Sachinder Hans
- Henry Ford Malcomb Hospital, Wyndott, MI, United States of America
| | - Paul Bove
- Beaumont Health System, Royal Oak, MI, United States of America
| | - Robert Cuff
- Spectrum Health System, Grand Rapids, MI, United States of America
| | - Andris Kazmers
- McLaren Northern Michigan Health System, Traverse City, MI, United States of America
| | | | - Hitinder S. Gurm
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - P. Michael Grossman
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States of America
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Complications of Transfusion. Transfus Med 2016. [DOI: 10.1002/9781119236504.ch14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Fukuda H. Patient-related risk factors for surgical site infection following eight types of gastrointestinal surgery. J Hosp Infect 2016; 93:347-54. [DOI: 10.1016/j.jhin.2016.04.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 04/11/2016] [Indexed: 12/29/2022]
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Pertinhez TA, Casali E, Baroni F, Berni P, Baricchi R, Spisni A. A Comparative Study of the Effect of Leukoreduction and Pre-storage Leukodepletion on Red Blood Cells during Storage. Front Mol Biosci 2016; 3:13. [PMID: 27148539 PMCID: PMC4839302 DOI: 10.3389/fmolb.2016.00013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 03/24/2016] [Indexed: 11/24/2022] Open
Abstract
Blood transfusion is a fundamental therapy in numerous pathological conditions. Regrettably, many clinical reports describe adverse transfusion's drawbacks due to red blood cells alterations during storage. Thus, the possibility for a blood bank to ameliorate the quality of the erythrocyte concentrates units is crucial to improve clinical results and reduce transfusion adverse occurrences. Leukodepletion is a pre-storage treatment recognized to better preserve the quality of red blood cells with respect to leukoreduction. Aim of this work is to unravel the biochemical and biophysical basis that sustain the good clinical outcomes associated to the use of leukodepleted erythrocytes units. Erythrocytes concentrates were prepared as leukoreduced (n = 8) and pre-storage leukodepleted (n = 8) and then studied during 6 weeks in blood bank conditions. Overall, the data indicate that leukodepletion not only provide red blood cells with an appropriate amount of nutrients for a longer time but also selects red blood cells characterized by a more resilient plasma membrane fit to prolong their viability. We believe these results will stimulate new ideas to further optimize the current storage protocols.
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Affiliation(s)
- Thelma A Pertinhez
- Transfusion Medicine Unit, Arcispedale Santa Maria Nuova - IRCCSReggio Emilia, Italy; Department of Biomedical, Biotechnological and Translational Sciences, University of ParmaParma, Italy
| | - Emanuela Casali
- Department of Biomedical, Biotechnological and Translational Sciences, University of Parma Parma, Italy
| | - Fabio Baroni
- Transfusion Medicine Unit, Arcispedale Santa Maria Nuova - IRCCS Reggio Emilia, Italy
| | - Pamela Berni
- Transfusion Medicine Unit, Arcispedale Santa Maria Nuova - IRCCS Reggio Emilia, Italy
| | - Roberto Baricchi
- Transfusion Medicine Unit, Arcispedale Santa Maria Nuova - IRCCS Reggio Emilia, Italy
| | - Alberto Spisni
- Department of Surgical Sciences, University of Parma Parma, Italy
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Long-term outcomes of an integrated transfusion reduction initiative in patients undergoing resection for colorectal cancer. Am J Surg 2015; 210:990-4; discussion 995. [PMID: 26455522 DOI: 10.1016/j.amjsurg.2015.06.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/18/2015] [Accepted: 06/19/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Perioperative blood transfusion in patients with colorectal cancer has been associated with increased cost, morbidity, mortality, and decreased survival. Five years ago, a transfusion reduction initiative (TRI) was implemented. We sought to evaluate the 5-year effectiveness and patient outcomes before and after the TRI. METHODS Patients who underwent colorectal resection for adenocarcinomas before (January 2006 to October 2009) and after the TRI (November 2009 to December 2013) were reviewed. RESULTS A total of 484 patients were included; 267 and 217 patients were in the pre- and post-TRI groups, respectively. Decreased overall transfusion rates were sustained throughout the entire post-TRI era (17% vs 28%, P = .006). Three-year colorectal cancer disease-free survival rates were similar in the pre- and post-TRI eras at 85.3% (95% confidence interval [CI]: 79.9 to 89.3) and 81.6% (95% CI: 71.9 to 88.2), respectively. Three-year disease-free survival rate was lower in those receiving BTs vs those without BTs at 78.4% (95% CI: 65.7 to 86.8) vs 85.3% (95% CI: 80.4 to 89.1), respectively. CONCLUSIONS A TRI remains a safe, effective way to reduce blood utilization in colorectal cancer surgery.
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The association of perioperative transfusion with 30-day morbidity and mortality in patients undergoing major vascular surgery. J Vasc Surg 2015; 61:1000-9.e1. [DOI: 10.1016/j.jvs.2014.10.106] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 10/30/2014] [Indexed: 01/28/2023]
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20
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Elhenawy AM, Meyer SR, Bagshaw SM, MacArthur RG, Carroll LJ. Role of preoperative intravenous iron therapy to correct anemia before major surgery: study protocol for systematic review and meta-analysis. Syst Rev 2015; 4:29. [PMID: 25874460 PMCID: PMC4369835 DOI: 10.1186/s13643-015-0016-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 02/24/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Preoperative anemia is a common and potentially serious hematological problem in elective surgery and increases the risk for perioperative red blood cell (RBC) transfusion. Transfusion is associated with postoperative morbidity and mortality. Preoperative intravenous (IV) iron therapy has been proposed as an intervention to reduce perioperative transfusion; however, studies are generally small, limited, and inconclusive. METHODS/DESIGN We propose performing a systematic review and meta-analysis. We will search MEDLINE, EMBASE, EBM Reviews, Cochrane-controlled trial registry, Scopus, registries of health technology assessment and clinical trials, Web of Science, ProQuest Dissertations and Theses, and conference proceedings in transfusion, hematology, and surgery. We will contact our study drug manufacturer for unpublished trials. Titles and abstracts will be identified and assessed by two reviewers for potential relevance. Eligible studies are: randomized or quasi-randomized clinical trials comparing preoperative administration of IV iron with placebo or standard of care to reduce perioperative blood transfusion in anemic patients undergoing major surgery. Screening, data extraction, and quality appraisal will be conducted independently by two authors. Data will be presented in evidence tables and in meta-analytic forest plots. Primary efficacy outcomes are change in hemoglobin concentration and proportion of patients requiring RBC transfusion. Secondary outcomes include number of units of blood or blood products transfused perioperatively, transfusion-related acute lung injury, neurologic complications, adverse events, postoperative infections, cardiopulmonary complications, intensive care unit (ICU) admission/readmission, length of hospital stay, acute kidney injury, and mortality. Dichotomous outcomes will be reported as pooled relative risks and 95% confidence intervals. Continuous outcomes will be reported using calculated weighted mean differences. Meta-regression will be performed to evaluate the impact of potential confounding variables on study effect estimates. DISCUSSION Reducing unnecessary RBC transfusions in perioperative medicine is a clinical priority. This involves the identification of patients at risk of receiving transfusions along with blood conservation strategies. Of potential pharmacological blood conservation strategies, IV iron is a compelling intervention to treat preoperative anemia; however, existing data are uncertain. We propose performing a systematic review and meta-analysis evaluating the efficacy and safety of IV iron administration to anemic patients undergoing major surgery to reduce transfusion and perioperative morbidity and mortality. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015016771.
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Affiliation(s)
- Abdelsalam M Elhenawy
- School of Public Health, University of Alberta, 4075 RTF, 8308 114 Street, Edmonton, Alberta, T6G 2E1, Canada.
| | - Steven R Meyer
- Division of Cardiac Surgery, Department of Cardiac Surgery, Faculty of Medicine and Dentistry, University of Alberta, 8440-112 Street, Edmonton, Alberta, T6G 2B7, Canada.
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building 8440-112 Street, Edmonton, Alberta, T6G 2B7, Canada.
| | - Roderick G MacArthur
- Division of Cardiac Surgery, Department of Cardiac Surgery, Faculty of Medicine and Dentistry, University of Alberta, 8440-112 Street, Edmonton, Alberta, T6G 2B7, Canada.
| | - Linda J Carroll
- School of Public Health, University of Alberta, 4075 RTF, 8308 114 Street, Edmonton, Alberta, T6G 2E1, Canada.
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Refaai MA, Blumberg N. Transfusion immunomodulation from a clinical perspective: an update. Expert Rev Hematol 2014; 6:653-63. [DOI: 10.1586/17474086.2013.850026] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Abstract
Evidence from a variety of sources indicate that allogeneic blood transfusions can induce clinically significant immunosuppression, as well as other effects, in recipients. This clinical syndrome is generally referred to in the Transfusion Medicine literature as transfusion-associated immunomodulation, or TRIM. TRIM has been linked to an improved clinical outcome in the setting of renal allograft transplantation. Possible deleterious TRIM-associated effects include an increased rate of cancer recurrence and of post-operative bacterial infection. The recognition that TRIM can increase morbidity and mortality in allogeneically transfused individuals has become a major concern for those involved in Transfusion Medicine. However, based on available randomized controlled trials, whether TRIM predisposes recipients to increased risk for cancer recurrence and/or bacterial infection is still unproven. In contrast, data from experimental animal studies suggest that TRIM is an immunologically mediated biological effect, associated with the transfusion of allogeneic leukocytes; an effect, which can be completely ameliorated by the pre-storage leukoreduction of blood products. Relevantly, several (n = 5) recent large observational trials have provided important evidence for the existence of deleterious TRIM and related effects (mortality and organ dysfunction) of leukocyte-containing allogeneic cellular blood products. These latter data suggest that allogeneic blood product transfusions, containing leukocytes, are associated with an increased risk both for mortality, and organ dysfunction in recipients.
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Affiliation(s)
- M A Blajchman
- Department of Pathology, Canadian Blood Services Hamilton, McMaster University, Ontario, Canada.
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Mathew M, Panicker VT, Mathew T, Menon S, Jayakumar K. Risk factors for microbiologically documented nosocomial infections after on pump –CABG. Indian J Thorac Cardiovasc Surg 2013. [DOI: 10.1007/s12055-013-0210-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Zalpuri S, Middelburg RA, van de Watering L, Vamvakas E, Zwaginga JJ, van der Bom JG. Association Vs Causality in Transfusion Medicine: Understanding Multivariable Analysis in Prediction Vs Etiologic Research. Transfus Med Rev 2013; 27:74-81. [DOI: 10.1016/j.tmrv.2013.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 02/13/2013] [Accepted: 02/15/2013] [Indexed: 10/27/2022]
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Froman JP, Mathiason MA, Kallies KJ, Bottner WA, Shapiro SB. The impact of an integrated transfusion reduction initiative in patients undergoing resection for colorectal cancer. Am J Surg 2012; 204:944-50; discussion 950-1. [PMID: 23022253 DOI: 10.1016/j.amjsurg.2012.05.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 05/19/2012] [Accepted: 05/22/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Perioperative blood transfusions in patients with colorectal cancer are associated with increased cost, morbidity, mortality and decreased survival. In 2009, a 3-part transfusion reduction initiative (TRI) was introduced. The hypothesis was that this would decrease transfusions without increasing complications in patients undergoing elective resection for colorectal cancer. METHODS After institutional review board approval was obtained, the medical records of patients who underwent colon resection before (January 2006 to October 2009) and after (November 2009 to March 2011) the TRI were reviewed. RESULTS Three hundred sixty-eight patients were included, 272 and 96 in the pre-TRI and post-TRI groups, respectively. Transfusion rates decreased in the post-TRI group compared with the pre-TRI group (15% vs 28%, P = .011). Median postoperative hemoglobin levels among transfused patients were 8.4 and 7.3 g/dL in the pre-TRI and post-TRI groups, respectively (P = .009). There was no difference in complications or 30-day mortality. Transfused patients with stages I to III adenocarcinoma had worse 4-year survival (P < .05). CONCLUSIONS Perioperative transfusions in colorectal cancer surgery decreased after the implementation of a TRI. Complication rates did not change. Perioperative transfusions were associated with worse survival in patients with stages I to III cancer.
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Affiliation(s)
- Joshua P Froman
- Department of Medical Education, Gundersen Lutheran Medical Foundation, La Crosse, WI, USA
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Subramanian A, Berbari EF, Brown MJ, Allen MS, Alsara A, Kor DJ. Plasma Transfusion Is Associated With Postoperative Infectious Complications Following Esophageal Resection Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2012; 26:569-74. [DOI: 10.1053/j.jvca.2011.12.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Indexed: 12/26/2022]
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Nielsen K, Meyhoff CS, Johansson PI, Jorgensen LN, Rasmussen LS. Transfusion practice and complications after laparotomy - an observational analysis of a randomized clinical trial. Vox Sang 2012; 103:294-300. [DOI: 10.1111/j.1423-0410.2012.01626.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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[Relationship between arginase activity and the storage time of packed red blood cells]. ACTA ACUST UNITED AC 2012; 59:315-20. [PMID: 22703829 DOI: 10.1016/j.redar.2012.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 04/23/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Given the increasing evidence regarding a relationship between packed red blood cells storage time and post-transfusion complications, we decided to determine the relationship between the arginase enzyme levels, biochemical parameters and haemolysis, with the storage time of transfused packed red blood cells. MATERIAL AND METHODS We designed a prospective study that included 24 units of packed cells that had been consecutively transfused to patients of our hospital. After recording the storage time of each bag, 15 ml of blood was removed to determine arginase activity, biochemical parameters and haemolysis. A univariate analysis was performed on all the recorded parameters, and included those that were significant in the multiple regression model (P<.05). RESULTS The mean storage time was 18.6±6.1 days (range: 6-31 days), with a haematocrit of 59.8%±0.05%, a haemoglobin of 20.3±1.8 g/dl, a pH of 6.5±0.1, and an arginase activity of 140.1±124.0 mU/ml. A linear relationship was observed in the univariate analysis between the storage time and the pH (P=.001), the actual HCO(3) (P=.001), the haemolysis index (P=.035) and the SpO(2) (P=.01). Once adjusted for the confounding variables of the univariate model, a linear relationship was observed between the arginase activity and the storage time (P=.031). CONCLUSIONS Our study shows a directly proportional linear relationship between the storage time of packed red blood cells and their arginase activity. We suggest that these findings could be associated with the high incidence of complications after transfusion that may be directly proportional to their storage time.
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Complications of Transfusion. Transfus Med 2011. [DOI: 10.1002/9781444398748.ch14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Nearly 15 million units of packed red blood cells and whole blood are transfused annually in the United States alone. Until recently, the major risks from blood transfusion were thought to be transmission of viral infections, and overall, blood transfusion was believed by most providers to be safe. A safe hemoglobin threshold above which red cell transfusion is clearly unnecessary has not been established. This article addresses the numerous problems that surround the use and consequences of blood transfusion, such as hemoglobin and hematocrit levels, oxygenation, storage time, immunomodulation, infection, and anemia. The relevant literature is comprehensively reviewed.
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Costantini TW, Deree J, Martins JO, Loomis WH, Bansal V, Coimbra R. Pentoxifylline attenuates leukoreduced stored blood-induced neutrophil activation through inhibition of mitogen-activated protein kinases. Immunopharmacol Immunotoxicol 2010. [DOI: 10.3109/08923970903143965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Effects of perioperative blood product use on surgical site infection following thoracic and lumbar spinal surgery. Spine (Phila Pa 1976) 2010; 35:340-6. [PMID: 20075776 DOI: 10.1097/brs.0b013e3181b86eda] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case-control review. OBJECTIVE This retrospective study explored the hypothesis that the perioperative administration of blood products is an identifiable risk factor of increased surgical site infections (SSIs) after thoracic and lumbar spine surgical procedures. SUMMARY OF BACKGROUND DATA Surgical site infections are a significant cause of postoperative morbidity and mortality. According to the Center for Disease Control's National Nosocomial Infections Surveillance system, which monitors the rate of hospital-acquired infections in the United States, SSIs represent the third most commonly reported type of nosocomial infection, accounting for 14% to 16% of all nosocomial infections. The incidence of SSIs after spinal surgery is influenced by both preoperative and intraoperative risk factors. The relationship between blood products and SSIs has been a matter of debate for more than 2 decades. Several studies have supported the association between the use of blood products and the development of postoperative surgical site infections. METHODS A retrospective case-control study was performed. We reviewed the charts of all patients who had undergone thoracic and/or lumbar spinal surgery at the NYU Hospital for Joint Diseases between 2002 and 2007. All patients who had developed surgical site infections following spine surgery in this 5-year period were identified. RESULTS Data for 61 cases and 71 controls were included in this study. The analysis of the preoperative risk factors was performed for the entire population of patients. Body mass index and blood transfusions were found to be statistically significant risk factors for increased surgical site infections for this population. CONCLUSION Our findings support current theories that blood transfusions may have modulatory effects on the immune system of the recipients. Our specific study in spine patients may contribute to the expanding literature on allogeneic blood transfusions and the risk of nosocomial infections and encourage surgeons to favor a more restrictive policy with regard to transfusions.
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Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care*. Crit Care Med 2009; 37:3124-57. [DOI: 10.1097/ccm.0b013e3181b39f1b] [Citation(s) in RCA: 364] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Duggan JM. Gastrointestinal hemorrhage: should we transfuse less? Dig Dis Sci 2009; 54:1662-6. [PMID: 19034655 DOI: 10.1007/s10620-008-0561-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 09/26/2008] [Indexed: 01/05/2023]
Abstract
Although blood transfusion has an established place in the conventional management of acute upper gastrointestinal (GI) hemorrhage, there is growing evidence of adverse side effects of transfusion, both acute and later. An Ovid Medline literature search was performed to evaluate the significance and importance of these effects. Evidence of impaired hemostasis with repletion of blood volume in the acute phase was found in multiple studies and in uncontrolled studies in combat casualties. There are multiple large studies of a so-called immunosuppressive effect of transfused blood leading to increased infection rates and mortality dependent both on dose and on the age of the stored blood. In view of evidence of increased bleeding with early blood volume restoration and the growing evidence of so-called immunosuppressive effects of stored blood, there is a need to consider trials using a conservative utilization of blood in acute GI bleeding.
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Affiliation(s)
- John M Duggan
- Division of Clinical Practice and Population Health, Faculty of Health Sciences, Newcastle University, Newcastle, 2308, Australia.
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Abstract
Allogeneic blood transfusions have been associated with several risks and complications and with worse outcomes in a substantial number of patient populations and clinical scenarios. Allogeneic blood is costly and difficult to procure, transport, and store. Global and local shortages are imminent. Alternatives to transfusion provide many advantages, and their use is likely to improve outcomes as safer and more effective agents are developed.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, NJ 07631, USA.
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Brar MS, Brar SS, Dixon E. Perioperative supplemental oxygen in colorectal patients: a meta-analysis. J Surg Res 2009; 166:227-35. [PMID: 19922947 DOI: 10.1016/j.jss.2009.06.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Revised: 04/27/2009] [Accepted: 06/08/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Perioperative supplemental oxygen has been proposed to decrease the incidence of surgical site infection (SSI) in colorectal surgery. A number of randomized controlled trials (RCTs) have been reported with inconsistent results. In addition, relevant clinical outcomes other than SSIs have been collected in these studies and have been equivocal. A meta-analysis of RCTs was performed to elucidate the effects of perioperative supplemental oxygen in colorectal surgery on SSI incidence, mortality, ICU admission, and length of stay. MATERIALS AND METHODS A literature search of MEDLINE, PubMed, EMBASE, the Cochrane Library, and the Cochrane Clinical Trials Registry was performed in duplicate. In addition, bibliographic searches were performed, and experts were contacted for unpublished data. RCTs involving colorectal patients that included perioperative supplemental oxygen as a treatment arm and defined SSI as an outcome were included. RESULTS Five studies met inclusion criteria. Using a random-effects model, perioperative supplemental oxygen did not significantly reduce SSIs (OR = 0.69, 95% CI [0.43, 1.10], P = 0.12). However, a significant mortality benefit was observed (OR = 0.18, 95% CI [0.05, 0.69], P = 0.01). There was no significant difference in the rate of ICU admission or length of stay. Tests of heterogeneity were performed, and significant heterogeneity was only present with respect to length of stay. CONCLUSIONS Perioperative supplemental oxygen in colorectal surgery does not significantly reduce SSI. However, supplemental oxygen appears to confer a mortality benefit, a previously unreported finding. Further RCTs are required to confirm these conclusions.
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Affiliation(s)
- Mantaj S Brar
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Lelubre C, Piagnerelli M, Vincent JL. Association between duration of storage of transfused red blood cells and morbidity and mortality in adult patients: myth or reality? Transfusion 2009; 49:1384-94. [PMID: 19453985 DOI: 10.1111/j.1537-2995.2009.02211.x] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The duration of red blood cell (RBC) storage before transfusion may alter RBC function and, therefore, influence the incidence of complications. STUDY DESIGN AND METHODS With a computerized literature search from 1983 to 2008, 27 studies reporting the relationship between age of transfused RBCs and physiologic variables or incidence of complications in adult patients were identified. RESULTS Three studies (one abstract only, two foreign language) were excluded. The 24 remaining studies were grouped according to the patient population: cardiac surgery (eight studies), colorectal surgery (three), intensive care unit (ICU; seven), and trauma (six). The studies were too heterogeneous to allow a formal meta-analysis. Twenty-one of the 24 studies were single-center, and 12 were retrospective. The number of patients was highly variable, ranging from 15 to 6002. In cardiac surgery, two studies reported an increased risk of mortality but had statistical limitations. In colorectal surgery, two studies that addressed the effect on postoperative infections in the same database but with different designs yielded conflicting results. In general ICU patients, two retrospective studies reported a significant correlation between length of RBC storage and microcirculatory alterations or mortality, but the results were not confirmed in subsequent prospective, double-blinded studies. In trauma, five studies reported a correlation between RBC age and development of infection, multiple organ dysfunction, or mortality. CONCLUSIONS From the currently available published data, it is difficult to determine whether there is a relationship between the age of transfused RBCs and outcome in adult patients, except possibly in trauma patients receiving massive transfusion.
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Affiliation(s)
- Christophe Lelubre
- Department of Intensive Care Medicine, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, Brussels, Belgium
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Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med 2008; 36:2667-74. [PMID: 18679112 DOI: 10.1097/ccm.0b013e3181844677] [Citation(s) in RCA: 609] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Red blood cell (RBC) transfusions are common in intensive care unit, trauma, and surgical patients. However, the hematocrit that should be maintained in any particular patient because the risks of further transfusion of RBC outweigh the benefits remains unclear. OBJECTIVE A systematic review of the literature to determine the association between red blood cell transfusion, and morbidity and mortality in high-risk hospitalized patients. DATA SOURCES MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles. STUDY SELECTION Cohort studies that assessed the independent effect of RBC transfusion on patient outcomes. From 571 articles screened, 45 met inclusion criteria and were included for data extraction. DATA EXTRACTION Forty-five studies including 272,596 were identified (the outcomes from one study were reported in four separate publications). The outcome measures were mortality, infections, multiorgan dysfunction syndrome, and acute respiratory distress syndrome. The overall risks vs. benefits of RBC transfusion on patient outcome in each study was classified as (i) risks outweigh benefits, (ii) neutral risk, and (iii) benefits outweigh risks. The odds ratio and 95% confidence interval for each outcome measure was recorded if available. The pooled odds ratios were determined using meta-analytic techniques. DATA SYNTHESIS Forty-five observational studies with a median of 687 patients/study (range, 63-78,974) were analyzed. In 42 of the 45 studies the risks of RBC transfusion outweighed the benefits; the risk was neutral in two studies with the benefits outweighing the risks in a subgroup of a single study (elderly patients with an acute myocardial infarction and a hematocrit <30%). Seventeen of 18 studies, demonstrated that RBC transfusions were an independent predictor of death; the pooled odds ratio (12 studies) was 1.7 (95% confidence interval, 1.4-1.9). Twenty-two studies examined the association between RBC transfusion and nosocomial infection; in all these studies blood transfusion was an independent risk factor for infection. The pooled odds ratio (nine studies) for developing an infectious complication was 1.8 (95% confidence interval, 1.5-2.2). RBC transfusions similarly increased the risk of developing multi-organ dysfunction syndrome (three studies) and acute respiratory distress syndrome (six studies). The pooled odds ratio for developing acute respiratory distress syndrome was 2.5 (95% confidence interval, 1.6-3.3). CONCLUSIONS Despite the inherent limitations in the analysis of cohort studies, our analysis suggests that in adult, intensive care unit, trauma, and surgical patients, RBC transfusions are associated with increased morbidity and mortality and therefore, current transfusion practices may require reevaluation. The risks and benefits of RBC transfusion should be assessed in every patient before transfusion.
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Teixeira PG, Oncel D, Demetriades D, Inaba K, Shulman I, Green D, Plurad D, Rhee P. Blood Transfusions in Trauma: Six-Year Analysis of the Transfusion Practices at a Level I Trauma Center. Am Surg 2008. [DOI: 10.1177/000313480807401015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to analyze the transfusion practices in trauma patients in one institution. A retrospective analysis of the Trauma Registry linked with the Blood Bank Database of a Level 1 trauma center was conducted. Over 6 years, 17 per cent of the 25,599 trauma patients received blood transfusions. The overall mortality in transfused patients was 20 per cent and remained the same during the study period. There was no change in the proportion of patients receiving transfusions throughout the years, however there was a significant 23.5 per cent reduction in the mean number of packed red blood cells (PRBC) units transfused (P < 0.001 for trend). This reduction in PRBC used remained true and even more evident in the group of more severely injured patients (Injury Severity Score ≥ 16), with a 27.9 per cent decrease in mean units of PRBC (P < 0.001 for trend). The highest reduction in PRBC transfusion was seen in blunt trauma patients (34.6%, P < 0.001). During the study period there was a concurrent increase in mean units of fresh frozen plasma used (60.7%, P < 0.001) and no change in the use of platelets and cryoprecipitate. In conclusion, transfusions of PRBC were significantly reduced over time in trauma patients without any evident negative impact on mortality.
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Affiliation(s)
| | - Didem Oncel
- Division of Trauma Surgery and Surgical Critical Care
| | | | - Kenji Inaba
- Division of Trauma Surgery and Surgical Critical Care
| | | | - Donald Green
- Division of Trauma Surgery and Surgical Critical Care
- Department of Pathology
| | - David Plurad
- Division of Trauma Surgery and Surgical Critical Care
- Department of Pathology
| | - Peter Rhee
- Division of Trauma, Critical Care and Emergency Surgery, University of Arizona, Tucson, Arizona
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Panagopoulos ND, Karakantza M, Koletsis E, Apostolakis E, Sakellaropoulos GC, Filos KS, Eleni T, Dougenis D. Influence of blood transfusions and preoperative anemia on long-term survival in patients operated for non-small cell lung cancer. Lung Cancer 2008; 62:273-80. [PMID: 18430486 DOI: 10.1016/j.lungcan.2008.02.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Revised: 02/13/2008] [Accepted: 02/28/2008] [Indexed: 10/22/2022]
Abstract
It has been postulated that transfusions have immunosuppressive effects that promote tumor growth and metastasis. Moreover perioperative anemia is considered an independent prognostic factor on outcome in patients operated for malignancy. We evaluated the influence of red blood cell (RBC) transfusions and perioperative anemia on survival in non-small cell lung carcinoma (NSCLC) patients. From 1999 through 2005, 331 consecutive patients, male/female=295/36 (mean age 64+/-9 years), who underwent radical surgery for NSCLC were prospectively enrolled in this cohort and followed up for a mean of 27.2 months. The overall survival of patients was analyzed in relation to RBC transfusions and perioperative anemia. These parameters were analyzed in the whole cohort of patients and separately for stage I patients. Patients were divided according to perioperative transfusion, into Group A (transfused) and Group B (non-transfused) and according to the preoperative haemoglobin (Hb) level into Group 1(Hb<12g/dl) and Group 2(Hb> or =12g/dl), respectively. The overall transfusion rate was 25.7%. Univariate analysis showed that in the whole cohort of patients overall survival was significantly shorter in Group A (mean 33.6 months, 5-year survival 25.1%) compared to Group B (mean 48.0 months, 5-year survival 37.3%) (p=0.001). It also showed that patients with preoperative Hb level <12g/dl (Group 1), (mean of 33.0 months, 5-year survival 21.3%) had shorter survival compared to Group 2 patients (mean 49.3 months and 5-year survival 40.0%), respectively (p=0.002). Multivariate analysis in the whole cohort of patients showed that preoperative anemia was an independent risk factor for survival while RBC transfusion was not. In particular for stage I patients, it was shown that RBC transfusion was an independent prognostic factor for long-term survival as detected by multivariate analysis (p=0.043), while anemia was not. RBC transfusions affect adversely the survival of stage I NSCLC patients, while do not exert any effect on survival of patients with surgically resectable more advanced disease, where preoperative anemia is an independent negative prognostic factor. These findings indicate that RBC transfusion might exert an immunomodulatory effect on patients with early disease while in more advanced stages this effect is not apparent.
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Duane TM, Mayglothling J, Grandhi R, Warrier N, Aboutanos MB, Wolfe LG, Malhotra AK, Ivatury RR. The effect of anemia and blood transfusions on mortality in closed head injury patients. J Surg Res 2008; 147:163-7. [PMID: 18498864 DOI: 10.1016/j.jss.2008.02.044] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 02/12/2008] [Accepted: 02/12/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND The purpose of this study was to determine if anemia in isolated head trauma patients results in a higher mortality rate that would justify a more liberal use of blood transfusions. METHODS A retrospective review of isolated blunt head trauma patients was performed between January 2001 and December 2006. Comparisons were made between survivors and nonsurvivors regarding demographics, laboratory values, transfusions received, and lengths of stay. RESULTS There were 788 patients with 735 survivors who were significantly younger (46.3 y +/- 21.5 survivors versus 68.9 y +/- 18.8 nonsurvivors, P < 0.0001) and less injured [(ISS: 14.7 +/- 5.2 survivors versus 23.2 +/- 4.7 nonsurvivors, P < 0.0001), (head abbreviated injury severity: 3.7 +/- 0.7 survivors versus 4.7 +/- 0.5 nonsurvivors, P < 0.0001)] than those who died (n = 53). The survivors also had shorter lengths of stay (days) [(ICU: 2.4 +/- 4.2 versus 5.6 +/- 11.7, P = 0.03), (hospital: 6.3 +/- 9.8 versus 7.8 +/- 14.8, P = 0.02)]. Multivariate logistic regression showed age (OR 1.063, CI 1.042-1.084), ISS (OR 1.376, CI 1.270-1.491), minimum hemoglobin (OR 0.855, CI 0.732-1.000), and total blood products transfused (OR 1.073, CI 1.008-1.142) to be independent predictors of mortality with an ROC of 0.942. Outcome was independent of the operative procedures, hematocrit and packed red blood cells transfused at 24, 48, and 72 h. Hemoglobin levels of <8 mg/dL were more predictive of death than >8 mg/dL (P = 0.01). CONCLUSIONS This study supports the need to balance mild anemia with judicious blood product use in the head trauma patient. Given the risk with blood product use, each transfusion should be carefully considered and the patient re-evaluated regularly to determine the need for further intervention.
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Affiliation(s)
- Therèse M Duane
- Division of Trauma, Critical Care, and Emergency General Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298, USA.
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Netzer G, Shah CV, Iwashyna TJ, Lanken PN, Finkel B, Fuchs B, Guo W, Christie JD. Association of RBC Transfusion With Mortality in Patients With Acute Lung Injury. Chest 2007; 132:1116-23. [PMID: 17505028 DOI: 10.1378/chest.07-0145] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND RBC transfusion has been associated with increased morbidity and mortality in a variety of clinical settings. We assessed the effect of RBC transfusion on in-hospital mortality in patients with acute lung injury (ALI). METHODS Cohort study of 248 consecutive patients with ALI. RBC transfusion was evaluated as both dichotomous and continuous variables, with outcome being in-hospital mortality adjusted for clinical confounders and length of total hospital stay. RESULTS Overall in-hospital mortality rate was 39.5%. Of these patients, 207 of 248 patients (83.5%) received > or = 1 U of packed RBCs. The transfusion of any packed RBCs was associated with an increased risk of death (adjusted odds ratio [OR], 3.12; 95% confidence interval [CI], 1.28 to 7.58; p < 0.001). The overall OR per unit was 1.06 (95% CI, 1.04 to 1.09; p < 0.001) in the complete multivariable model. Transfusion after ALI onset was associated with an adjusted OR of 1.13 (95% CI, 1.07 to 1.20; p < 0.001), while transfusion before ALI onset was not associated with higher risk. The adjusted OR per unit of nonleukoreduced RBC transfused was 1.14 (95% CI, 1.07 to 1.21; p < 0.001), while the adjusted OR for leukoreduced cells per unit transfused was 1.06 (95% CI, 1.03 to 1.09; p < 0.001). CONCLUSIONS Transfusion of RBCs in patients with ALI was associated with increased in-hospital mortality. This risk occurred with RBC transfusion after the onset of ALI, and was greater for nonleukoreduced than for leukoreduced RBCs. Aggressive transfusion strategies in patients with established ALI should be questioned, pending further study.
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Affiliation(s)
- Giora Netzer
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, MSTF Bldg, Room 800, 685 W Baltimore St, Baltimore, MD 21201, USA.
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Abstract
Clinical pharmacists often participate on critical care teams that manage patients with bleeding emergencies. Although blood products are usually dispensed from the blood bank and not the pharmacy, pharmacists should be conversant in the language and trends of transfusion medicine, much like they are with other therapeutic agents. Toward that goal, this review provides a concise transfusion medicine tutorial, covering all commonly used blood products, including red blood cells, platelets, fresh frozen plasma, and plasma derivatives such as cryoprecipitate, prothrombin complex concentrates, and albumin. Usage patterns, the rationale for administering the various blood products, and studies that have attempted to determine appropriate criteria for ordering transfusions (transfusion triggers) are discussed. The benefits, risks, and several ongoing controversies that relate to the appropriateness and safety of blood product use are also summarized.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care and Hyperbaric Medicine and the New Jersey Institute for the Advancement of Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, Englewood, New Jersey 07631, USA.
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Vitale MG, Roye BD, Ruchelsman DE, Roye DP. Preoperative use of recombinant human erythropoietin in pediatric orthopedics: a decision model for long-term outcomes. Spine J 2007; 7:292-300. [PMID: 17482112 DOI: 10.1016/j.spinee.2006.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2005] [Revised: 11/15/2005] [Accepted: 04/07/2006] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spine surgery for scoliosis is associated with significant blood loss and may require blood transfusion. The risks inherent in blood transfusion have inspired interventions, including human recombinant erythropoietin (rHuEPO), which has emerged as a safe and effective adjunct in minimizing exposure to allogenic blood in children undergoing scoliosis surgery. However, there is little information in the literature on their economic impact on the health-care system. PURPOSE The purpose of this study was to evaluate the cost-effectiveness of rHuEPO in adolescent idiopathic scoliosis. STUDY DESIGN/SETTING We designed a decision analytic model capturing costs and potential long-term outcomes of transfusion-related complications to compare the cost-effectiveness of preoperative rHuEPO with a control group and a common alternative, preoperative autologous donation (PAD). PATIENT SAMPLE This is a decision analytic model. Decision modeling relies on a summation of the probability of different clinical studies; no patients were specifically studied. OUTCOME MEASURES The standard cost-effectiveness ratio (C/E) of $50,000 per quality-adjusted life year (QALY) was used as the threshold value for determining the cost-effectiveness of these two preoperative intervention strategies. METHODS From the model we calculated the probability that a patient would experience transfusion-related complications based on the mean number of allogenic units transferred as a result of scoliosis surgery. The standard C/E of $50,000 per QALY was used as the threshold value for determining the cost-effectiveness. Some aspects of the model were derived from retrospective data from the literature. Sensitivity analyses were also conducted to discover which variables, when changed within the accepted range, caused the final result of the model to change significantly. RESULTS Results indicated a cost per year-of-life-saved exceeding $1 million for the PAD arm and over $1.5 million for the rHuEPO arm. The low rates of transfusion in adolescent idiopathic scoliosis surgery and the relative safety of the blood supply create a scenario where even inexpensive interventions are not cost-effective. However, rHuEPO would become cost-effective if decreased transfusion rates or higher postoperative hematocrit resulted in decreased length of stay. CONCLUSION The use of rHuEPO preoperatively and the use of PAD are not cost-effective although both techniques remain clinically effective tools.
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Affiliation(s)
- Michael G Vitale
- Columbia University and New York Presbyterian Hospital, 600 W. 168th Street, 7th Floor, New York, NY 10032, USA.
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Abstract
An acceptable strategy for transfusion of burn patients has not been specifically identified. In 1999, we empirically adopted a hemoglobin (Hb) transfusion trigger of 7.0 g/dl or greater in our burn center. The purpose of this study was to evaluate the effects of this restrictive transfusion strategy. Retrospective comparison of adults with 20% or greater TBSA treated from 1999 to 2004 (restrictive group; REST) with patients treated before our adoption of the restrictive transfusion strategy (1997-1998: liberal group; LIB). The REST group (n = 135, age 42 +/- 17 years, %TBSA burn 37 +/- 14, and 26% incidence of inhalation injury) did not differ significantly from the LIB group (n = 37, age 42 +/- 16 years, %TBSA burn 38 +/- 17, and 35% inhalation injury). The Hb triggering a transfusion was 7.1 +/- 1.2 g/dl in the REST group, compared with 9.2 +/- 2.1 g/dl in the LIB group (P < .001). The REST group received significantly fewer units of blood per day than the LIB Group. Patients in the REST group appeared to have significantly better organ function, and there were no differences between the groups in the incidence of acute myocardial infarction. Mortality at 30 days was significantly lower in the REST group (19% vs 38%; P = .03), as was overall in-hospital mortality (22% vs 46%; P = .003). Transfusion restriction appears to be safe and resulted in fewer transfusions among this group of burn patients. Prospective studies are needed before broadly recommending a transfusion trigger of 7.0 g/dl.
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Affiliation(s)
- Peter Kwan
- The Ross Tilley Burn Centre, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
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Evans HL, Lefrak SN, Lyman J, Smith RL, Chong TW, McElearney ST, Schulman AR, Hughes MG, Raymond DP, Pruett TL, Sawyer RG. Cost of Gram-negative resistance*. Crit Care Med 2007; 35:89-95. [PMID: 17110877 DOI: 10.1097/01.ccm.0000251496.61520.75] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE It is unclear that infections with Gram-negative rods resistant to at least one major class of antibiotics (rGNR) have a greater effect on patient morbidity than infections caused by sensitive strains (sGNR). We wished to test the hypothesis that rGNR infections are associated with higher resource utilization. DESIGN Retrospective observational cohort study of prospectively collected data. SETTING University hospital surgical intensive care unit and ward. PATIENTS Surgical patients with at least one GNR infection. MEASUREMENTS We compared admissions treated for rGNR infection with those with sGNR infections. Primary outcomes were total hospital costs and hospital length of stay. Other outcomes included antibiotic treatment cost, in-hospital death, and intensive care unit length of stay. After univariate analysis comparing outcomes after rGNR infection with those after sGNR infection, multivariate linear regression models for hospital cost and length of stay were created to account for potential confounders. MAIN RESULTS Cost data were available for 604 surgical admissions treated for at least one GNR infection (Centers for Disease Control and Prevention criteria), 137 (23%) of which were rGNR infections. Admissions with rGNR infections were associated with a higher severity of illness at the time of infection (Acute Physiology and Chronic Health Evaluation II score, 17.6 +/- 0.6 vs. 13.9 +/- 0.3), had higher median hospital costs ($80,500 vs. $29,604, p < .0001) and median antibiotic costs ($2,607 vs. $758, p < .0001), and had longer median hospital length of stay (29 vs. 13 days, p < .0001) and median intensive care unit length of stay (13 days vs. 1 day, p < .0001). Infection with rGNR within the first 7 days of admission was independently predictive of increased hospital cost (incremental increase in median hospital cost estimated at $11,075; 95% confidence interval, $3,282-$20,099). CONCLUSIONS Early infection with rGNR is associated with a high economic burden, which is in part related to increased antibiotic utilization compared with infection with sensitive organisms. Efforts to control overuse of antibiotics should be pursued.
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Affiliation(s)
- Heather L Evans
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
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Tinmouth A, Fergusson D, Yee IC, Hébert PC. Clinical consequences of red cell storage in the critically ill. Transfusion 2006; 46:2014-27. [PMID: 17076859 DOI: 10.1111/j.1537-2995.2006.01026.x] [Citation(s) in RCA: 436] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Red cell (RBC) transfusions are a potentially life-saving therapy employed during the care of many critically ill patients to replace losses in hemoglobin to maintain oxygen delivery to vital organs. During storage, RBCs undergo a series of biochemical and biomechanical changes that reduce their survival and function. Additionally, accumulation of other biologic by-products of RBC preservation may be detrimental to recipients of blood transfusions. Laboratory studies and an increasing number of observational studies have raised the possibility that prolonged RBC storage adversely affects clinical outcomes. In this article, the laboratory and animal experiments evaluating changes to RBCs during prolonged storage are reviewed. Subsequently, the clinical studies that have evaluated the clinical consequences of prolonged RBC storage are reviewed. These data suggest a possible detrimental clinical effect associated with the transfusion of stored RBCs; randomized clinical trials further evaluating the clinical consequences of transfusing older stored RBCs are required.
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Affiliation(s)
- Alan Tinmouth
- Center for Transfusion and Critical Care Research, Clinical Epidemiology Unit, Critical Care Program, University of Ottawa and Ottawa Health Research Institute, Ottawa, Ontario, Canada
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Madbouly KM, Senagore AJ, Remzi FH, Delaney CP, Waters J, Fazio VW. Perioperative blood transfusions increase infectious complications after ileoanal pouch procedures (IPAA). Int J Colorectal Dis 2006; 21:807-13. [PMID: 16583193 DOI: 10.1007/s00384-006-0116-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE Assessment of risk factors associated with the use of perioperative allogeneic blood transfusion and the effect of transfusion on infectious complications after ileal pouch-anal anastomosis (IPAA). METHODS All patients included had IPAA with ileostomy. They were divided into two groups: transfused (TRAN); nontransfused (NON). Data included age, gender, preoperative anemia (Hgb <9 l g/dl), operative blood loss, transfusion volume, incidence of postoperative infectious or anastomotic complications, and length of stay (LOS). RESULTS The 1,202 patients eligible for the study were divided into: TRAN = 240 patients and NON = 962 patients. The patient age, sex, and preoperative steroid use were similar in both groups. Significantly, more patients in the TRAN group were anemic preoperatively (32 vs 11%; p<0.05) and the preoperative Hgb level was significantly lower in the TRAN (12.07; p<0.05 vs 13.34 g/dl). Transfusion was required more frequently in anemic patients (p<0.001). The overall infection rate was significantly higher in the TRAN (48.75 vs 11.22%, p<0.001), Anastomotic separation (10.83 vs 3.32%, TRAN and NON, respectively; p<0.001) and fistula formation percentage (20.8 vs 4.46%, TRAN and NON, respectively; p<0.001) was significantly higher in the TRAN group. Pelvic sepsis also occurred more frequent in TRAN (22.9 vs 4.2%, TRAN and NON, respectively; p<0.001). The incidence of any infectious complication at any site was higher in anemic patients irrespective of transfusion status (18.2 vs 2.8%, p<0.05). Transfusion was the only significant independent risk factor for postoperative infections. LOS was adversely affected by an infectious complication (9 vs 7 days, p<0.001). CONCLUSIONS Preoperative anemia is a significant risk factor for perioperative transfusion with significant increase in postoperative infectious complications and anastomotic complications after IPAA. Strategies to correct preoperative anemia, refine indications for transfusion, and define the use of blood salvage techniques may be helpful in decreasing this risk.
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Abstract
PURPOSE OF REVIEW Transfusion of red blood cells in the trauma patient can be lifesaving. The question is how much and when? It is important to weigh the risks and benefits of red blood cell transfusions, as well alternatives to transfusion as these products are not benign. RECENT FINDINGS We explore the evidence, and provide the rationale for current and future red blood cell transfusion strategies within a framework of prehospital and hospital care of the trauma patient. We also describe how red blood cell transfusion trends are changing in trauma, discuss alternatives to red blood cell transfusion and present evidence from randomized controlled trials that support a lower transfusion trigger. SUMMARY Optimal transfusion practice and use of alternatives in trauma is a rapidly expanding and important area of research. Strong clinical evidence derived by future randomized controlled trials in the area of transfusion triggers as well as transfusion alternatives is required to determine their roles in clinical practice.
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Affiliation(s)
- Lauralyn A McIntyre
- Department of Medicine, Division of Critical Care, Centre for Transfusion and Critical Care Research, Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada.
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