Emerging risks and outcomes of blood transfusion in surgery

Development of machine learning models to predict perioperative blood transfusion in hip surgery

BACKGROUND

Allogeneic Blood transfusion is common in hip surgery but is associated with increased morbidity. Accurate prediction of transfusion risk is necessary for minimizing blood product waste and preoperative decision-making. The study aimed to develop machine learning models for predicting perioperative blood transfusion in hip surgery and identify significant risk factors.

METHODS

Data of patients undergoing hip surgery between January 2013 and October 2021 in the Peking Union Medical College Hospital were collected to train and test predictive models. The primary outcome was perioperative red blood cell (RBC) transfusion within 72 h of surgery. Fourteen machine learning algorithms were established to predict blood transfusion risk incorporating patient demographic characteristics, preoperative laboratory tests, and surgical information. Discrimination, calibration, and decision curve analysis were used to evaluate machine learning models. SHapley Additive exPlanations (SHAP) was performed to interpret models.

RESULTS

In this study, 2431 hip surgeries were included. The Ridge Classifier performed the best with an AUC = 0.85 (95% CI, 0.81 to 0.88) and a Brier score = 0.21. Patient-related risk factors included lower preoperative hemoglobin, American Society of Anesthesiologists (ASA) Physical Status > 2, anemia, lower preoperative fibrinogen, and lower preoperative albumin. Surgery-related risk factors included longer operation time, total hip arthroplasty, and autotransfusion.

CONCLUSIONS

The machine learning model developed in this study achieved high predictive performance using available variables for perioperative blood transfusion in hip surgery. The predictors identified could be helpful for risk stratification, preoperative optimization, and outcomes improvement.

Management of Postpartum Hemorrhage in Critical Care Transport

Postpartum hemorrhage is a relatively common and highly morbid complication of the postpartum period that often requires management by specialized providers at tertiary care facilities. Critical care transport teams may be tasked with transporting postpartum patients who are already experiencing postpartum hemorrhage, but they should also be aware that other peripartum patients may be at risk for developing postpartum hemorrhage while in the process of transport. As such, it is imperative that transport providers understand the signs, symptoms, causes, and complications of postpartum hemorrhage as well as the options for intervention and treatment. This article reviews the current clinical evidence regarding resuscitation and medical management strategies that transport teams should be familiar with as well as more advanced and invasive management techniques they may encounter and be expected to monitor during transport, such as balloon tamponade and aortic balloon occlusion.

Red blood cell alloimmunisation in multi-transfused patients with chronic renal failure undergoing haemodialysis in Ouagadougou, Burkina Faso, 2018

Background

In Burkina Faso, red blood cell (RBC) transfusion remains the crucial anaemia treatment following chronic renal failure (CRF) as erythropoietin and its analogues are unavailable. However, blood group matching beyond the ABO and Rhesus is not common in Burkina Faso. Thus, alloimmunisation is a potential issue for transfused patients.

Objective

Our study aimed to identify anti-erythrocyte antibodies in multi-transfused CRF patients at the Yalgado Ouedraogo Teaching Hospital, Ouagadougou, Burkina Faso.

Methods

This cross-sectional study, conducted from October 2018 to November 2019, included CRF patients who had received at least two RBC units. We screened patients for the presence of RBC antibodies using three commercial Cells panels and identified antibody specificities for positive screenings using 11 Cells panels for an indirect antiglobulin test (IAT) in a low ionic strength microcolumn gel-card system.

Results

Two hundred and thirty-five patients (45.1% female; average age: 41.5 years) were included. The median number of blood units received per patient was 10 (interquartile range: 5–20). The overall alloimmunisation rate was 5.9% (14/235). Antibodies identified included: anti-D (1 case), anti-C (1 case), anti-D+C (4 cases), anti-C^W (1 case), anti-E (1 case), anti-S (1 case) and anti-Le^a (1 case). In four positive patients, the specificity of the antibodies was indeterminate. No risk factors were associated with alloimmunisation.

Conclusion

In Burkina Faso, screening for RBC alloantibodies should be mandated for patients at risk. The high rate of indeterminate antibodies suggests the need to develop a local RBC antibody panel adapted to the local population.

Postpartum Hemorrhage Management and Blood Component Therapy

This article serves to highlight both the common nature and severity of postpartum hemorrhage (PPH). Identification of etiologies and management of each is reviewed. In addition, the evaluation and administration of proper blood component therapies and massive transfusion are also explained to help providers become comfortable with early administration and delivery of blood component therapies.

Multi-center Retrospective Study of Factors Affecting Perioperative Transfusion of Packed Red Blood Cells for Pelvic Fracture Patients

Objective

To analyze the use of packed red blood cells (PRBCs) for patients with pelvic fracture and evaluate factors associated with PRBC transfusion for patients with pelvic fracture.

Methods

This retrospective cohort study collected 551 patients with pelvic fractures from six hospitals between September 1, 2012, and June 31, 2019. The age span of patients varied from 10 to 95 years old, and they were classified into two groups based on high‐energy pelvic fractures (HE‐PFs) or low‐energy pelvic fractures (LE‐PFs). The study's outcome was the use of PRBCs, fresh frozen plasma (FFP), and albumin. Demographic data, characteristics, laboratory tests, clinical treatment details, and clinical outcomes were compared between the two groups. Factors that were statistically associated with perioperative PRBCs in univariate analyses were included to conduct an optimal scale regression to determine the independent factors for perioperative PRBCs.

Results

A total of 551 patients were screened from six hospitals, and after inclusion and exclusion, 319 were finally included and finished the follow‐up from admission to discharge, while four patients died during hospitalization. Three hundred and nineteen patients were classified into two groups by their injury mechanisms. A total of 230/319 (72.1%) patients were classified into the HE‐PF group, and 89/319 (27.8%) patients were classified into the LE‐PF group. Patients in the HE‐PF group were transfused with 4.5 (3–8) units of PRBCs, 300 (0–600) ml of FFP, and 0 (0–30) g of albumin, while patients in the LE‐PF group were transfused with 3.5 (2–4.5) units of PRBCs, 0 (0–295) ml of FFP, and 0 (0–0) g of albumin (all P < 0.001). There were higher proportions of male patients and patients under 65 in the HE‐PF group (all P < 0.001). HE‐PF group patients were more severely injured and likely to take external fixation. The optimal scale regression revealed four significant factors associated with perioperative transfused PRBCs, which were patients on admission with hemorrhagic shock (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.148, P = 0.039), and methods of pelvic fixation (importance = 0.008, P = 0.026), ranked by the importance.

Conclusion

Patients with HE‐PFs had increased transfusions of PRBCs, FFP, and albumin, and hemorrhagic shock on admission, Tile classification, Hb levels, and stabilization methods were found to be associated with perioperative PRBCs.

Does Postoperative Intravenous Ferric Carboxymaltose Hasten the Recovery of Hemoglobin in Patients Post Total Knee Arthroplasty?

BACKGROUND

Timely and effective iron supplementation may help reduce the incidence of postoperative anemia and its associated problems. In this study, we aim to assess the efficacy of intravenous ferric carboxy maltose (FCM) on improving hemoglobin(Hb) level posttotal knee arthroplasty (TKA).

METHODS

We retrospectively reviewed 263 patients who had undergone unilateral TKA with 157 patients in the study group (year 2019) and 106 in the control group (year 2016). Patients in the study group received FCM (500 mg IV) on postoperative day 1, whereas patients in the control group did not receive FCM or any other iron supplementation postoperatively. Hb levels were recorded preoperatively (Pr-Hb), postoperatively on day 3 (Day3-Hb) and postoperatively at 5(+1) weeks (Week5-Hb). Statistical analysis was performed using student's paired and unpaired t-tests.

RESULTS

Pr-Hb and Day3-Hb levels were comparable in the control and study group, while Week5-Hb levels were significantly higher (P < .001) in the study group. The drop in Hb at Day3 from preoperative values was comparable between the two groups (P = 1.0). The rise in Hb from Day3 to 5 weeks was significantly higher in the study group as compared to the control group (P < .001). The difference between Pr-Hb and Week5-Hb was significantly lower (P < .001) in the study group compared to the control group. However, Week5-Hb in both groups remained lower than Pr-Hb (P < .001) in all patients.

CONCLUSION

Intravenous FCM (500 mg) was found to be a safe method of iron supplementation to improve hemoglobin levels rapidly and consistently, post-TKA. We need to further study the additive effect of higher dose FCM (1000 mg) on hemoglobin recovery.

Blood transfusion and lung surgeries in pediatric age group: A single center retrospective study

Background:

Blood transfusion is not without harm, and recent studies suggest association between transfusion and poor outcome in critically ill patients. Although it is prescribed for many reasons based on the firm belief that blood transfusion improves oxygen carrying capacity, it carries notable adverse hazards. Importantly, lung surgeries are counted as moderate to high-risk operations and take a significant risk of blood loss.

Aim:

This study aims to reveal the association between blood transfusion and poor clinical outcomes and characterize the epidemiology of blood transfusion after pediatric chest surgery.

Settings and Design:

Retrospective cohort study, done throughout 3 years.

Materials and Methods:

A total of 248 patients who underwent open thoracotomy and lung surgery and aged ≤18 years were classified according to the need of intraoperative or postoperative blood transfusion into two groups: Group I (non-transfused = 130) and Group II (transfused = 118).

Statistical Analysis:

SPSS v25 was used for analysis.

Results:

Transfusion probability ranged between 42.8% and 50% according to type of surgery. As regard to postoperative variables, there was no significant difference between both groups regarding the duration of analgesia, allergic reactions, need of re-operation and in-hospital mortality. However, transfused group showed significant increase in duration of antibiotic, persistent postoperative fever, time to remove chest drains, ICU stays, hospital stay and pneumonia. Incidence of pneumonia had a relative risk 1.82 with transfused compared to non-transfused group.

Conclusion:

Transfusion group in pediatrics undergoing lung surgeries in our study was more prone to adverse outcomes such as pneumonia, delayed time to remove chest drains, prolonged ICU stay, and hospital stay.

Blood consumption in total arterial coronary artery bypass grafting

Background

Accumulating evidence consistently demonstrates that blood transfusion in cardiac surgery is related to decreased short- and long-term survival. We aimed to evaluate periprocedural blood loss and transfusion rates in elective, isolated total arterial coronary artery bypass grafting (CABG) using exclusively skeletonized bilateral internal mammary arteries (IMAs).

Methods

We identified 1011 consecutive patients with coronary artery disease who underwent CABG between 1/2007 and 12/2014. Of them, 595 patients who presented preoperative hemoglobin levels >9md/dl and underwent elective, isolated CABG for multi-vessel coronary artery disease were included in the study population. 419 patients (70.4%) received total arterial CABG using skeletonized bilateral IMAs, in 176 patients (29.6%) mixed CABG (single IMA & saphenous vein) was performed. Propensity score adjustment using 16 variables was applied to control for treatment effect.

Results

In patients undergoing total arterial CABG, heterologous blood transfusion could be avoided in 87.8% of all cases. Propensity score adjusted results showed a significantly lower incidence of erythrocyte concentrate transfusion in patients undergoing total arterial CABG compared to mixed CABG (odds ratio 2.74, 95% confidence interval 1.38–5.43, P = 0.004). There were no statistically significant differences in the rates of thrombocyte concentrate (P = 0.39) and fresh frozen plasma transfusions (P = 0.07).

Conclusions

In this study, patients who underwent elective, isolated total arterial CABG using exclusively skeletonized bilateral IMAs showed reduced transfusion rates of erythrocyte concentrates compared to mixed CABG using a combination of single IMA and saphenous vein grafts. No evidence for a higher incidence of complications was found with a total arterial approach.

Improved hemostasis with major hepatic resection in the current surgical era

BACKGROUND

Major hepatic resection, predominantly performed for oncologic intent, is a complex procedure with the potential for severe intraoperative hemorrhage. The current surgical era has the ability to improve hemostasis throughout the performance of major hepatic resections which decreases blood transfusions and the detrimental effects associated with transfusion. We evaluated hemostasis and outcomes in the current surgical era of performing hepatic resections.

METHODS

Utilizing the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database all major hepatic resections performed between 2012 and 2016 were analyzed in regards to hemostasis. Hemostasis was evaluated by the need for and magnitude of blood transfusions. Additional perioperative variables (including operative time, length of hospital stay, and mortality rates) were analyzed to assess for outcomes with hemostasis. The NSQIP results were compared to previous publications involving major hepatic resections to detect improvement in hemostasis and outcomes in the current surgical era.

RESULTS

A total of 22777 major hepatic resections met the inclusion criteria for analysis in the NSQIP database. An additional 21198 cases were compiled within the selected publications for comparative analysis. The transfusion rate in the current surgical era was 13.3% versus 38.7% in the previous era (P = 0.0001). When a transfusion was required in the current surgical era there was a two-fold reduction in the number of units transfused (1.5 U vs. 3.8 U, P = 0.0001). Statistically significant improvements in operative time and length of hospital stay were presented within the current surgical era (P = 0.0001). When a transfusion was required there was an increased relative risk score of 7 for mortality (4.9% vs. 0.7%, P = 0.0001), however, improvement in mortality rates did not reach statistical significance across surgical eras (1.3% vs. 4.0%, P = 0.0001).

CONCLUSIONS

The conduction of major hepatic resection in the current surgical era is more hemostatic. Correlated with improved hemostasis are better outcomes for both clinical and financial endpoints. These findings should encourage continued and increased performance of major hepatic resections.

Validation of a Nomogram to Predict the Risk of Perioperative Blood Transfusion for Liver Resection

BACKGROUND

Nomograms may be important clinical tools to estimate the preoperative risk of transfusion and allow for preemptive arrangements for alternatives to allogeneic blood transfusions.

METHODS

A multicentric international cohort of 1345 patients who underwent hepatectomy for benign or malign liver diseases was used to validate a nomogram developed by the Memorial Sloan-Kettering Cancer Center.

RESULTS

A total of 449 (33.3 %) patients received a blood transfusion after hepatectomy. Several variables were associated with the need of transfusion on univariate analysis: age, BMI, hemoglobin, PT-INR, bilirubin, AST, ALT, GGT, albumin, primary liver cancer, and number of segments resected. The MSKCC nomogram, including the number of segments resected, diagnosis (primary vs. non-primary), extrahepatic organ resection, as well as platelet and hemoglobin levels, had a good predictive ability (AUC = 0.69). The frequency of patients transfused ranged from 19 % for patients who were at "low risk" (<20 % risk to be transfused) up to 68 % for patients at "high risk" (>70 % risk to be transfused). The nomogram was tested in a multivariable model including other factors associated with risk of transfusion. The final model included age (OR 1.02, 95 % CI 1.01-1.03, p < 0.001), PT-INR (OR 1.54, 95 % CI 1.01-2.36, p = 0.048), and bilirubin (OR 1.86, 95 % CI 1.09-3.18, p = 0.021). The prediction ability for the integrated prediction model was AUC = 0.73.

CONCLUSION

The MSKCC nomogram was an effective clinical tool able to predict the perioperative risk of transfusion in our independent external validation. The inclusion of patient age, as well as factors associated with liver functional status (bilirubin and PT-INR), improved the predictive ability of the MSKCC nomogram.

Restrictive versus liberal fluid therapy in major abdominal surgery (RELIEF): rationale and design for a multicentre randomised trial

INTRODUCTION

The optimal intravenous fluid regimen for patients undergoing major abdominal surgery is unclear. However, results from many small studies suggest a restrictive regimen may lead to better outcomes. A large, definitive clinical trial evaluating perioperative fluid replacement in major abdominal surgery, therefore, is required.

METHODS/ANALYSIS

We designed a pragmatic, multicentre, randomised, controlled trial (the RELIEF trial). A total of 3000 patients were enrolled in this study and randomly allocated to a restrictive or liberal fluid regimen in a 1:1 ratio, stratified by centre and planned critical care admission. The expected fluid volumes in the first 24 hour from the start of surgery in restrictive and liberal groups were ≤3.0 L and ≥5.4 L, respectively. Patient enrolment is complete, and follow-up for the primary end point is ongoing. The primary outcome is disability-free survival at 1 year after surgery, with disability defined as a persistent (at least 6 months) reduction in functional status using the 12-item version of the World Health Organisation Disability Assessment Schedule.

ETHICS/DISSEMINATION

The RELIEF trial has been approved by the responsible ethics committees of all participating sites. Participant recruitment began in March 2013 and was completed in August 2016, and 1-year follow-up will conclude in August 2017. Publication of the results of the RELIEF trial is anticipated in early 2018.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier NCT01424150.

Anesthesia for Patients with Anemia

Anemia is a common and often ignored condition in surgical patients. Anemia is usually multifactorial and iron deficiency and inflammation are commonly involved. An exacerbating factor in surgical patients is iatrogenic blood loss. Anemia has been repeatedly shown to be an independent predictor of worse outcomes. Patient blood management (PBM) provides a multimodality framework for prevention and management of anemia and related risk factors. The key strategies in PBM include support of hematopoiesis and improving hemoglobin level, optimizing coagulation and hemostasis, use of interdisciplinary blood conservation modalities, and patient-centered decision making throughout the course of care.

Risks of Anemia in Cardiac Surgery Patients

Anemia is an common condition in patients undergoing cardiac surgery, and it is often present in one quarter to half of patients at admission. Several studies have indicated that anemia is a major risk factor for worse outcomes, including increased risk of mortality and major morbidity and prolonged hospitalization. Anemia is a leading reason for use of allogeneic blood transfusions. Harmful effects of anemia are often attributed to the reduced oxygen carrying capacity of blood, reduced viscosity and the resulting impaired rheologic characteristics of blood, underlying comorbidities, and the side effects of treatments given for anemia, namely, allogeneic blood transfusions. Patients undergoing cardiac surgery may be at increased risk of anemia given the often-existing cardiac comorbidities and the negative impacts of cardiopulmonary bypass. However, whether less restrictive transfusion practices are justified in patients undergoing cardiac surgery is still a matter of debate. The prevalence of anemia often increases during hospital stay, and it can persist for a long time beyond hospital discharge. Given the associated risks and available management strategies, clinicians should remain vigilant to detect and treat anemia throughout the course of care for patients undergoing cardiac surgery.

Transfusion of Blood Products Affects Outcome in Cardiac Surgery

There remains controversy as to when patients undergoing cardiac surgery should receive a transfusion and whether a low hematocrit and its treatment with a transfusion of red cells influences outcome. The data related to this controversy are reviewed. Although the risk of known viral transmission is currently low, stored red cells do not function normally, and each unit contains activated inflammatory cells and mediators. These changes cause limited oxygen release, impaired microcirculatory flow, and immune suppression. A number of studies have observed decreased survival associated with transfusions in trauma, coronary artery bypass grafting, and intensive care unit patients. Studies that show an adverse outcome associated with low hematocrit are not definitive, because they fail to distinguish between the impact of low hematocrit per se and the possible adverse effects of transfusion, for what the low hematocrit may simply be a surrogate. The observation that a low hematocrit is associated with an adverse outcome does not necessarily prove that “treatment” of the anemia with a red cell transfusion will improve the outcome. Stored platelets contain a highly activated mixture of platelets with storage lesions and inflammatory mediators. Two retrospective post hoc multifactorial analyses suggest that platelet transfusions are associated with substantial increased morbidity and mortality. Clearly, large prospective studies are required to define the proper trigger for blood product transfusion to balance the adverse effects of anemia and platelet deficiency or dysfunction with the adverse effects of transfusion of blood products on morbidity and mortality associated with cardiac surgery and anesthesia.

The Safety and Efficacy of “Bloodless” Cardiac Surgery

Nearly 20% of blood transfusions in the United States are associated with cardiac surgery. Despite the many blood conservation techniques that are available, safe, and efficacious for patients undergoing cardiac surgery, many of these operations continue to be associated with significant amounts of blood transfusion. Although surgical bleeding after cardiopulmonary bypass is a common problem as reflected by the substantial use of blood products, it is the individual physician and institutional behavior that have been identified as reasons for transfusion and not necessarily patient comorbidity or blood loss. Transfusion rates in cardiac surgery remain high despite major advances in perioperative blood conservation, with large variations among individual centers. The adoption of available blood conservation techniques, either alone or in combination in patients undergoing cardiac surgery, could result in an estimated 75% reduction of unnecessary transfusions. The success of previously reported blood conservations programs in cardiac surgery should call for a reevaluation of allogeneic transfusion practices in patients undergoing cardiac surgery. By applying the numerous reported blood conservation strategies for the management of patients presenting for cardiac surgery, we can preserve our dwindling blood resources and help alleviate some of the direct costs of blood as well as the indirect costs of treating noninfectious and infectious complications of transfusion.

Inflammatory Changes and Coagulopathy in Multiply Injured Patients

Severe tissue trauma leads to an early activation of several danger recognition systems, including the complement and the coagulation system, often resulting in an overwhelming almost synchronic pro- and anti-inflammatory response of the host. Although the immune response is associated with beneficial effects at the site of injury including the elimination of exogenous and endogenous danger molecules as well as the initiation of regenerative processes, an exaggerated systemic inflammatory response significantly contributes to posttraumatic complications such as multiple organ failure (MOF) and early death. Besides pre-existing physical conditions, age, gender, and underlying comorbidities, surgical and anesthesiological management after injury is decisive for outcome. Improvements in surgical intensive care have increased number of patients who survive the initial phase after trauma. However, instead of progressing to normal recovery, patients often pass into persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The characterization and management of PICS will require new strategies for direct monitoring and therapeutic intervention into the patient’s immune function. In this chapter, we describe various factors involved in the inflammatory changes after trauma and aim to understand how these factors interact to progress to systemic inflammation, MOF, and PICS.

Analysis of complications after blood components’ transfusions

Complications after blood components still constitute an important clinical problem and serve as limitation of liberal-transfusion strategy.

The aim of the study was to present the 5-year incidence of early blood transfusions complications and to assess their relation to the type of the transfused blood components.

Material and methods. 58,505 transfusions of blood components performed in the years 2006-2010 were retrospectively analyzed. Data concerning the amount of the transfused blood components and the numbers of adverse transfusion reactions reported to the Regional Blood Donation and Treatment Center (RBDTC) was collected.

Results. 95 adverse transfusion reactions were reportedto RBDTC 0.16% of alldonations (95/58 505) - 58 after PRBC transfusions, 28 after platelet concentrate transfusions and 9 after FFP transfusion. Febrile nonhemolytic and allergic reactions constitute respectively 36.8% and 30.5% of all complications.

Conclusion. Nonhemolyticand allergic reactions are the most common complications of blood components transfusion and they are more common after platelet concentrate transfusions in comparison to PRBC and FFP donations.

Patient blood management--the new frontier

As one of the oldest and most common procedures in clinical practice, allogeneic blood transfusions face many issues including questionable safety and efficacy, increasing costs and limited supply. The need to provide effective care for a relatively small population of patients who could not be transfused for various reasons gave rise to 'bloodless medicine and surgery', which was subsequently proposed as a care strategy for all patients, with the goal of minimising the use of allogeneic blood components. The next evolution came from the shift from a 'product-centred' approach towards a 'patient-centred' approach, that is, a focus on patient outcome rather than use of blood components, which gave birth to 'patient blood management'. Defined as "the timely application of evidence-based medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis and minimise blood loss in an effort to improve patient outcome", patient blood management is expected to reshape the future of transfusion medicine and the way blood components are used in clinical practice.

Ulinastatin, a protease inhibitor, may inhibit allogeneic blood transfusion-associated pro-inflammatory cytokines and systemic inflammatory response syndrome and improve postoperative recovery

BACKGROUND

The aim of this study was to investigate the effects of ulinastatin, a protease inhibitor, and blood transfusion on perioperative surgical complications, changes of systemic inflammatory response syndrome (SIRS) scores, and levels of interleukin-6 (IL-6), interleukin-8 (IL-8) and tumour necrosis factor-α (TNF-α) in patients undergoing liver resection.

MATERIALS AND METHODS

Patients aged 18-65 years were enrolled and divided into four groups (12 patients in each group): a control group, a group given ulinastatin (UTI group), a group given blood transfusion (BT group), and a group given both blood transfusion and ulinastatin (BT+UTI group). Patients were randomised to receive ulinastatin or not, whereas blood transfusion was administered based on a transfusion trigger. Ulinastatin was given at a dose of 100,000 units/10 kg, infused 15 min before allogeneic blood transfusion or after completion of the liver resection. The patients were followed up for 3 days to record surgical complications, SIRS scores and levels of IL-6, IL-8 and TNF-α.

RESULTS

Forty-four patients were included in the data analysis. The SIRS rate (SIRS scores≥2) was significantly higher in the BT groups than in the control group at 6 hours and on day 3 after surgery and was significantly lower in the BT+UTI group than in the BT group on day 3 after surgery. Allogeneic blood transfusion significantly increased and ulinastatin significantly decreased postoperative levels of IL-6, IL-8, and TNF-α. The length of stay in hospital was significantly longer in the BT groups than in the control group but was not significantly different between the BT+UTI and BT groups.

CONCLUSION

A single dose of ulinastatin before allogeneic blood transfusion may lower the rate of postoperative SIRS and levels of IL-6, IL-8 and TNF-α associated with allogeneic blood transfusion and improve patients' postoperative recovery.

Transfusion of shed mediastinal blood reduces the use of allogenic blood transfusion without increasing complications

BACKGROUND

Reduced use of allogenic blood components is a key issue in cardiac surgery. Several methods to conserve blood have been used; reinfusion of shed mediastinal blood (RSMB) has found widespread acceptance, but the efficacy and safety are still debated. The purpose of this study was to evaluate the effects of RSMB on the use of allogenic blood components and selected complications.

MATERIAL AND METHODS

Six hundred and twenty-three consecutive cardiac surgery patients in three successive periods, of whom patients in the middle period did not receive RSMB due to manufacturer delivery problems, were evaluated. Patients and procedures were characterized by EuroSCORE. Prospective collected data were: units of transfused allogenic blood, fresh frozen plasma (FFP) and platelets, postoperative blood loss and postoperative complications such as dialysis, re-operation due to bleeding, sternal infection and stroke. Length of stay in ICU was used as a general indicator of perioperative complications.

RESULTS

The number of patients receiving allogenic blood in periods with RSMB was significantly lower (36.5% versus 54.9%, p<0.005), while no difference was seen in FFP and platelets. The average number of transfused blood units was lower in patients receiving RSMB (2.07 versus 3.41, p=0.029), while FFP (1.34 versus 2.01, p=0.11) and platelets (0.58 versus 0.95, p=0.05) were not statistically significantly different. Postoperative bleeding was lower (759 versus 967 ml, p=0.032) in the periods with RSMB.

CONCLUSION

Patients receiving RSMB were less transfused with allogenic blood and had less postoperative drainage, while the frequency of observed postoperative complications was not different from patients who did not receive RSMB.

Hemorrhage and subsequent allogenic red blood cell transfusion are associated with characteristic monocyte messenger RNA expression patterns in patients after multiple injury-a genome wide view

INTRODUCTION

As outcome to severe trauma is frequently affected by massive blood loss and consecutive hemorrhagic shock, replacement of red blood cell (RBC) units remains indispensable. Administration of RBC units is an independent risk factor for adverse outcome in patients with trauma. The impact of massive blood transfusion or uncrossmatched blood transfusion on the patients' immune response in the early posttraumatic period remains unclear.

MATERIAL

Thirteen patients presenting with blunt multiple injuries (Injury Severity Score >16) were studied. Monocytes were obtained on admission and at 6, 12, 24, 48, and 72 hours after trauma. Biotinylated complementary RNA targets were hybridized to Affymetrix HG U 133A microarrays. The data were analyzed by a supervised analysis based on whether the patients received massive blood transfusions, and then subsequently, by hierarchical clustering, and by Ingenuity pathway analysis.

RESULTS

Supervised analysis identified 224 probe sets to be differentially expressed (p < 0.001) in patients who received massive blood transfusion, when compared with those who did not. In addition, 331 probe sets were found differentially expressed (p < 0.001) in patients who received uncrossmatched RBC units in comparison with those who exclusively gained crossmatched ones. Functional pathway analysis of the respectively identified gene expression profiles suggests a contributory role by the AKT/PI3Kinase pathway, the mitogen-activated protein-kinase pathway, the Ubiquitin pathway, and the diverse inflammatory networks.

CONCLUSION

We exhibited for the first time a serial, sequential screening analysis of monocyte messenger RNA expression patterns in patients with multiple trauma indicating a strongly significant association between the patients' genomic response in blood monocytes and massive or uncrossmatched RBC substitution.

Why an alternative to blood transfusion?

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.

Blood conservation in practice: an overview

Allogeneic blood transfusions are associated with risks and unfavourable outcomes. Blood conservation provides an alternative, with potential to improve patient care with limited or no blood transfusion. Many approaches are available, but the most essential ones are simple and cost free.

Use of recombinant activated factor VII to arrest uncontrolled bleeding: a case series

A retrospective analysis is described to assess the effects of using recombinant activated factor VII to control bleeding in a series of patients who had failed to respond to conventional hemostatic measures. In all, 18 patients (aged 16-65 years) with a range of conditions resulting in bleeding refractory to conventional methods of control were treated with recombinant activated factor VII (60-120 Amicrog/kg; 1-4 doses). The effects of recombinant activated factor VII on bleeding were noted together with the patients' transfusion requirements and hematological parameters. Administration of recombinant activated factor VII successfully stopped bleeding in 17 of the 18 patients. Therapy with recombinant activated factor VII significantly decreased transfusion requirements for packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate compared with pretreatment values along with significant improvement in hemostasis. In various serious bleeding situations, treatment with recombinant activated factor VII may effectively arrest bleeding, which has remained refractory to conventional methods of control.

Role of biological modifiers regulating the immune response after trauma

Trauma induces a profound immunological dysfunction. This is characterised by an early state of hyperinflammation, followed by a phase of immunosuppression with increased susceptibility to infection and multiple organ failure. Therapeutic strategies directed at restoring immune homeostasis after traumatic injuries have largely failed in translation from "bench to bedside". The present review illustrates the role of biological modifiers of the posttraumatic immune response by portraying different modalities of therapeutic immune modulation. The emphasis is placed on anti-inflammatory (steroids) and immune-stimulatory (interferon) pharmacological strategies and modified resuscitative strategies, as well as more unconventional immunomodulatory approaches, such as immunonutrition.

Blood tranfusion in critically ill patients: state of the art

Anemia is one of the most common abnormal findings in critically ill patients, and many of these patients will receive a blood transfusion during their intensive care unit stay. However, the determinants of exactly which patients do receive transfusions remains to be defined and have been the subject of considerable debate in recent years. Concerns and doubts have emerged regarding the benefits and safety of blood transfusion, in part due to the lack of evidence of better outcomes resulting from randomized studies and in part related to the observations that transfusion may increase the risk of infection. As a result of these concerns and of several studies suggesting better or similar outcomes with a lower transfusion trigger, there has been a general tendency to decrease the transfusion threshold from the classic 10 g/dL to lower values. In this review, we focus on some of the key studies providing insight into current transfusion practices and fueling the current debate on the ideal transfusion trigger.

Red cell transfusions and guidelines: a work in progress

Blood transfusion utilization continues to rise, yet it has never undergone prospective safety and efficacy testing. Recent data regarding oxygen delivery, microcirculation, and inflammation all point toward potential problems with allogeneic transfusion. Outcome data from retrospective data bases are sobering, calling to question the present practices of red cell transfusion.

Transfusion Algorithms and How They Apply to Blood Conservation: The High-risk Cardiac Surgical Patient

Considerable blood product support is administered to the cardiac surgery population. Due to the multifactorial etiology of bleeding in the cardiac bypass patient, blood products frequently and empirically are infused to correct bleeding, with varying success. Several studies have demonstrated the benefit of algorithm-guided transfusion in reducing blood loss, transfusion exposure, or rate of surgical re-exploration for bleeding. Some transfusion algorithms also incorporate laboratory-based decision points in their guidelines. Despite published success with standardized transfusion practices, generalized change in blood use has not been realized, and it is evident that current laboratory-guided hemostasis measures are inadequate to define and address the bleeding etiology in these patients.

Massive blood transfusion and outcome in 1062 polytrauma patients: a prospective study based on the Trauma Registry of the German Trauma Society

BACKGROUND AND OBJECTIVES

About 15% of polytrauma patients receive massive blood transfusion (MBT) defined as > or = 10 units of packed red blood cells (PRBC). In general, the prognosis of trauma patients receiving MBT is considered to be poor. The purpose of this study was to investigate the impact of MBT on the outcome of polytrauma patients.

MATERIALS AND METHODS

Records of 10 997 patients in the Trauma Registry of the German Trauma Society were analysed. Transfusion data were available from 8182 severe trauma patients with a mean injury severity score of 24.5 and, of these 8182 patients, 1062 received > or = 10 units of PRBC. First, a logistic regression model for the predictors of mortality was performed. Second, incidences of organ failure and sepsis as well as survival rates were analysed.

RESULTS

The highest risk for mortality was age over 55 years (odds ratios [OR] 4.7; confidence intervals [CI 95%], 3.5-6.5) followed by Glasgow Coma Scale < or = 8 (OR 4.6; 3.4-6.1), MBT > or = 20 units of PRBC (OR 3.3; 2.1-5.4), thromboplastin time < 50% (OR 3.2; 2.2-4.4) and injury severity score > or = 24 (OR 2.9; 2.1-4.1). Transfusion of 10-19 PRBC was identified as the variable with the lowest risk for mortality (OR 1.5; 1.0-2.3). Risk of organ failure, sepsis and death correlated with increasing transfusion amount. For the MBT patients, the survival rate was 56.9% (CI 95%, 53.9-59.9%) compared to 85.2% (84.4-86.0%) of non-MBT patients (P < 0.001). In the MBT group with > 30 PRBC (mean 40.6 PRBC) 39.6% survived (31.7-47.5%).

CONCLUSION

Massive blood transfusion is one main prognostic factor for mortality in trauma. Although MBT is generally considered to be critical, every second trauma patient with MBT survived. A cut-off value for the number of PRBC could not be determined. Extended transfusion management even with high amounts of PRBC seems to be justified.

[Influence of blood transfusion on development of infection in patients with malignant neoplasms of the digestive system]

BACKGROUND

Anemia affects up to 90% of cancer patients, with more than 60% requiring blood transfusion during or after treatment.

AIM

To determine the influence of the allogeneic blood transfusion as a possible related factor to infection in patients with malignant neoplasms of the gastrointestinal system.

PATIENTS AND METHOD

Charts of 400 oncological patients were randomly selected and divided into two groups: group 1 (n = 200)--patients submitted to allogeneic blood transfusion and group 2 (n = 200)--non transfused patients. Both groups were evaluated and compared according to the presence and type of infection and a possible association with age, sex, types of tumors and therapeutics approach.

RESULTS

The relation between infection and blood transfusion, as well as age, sex, management and type of presented tumors were not significant. There was no difference in the incidence of infection between the non transfused patients (28) and those submitted to allogeneic blood transfusion (31).

CONCLUSIONS

In the present investigation allogeneic blood transfusion was apparently not related to development of infection in patients with malignant gastrointestinal tumors.

The emerging role of recombinant activated Factor VII (rFVIIa) in the treatment of blunt traumatic haemorrhage

Recombinant activated Factor VII (rFVIIa; eptacog alpha [activated], NovoSeven) is currently used for the management of a subgroup of haemophilia patients with inhibitors to Factors VIII or IX, and is under investigation as an adjuvant therapy for critical bleeding from other causes, including trauma. rFVIIa has a mode of action founded on physiological coagulation processes, and causes localised haemostasis at injury sites, both spontaneous and traumatic, with the capacity to correct the systemic coagulopathy associated with massive blood loss and its management. This review charts the development of rFVIIa as a new and potent adjuvant therapy for severe bleeding and coagulopathy caused by blunt trauma, where it is reported to produce rapid and significant haemostasis, reducing transfusion requirements and improving clinical outcome.

Transfusions of CPDA-1 red blood cells stored for up to 28 days decrease donor exposures in very low-birth-weight premature infants

The goal of this research was to study the safety and the efficacy of transfusing citrate-phosphate-adenine anticoagulant-preservative (CPDA-1) RBC stored for up to 28 days to reduce donor exposures in premature infants. A prospective randomized two-group study was conducted with very low-birth-weight premature infants that received at least one RBC transfusion during hospital stay. Neonates randomly assigned to Group 1 (26 infants) were transfused with CPDA-1 RBC stored for up to 28 days; those assigned to Group 2 (26 infants) received CPDA-1 RBC stored for up to 3 days. Demographic and transfusion-related data were collected. Neonates from both groups showed similar demographics and clinical characteristics. The number of transfusions per infant transfused was 4.4 +/- 4.0 in Group 1 and 4.2 +/- 3.1 in Group 2, and the number of donors per infant transfused was 1.5 +/- 0.8 (Group 1) and 4.3 +/- 3.4 (Group 2), P < 0.001. RBC transfusions containing 29.7 +/- 18.3 mmol L(-1) of potassium (RBC stored for up to 28 days) did not cause clinical or biochemical changes and reduced donor exposures by 70.2%, compared to transfusions containing 19.8 +/- 12.3 mmol L(-1) of potassium (RBC stored for up to 3 days), P < 0.001. In conclusion, RBC stored for up to 28 days safely reduced donor exposures in premature infants.

Transfusion free surgery: single institution experience of 27 consecutive liver transplants in Jehovah's Witnesses

BACKGROUND

Despite the risks associated with transfusion, the medical community continues to view blood as a safe and abundant product. In this article, we provide an effective strategy to accomplish orthotopic liver transplantation without transfusion.

STUDY DESIGN

From June 1999 through July 2004, 27 liver transplantations were performed in Jehovah's Witness patients at the USC-University Hospital (24 adults, 3 children). Nineteen of these were living donor (LD) and eight were deceased donor (DD) liver transplants. Preoperative blood augmentation with erythropoietin and iron was achieved. At induction, all LD and six of eight DD recipients underwent acute normovolemic hemodilution (ANH), and the operation was conducted under conditions of moderate anemia. Cell scavenging techniques were used. Acute normovolemic hemodilution and salvaged blood were returned as needed during bleeding or on completion of transplantation.

RESULTS

The preoperative liver disease severity score was higher in the deceased donor group. We had 100% graft and patient survivals in the LD group, and 75% in the DD recipients. Two DD recipients died. The remaining are all alive and well, with a mean followup of 965 days (range 266 to 1,979 days) in the LD group and 624 days (range 119 to 1,132 days) in the DD group.

CONCLUSIONS

Preoperative blood augmentation and acute normovolemic hemodilution provide a safe cushion against operative blood loss. Elective living donor liver transplantation allows full implementation of a transfusion-free strategy in the setting of early hepatic failure, portal hypertension, and anemia. This feat is an important step toward global standardization of transfusion-free surgical practice and an important response to widespread blood shortages and transfusion risks.

Uses of recombinant factor VIIa in trauma

PURPOSE OF REVIEW

Despite advances in the care of the injured, the morbidity and mortality of traumatic hemorrhage remain a significant problem. Traumatologists continue to look for ways to treat bleeding and prevent the sequelae of hemorrhagic shock. Recombinant factor VIIa, developed for the treatment of patients with hemophilia, has been used with some success in acute bleeding associated with injuries.

RECENT FINDINGS

The mechanism of action is via a tissue factor-dependent effect and/or platelet activation. Coagulation occurs at the site of tissue injury, where tissue factor is exposed. Case series have described the beneficial effects of recombinant factor VIIa in the treatment of acute hemorrhage, early treatment of traumatic brain injury, and reversal of premorbid anticoagulation. In addition, there have been numerous reports of recombinant factor VIIa use in acute bleeds secondary to other causes as well as some evidence that recombinant factor VIIa may be efficacious when used prophylactically in high-risk patients and for high-risk procedures. Typical doses range from 50 to 100 microg/kg as a single bolus. Although there has been concern over the risk of inappropriate thrombosis with recombinant factor VIIa administration, this complication has seldom been described in published series.

SUMMARY

Although case experience is encouraging, no level 1 evidence has been published that demonstrates clinical or economic benefit of the use of recombinant factor VIIa in trauma patients. Many questions remain to be answered, ideally through randomized, prospective clinical trials. In particular, the issues of patient selection, ideal dosing, and factors associated with futile administration need to be elucidated.

Guidelines for the use of recombinant activated factor VII (rFVIIa) in uncontrolled bleeding: a report by the Israeli Multidisciplinary rFVIIa Task Force

BACKGROUND

Recombinant activated factor VII (rFVIIa) has been approved by the U.S. Food and Drug Administration (FDA) for almost a decade for hemophilic patients with inhibitors. Its off-label use as a hemostatic agent in massive bleeding caused by a wide array of clinical scenarios is rapidly expanding. While evidence-based guidelines exist for rFVIIa treatment in hemophilia, none are available for its off-label use.

OBJECTIVES

The aim of this study is to develop expert recommendations for the use of rFVIIa in patients suffering from uncontrolled bleeding (with special emphasis on trauma) until randomized, controlled trials allow for the introduction of more established evidence-based guidelines.

METHODS

A multidisciplinary task force comprising representatives of the relevant National Medical Associations, experts from the Medical Corps of the Army, Ministry of Health and the Israel National Trauma Advisory Board was established in Israel. Recommendations were construed based on the analysis of the first 36 multi-trauma patients accumulated in the prospective national registry of the use of rFVIIa in trauma, and an extensive literature search consisting of published and prepublished controlled animal trials, case reports and series. The final consensus guidelines, together with the data of the first 36 trauma patients treated in Israel, are presented in this article.

RESULTS

Results of the first 36 trauma patients: The prolonged clotting assays [prothrombin time (PT) and partial thromboplastin time (PTT)] shortened significantly within minutes following administration of rFVIIa. Cessation of bleeding was achieved in 26 of 36 (72%) patients. Acidosis diminished the hemostatic effect of the drug, while hypothermia did not affect it. The survival rate of 61% (22/36) seems to be favorable compared with published series of similar, or less severe, trauma patients (range 30%-57%).

CONCLUSIONS

As a result of the lack of controlled trials, our guidelines should be considered as suggestive rather than conclusive. However, they provide a valuable tool for physicians using rFVIIa for the expanding off-label clinical uses.