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Connor JP, Destrampe E, Robbins D, Hess AS, McCarthy D, Maloney J. Pre-operative anemia and peri-operative transfusion are associated with poor oncologic outcomes in cancers of the esophagus: potential impact of patient blood management on cancer outcomes. BMC Cancer 2023; 23:99. [PMID: 36709278 PMCID: PMC9883921 DOI: 10.1186/s12885-023-10579-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/24/2023] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Both Red Blood Cell (RBC) transfusion and anemia are thought to negatively impact cancer survival. These effects have been reported with mixed findings in cancer of the esophagus. The potential impact of the application of restrictive transfusion strategies on this patient population has not been defined. MATERIALS AND METHODS We conducted a retrospective study of esophagectomies and studied cases based on whether they were anemic or were transfused peri-operatively. Clinical characteristics and known clinicopathologic prognosticators were compared between these groups. Survival was compared by Cox proportional hazard modeling. Post-operative transfusions were assessed for compliance with restrictive transfusion thresholds. RESULTS Three-hundred ninety-nine esophagectomy cases were reviewed and after exclusions 348 cases were analyzed. The median length of follow-up was 33 months (range 1-152 months). Sixty-four percent of patients were anemic pre-operatively and 22% were transfused. Transfusion and anemia were closely related to each other. Microcytic anemia was uncommon but was evaluated and treated in only 50% of cases. Most anemic patients had normocytic RBC parameters. Transfusion but not anemia was associated with a protracted/prolonged post-operative stay. Transfusion and anemia were both associated with reduced survival however only anemia was associated with decreased survival in multi-variable modeling. Sixty-eight percent of patients were transfused post-operatively and 11% were compliant with the restrictive threshold of 7 g/dL. CONCLUSIONS Pre-operative anemia and transfusion are closely associated, however only anemia was found to compromise survival in our esophageal cancer cohort, supporting the need for more aggressive evaluation and treatment of anemia. Adherence to restrictive transfusion guidelines offers an opportunity to reduce transfusion rates which may also improve short-term outcomes.
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Affiliation(s)
- Joseph P. Connor
- grid.28803.310000 0001 0701 8607Department of Pathology and Laboratory Medicine, Section of Transfusion Medicine, University of Wisconsin, 3147 MFCB 1685 Highland Ave, Madison, WI 53705 USA
| | - Eric Destrampe
- grid.28803.310000 0001 0701 8607Department of Pathology and Laboratory Medicine, Section of Transfusion Medicine, University of Wisconsin, 3147 MFCB 1685 Highland Ave, Madison, WI 53705 USA
| | - Daniel Robbins
- grid.28803.310000 0001 0701 8607Department of Pathology and Laboratory Medicine, University of Wisconsin, Madison, WI USA
| | - Aaron S. Hess
- grid.28803.310000 0001 0701 8607Department of Pathology and Laboratory Medicine, Section of Transfusion Medicine, University of Wisconsin, 3147 MFCB 1685 Highland Ave, Madison, WI 53705 USA ,grid.28803.310000 0001 0701 8607Department of Anesthesiology, University of Wisconsin, Madison, WI USA
| | - Daniel McCarthy
- grid.28803.310000 0001 0701 8607Department of Surgery, Section of Thoracic Surgery, University of Wisconsin, Madison, WI USA
| | - James Maloney
- grid.28803.310000 0001 0701 8607Department of Surgery, Section of Thoracic Surgery, University of Wisconsin, Madison, WI USA
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Defining Usage and Clinical Outcomes Following Perioperative Fresh Frozen Plasma and Platelet Administration in Spine Surgery Patients. Clin Spine Surg 2019; 32:E246-E251. [PMID: 30864971 DOI: 10.1097/bsd.0000000000000815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective study. OBJECTIVES The main objectives of this study were to characterize the utilization of fresh frozen plasma (FFP) and platelets in spine surgery and the clinical outcomes following their administration. SUMMARY OF BACKGROUND DATA Blood component transfusion is often a crucial therapy during spine surgery. Little is known about the association between transfusion with FFP and/or platelets and perioperative morbidity in patients undergoing spine surgery. MATERIALS AND METHODS At a single large tertiary medical center, the surgical billing database was retrospectively queried for patients undergoing spinal surgery from 2008 to 2015. A univariate analysis compared patient characteristics for those who received FFP and/or platelets perioperatively and those who did not. To determine independent predictors of FFP and platelet administration and independent predictors of perioperative complications, both univariate and multivariate analyses were used. RESULTS In total, 6931 patients met inclusion criteria. One thousand seven (14.5%) patients received perioperative FFP transfusion and 432 (6.2%) received platelets. In multivariate analysis, Charlson Comorbidity Index (CCI) ≥4, preoperative hemoglobin <12 g/dL, preoperative international normalized ratio (INR) ≥1.7, higher estimated blood loss, and receipt of packed red blood cell or platelet transfusion were associated with perioperative FFP administration (all P≤0.001). More than half of all patients received FFP with an INR trigger of <1.7. Those who received perioperative FFP were more likely to experience infection, increased length of stay, and ischemic, respiratory, thrombotic, and renal complications (all P<0.0001). Perioperative FFP [odds ratio (OR): 2.43], platelet transfusion (OR: 1.81), American Society of Anesthesiologists (ASA) grade 3 or 4 (OR: 1.84), CCI≥4 (OR: 1.75), and receipt of packed red blood cells (OR: 1.73) were independent predictors of experiencing any complication (all P≤0.008). CONCLUSIONS The majority of patients were given FFP with a liberal INR trigger of >1.7. Perioperative FFP and platelet administration are independent predictors of perioperative complications following spine surgery.
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Connor JP, O'Shea A, McCool K, Sampene E, Barroilhet LM. Peri-operative allogeneic blood transfusion is associated with poor overall survival in advanced epithelial ovarian Cancer; potential impact of patient blood management on Cancer outcomes. Gynecol Oncol 2018; 151:294-298. [PMID: 30201233 DOI: 10.1016/j.ygyno.2018.08.040] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 08/23/2018] [Accepted: 08/27/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transfusion related immune modulation associated with red blood cell (RBC) transfusion is thought to result in decreased cancer survival. Results in epithelial ovarian cancer (EOC) have been mixed however most suggest worse oncologic outcomes in patients who were transfused at the time of debulking surgery. The impact of restrictive transfusion strategies on this patient population is currently not known. METHODS We conducted a retrospective study of women with EOC. The study population was divided into two groups based on whether they were transfused RBCs during the peri-operative period or not. Clinical characteristics and prognosticators were compared between groups. Overall survival was compared between groups based on transfusion status and other known prognostic factors. Cox proportional hazard modeling was used to examine the association between the prognostic factors and the study endpoint. RESULTS Sixty-six percent of women were transfused. Transfusion was associated with CA125, the use of neoadjuvant chemotherapy (NACT), surgical blood loss, and anemia. The mean pre-transfusion Hgb was 7.8 + 0.6 g/dL and 94% had a hemoglobin level greater than the transfusion threshold of 7 g/dL. RBC transfusion, suboptimal debulking, anemia, and NACT were associated with decreased survival. Only RBC transfusion and suboptimal debulking status remained significant in a multivariate model. CONCLUSIONS Peri-operative RBC transfusion compromises survival in ovarian cancer supporting the need to minimize the use of transfusion at the time of debulking surgery. Adherence to evidence-based transfusion guidelines offers an opportunity to reduce transfusion rates in this population with a resulting positive influence on survival.
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Affiliation(s)
- Joseph P Connor
- University of Wisconsin, Department of Pathology and Laboratory Medicine, Section of Transfusion Medicine, Madison, WI, United States of America.
| | - Andrea O'Shea
- University of Wisconsin, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Madison, WI, United States of America
| | - Kevin McCool
- University of Wisconsin, Department of Obstetrics and Gynecology, Madison, WI, United States of America
| | - Emmanuel Sampene
- University of Wisconsin, Department of Biostatistics and Medical Informatics, Madison, WI, United States of America
| | - Lisa M Barroilhet
- University of Wisconsin, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Madison, WI, United States of America
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Purvis TE, Goodwin CR, Molina CA, Frank SM, Sciubba DM. Percentage change in hemoglobin level and morbidity in spine surgery patients. J Neurosurg Spine 2018; 28:345-351. [DOI: 10.3171/2017.7.spine17301] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe aim of this study was to characterize the association between percentage change in hemoglobin (ΔHb)—i.e., the difference between preoperative Hb and in-hospital nadir Hb concentration—and perioperative adverse events among spine surgery patients.METHODSPatients who underwent spine surgery at the authors’ institution between December 4, 2008, and June 26, 2015, were eligible for this retrospective study. Patients who underwent the following procedures were included: atlantoaxial fusion, subaxial anterior cervical fusion, subaxial posterior cervical fusion, anterior lumbar fusion, posterior lumbar fusion, lateral lumbar fusion, excision of intervertebral disc, and excision of spinal cord lesion. Data on intraoperative transfusion were obtained from an automated, prospectively collected, anesthesia data management system. Data on postoperative hospital transfusions were obtained through an Internet-based intelligence portal. Percentage ΔHb was defined as: ([preoperative Hb − nadir Hb]/preoperative Hb) × 100. Clinical outcomes included in-hospital morbidity and length of stay associated with percentage ΔHb.RESULTSA total of 3949 patients who underwent spine surgery were identified. Of these, 1204 patients (30.5%) received at least 1 unit of packed red blood cells. The median nadir Hb level was 10.6 g/dl (interquartile range 8.7–12.4 g/dl), yielding a mean percentage ΔHb of 23.6% (SD 15.4%). Perioperative complications occurred in 234 patients (5.9%) and were more common in patients with a larger percentage ΔHb (p = 0.017). Hospital-related infection, which occurred in 60 patients (1.5%), was also more common in patients with greater percentage ΔHb (p = 0.001).CONCLUSIONSPercentage ΔHb is independently associated with a higher risk of developing any perioperative complication and hospital-related infection. The authors’ results suggest that percentage ΔHb may be a useful measure for identifying patients at risk for adverse perioperative events.
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Affiliation(s)
| | - C. Rory Goodwin
- 2Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | | | - Steven M. Frank
- 3Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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Remy KE, Hall MW, Cholette J, Juffermans NP, Nicol K, Doctor A, Blumberg N, Spinella PC, Norris PJ, Dahmer MK, Muszynski JA. Mechanisms of red blood cell transfusion-related immunomodulation. Transfusion 2018; 58:804-815. [PMID: 29383722 DOI: 10.1111/trf.14488] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 11/13/2017] [Accepted: 12/10/2017] [Indexed: 01/28/2023]
Abstract
Red blood cell (RBC) transfusion is common in critically ill, postsurgical, and posttrauma patients in whom both systemic inflammation and immune suppression are associated with adverse outcomes. RBC products contain a multitude of immunomodulatory mediators that interact with and alter immune cell function. These interactions can lead to both proinflammatory and immunosuppressive effects. Defining clinical outcomes related to immunomodulatory effects of RBCs in transfused patients remains a challenge, likely due to complex interactions between individual blood product characteristics and patient-specific risk factors. Unpacking these complexities requires an in-depth understanding of the mechanisms of immunomodulatory effects of RBC products. In this review, we outline and classify potential mediators of RBC transfusion-related immunomodulation and provide suggestions for future research directions.
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Affiliation(s)
- Kenneth E Remy
- Department of Pediatrics, Division of Pediatric Critical Care, Washington University School of Medicine, St Louis, Missouri
| | - Mark W Hall
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio.,The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Jill Cholette
- Pediatric Critical Care and Cardiology, University of Rochester, Rochester, New York
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Kathleen Nicol
- Department of Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Allan Doctor
- Department of Pediatrics, Division of Pediatric Critical Care, Washington University School of Medicine, St Louis, Missouri
| | - Neil Blumberg
- Transfusion Medicine/Blood Bank and Clinical Laboratories, Departments of Pathology and Laboratory Medicine, University of Rochester, Rochester, New York
| | - Philip C Spinella
- Department of Pediatrics, Division of Pediatric Critical Care, Washington University School of Medicine, St Louis, Missouri
| | - Philip J Norris
- Blood Systems Research Institute, San Francisco, California.,Departments of Laboratory Medicine and Medicine, University of California at San Francisco, San Francisco, California
| | - Mary K Dahmer
- Department of Pediatrics, Division of Pediatric Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio.,The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
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Purvis TE, Goodwin CR, De la Garza-Ramos R, Ahmed AK, Lafage V, Neuman BJ, Passias PG, Kebaish KM, Frank SM, Sciubba DM. Effect of liberal blood transfusion on clinical outcomes and cost in spine surgery patients. Spine J 2017; 17:1255-1263. [PMID: 28458067 DOI: 10.1016/j.spinee.2017.04.028] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 01/12/2017] [Accepted: 04/24/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Blood transfusions in spine surgery are shown to be associated with increased patient morbidity. The association between transfusion performed using a liberal hemoglobin (Hb) trigger-defined as an intraoperative Hb level of ≥10 g/dL, a postoperative level of ≥8 g/dL, or a whole hospital nadir between 8 and 10 g/dL-and perioperative morbidity and cost in spine surgery patients is unknown and thus was investigated in this study. PURPOSE This study aimed to describe the perioperative outcomes and economic cost associated with liberal Hb trigger transfusion among spine surgery patients. STUDY DESIGN/SETTING This is a retrospective study. PATIENT SAMPLE The surgical billing database at our institution was queried for inpatients discharged between 2008 and 2015 after the following procedures: atlantoaxial fusion, anterior cervical fusion, posterior cervical fusion, anterior lumbar fusion, posterior lumbar fusion, lateral lumbar fusion, other procedures, and tumor-related surgeries. In total, 6,931 patients were included for analysis. OUTCOME MEASURES The primary outcome was composite morbidity, which was composed of (1) infection (sepsis, surgical-site infection, Clostridium difficile infection, or drug-resistant infection); (2) thrombotic event (pulmonary embolus, deep venous thrombosis, or disseminated intravascular coagulation); (3) kidney injury; (4) respiratory event; and (5) ischemic event (transient ischemic attack, myocardial infarction, or cerebrovascular accident). MATERIALS AND METHODS Data on intraoperative transfusion were obtained from an automated, prospectively collected anesthesia data management system. Data on postoperative hospital transfusion were obtained through a Web-based intelligence portal. Based on previous research, we analyzed the data using three definitions of a liberal transfusion trigger in patients who underwent red blood cell transfusion: a liberal intraoperative Hb trigger as a nadir Hb level of 10 g/dL or greater, a liberal postoperative Hb trigger as a nadir Hb level of 8 g/dL or greater, or a whole hospital nadir Hb level of 8-10 g/dL. Variables analyzed included in-hospital morbidity, mortality, length of stay, and total costs associated with a liberal transfusion strategy. RESULTS Among patients with a whole hospital stay nadir Hb between 8 and 10 g/dL, transfused patients demonstrated a longer in-hospital stay (median [interquartile range], 6 [5-9] vs. 4 [3-6] days; p<.0001) and a higher perioperative morbidity (n=145 [11.5%] vs. n=74 [6.1%], p<.0001) than those not transfused. Even after adjusting for age, gender, race, American Society of Anesthesiologists class, Charlson Comorbidity Index score, estimated blood loss, baseline Hb value, and surgery type, logistic regression analysis revealed that patients with a nadir Hb of 8-10 g/dL who were transfused had an independently higher risk of perioperative morbidity (odds ratio=2.11, 95% confidence interval, 1.44-3.09; p<.0001). Estimated additional costs associated with liberal trigger use, defined as a transfusion occurring in patients with a whole hospital stay nadir Hb of 8-10 g/dL, ranged from $202,675 to $700,151 annually. CONCLUSIONS Transfusion using a liberal trigger is associated with increased morbidity, even after controlling for possible confounders. Our results suggest that modification of transfusion practice may be a potential area for improving patient outcomes and reducing costs.
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Affiliation(s)
- Taylor E Purvis
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Brian J Neuman
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter G Passias
- Division of Spinal Surgery, NYU Medical Center-Hospital for Joint Diseases, New York City, NY, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Interdisciplinary Blood Management Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Carnevale J, Feller R, Shalvoy RM. Transfusion-Transmitted Babesiosis During Total Hip Arthroplasty. Orthopedics 2015; 38:e852-5. [PMID: 26375547 DOI: 10.3928/01477447-20150902-92] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 02/23/2015] [Indexed: 02/03/2023]
Abstract
Babesiosis is a potentially life-threatening zoonotic disease that is endemic to the northeastern United States and increasing in prevalence worldwide. Transmitted by the same Ixodes tick responsible for Lyme disease, the intraerythrocytic parasite Babesia causes a wide range of clinical presentations--from asymptomatic carriage to a fulminant course with rapid deterioration. Symptoms typically present 1 to 6 weeks after inoculation, with the gradual onset of fatigue, malaise, weakness, and intermittent or sustained fever as high as 40.9°C. Severe cases are associated with parasitemia greater than 4%, alkaline phosphatase greater than 125 U/L, and white blood cell counts greater than 5×10(9)/L. Definitive diagnosis is made by microscopic examination of thin blood smears, polymerase chain reaction, and indirect immunofluorescent antibody testing. The increasing frequency of babesiosis paired with a lack of blood-donor screening assays poses a serious threat to the safety of the US blood supply. Although babesiosis is responsible for 3.6% of transfusion-related deaths, the Food and Drug Administration has yet to approve mandatory screening for the parasite in donated blood. Historically, transfusion-transmitted babesiosis has been thought to be isolated to the immunocompromised patient population. However, a recent case of transfusion-transmitted babesiosis in an immunocompetent patient following total hip arthroplasty is the first reported in the literature and may represent a growing risk to a far greater segment of the population than previously thought. This article summarizes the current state of transfusion-transmitted babesiosis and the detrimental impact of this infection on blood transfusion safety.
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Kluger MD, Salceda JA, Laurent A, Tayar C, Duvoux C, Decaens T, Luciani A, Van Nhieu JT, Azoulay D, Cherqui D. Liver resection for hepatocellular carcinoma in 313 Western patients: tumor biology and underlying liver rather than tumor size drive prognosis. J Hepatol 2015; 62:1131-40. [PMID: 25529622 DOI: 10.1016/j.jhep.2014.12.018] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 12/08/2014] [Accepted: 12/10/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Treatment decisions for hepatocellular carcinoma are mostly guided by tumor size. The aim of this study was to analyze resection outcomes according to tumor size and characterize prognostic factors. METHODS Patients resected at a Western center between 1989 and 2010 were grouped by largest tumor size: <50mm, 50-100mm, and >100mm. The primary end points were overall- and recurrence-free survival. Univariate associations with primary endpoints were entered into a Cox proportional hazard regression model. RESULTS Three hundred thirteen patients underwent resection: 111 (36%) had tumors <50mm, 113 (36%) had tumors between 50 and 100mm, and 89 (28%) had tumors >100mm. Five-year overall and disease-free survival rates for the three groups were 67%, 46%, and 34%, and 32%, 27%, and 27%, respectively. Thirty-five patients, mostly from <50mm group, underwent transplantation which was associated with a 91% 5 year survival rate. Tumor size was not an independent predictor of overall or recurrence-free survival on multivariate analyses. Independent predictors of decreased overall survival were: intraoperative transfusion (HR=2.60), cirrhosis (HR=2.42), poorly differentiated tumor (HR=2.04), satellite lesions (HR=1.69), alpha-fetoprotein >200 (HR=1.53), and microvascular invasion (HR=1.48). The use of salvage transplantation was an independent predictor of improved survival (HR=0.21). Recurrence-free survival was predicted by intraoperative transfusion (HR=2.15), poorly differentiated tumor (HR=1.87), microvascular invasion (HR=1.71) and cirrhosis (HR=1.69). CONCLUSION By studying a large group of patients across a distribution of tumor sizes and background liver diseases, it is demonstrated that size alone is a limited prognostic factor. Tumor biology and condition of the underlying liver are better prognosticators and should be given closer attention. Although hampered by recurrence rates, resection is safe and offers good overall survival. In addition, it may allow for better selection for salvage transplantation after consideration of histopathological risk factors.
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Affiliation(s)
- Michael D Kluger
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France; Section of Gastrointestinal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, United States
| | - Juan A Salceda
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Alexis Laurent
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Claude Tayar
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Christophe Duvoux
- Service d'Hepatologie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Thomas Decaens
- Service d'Hepatologie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Alain Luciani
- Service d'Imagerie Medicale, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Jeanne Tran Van Nhieu
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Daniel Azoulay
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Daniel Cherqui
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France; Centre Hépato Biliaire, Paul Brousse Hôpital, Université Paris Sud, Villejuif, France.
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Kozanek M, Menendez ME, Ring D. Association of perioperative blood transfusion and adverse events after operative treatment of proximal humerus fractures. Injury 2015; 46:270-4. [PMID: 25528399 DOI: 10.1016/j.injury.2014.11.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 11/13/2014] [Accepted: 11/21/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to assess the relationship between perioperative blood transfusion for proximal humerus fracture and inpatient mortality, adverse events, prolonged hospital stay, and nonroutine disposition. METHODS Among the >55,000 patients with an operatively treated proximal humerus fracture identified in the Nationwide Inpatient Sample between 2008 and 2011, 17% received a perioperative blood transfusion. Multivariable logistic regression analyses addressed the association of blood transfusion with inpatient mortality, adverse events, hospital stay, and nonroutine discharge, accounting for comorbidities and other known confounders. RESULTS Perioperative blood transfusion for fracture of the proximal humerus was not associated with inhospital death, but it was independently associated with inpatient adverse events (odds ratio (OR) 4.4, 95% confidence interval (CI) 4.2-4.6), prolonged hospital stay (OR 2.8, 95% CI 2.7-2.9), and increased nonroutine discharge (OR 1.8, 95% CI 1.7-1.9). CONCLUSIONS Inpatients with fracture of the proximal humerus who receive transfusion are not more likely to die in hospital, but they do stay longer, experience more adverse events, and are less likely to be discharged home. Additional study is merited to determine if the judicious use of blood transfusion in the perioperative period can decrease inpatient morbidity and health-care resource utilisation. LEVEL OF EVIDENCE Level II, Retrospective Design, Prognosis Study.
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Affiliation(s)
- Michal Kozanek
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114, USA.
| | - Mariano E Menendez
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114, USA.
| | - David Ring
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114, USA.
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Obrador R, Musulin S, Hansen B. Red blood cell storage lesion. J Vet Emerg Crit Care (San Antonio) 2014; 25:187-99. [PMID: 25428860 DOI: 10.1111/vec.12252] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 10/01/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To summarize current understanding of the mechanisms responsible for changes occurring during red blood cell (RBC) storage, collectively known as the storage lesion, and to review the biological and clinical consequences of increasing storage time of RBCs. DATA SOURCES Human and veterinary clinical studies, experimental animal model studies, and reviews of the RBC storage lesion with no date restrictions. HUMAN DATA SYNTHESIS Experimental studies have characterized the evolution of human RBC and supernatant changes that occur during storage and form the basis for concern about the potential for harm from long-term storage of RBCs. Although 4 randomized controlled trials of varying sizes failed to find an association between RBC storage time and negative clinical outcomes, a recent meta-analysis and numerous observational clinical studies have demonstrated that transfusion of old versus fresh stored RBCs is associated with an increased risk of morbidity and mortality, particularly among trauma victims and cardiac surgery patients. Potential clinical consequences of RBC transfusion following development of the storage lesion include risk of organ dysfunction, organ failure, infections, and death. VETERINARY DATA SYNTHESIS Experimental animal models have contributed to the evidence supporting adverse consequences of the RBC storage lesion. Studies on relevant RBC storage issues such as the effect of different preservative solutions and leukoreduction have been completed. Transfusion with RBCs stored for 42 days increases mortality in dogs with experimental sepsis. CONCLUSION Storage of RBCs induces progressive biochemical, biomechanical, and immunologic changes that affect red cell viability, deformability, oxygen carrying capacity, microcirculatory flow, and recipient response. Most reports in the human and veterinary literature support the concept that there are deleterious effects of the RBC storage lesion, but additional studies with improved experimental design are needed to identify compelling reasons to modify current blood banking and transfusion practices.
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Affiliation(s)
- Rafael Obrador
- From the Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607
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Schneider SO, Rensing H, Hartmann L, Grundmann U, Volk T, Biedler A. Impact of intraoperatively salvaged and washed blood on stimulated cytokine release in vitro. Transfusion 2014; 54:2782-90. [PMID: 25294235 DOI: 10.1111/trf.12781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 05/21/2014] [Accepted: 06/02/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Intraoperative blood salvage and processing it with commercially available devices is a widespread standard procedure to reduce allogeneic blood transfusion in patients undergoing major orthopedic surgery. The aim of this study was to investigate the impact of such processed blood on the immune system by measuring pro- and anti-inflammatory cytokines. STUDY DESIGN AND METHODS Salvaged blood from 20 patients undergoing hip arthroplasty was processed with a continuous autotransfusion system. One part of the processed blood was left without further treatment, one part was additionally leukoreduced, one part was irradiated, and one part was separated into its cellular and soluble fraction by centrifugation. Specimens from each part were mixed in vitro with venous blood from the patient in ratios of 3:1, 1:1, and 1:3 and incubated with endotoxin for 24 hours. Tumor necrosis factor (TNF)-α and interleukin (IL)-10 were measured in cell culture supernatants by enzyme-linked immunosorbent assay. RESULTS All parts of the salvaged blood were without a significant influence on TNF-α release. In contrast, IL-10 was significantly increased, independently of the admixtured salvaged blood being plain, additionally irradiated, or additionally leukoreduced. This IL-10 increase was also found with the cellular fraction of the plain salvaged blood, whereas the soluble fraction had no influence on IL-10 release. CONCLUSION Intraoperative salvaged blood is not immunologically inert. We observed a significant increase in the anti-inflammatory IL-10 response without affecting the proinflammatory TNF-α release. Neither leukofiltration nor gamma irradiation eliminated this effect that was limited only to the cellular fraction of the salvaged blood, suggesting red blood cells to be responsible for the observed immunomodulation.
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Affiliation(s)
- Sven Oliver Schneider
- Department for Anesthesiology, Critical Care Medicine and Pain Therapy, Saarland University Hospital, Homburg, Germany
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Ejaz A, Spolverato G, Kim Y, Frank SM, Pawlik TM. Identifying Variations in Blood Use Based on Hemoglobin Transfusion Trigger and Target among Hepatopancreaticobiliary Surgeons. J Am Coll Surg 2014; 219:217-28. [DOI: 10.1016/j.jamcollsurg.2014.02.033] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Revised: 02/18/2014] [Accepted: 02/19/2014] [Indexed: 11/29/2022]
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Frank SM, Resar LM, Rothschild JA, Dackiw EA, Savage WJ, Ness PM. A novel method of data analysis for utilization of red blood cell transfusion. Transfusion 2013; 53:3052-9. [DOI: 10.1111/trf.12227] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 03/16/2013] [Accepted: 03/22/2013] [Indexed: 01/01/2023]
Affiliation(s)
- Steven M. Frank
- Department of Anesthesiology/Critical Care Medicine; Department of Medicine (Hematology), Oncology & Pediatrics; The Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Pathology (Transfusion Medicine); The Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Pathology (Transfusion Medicine); Brigham and Women's Hospital; Boston Massachusetts
| | - Linda M.S. Resar
- Department of Anesthesiology/Critical Care Medicine; Department of Medicine (Hematology), Oncology & Pediatrics; The Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Pathology (Transfusion Medicine); The Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Pathology (Transfusion Medicine); Brigham and Women's Hospital; Boston Massachusetts
| | - James A. Rothschild
- Department of Anesthesiology/Critical Care Medicine; Department of Medicine (Hematology), Oncology & Pediatrics; The Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Pathology (Transfusion Medicine); The Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Pathology (Transfusion Medicine); Brigham and Women's Hospital; Boston Massachusetts
| | - Elizabeth A. Dackiw
- Department of Anesthesiology/Critical Care Medicine; Department of Medicine (Hematology), Oncology & Pediatrics; The Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Pathology (Transfusion Medicine); The Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Pathology (Transfusion Medicine); Brigham and Women's Hospital; Boston Massachusetts
| | - Will J. Savage
- Department of Anesthesiology/Critical Care Medicine; Department of Medicine (Hematology), Oncology & Pediatrics; The Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Pathology (Transfusion Medicine); The Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Pathology (Transfusion Medicine); Brigham and Women's Hospital; Boston Massachusetts
| | - Paul M. Ness
- Department of Anesthesiology/Critical Care Medicine; Department of Medicine (Hematology), Oncology & Pediatrics; The Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Pathology (Transfusion Medicine); The Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Pathology (Transfusion Medicine); Brigham and Women's Hospital; Boston Massachusetts
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The age of transfused blood predicts hematocrit response among critically ill surgical patients. Am J Surg 2012; 204:269-73. [PMID: 22465434 DOI: 10.1016/j.amjsurg.2011.10.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 10/27/2011] [Accepted: 10/27/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND In vitro data suggest that erythrocytes undergo storage time-dependent degradation, eventuating in hemolysis. We hypothesize that transfusion of old blood, as compared with newer blood, results in a smaller increment in hematocrit. METHODS We performed an analysis of packed red blood cell transfusions administered in the surgical intensive care unit. Age of blood was analyzed as continuous, dichotomized at 14 days (old vs new), and grouped by weeks old. RESULTS A total of 136 U of packed red blood cells were given to 52 patients; 110 (80.9%) were 14 days old or more. A linear, inverse correlation was observed between the age of blood and the increment in hematocrit (r(2) = -.18, P = .04). The increment in hematocrit was greater after transfusion of new as compared with old blood (5.6% vs 3.5%, respectively; P = .005). A linear relationship also was observed between the age of transfused blood in weeks and the increment in hematocrit (P = .02). CONCLUSIONS There is an inverse relationship between the age of blood and the increment in hematocrit. The age of blood should be considered before transfusion of surgical patients with intensive care unit anemia.
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Perisanidis C, Dettke M, Papadogeorgakis N, Schoppmann A, Mittlböck M, Kyzas PA, Ewers R, Seemann R. Transfusion of allogenic leukocyte-depleted packed red blood cells is associated with postoperative morbidity in patients undergoing oral and oropharyngeal cancer surgery. Oral Oncol 2012; 48:372-8. [DOI: 10.1016/j.oraloncology.2011.11.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 11/21/2011] [Accepted: 11/22/2011] [Indexed: 11/25/2022]
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Pieracci FM, Barnett CC, Townsend N, Moore EE, Johnson J, Biffl W, Bensard DD, Burlew CC, Gerber A, Silliman CC. Sexual dimorphism in hematocrit response following red blood cell transfusion of critically ill surgical patients. ISRN HEMATOLOGY 2012; 2012:298345. [PMID: 22536521 PMCID: PMC3320002 DOI: 10.5402/2012/298345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 01/17/2012] [Indexed: 12/03/2022]
Abstract
The change in hematocrit (ΔHct) following packed red blood cell (pRBCs) transfusion is a clinically relevant measurement of transfusion efficacy that is influenced by post-transfusion hemolysis. Sexual dimorphism has been observed in critical illness and may be related to gender-specific differences in immune response. We investigated the relationship between both donor and recipient gender and ΔHct in an analysis of all pRBCs transfusions in our surgical intensive care unit (2006–2009). The relationship between both donor and recipient gender and ΔHct (% points) was assessed using both univariate and multivariable analysis. A total of 575 units of pRBCs were given to 342 patients; 289 (49.9%) donors were male. By univariate analysis, ΔHct was significantly greater for female as compared to male recipients (3.81% versus 2.82%, resp., P < 0.01). No association was observed between donor gender and ΔHct, which was 3.02% following receipt of female blood versus 3.23% following receipt of male blood (P = 0.21). By multivariable analysis, recipient gender remained associated significantly with ΔHct (P < 0.01). In conclusion, recipient gender is independently associated with ΔHct following pRBCs transfusion. This association does not appear related to either demographic or anthropomorphic factors, raising the possibility of gender-related differences in recipient immune response to transfusion.
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Affiliation(s)
- Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, University of Colorado Health Science Center, 777 Bannock Street MC0206, Denver, CO 80206, USA
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17
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Frank SM. Who benefits from red blood cell salvage?-Utility and value of intraoperative autologous transfusion. Transfusion 2011; 51:2058-60. [DOI: 10.1111/j.1537-2995.2011.03293.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Prittie JE. Controversies related to red blood cell transfusion in critically ill patients. J Vet Emerg Crit Care (San Antonio) 2010; 20:167-76. [PMID: 20487245 DOI: 10.1111/j.1476-4431.2010.00521.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To review the evolution of and controversies associated with allogenic blood transfusion in critically ill patients. DATA SOURCES Veterinary and human literature review. HUMAN DATA SYNTHESIS RBC transfusion practices for ICU patients have come under scrutiny in the last 2 decades. Human trials have demonstrated relative tolerance to severe, euvolemic anemia and a significant outcome advantage following implementation of more restricted transfusion therapy. Investigators question the ability of RBCs stored longer than 2 weeks to improve tissue oxygenation, and theorize that both age and proinflammatory or immunomodulating effects of transfused cells may limit efficacy and contribute to increased patient morbidity and mortality. Also controversial is the ability of pre- and post-storage leukoreduction of RBCs to mitigate adverse transfusion-related events. VETERINARY DATA SYNTHESIS While there are several studies evaluating the transfusion trigger, the RBC storage lesion and transfusion-related immunomodulation in experimental animal models, there is little research pertaining to clinical veterinary patients. CONCLUSIONS RBC transfusion is unequivocally indicated for treatment of anemic hypoxia. However, critical hemoglobin or Hct below which all critically ill patients require transfusion has not been established and there are inherent risks associated with allogenic blood transfusion. Clinical trials designed to evaluate the effects of RBC age and leukoreduction on veterinary patient outcome are warranted. Implementation of evidence-based transfusion guidelines and consideration of alternatives to allogenic blood transfusion are advisable.
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Affiliation(s)
- Jennifer E Prittie
- Department of Emergency and Critical Care, Animal Medical Center, New York, NY 10065, USA.
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Trannoy L, Roelen D, Koekkoek K, Brand A. Impact of Photodynamic Treatment with Meso-substituted Porphyrin on the Immunomodulatory Capacity of White Blood Cell-containing Red Blood Cell Products. Photochem Photobiol 2010; 86:223-30. [DOI: 10.1111/j.1751-1097.2009.00624.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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21
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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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22
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Coppage M, Baker M, Fialkow L, Meehan D, Gettings K, Chen L, Massey HT, Blumberg N. Lack of significant de novo HLA allosensitization in ventricular assist device recipients transfused with leukoreduced, ABO identical blood products. Hum Immunol 2009; 70:413-6. [PMID: 19275923 DOI: 10.1016/j.humimm.2009.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 02/10/2009] [Accepted: 03/02/2009] [Indexed: 11/17/2022]
Abstract
Ventricular assist devices provide support for a failing heart and often serve as a bridge to transplantation. The use of these devices has also been associated with allosensitization to HLA antigens because of transfusion of blood products. Our program established a protocol mandating the use of leukoreduced, irradiated and ABO identical products, including platelets, in patients receiving initial implantations of VADs as a bridge to transplantation. Recipients were tested for anti-HLA antibodies before VAD implantation and monthly post-implantation by cytotoxicity and solid phase assays. We observed minimal de novo anti-HLA sensitization (<10%) in this population of 55 patients, each receiving a mean of 90 blood components, using this approach. No patient developed broad sensitization (PRA>50%). In conclusion, The use of leukoreduced, irradiated, ABO identical blood products abrogates broad allosensitization in this highly transfused population.
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Affiliation(s)
- Myra Coppage
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, NY, USA.
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Zilberberg MD, Carter C, Lefebvre P, Raut M, Vekeman F, Duh MS, Shorr AF. Red blood cell transfusions and the risk of acute respiratory distress syndrome among the critically ill: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R63. [PMID: 17553147 PMCID: PMC2206425 DOI: 10.1186/cc5934] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Revised: 04/11/2007] [Accepted: 06/06/2007] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Recent data indicate that transfusion of packed red blood cells (pRBCs) may increase the risk for the development of acute respiratory distress syndrome (ARDS) in critically ill patients. Uncertainty remains regarding the strength of this relationship. METHODS To quantify the association between transfusions and intensive care unit (ICU)-onset ARDS, we performed a cohort study within Crit, a multicenter, prospective, observational study of transfusion practice in the ICU which enrolled 4,892 critically ill patients in 284 ICUs in the United States. Diagnostic criteria for ARDS were prospectively defined, and we focused on subjects without ARDS at admission. The development of ARDS in the ICU served as the primary endpoint. RESULTS Among the 4,730 patients without ARDS at admission, 246 (5.2%) developed ARDS in the ICU. At baseline, ARDS cases were younger, more likely to be in a surgical ICU, and more likely to be admitted with pneumonia or sepsis than controls without ARDS. Cases also were more likely to have a serum creatinine of greater than 2.0 mg/dl (23% versus 18%) and a serum albumin of less than or equal to 2.3 g/dl (54% versus 30%) and were more severely ill upon ICU admission as measured by either the APACHE II (Acute Physiology and Chronic Health Evaluation II) or SOFA (Sequential Organ Failure Assessment) score (p < 0.05 for all). Sixty-seven percent and 42% of cases and controls, respectively, had exposure to pRBC transfusions (p < 0.05), and the unadjusted odds ratio (OR) of developing ARDS in transfused patients was 2.74 (95% confidence interval [CI], 2.09 to 3.59; p < 0.0001) compared to those never transfused. After age, baseline severity of illness, admitting diagnosis, and process-of-care factors were adjusted for, the independent relationship between pRBC transfusions and ICU-onset ARDS remained significant (adjusted OR, 2.80; 95% CI, 1.90 to 4.12; p < 0.0001). CONCLUSION Development of ARDS after ICU admission is common, occurring in approximately 5% of critically ill patients. Transfusion of pRBCs is independently associated with the development of ARDS in the ICU.
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Affiliation(s)
- Marya D Zilberberg
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, P.O. Box 303, Goshen, MA 01032, USA
| | - Chureen Carter
- Ortho Biotech Clinical Affairs, LLC, 430 Route 22 East, Bridgewater, NJ 08807, USA
| | - Patrick Lefebvre
- Groupe d'analyse, 1080 Beaver Hall Hill, Suite 1810, Montreal, Quebec, H2Z 1S8, Canada
| | - Monika Raut
- Ortho Biotech Clinical Affairs, LLC, 430 Route 22 East, Bridgewater, NJ 08807, USA
| | - Francis Vekeman
- Groupe d'analyse, 1080 Beaver Hall Hill, Suite 1810, Montreal, Quebec, H2Z 1S8, Canada
| | - Mei Sheng Duh
- Analysis Group, 111 Huntington Avenue, Tenth Floor, Boston, MA 02199, USA
| | - Andrew F Shorr
- Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010, USA
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Nathens AB, Nester TA, Rubenfeld GD, Nirula R, Gernsheimer TB. The effects of leukoreduced blood transfusion on infection risk following injury: a randomized controlled trial. Shock 2006; 26:342-7. [PMID: 16980879 DOI: 10.1097/01.shk.0000228171.32587.a1] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Allogeneic blood transfusions in surgical patients have been associated with an increased risk of infectious complications and organ dysfunction. Residual leukocytes contaminating units of packed red blood cells have been incriminated through the induction of anergy and/or a potentiated inflammatory response, leading to the possibility that leukoreduced red blood cell transfusion might mitigate these effects. We set out to evaluate the effect of leukoreduced red cell transfusion on the risk of infections complications in patients requiring transfusion following injury. We conducted a single-center, double-blinded randomized controlled trial of leukoreduced versus standard, nonleukoreduced red blood cell transfusions in injured patients receiving transfusion within 24 hrs of injury. The primary endpoint was infectious complications within 28 days of randomization. Secondary end points were multiple organ failure, length of stay, febrile episodes, and mortality. Two hundred sixty eight subjects were eligible for analysis. Rates of infectious complications were similar in subjects receiving leukoreduced transfusions (30%) or standard transfusions (36%) ([RR], 0.84 [0.55-1.3]) and there was no statistically significant effect of leukoreduced blood transfusion on mortality [RR, 1.20 (0.74-1.9)], febrile episodes [RR, 1.01 (0.89-1.2)], or organ dysfunction scores (5.9 vs. 6.6; P=0.29). Thus, pre-storage leukoreduction of allogeneic red blood cells had a small, but non-significant effect on the rate of infectious complication in this high-risk population requiring transfusion. There was no effect on the rates of febrile episodes, mortality, length of stay, or severity of organ dysfunction.
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Affiliation(s)
- Avery B Nathens
- Department of Surgery and the Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA.
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Yepes D, Gil B, Hernandez O, Murillo R, Gonzalez M, Velasquez JP. Ventilator associated pneumonia and transfusion, is there really an association? (the NAVTRA study). BMC Pulm Med 2006; 6:18. [PMID: 16869962 PMCID: PMC1550257 DOI: 10.1186/1471-2466-6-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2006] [Accepted: 07/25/2006] [Indexed: 12/02/2022] Open
Abstract
Background Anemic syndrome is a frequent problem in intensive care units. The most probable etiology is the suppression of the erythropoietin response due to the direct effects of cytokines, as well as frequent blood sampling. Transfusions are not free of complications, therefore transfusion reactions are estimated to occur in 2% of the total packed red blood cells (pRBCs) transfused. In the past several years, several trials had tried to compare the restrictive with the more liberal use of transfusions, and they were found to be equally effective. Nosocomial pneumonia is the most common nosocomial infection in intensive care units; the prevalence is 47% with an attributive mortality of 33%. There are multiple risk factors for the development of nosocomial pneumonia. Colonization of the upper airways is the most important pathophysiological factor but there are other factors implicated like, sedation techniques, inappropriate use of antibiotics and recumbent positioning. A secondary analysis of the CRIT study describes transfusion therapy and its practices in the United States. They found that transfusion practice is an independent risk factor for the development of nosocomial pneumonia. Methods This is a multicenter, prospective cohort study in different intensive care units in Colombia. A total of 474 patients were selected who had more than 48 hours of mechanical ventilation. The primary objective is to try to demonstrate the hypothetical relationship between the use of transfusions and nosocomial pneumonia. Secondly, we will try to determine which other factors are implicated in the development of pneumonia in intensive care units and describe the incidence of pneumonia and transfusion practices. Discussion Ventilator associated pneumonia is a primary problem in the intensive care unit, multiple factors have been associated with its presence in this study we try to explore the possible association between pneumonia and transfusion, describe all other factors associated with this, and the possible association with other nosocomial infections.
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Affiliation(s)
- David Yepes
- Department of critical care, Clinica Universitaria Bolivariana and Clinica CES, Department of epidemiology, University CES, Medellín, Colombia
| | - Bladimir Gil
- Department of critical care, Clínica Las Américas, Clínica Medellín, Grupo de Investigación en Cuidado Crítico, Universidad Pontificia Bolivariana, Department of epidemiology, University CES, Medellín, Colombia
| | - Olga Hernandez
- Department of critical care, Clinica Medellín, Medellín, Colombia
| | - Rodrigo Murillo
- Department of critical care, Clinica Medellin, Hospital Pablo Tobon Uribe, Grupo de Investigacion en cuidado critico, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Marco Gonzalez
- Department of critical care, Clinica Medellín, Grupo de Investigacion en cuidado critico, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Juan Pablo Velasquez
- Division medical and critical care medicine, Surgical Critical Care unit, University Nueva Granada, Hospital Militar, Bogota, Colombia
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Karger R, Weber C, Schmidt J, Kretschmer V. Immunomodulatory Effects of Non-Leukocyte-Depleted and Leukocyte-Depleted Autologous Blood. Transfus Med Hemother 2006. [DOI: 10.1159/000092257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
In trying to develop a cohesive and logical transfusion strategy, one must try to keep all of the previously mentioned information in mind. While recognizing that RBC transfusions are an integral part of care for critically ill patients, one also must recognize that there are large amounts of data that associate multiple transfusions of allogeneic blood with increased risk of morbidity and mortality. Some data exist showing causation and association, such as studies demonstrating the immunomodulatory effects of allogeneic transfusions. In addition, the blood supply is a limited resource that should not be used indiscriminately. It therefore behooves clinicians to subject each unit of blood transfused to scrutiny. In all likelihood, patients who are not actively bleeding and who are not hypovolemic probably get little to no benefit from allogeneic blood transfusions while their hemoglobin is greater than 7 g/dL. They do, however, get needless exposure to a potentially toxic substance. Although it is the authors' hope that more research will be performed to clarify the risks and benefits of blood transfusion, the authors also hope that knowledge of already published studies will continue to spread and replace the unfounded practices of the past.
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Affiliation(s)
- Nicholas S Ward
- Neurointensive Care Unit, Rhode Island Hospital, Brown Medical School, 593 Eddy Street, Providence, RI 02903, USA
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Ortolano GA, Russell RL, Angelbeck JA, Schaffer J, Wenz B. Contamination control in nursing with filtration: part 2: emerging rationale for bedside (final) filtration of prestorage leukocyte-reduced blood products. JOURNAL OF INFUSION NURSING 2004; 27:157-65. [PMID: 15118453 DOI: 10.1097/00129804-200405000-00004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The first part of this 2-part series focused on the manufacture of filters and the application of filtration technology to intravenous fluids and point-of-care hospital water. This second part describes an apparent emerging potential for final filtration defined as bedside filtration of blood and component blood products leukocyte-reduced at the blood center prior to storage. Final filtration serves to further reduce the leukocyte burden in a previously leukocyte-reduced blood product. Another target for final filtration includes putative soluble mediators of morbidity.Selected patients may be at greater risk for alloimmunization and refractory to the benefits afforded by transfusion of blood leukocyte reduced to the current established standards. Multiparous patients who subsequently find themselves in need of a transplanted organ are alloimmunized by exposure to fetal proteins and may be further alloimmunized by transfusion. Such effects can put them at risk for increased latency for donor organ availability and organ rejection. Kidney transplant patients find themselves the recipients of transfused blood products particularly during end-stage renal disease and recent data suggest such patients are not benefited by the levels of leukoreduction prescribed by current standards and may need more dramatic leukocyte removal. The process of blood production is described and affords a greater appreciation for the levels of white cells found in component blood products. The development of alloimmunization is reviewed and fosters greater appreciation for a discussion of the potential for therapeutic value of more dramatic leukocyte reduction and blood conditioning accomplished through the removal of soluble mediators of morbidity.
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Abstract
Blood transfusions remain common practice in the critical care and surgical settings. Transfusions carry significant risks, including risks for transmission of infectious agents and immune suppression. Transmission of bacterial infections, although rare, is the most common adverse event with transfusion. The risk for transmission of viral infections has decreased over time, clearly because tests are becoming more sensitive in detecting certain viral infections such as hepatitis B, hepatitis C, and HIV. Several immunomodulatory effects are thought to be related to transfusions, and these can result in cancer recurrence, mortality, and postoperative infections. Numerous studies have been performed to examine the role of leukoreduction in decreasing these transfusion-related complications but results remain contradictory. We review the infectious risks associated with blood transfusion and the most recent data on its immunologic effects, specifically on cancer recurrence, mortality, and postoperative infections in surgical patients. We also review the use of leukoreduction in blood transfusion and its role in preventing transfusion-transmitted infections and immunomodulatory complications.
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Affiliation(s)
- E Patchen Dellinger
- Department of Surgery, Division of General Surgery, University of Washington Medical Center, Seattle, Washington, USA.
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Shorr AF, Duh MS, Kelly KM, Kollef MH. Red blood cell transfusion and ventilator-associated pneumonia: A potential link? Crit Care Med 2004; 32:666-74. [PMID: 15090945 DOI: 10.1097/01.ccm.0000114810.30477.c3] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine the relationship between packed red blood cell transfusion practice and the development of ventilator-associated pneumonia (VAP). DESIGN Secondary analysis of a multicentered, prospective observational study of transfusion practice in intensive care units in the United States. SETTING A total of 284 intensive care units in the United States were studied from August 2000 to April 2001. PATIENTS Patients without pneumonia at intensive care unit admission and who then required at least 48 hrs of mechanical ventilation were considered at risk for VAP. MEASUREMENTS AND MAIN RESULTS VAP was diagnosed based on prospectively defined clinical criteria and represented the primary study end point. Late-onset VAP (VAP arising after > or =5 days of mechanical ventilation) represented a secondary end point. Transfusions given during the intensive care unit stay and before the onset of VAP were tracked prospectively. Of 4,892 subjects in the original cohort, 1,518 received mechanical ventilation of > or =48 hrs and did not have preexisting pneumonia. VAP was diagnosed in 311 (20.5%) patients. Multivariate analysis revealed that transfusion independently increased the risk for VAP (odds ratio, 1.89; 95% confidence interval [CI], 1.33-2.68). Other factors increasing the risk for VAP included male sex (odds ratio, 1.54; 95% CI, 1.15-2.07), admission after trauma (odds ratio, 1.68; 95% CI, 1.15-2.47), use of continuous sedation (odds ratio, 1.43; 95% CI, 1.07-1.92), and type of nutritional support (e.g., early enteral nutrition: odds ratio, 2.65; 95% CI, 1.93-3.63; total parenteral nutrition: odds ratio, 3.27; 95% CI, 2.24-4.75). The effect of transfusion on late-onset VAP was more pronounced (odds ratio, 2.16; 95% CI, 1.27-3.66) and demonstrated a positive dose-response relationship (p =.0223 for trend test). CONCLUSIONS Transfusion of packed red blood cells increases the risk of developing VAP. Avoiding the unnecessary use of packed red blood cell transfusions may decrease the occurrence of VAP.
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Affiliation(s)
- Andrew F Shorr
- Pulmonary and Critical Care Medicine Service, Walter Reed Army Medical Center, Washington, DC, USA
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Bein G. Immunmodulatorische Wirkung von Bluttransfusionen. TRANSFUSIONSMEDIZIN 2004. [DOI: 10.1007/978-3-662-10597-9_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ghio M, Ottonello L, Contini P, Amelotti M, Mazzei C, Indiveri F, Puppo F, Dallegri F. Transforming growth factor-beta1 in supernatants from stored red blood cells inhibits neutrophil locomotion. Blood 2003; 102:1100-7. [PMID: 12869488 DOI: 10.1182/blood.v102.3.1100] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Studies comparing transfusion and nontransfusion patients suggest an increased risk of postoperative infections in transfusion groups. Supernatants of blood components have been shown to affect the function of T lymphocytes and natural killer cells. Here, we found that supernatants from stored red blood cells (RBCs) inhibit human neutrophil migration in response to formyl peptides and stimulate neutrophil locomotion. These effects can be observed with high dilutions of RBC supernatants, such as 1:5 x 106 (vol/vol), able to trigger locomotion as well as desensitization of the cells to alternative chemoattractants. The phenomenon might be mediated by chemoattractants present in the supernatants. As RBC supernatants failed to mobilize intracellular free calcium, the chemoattractants should belong to the group of pure chemoattractants, that is, soluble Fas ligand (sFasL) and transforming growth factor-beta1 (TGF-beta1), known to act without increasing calcium levels. Recombinant TGF-beta1, but not sFasL, was found to reproduce the ability of RBC supernatants to both inhibit neutrophil response to formyl peptides and stimulate neutrophil locomotion. Moreover, TGF-beta1-immunodepleted supernatants did not display neutrophil-directed activities. Finally, RBC supernatants from RBCs stored after depletion of leukocytes were incapable of affecting neutrophil function. With neutrophils acting as a first-line antimicrobial defense, the ability, shown here, of high dilutions of RBC supernatants to inhibit neutrophil chemotaxis through TGF-beta1 may be a relevant determinant of infections in the postoperative period for transfusion patients. Consistently, the neutrophil chemotactic response to formyl peptide was inhibited by the plasma obtained from 5 transfusion patients.
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Affiliation(s)
- Massimo Ghio
- Department of Internal Medicine and Center of Excellence for Biomedical Research (CEBR), University of Genoa, Italy
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Wortham ST, Ortolano GA, Wenz B. A brief history of blood filtration: clot screens, microaggregate removal, and leukocyte reduction. Transfus Med Rev 2003; 17:216-22. [PMID: 12881782 DOI: 10.1016/s0887-7963(03)00023-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A historical perspective of the evolution of blood filtration is presented. Topics addressed include recognition of aggregates in blood as mediators of morbidity, targeted for removal with gross clot screens, and evolution through the implementation of universal leukocyte reduction. Future directions for the development of blood filters are also described.
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Abstract
OBJECTIVE To test the hypothesis that red blood cell transfusions are associated with increased resource utilization and mortality in critically ill children. METHODS Five pediatric intensive care units (PICUs) participated in a retrospective, cohort analysis (1996-1999). Children with a hemoglobin value <or=9 g/dL during their PICU stay were enrolled. Data consisted of descriptive information, hemoglobin values, use of blood products, PICU resource use, and hospital mortality rate. RESULTS Among 240 children, 131 were transfused and 109 were not transfused. After controlling for the effects of other variables, transfusion was associated with an increase in days of oxygen use (4.48 +/- 1.37 days), days of mechanical ventilation (4.05 +/- 1.10 days), days of vasoactive agent infusions (1.27 +/- 0.44 days), and an increase of PICU and hospital lengths of stay (4.44 +/- 1.32, and 7.75 +/- 2.36 days, respectively). CONCLUSION Red blood cell transfusions are associated with an increase in resource utilization in critically ill children. The decision to transfuse patients should incorporate this potential morbidity.
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Affiliation(s)
- Allyson M Goodman
- Divisions of Critical Care Medicine, Children's Research Institute, George Washington University School of Medicine, Washington, DC 20010, USA
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Ariga H, Lee TH, Laycock ME, Mohr BA, Kalish LA, Yomtovian R, Gernsheimer T, Busch MP. Residual WBC subsets in filtered prestorage RBCs. Transfusion 2003; 43:98-106. [PMID: 12519437 DOI: 10.1046/j.1537-2995.2003.00270.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND New-generation RBC filters reduce WBC concentrations by 4 to 5 logs and may prevent or decrease transfusion complications such as HLA alloimmunization, nonhemolytic febrile reaction, and transfusion-transmitted infections. The residual level of WBC subsets may influence efficacy of WBC reduction for preventing various complications. This study analyzed subsets of residual WBCs in WBC-reduced RBC components prepared for a large, multicenter prospective study. STUDY DESIGN AND METHODS The Viral Activation Transfusion Study (VATS) assessed the impact of WBC reduction in HIV-1-infected patients undergoing RBC transfusion. WBC-reduced RBC from 11 clinical sites with variable filtration practices were sorted into "low,""middle," and "high" groups based on residual WBC concentration. Subsets were isolated from units by immunocapture (anti-CD4-, anti-CD8-, anti-CD15-, and anti-CD19-coated magnetic beads) and quantified by PCR amplification. RESULTS After validation studies confirming test methodology, 105 VATS WBC-reduced RBC samples were analyzed. Concentrations of subsets in low and middle residual WBC groups were very low in contrast to relatively high concentrations in the high group. Although highly significant differences were identified between the middle and high groups for total WBCs and all subsets, no single subset predominated. CONCLUSION These results suggest that overall efficacy of WBC filtration correlates with removal of WBC subsets.
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Affiliation(s)
- Hiromichi Ariga
- Department of Medicine, Neonatal Intensive Care Unit, Fukushima Medical University, Japan
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van Hilten JA, Brand A. A multi-center prospective randomized trial of buffy coat depleted- and leukocyte filtered erythrocyte transfusions in vascular- and gastrointestinal oncologic surgery. Vox Sang 2002; 83 Suppl 1:453-6. [PMID: 12617185 DOI: 10.1111/j.1423-0410.2002.tb05351.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- J A van Hilten
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, The Netherlands.
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Sanders G, Coker AO, Mellor NJ, Richards K, Rushton ARA, Christie I, Hosie KB. Acute normovolaemic haemodilution in colorectal surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2002; 28:520-2. [PMID: 12217305 DOI: 10.1053/ejso.2002.1286] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS Blood transfusions are often given to surgical patients. This study was designed to assess whether acute normovolaemic haemodilution (ANH) reduces exposure to allogeneic blood, affects clinical outcome and hospital stay, and is feasible in colorectal surgery. METHODS All ASA 1 and 11 patients undergoing colectomies performed between 1997 and 1999 were identified retrospectively from our colorectal cancer database to ascertain our current peri and postoperative transfusion practice. Twenty-six selected patients subsequently underwent ANH during colectomy surgery. The number of patients and units transfused were identified. RESULTS One hundred and twenty-three of 317 (39%) patients identified from our colorectal cancer database were transfused a total of 328 units (median 2, range 1-7). Of the 26 patients undergoing ANH, 4 (15%) were transfused a total of 13 units (median 3, range 2-5). The reduction in number of patients transfused was statistically significant (P=0.017). ANH increased anaesthetic time by a median of 19 min. There were no complications associated with ANH and the median hospital stay was 9 days (range 6-13). CONCLUSIONS In this pilot study of selected patients, ANH is a feasible and effective method of reducing allogeneic blood exposure in major colorectal surgery. A prospective randomised controlled trial is now urgently required.
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Affiliation(s)
- G Sanders
- Colorectal Unit, Department of Surgery, Derriford Hospital, Plymouth, UK
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Affiliation(s)
- Fiona Regan
- Hammersmith Hospitals NHS Trust, London W12 0HS, b Royal Free Hampstead NHS Trust, London NW3 2QG.
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