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Raphael J, Chae A, Feng X, Shotwell MS, Mazzeffi MA, Bollen BA, Pfeil D, Feduska E, Shah AS, Kertai MD. Red Blood Cell Transfusion and Pulmonary Complications: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis. Ann Thorac Surg 2024; 117:839-846. [PMID: 38216079 DOI: 10.1016/j.athoracsur.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 11/09/2023] [Accepted: 12/19/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Intraoperative packed red blood cell (PRBC) transfusion during cardiac surgery is associated with increased postoperative morbidity and mortality; however, data on the association between PRBC transfusion and postoperative pulmonary complications (PPCs) are somewhat conflicting. Using The Society of Thoracic Surgeons Adult Cardiac Surgery Database, we sought to determine whether intraoperative PRBC transfusion was associated with PPCs as well as with longer intensive care unit (ICU) stay after isolated coronary artery bypass grafting (CABG) surgery. METHODS A registry-based cohort study was performed on 751,893 patients with isolated CABG between January 1, 2015, to December 31, 2019. Using propensity score-weighted regression analysis, we analyzed the effect of intraoperative PRBC on the incidence of PPCs (hospital-acquired pneumonia [HAP], mechanical ventilation for >24 hours, or reintubation), ICU length of stay, and ICU readmission. RESULTS Transfusion of 1, 2, 3, and ≥4 units of PRBCs was associated with increased odds for HAP (odds ratios [ORs], 1.24 [95% CI, 1.21-1.26], 1.28 [95% CI, 1.26-1.32], 1.36 [95% CI, 1.33-1.39], 1.31 [95% CI, 1.28-1.34]), reintubation (ORs, 1.23 [95% CI, 1.21-1.25], 1.38 [95% CI, 1.35-1.40], 1.57 [95% CI, 1.55-1.60], 1.70 [95% CI, 1.67-1.73]), prolonged ventilation (ORs, 1.34 [95% CI, 1.33-1.36], 1.56 [95% CI, 1.53-1.58], 1.97 [95% CI, 1.94-2.00], 2.27 [95% CI, 2.24-2.30]), initial ICU length of stay (mean difference in hours, 6.79 [95% CI, 6.00-7.58], 9.55 [95% CI, 8.71-10.38], 17.26 [95% CI, 16.38-18.15], 22.14 [95% CI, 21.22-23.06]), readmission to ICU (ORs, 1.14 [95% CI, 1.12-1.64], 1.15 [95% CI, 1.12-1.17], 1.15 [95% CI, 1.13-1.18], 1.32 [95% CI, 1.29-1.35]), and additional ICU length of stay (mean difference in hours, 0.55 [95% CI, 0.18-0.92], 0.38 [95% CI, 0.00-0.77], 1.02 [95% CI, 0.61-1.43], 1.83 [95% CI, 1.40-2.26]), respectively. CONCLUSIONS Intraoperative PRBC transfusion was associated with increased incidence of PPCs, prolonged ICU stay, and ICU readmissions after isolated CABG surgery.
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Affiliation(s)
- Jacob Raphael
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Alice Chae
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | | | - Douglas Pfeil
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Eric Feduska
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
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Monaco F, Licheri M, Barucco G, De Bonis M, Lapenna E, Pieri M, Zangrillo A, Ortalda A. Four-Factor Prothrombin Complex Concentrate in Left Ventricular Assist Device Implantation: Inverse Propensity Score-Weighted Analysis. ASAIO J 2023; 69:e293-e300. [PMID: 37146590 DOI: 10.1097/mat.0000000000001974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
We compare the effect of intraoperative administration of four-factor prothrombin complex concentrates (PCCs) versus fresh frozen plasma (FFP) on major bleeding, transfusions, and complications. Out of 138 patients undergoing left ventricle assist device (LVAD) implantation, 32 received PCCs as first-line hemostatic agents and 102 FFP (standard group). The crude treatment estimates indicated that, compared with the standard group, the PCC group required more FFP units (odds ratio [OR]: 4.17, 95% confidence interval [CI]: 1.58-11; p = 0.004) intraoperatively, whereas a greater number of patients received FFP at 24 hours (OR: 3.01, 95% CI: 1.19-7.59; p = 0.021) and less packed red blood cells (RBC) at 48 hours (OR: 0.61, 95% CI: 0.01-1.21; p = 0.046). After the inverse probability of treatment weighting (IPTW) adjusted analyses, in the PCC group there was still a higher number of patients who required FFP (OR: 2.9, 95% CI: 1.02-8.25; p = 0.048) or RBC (OR: 6.23, 95% CI: 1.67-23.14; p = 0.007] at 24 hours and RBC at 48 hours (OR: 3.09, 95% CI: 0.89-10.76; p = 0.007). Adverse events and survival were similar before and after the ITPW adjustment. In conclusion, the PCCs, although relatively safe with respect to thrombotic events, were not associated with a reduction of major bleeding and blood product transfusions.
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Affiliation(s)
- Fabrizio Monaco
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Licheri
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gaia Barucco
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele De Bonis
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Elisabetta Lapenna
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Ortalda
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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3
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Ishida Y, Nakazawa K, Itabashi T, Tomino M. Transfusion-related acute lung injury under general anesthesia successfully treated with extracorporeal membrane oxygenation: A case report. Clin Case Rep 2023; 11:e7386. [PMID: 37220518 PMCID: PMC10199813 DOI: 10.1002/ccr3.7386] [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: 03/24/2023] [Revised: 04/08/2023] [Accepted: 05/05/2023] [Indexed: 05/25/2023] Open
Abstract
Transfusion-related acute lung injury (TRALI) is a serious complication of blood transfusion and can also develop severe hypoxemia. In TRALI cases with difficult blood oxygenation on mechanical ventilation support, temporary veno-venous extracorporeal membrane oxygenation support appears to maintain oxygen levels.
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Affiliation(s)
- Yusuke Ishida
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
| | - Koichi Nakazawa
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
| | - Toshio Itabashi
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
| | - Mikiko Tomino
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
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4
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Leong SL, Chen SH, Wei JCC. Total Intravenous Anesthesia and Postoperative Pulmonary Complications. JAMA Otolaryngol Head Neck Surg 2023; 149:375-376. [PMID: 36757753 DOI: 10.1001/jamaoto.2022.4964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- Suet-Li Leong
- Department of Anesthesiology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Shih-Hsuan Chen
- Department of Anesthesiology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Allergy, Immunology & Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
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Shamsasenjan K, Gharehdaghi S, Khalaf-Adeli E, Pourfathollah AA. New horizons for reduction of blood use: Patient blood management. Asian J Transfus Sci 2023; 17:108-116. [PMID: 37188016 PMCID: PMC10180789 DOI: 10.4103/ajts.ajts_14_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 07/11/2022] [Accepted: 08/07/2022] [Indexed: 05/17/2023] Open
Abstract
A countrywide study over the eras indicates overuse of blood transfusion can have considerable risks to patients accompanied by significant costs of blood transfusion for patients, hospitals, and health-care systems. Besides, more than 30% of the world's population is anemic. Typically, blood transfusion helps continue suitable oxygen transfer in anemia, i.e., more and more documented as a threatening factor with several adverse outcomes including long hospitalization, morbidity, and mortality. Transplantation of allogeneic blood is thus like a two-edged sword. There is no doubt that the blood transfusion is a life-saving treatment, but it should be underpinned by much of up-to-date health-care services. The new theory considered for patient blood management (PBM) also discusses the timely application of evidence-based surgical and clinical theories and focuses on patient outcomes. Furthermore, PBM involves a multidisciplinary methodology to reduce unnecessary transfusions, minimize costs, and cut risks.
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Affiliation(s)
- Karim Shamsasenjan
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Somayeh Gharehdaghi
- Department of Immunology, Division of Hematology, Faculty of Medicine, Tabriz University of Medical Sciences, Tehran, Iran
| | - Elham Khalaf-Adeli
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Ali Akbar Pourfathollah
- Department of Immunology, Faculty of Medical Science, Tarbiat Modares University, Tehran, Iran
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Tanaka KA, Pontikes AE, Van D, Vandyck K, Butt A, Mazzeffi MA, Thakral R, Stewart KE. Relationships Between Body Mass Index, Allogeneic Transfusion, and Surgical Site Infection After Knee and Hip Arthroplasty Surgery. Anesth Analg 2023; 136:123-129. [PMID: 35389377 DOI: 10.1213/ane.0000000000006036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Increased body mass index (BMI) is considered as an important factor that affects the need for total knee and hip arthroplasty (TKA/THA) and the rate of perioperative complications. Previous investigations have not fully established the relationship of BMI and perioperative transfusion with surgical site infection (SSI) or the relationship of BMI and perioperative transfusion after TKA or THA. METHODS The National Surgical Quality Improvement Program database was used to perform a retrospective cohort study involving 333,223 TKA and 41,157 THA cases between 2011 and 2018. Multivariable regression assessed the associations of BMI (5 standard categories) and transfusion with SSI. Odds ratio (OR) of SSI was calculated relative to a normal BMI (18.5-24.9 kg/m 2 ) after adjustment of potential confounding factors. RESULTS Perioperative transfusion decreased significantly over time for both TKA and THA; however, SSI rates remained steady at just under 1% for TKA and 3% for THA. In TKA, a higher OR for SSI was associated only with a BMI of 40+ (OR, 1.86; 95% confidence interval [CI], 1.60-2.18) compared to a referent BMI. In THA, increased ORs of SSI were seen for all BMI levels above normal and were highest for a BMI 40+ (OR, 3.08; 95% CI, 2.47-3.83). In TKA, ORs of transfusion decreased with increasing BMI and were lowest for a BMI 40+ (OR, 0.51; 95% CI, 0.47-0.54). In THA, ORs of transfusion began to increase slightly in overweight patients, reaching an OR of 1.36 (95% CI, 1.21-1.54) for a BMI 40+. CONCLUSIONS SSI incidence remained unchanged despite continuous reductions in blood transfusion in TKA and THA patients over 8 years. In TKA, ORs for SSI increased, but ORs for transfusion decreased with increasing BMI above normal. Conversely, in THA, ORs for SSI and transfusion both increased for a BMI 40+, but only OR for transfusion increased in underweight patients. These findings suggest the importance of controlling obesity in reducing SSI following TKA and THA.
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Affiliation(s)
- Kenichi A Tanaka
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Andrew E Pontikes
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - David Van
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Kofi Vandyck
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Amir Butt
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Michael A Mazzeffi
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences
| | - Rishi Thakral
- Departments of Orthopedic Surgery and Rehabilitation
| | - Kenneth E Stewart
- Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Khandelwal A, Minuk L, Liu Y, Arnold DM, Heddle NM, Barty R, Hsia C, Solh Z, Shehata N, Thompson T, Tinmouth A, Perelman I, Skeate R, Kron AT, Callum J. Plasma transfusion practices: A multicentre electronic audit. Vox Sang 2022; 117:1211-1219. [PMID: 36102150 DOI: 10.1111/vox.13355] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/02/2022] [Accepted: 08/16/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Plasma is often transfused to patients with bleeding or requiring invasive procedures and with abnormal tests of coagulation. Chart audits find half of plasma transfusions unnecessary, resulting in avoidable complications and costs. This multicentre electronic audit was conducted to determine the proportion of plasma transfused without an indication and/or at a sub-therapeutic dose. METHODS Data were extracted on adult inpatients in 2017 at five academic sites from the hospital electronic chart, laboratory information systems and the Canadian Institute for Health Information Discharge Abstract Database. Electronic criteria for plasma transfusion outside recommended indications were: (1) international normalized ratio (INR) < 1.5 with no to moderate bleeding; (2) INR ≥ 1.5, with no to mild bleeding and no planned procedures; and (3) no INR before or after plasma infusion. Sub-therapeutic dose was defined as ≤2 units transfused. RESULTS In 1 year, 2590 patients received 6088 plasma transfusions encompassing 11,490 units of plasma occurred at the five sites. 77.7% of events were either outside indications or under-dosed. Of these, 34.8% of plasma orders had no indication identified, and 62% of these occurred in non-bleeding patients and no planned procedure with an isolated elevated INR. 70.7% of transfusions were under-dosed. Most plasma transfusions occurred in the intensive care unit or the operating room. Inter-hospital variability in peri-transfusion testing and dosing was observed. CONCLUSION The majority of plasma transfusions are sub-optimal. Local hospital culture may be an important driver. Electronic audits, with definitions employed in this study, may be a practical alternative to costly chart audits.
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Affiliation(s)
- Aditi Khandelwal
- Canadian Blood Services, Toronto, Ontario, Canada.,The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada
| | - Leigh Minuk
- Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yang Liu
- McMaster Centre for Transfusion Research (MCTR), McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- McMaster Centre for Transfusion Research (MCTR), McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nancy M Heddle
- McMaster Centre for Transfusion Research (MCTR), McMaster University, Hamilton, Ontario, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Barty
- McMaster Centre for Transfusion Research (MCTR), McMaster University, Hamilton, Ontario, Canada.,Ontario Regional Blood Coordinating Network (ORBCoN), Toronto, Ontario, Canada
| | - Cyrus Hsia
- Department of Medicine, Western University, London, Ontario, Canada.,Department of Pathology and Laboratory Medicine, Western University, London, Ontario, Canada.,Transfusion Medicine Laboratories, London Health Sciences Centre, London, Ontario, Canada
| | - Ziad Solh
- Department of Medicine, Western University, London, Ontario, Canada.,Department of Pathology and Laboratory Medicine, Western University, London, Ontario, Canada.,Transfusion Medicine Laboratories, London Health Sciences Centre, London, Ontario, Canada
| | - Nadine Shehata
- The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Troy Thompson
- Ontario Regional Blood Coordinating Network (ORBCoN), Toronto, Ontario, Canada
| | - Alan Tinmouth
- Ottawa Hospital Centre for Transfusion Research, Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Iris Perelman
- Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Robert Skeate
- Canadian Blood Services, Toronto, Ontario, Canada.,The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada
| | - Amie T Kron
- The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada.,Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jeannie Callum
- The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada.,Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
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Schneider T, Jackups R. Transfusion Medicine Informatics: A Review of Current Practice and a Glimpse into the Future. Clin Lab Med 2021; 41:713-725. [PMID: 34689975 DOI: 10.1016/j.cll.2021.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Clinical informatics has been described as the "relentless pursuit of assisting people" by using data and information technology to improve health care. A core principle is that a person supported by information technology is superior to either a person or machine alone. Striving toward this harmonization, the transfusion medicine field has had a significant number of accomplishments. Clinical informatics interventions have helped achieve better quality, efficiency, and safety in nearly all aspects of transfusion medicine. This review summarizes these accomplishments and provides a preview of novel ideas that could transform transfusion medicine into a proactive, data-driven, and patient-centered discipline.
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Affiliation(s)
- Thomas Schneider
- Department of Pathology and Immunology, Washington University School of Medicine in Saint Louis, 660. S Euclid Avenue #8118, St. Louis, MO 63110, USA
| | - Ronald Jackups
- Department of Pathology and Immunology, Washington University School of Medicine in Saint Louis, 660. S Euclid Avenue #8118, St. Louis, MO 63110, USA.
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9
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Aubron C, Hourmant B, Menguy J, Sparrow RL. Transfusion-related respiratory complications in intensive care: A diagnosis challenge. Transfus Clin Biol 2021; 28:344-348. [PMID: 34536575 DOI: 10.1016/j.tracli.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Transfusion-related respiratory complications can be challenging to diagnose especially in mechanically-ventilated patients in the intensive care unit (ICU) due to the concurrent respiratory symptoms associated with the patients' primary diagnoses. In this narrative review, transfusion-related respiratory complications, including transfusion-associated dyspnea (TAD), transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), and transfusion-related allergic reaction (TRAR), are briefly presented in light of the recent consensus or experts' definitions; and the diagnosis issues for ICU patients are discussed. Acute respiratory failure occurring during, or within 6 to 24hours, of transfusion might be a transfusion-related respiratory complication. The recent updated definitions for TRALI and TACO should assist clinicians to differentiate between possible diagnoses. The issues for ICU clinicians are first to recognize the acute respiratory deterioration and the possible causality between the deterioration and blood transfusion and secondly to make the proper diagnosis. This remains challenging for mechanically-ventilated patients. Clinical assessment to identify ICU patients at particular risk of transfusion-related respiratory complications and non-invasive investigation tools could be beneficial and may help to remind clinicians to be alert to the link between transfusion and worsening of respiratory symptoms in these vulnerable critically ill patients.
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Affiliation(s)
- Cécile Aubron
- Médecine Intensive Réanimation, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Université de Bretagne Occidentale, Brest, France; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Baptiste Hourmant
- Médecine Intensive Réanimation, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Université de Bretagne Occidentale, Brest, France
| | - Juliette Menguy
- Médecine Intensive Réanimation, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Université de Bretagne Occidentale, Brest, France
| | - Rosemary L Sparrow
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Lo BD, Merkel KR, Dougherty JL, Kajstura TJ, Cruz NC, Sikorski RA, Frank SM. Assessing predictors of futility in patients receiving massive transfusions. Transfusion 2021; 61:2082-2089. [PMID: 33955577 DOI: 10.1111/trf.16410] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/21/2021] [Accepted: 04/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Massive transfusions are associated with a high mortality rate, but there is little evidence indicating when such efforts are futile. The purpose of this study was to identify clinical variables that could be used as futility indicators in massively transfused patients. METHODS We retrospectively analyzed 138 adult surgical patients at our institution receiving a massive transfusion (2016-2019). Peak lactate and nadir pH within 24 h of massive transfusion initiation, along with other clinical variables, were assessed as predictors of the primary outcome, in-hospital mortality. RESULTS The overall rate of in-hospital mortality among our patient population was 52.9% (n = 73). Increasing lactate and decreasing pH were associated with greater mortality among massively transfused patients. Mortality rates were ~2-fold higher for patients in the highest lactate category (≥10.0 mmol/L: 25 of 37; 67.6%) compared to the lowest category (0.0-4.9 mmol/L: 17 of 48; 35.4%) (p = .005), and ~2.5-fold higher for patients in the lowest pH category (<7.00: 8 of 9; 88.9%) compared to the highest category (≥7.40: 8 of 23; 34.7%) (p = .016). Increasing age was also associated with higher mortality (≥65 years: 24 of 33; 72.7%) when compared to younger patients (18-64 years: 49 of 105; 46.7%) (p = .010). CONCLUSIONS Peak lactate ≥10.0 mmol/L, nadir pH <7.00, and age ≥65 years were significantly associated with higher rates of in-hospital mortality among massively transfused patients. Incorporating these clinical parameters into a futility index for massive transfusions will be useful in situations where blood products are scarce and/or mortality may be unavoidable.
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Affiliation(s)
- Brian D Lo
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Kevin R Merkel
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - James L Dougherty
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Tymoteusz J Kajstura
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Nicolas C Cruz
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Robert A Sikorski
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.,The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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11
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Iyer MH, Kumar JE, Kumar N, Gorelik L, Hussain N, Stein E, Bhatt AM, Bhandary S, Essandoh MK, Flores AS. Transfusion-Related Acute Lung Injury During Liver Transplantation: A Scoping Review. J Cardiothorac Vasc Anesth 2021; 36:2606-2615. [PMID: 34099375 DOI: 10.1053/j.jvca.2021.04.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 12/31/2022]
Abstract
Liver transplantation is associated with significant blood loss, often requiring massive blood product transfusion. Transfusion-related acute lung injury (TRALI) is a devastating cause of transfusion-related deaths. While reports have investigated the general incidence of TRALI, the incidence of TRALI specifically following transfusion during liver transplant remains unclear. This scoping review summarizes existing literature regarding TRALI during the liver transplantation perioperative period. Databases were searched for all articles and abstracts reporting on TRALI after liver transplantation. Data collected included number of patients studied, patient characteristics, incidences of TRALI, TRALI characteristics, and patient outcomes. The primary outcome investigated was the incidence of TRALI in the setting of liver transplantation. Thirteen full-text citations were included in this review. The incidence of TRALI post-liver transplant was 0.68% (65 of 9,554). Based on reported transfusion data, patients diagnosed with TRALI received an average of 10.92 ± 10.81 units of packed red blood cells (pRBC), 20.05 ± 15.72 units of fresh frozen plasma, and 5.75 ± 10.00 units of platelets. Common interventions following TRALI diagnosis included mechanical ventilation with positive end-expiratory pressure, inhaled high-flow oxygen, inhaled pulmonary vasodilator, and pharmacologic treatment using pressors or inotropes, corticosteroids, or diuretics. Based on reported mortality data, 26.67% of patients (12 of 45) diagnosed with TRALI died during the postoperative period. This scoping review underscores the importance of better understanding the incidence and presentation of TRALI after liver transplant surgery. The clinical implications of these results warrant the development of identification and management strategies for liver transplant patients at increased risk for developing TRALI.
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Affiliation(s)
| | | | - Nicolas Kumar
- Wexner Medical Center, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH
| | | | | | | | | | - Sujatha Bhandary
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
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12
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Perioperative Respiratory Concerns in the Surgical Patient. PHYSICIAN ASSISTANT CLINICS 2021. [DOI: 10.1016/j.cpha.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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13
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Guo K, Ma S. The Immune System in Transfusion-Related Acute Lung Injury Prevention and Therapy: Update and Perspective. Front Mol Biosci 2021; 8:639976. [PMID: 33842545 PMCID: PMC8024523 DOI: 10.3389/fmolb.2021.639976] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/05/2021] [Indexed: 12/14/2022] Open
Abstract
As an initiator of respiratory distress, transfusion-related acute lung injury (TRALI) is regarded as one of the rare complications associated with transfusion medicine. However, to date, the pathogenesis of TRALI is still unclear, and specific therapies are unavailable. Understanding the mechanisms of TRALI may promote the design of preventive and therapeutic strategies. The immune system plays vital roles in reproduction, development and homeostasis. Sterile tissue damage, such as physical trauma, ischemia, or reperfusion injury, induces an inflammatory reaction that results in wound healing and regenerative mechanisms. In other words, in addition to protecting against pathogens, the immune response may be strongly associated with TRALI prevention and treatment through a variety of immunomodulatory strategies to inhibit excessive immune system activation. Immunotherapy based on immune cells or immunological targets may eradicate complications. For example, IL-10 therapy is a promising therapeutic strategy to explore further. This review will focus on ultramodern advances in our understanding of the potential role of the immune system in TRALI prevention and treatment.
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Affiliation(s)
- Kai Guo
- Department of Transfusion Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shuxuan Ma
- Department of Transfusion Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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14
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McVey MJ, Cohen R, Arsenault V, Escorcia A, Tasmin F, Pendergrast J, Lieberman L, Lin Y, Callum J, Cserti-Gazdewich C. Frequency and timing of all-cause deaths in visits involving suspected transfusion reactions, and the significance of cardiopulmonary disturbances. Vox Sang 2021; 116:898-909. [PMID: 33634884 DOI: 10.1111/vox.13086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/16/2021] [Accepted: 01/23/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND/OBJECTIVES Transfusion reactions (TRs) may cause or contribute to death. Cardiopulmonary TRs are distressing, and collectively account for most transfusion fatalities, though the degree to which they alter survival more broadly is unclear. Deaths (and their timing) after TRs may provide further insights. MATERIALS/METHODS Adult (tri-hospital network) haemovigilance data (2013-2016) recorded referrals with conclusions ranging from unrelated to transfusion (UTR) to entities such as: septic TRs, serologic/haemolytic reactions, transfusion-associated circulatory overload (TACO), transfusion-associated dyspnoea (TAD), transfusion-related acute lung injury (TRALI), allergic transfusion reaction (ATR), and others. For (in- or out-patient) visits involving suspected TRs (VISTRs), all-cause mortalities (% [95% confidence interval]) and associated time-to-death (TTD) (median days, [interquartile range]) were compared. Diagnoses were defined inclusively (possible-to-definite) or strictly (probable-to-definite). RESULTS Of 1144 events, rank order VISTR mortality following (possible-to-definite) TRs, and associated TTDs, were led by: DHTR 33% [6-19], 1 death at 123d; TRALI 32% [15-54], 6 deaths: 3d [2-20]; BaCon 21% [14-31], 17 deaths: 10d [3-28]; TACO 18% [12-26], 23 deaths: 16d [6-28]; TAD 17% [11-26]: 18 deaths, 6d [3-12]. Higher-certainty TRs ranked similarly (DHTR 50% [9-91]; BaCon 29% [12-55], 4 deaths: 12d [3-22]; and TACO 25% [16-38], 15 deaths: 21d [6-28]). VISTR mortality after TACO or TRALI significantly exceeded ATR (3·3% [2·4-5·8], P < 0·00001) but was not different from UTR events (P = 0·3). CONCLUSIONS Only half of cardiopulmonary TRs constituted high certainty diagnoses. Nevertheless, cardiopulmonary TRs and suspected BaCon marked higher VISTR mortality with shorter TTDs. Short (<1 week) TTDs in TAD, BaCon or TRALI imply either contributing roles in death, treatment refractoriness and/or applicable TR susceptibilities in the dying.
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Affiliation(s)
- Mark J McVey
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Medicine, SickKids, Toronto, ON, Canada.,Department of Physics, Ryerson University, Toronto, ON, Canada
| | - Robert Cohen
- Utilization, Efficacy, & Safety of Transfusion (QUEST) Research Program, University of Toronto Quality, Toronto, ON, Canada.,Transfusion Medicine and Tissue Bank, Department of Laboratory Medicine & Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Valerie Arsenault
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada.,Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Alioska Escorcia
- Blood Transfusion Laboratory (Laboratory Medicine Program), University Health Network, Toronto, ON, Canada
| | - Farzana Tasmin
- Blood Transfusion Laboratory (Laboratory Medicine Program), University Health Network, Toronto, ON, Canada
| | - Jacob Pendergrast
- Utilization, Efficacy, & Safety of Transfusion (QUEST) Research Program, University of Toronto Quality, Toronto, ON, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada.,Blood Transfusion Laboratory (Laboratory Medicine Program), University Health Network, Toronto, ON, Canada.,Department of Medicine (Medical Oncology & Hematology), University Health Network, Toronto, ON, Canada.,Department of Medicine, Division of Hematology, University of Toronto, Toronto, ON, Canada
| | - Lani Lieberman
- Utilization, Efficacy, & Safety of Transfusion (QUEST) Research Program, University of Toronto Quality, Toronto, ON, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada.,Blood Transfusion Laboratory (Laboratory Medicine Program), University Health Network, Toronto, ON, Canada
| | - Yulia Lin
- Utilization, Efficacy, & Safety of Transfusion (QUEST) Research Program, University of Toronto Quality, Toronto, ON, Canada.,Transfusion Medicine and Tissue Bank, Department of Laboratory Medicine & Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Hematology, University of Toronto, Toronto, ON, Canada
| | - Jeannie Callum
- Utilization, Efficacy, & Safety of Transfusion (QUEST) Research Program, University of Toronto Quality, Toronto, ON, Canada.,Transfusion Medicine and Tissue Bank, Department of Laboratory Medicine & Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Hematology, University of Toronto, Toronto, ON, Canada
| | - Christine Cserti-Gazdewich
- Utilization, Efficacy, & Safety of Transfusion (QUEST) Research Program, University of Toronto Quality, Toronto, ON, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada.,Blood Transfusion Laboratory (Laboratory Medicine Program), University Health Network, Toronto, ON, Canada.,Department of Medicine (Medical Oncology & Hematology), University Health Network, Toronto, ON, Canada.,Department of Medicine, Division of Hematology, University of Toronto, Toronto, ON, Canada
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15
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Lo BD, Cho BC, Hensley NB, Cruz NC, Gehrie EA, Frank SM. Impact of body weight on hemoglobin increments in adult red blood cell transfusion. Transfusion 2021; 61:1412-1423. [PMID: 33629773 DOI: 10.1111/trf.16338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/14/2021] [Accepted: 01/23/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Though weight is a major consideration when transfusing blood in pediatric patients, it is generally not considered when dosing transfusions in adults. We hypothesized that the change in hemoglobin (Hb) concentration is inversely proportional to body weight when transfusing red blood cells (RBC) in adults. METHODS A total of 13,620 adult surgical patients at our institution were assessed in this retrospective cohort study (2009-2016). Patients were stratified based on total body weight (kg): 40-59.9 (16.6%), 60-79.9 (40.4%), 80-99.9 (28.8%), 100-119.9 (11.3%), and 120-139.9 (2.9%). The primary outcome was the change in Hb per RBC unit transfused. Subgroup analyses were performed after stratification by sex (male/female) and the total number of RBC units received (1/2/≥3 units). Multivariable models were used to assess the association between weight and change in Hb. RESULTS As patients' body weight increased, there was a decrease in the mean change in Hb per RBC unit transfused (40-59.9 kg: 0.85 g/dL, 60-79.9 kg: 0.73 g/dL, 80-99.9 kg: 0.66 g/dL, 100-119.9 kg: 0.60 g/dL, 120-139.9 kg: 0.55 g/dL; p < .0001). This corresponded with a 35% difference in the change in Hb between the lowest and highest weight categories on univariate analysis. Similar trends were seen after subgroup stratification. On multivariable analysis, for every 20 kg increase in patient weight, there was a ~6.5% decrease in the change in Hb per RBC unit transfused (p < .0001). CONCLUSIONS Patient body weight differentially impacts the change in Hb after RBC transfusion. These findings justify incorporating body weight into the clinical decision-making process when transfusing blood in adult surgical patients.
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Affiliation(s)
- Brian D Lo
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Brian C Cho
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Nadia B Hensley
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Nicolas C Cruz
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Eric A Gehrie
- Department of Pathology (Transfusion Medicine), The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.,The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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16
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Kron AT, Collins A, Cserti-Gazdewich C, Pendergrast J, Webert K, Lieberman L, Zeller MP, Harding SR, Nahirniak S, Prokopchuk-Gauk O, Lin Y, Mendez B, Armali C, Lee C, Watson D, Arnott D, Xun F, Blain H, Panchuk H, Hughes H, Chorneyko K, Angers M, Pilutti N, Lett R, Dowsley S, Ruijs T, Cupido T, Kichinko T, Thompson T, Afshar-Ghotli Z, Callum J. A prospective multi-faceted interventional study of blood bank technologist screening of red blood cell transfusion orders: The START study. Transfusion 2021; 61:410-422. [PMID: 33423316 DOI: 10.1111/trf.16243] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/20/2020] [Accepted: 10/25/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transfusion of red blood cells (RBC) is a common procedure, which when prescribed inappropriately can result in adverse patient outcomes. This study sought to determine the impact of a multi-faceted intervention on unnecessary RBC transfusions at hospitals with a baseline appropriateness below 90%. STUDY DESIGN AND METHODS A prospective medical chart audit of RBC transfusions was conducted across 15 hospitals. For each site, 10 RBCs per month transfused to inpatients were audited for a 5-month pre- and 10-month post-intervention period, with each transfusion adjudicated for appropriateness based on pre-set criteria. Hospitals with appropriateness rates below 90% underwent a 3-month intervention which included: adoption of standardized RBC guidelines, staff education, and prospective transfusion order screening by blood bank technologists. Proportions of RBC transfusions adjudicated as appropriate and the total number of RBC units transfused per month in the pre- and post-intervention period were examined. RESULTS Over the 15-month audit period, at the 13 hospital sites with a baseline appropriateness below 90%, 1950 patients were audited of which 81.2% were adjudicated as appropriate. Proportions of appropriateness and single-unit orders increased from 73.5% to 85% and 46.2% to 68.2%, respectively from pre- to post-intervention (P < .0001). Pre- and post-transfusion hemoglobin levels and the total number of RBCs transfused decreased from baseline (P < .05). The median pre-transfusion hemoglobin decreased from a baseline of 72.0 g/L to 69.0 g/L in the post-intervention period (P < .0001). RBC transfusions per acute inpatient days decreased significantly in intervention hospitals, but not in control hospitals (P < .001). The intervention had no impact on patient length of stay, need for intensive care support, or in-hospital mortality. CONCLUSION This multifaceted intervention demonstrated a marked improvement in RBC transfusion appropriateness and reduced overall RBC utilization without impacts on patient safety.
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Affiliation(s)
- Amie T Kron
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Allison Collins
- Ontario Regional Blood Coordinating Network (ORBCoN), Toronto, Ontario, Canada
| | - Christine Cserti-Gazdewich
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Jacob Pendergrast
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Kathryn Webert
- Canadian Blood Services, Ottawa, Ontario, Canada.,Department of Molecular Medicine and Pathology, McMaster University, Hamilton, Ontario, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Michelle P Zeller
- Canadian Blood Services, Ottawa, Ontario, Canada.,Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Sheila R Harding
- Department of Laboratory Medicine and Pathology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Susan Nahirniak
- Department of Laboratory Medicine and Pathology, Alberta Precision Laboratories, Grande Prairie, Alberta, Canada.,Department of Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Oksana Prokopchuk-Gauk
- Department of Laboratory Medicine and Pathology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Brent Mendez
- Department of Laboratory Medicine and Pathology, Alberta Precision Laboratories, Grande Prairie, Alberta, Canada.,Department of Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Chantal Armali
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Christina Lee
- Department of Laboratory Medicine and Genetics Program, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Danielle Watson
- Department of Transfusion Medicine, Laboratory Services, Grey Bruce Health Services, Owen Sound, Ontario, Canada
| | - Dena Arnott
- Department of Laboratory Medicine and Pathology, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Fengju Xun
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Human Biology Program, Faculty of Arts and Science, University of Toronto, Toronto, Ontario, Canada
| | - Heather Blain
- Department of Laboratory Medicine and Pathology, Alberta Precision Laboratories, Grande Prairie, Alberta, Canada
| | - Heather Panchuk
- Department of Laboratory Medicine and Pathology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Hertha Hughes
- Department of Laboratory Medicine, Quinte Healthcare Corporation, Belleville, Ontario, Canada
| | - Kathy Chorneyko
- Department of Laboratory Services, Brant Community Healthcare System, Brantford, Ontario, Canada
| | - Michael Angers
- Laboratory Medicine Program, Lakeridge Health, Ajax, Ontario, Canada
| | - Nicole Pilutti
- Department of Laboratory Services, Windsor Regional Hospital, Windsor, Ontario, Canada
| | - Ryan Lett
- Department of Laboratory Medicine and Pathology, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Shauna Dowsley
- Department of Laboratory Medicine and Genetics Program, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Theodora Ruijs
- Department of Pathology, William Osler Health System, Brampton, Ontario, Canada
| | - Tracy Cupido
- Department of Anesthesiology, Quinte Healthcare Corporation, Belleville, Ontario, Canada
| | - Tracy Kichinko
- Department of Laboratory Services, Brant Community Healthcare System, Brantford, Ontario, Canada
| | - Troy Thompson
- Ontario Regional Blood Coordinating Network (ORBCoN), Toronto, Ontario, Canada
| | - Zohreh Afshar-Ghotli
- Department of Transfusion Medicine, Laboratory Services, Grey Bruce Health Services, Owen Sound, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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17
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Clinical Simulation Model of Fibrinogen Decline During Hemorrhage in Major Noncardiac Surgery. J Surg Res 2021; 261:43-50. [PMID: 33412508 DOI: 10.1016/j.jss.2020.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 11/05/2020] [Accepted: 12/07/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Monitoring of decrease in fibrinogen levels with surgical blood loss is crucial for timely transfusion of fresh frozen plasma (FFP) to avoid coagulopathic bleeding. Here, we validated a simulation model to predict hemorrhagic reductions in fibrinogen levels during major noncardiac surgery. METHODS We retrospectively performed exponential regression analysis of intraoperative blood loss and fibrinogen levels to develop a simulation model in the initial 50 patients and applied the model to another 59 patients to compare the measured and simulated fibrinogen levels. We examined the relationship between FFP transfusion and the measured fibrinogen levels or blood loss. The fibrinogen trigger level of FFP transfusion was below 130 mg/dL, although the decision of a perioperative blood transfusion was at the discretion of the anesthesiologists and surgeons. RESULTS Application of the simulation model based on the initial 50 patients to another 59 patients showed no difference between the measured and estimated fibrinogen levels (189 ± 61 versus 186 ± 62, P = 0.60, mean difference: -2.28, limits of agreement: -69.42 to 64.84). The estimated fibrinogen level (mg/dL) = preoperative fibrinogen × exp (-1.90 × [blood loss/estimated circulation volume]), in which the estimated circulation volume = (70 [mL/kg] × body weight [kg]). FFP transfusion was significantly related to the measured fibrinogen level (cutoff: 145; 95% confidence intervals: 124-168; P = 0.0003) but not blood loss (P = 0.12). CONCLUSIONS Fibrinogen level simulation predicted a hemorrhagic fibrinogen decline, thereby guiding FFP transfusion during active surgical bleeding. Further studies on the usefulness of fibrinogen level simulation are warranted.
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18
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Juffermans NP, Aubron C, Duranteau J, Vlaar APJ, Kor DJ, Muszynski JA, Spinella PC, Vincent JL. Transfusion in the mechanically ventilated patient. Intensive Care Med 2020; 46:2450-2457. [PMID: 33180167 PMCID: PMC7658306 DOI: 10.1007/s00134-020-06303-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/16/2020] [Indexed: 12/20/2022]
Abstract
Red blood cell transfusions are a frequent intervention in critically ill patients, including in those who are receiving mechanical ventilation. Both these interventions can impact negatively on lung function with risks of transfusion-related acute lung injury (TRALI) and other forms of acute respiratory distress syndrome (ARDS). The interactions between transfusion, mechanical ventilation, TRALI and ARDS are complex and other patient-related (e.g., presence of sepsis or shock, disease severity, and hypervolemia) or blood product-related (e.g., presence of antibodies or biologically active mediators) factors also play a role. We propose several strategies targeted at these factors that may help limit the risks of associated lung injury in critically ill patients being considered for transfusion.
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Affiliation(s)
- Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centre, Location Academic Medical Centre, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | - Cécile Aubron
- Medical Intensive Care, Brest University Hospital, Université de Bretagne Occidentale, Brest, France
| | - Jacques Duranteau
- Department of Anesthesiology and Critical Care, Bicêtre, Hôpitaux Universitaires Paris Saclay, Université Paris Saclay, AP-HP, Le Kremlin Bicêtre, France
| | - Alexander P J Vlaar
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centre, Location Academic Medical Centre, Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jennifer A Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Philip C Spinella
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
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19
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First experience with a ROTEM-enhanced transfusion algorithm in patients undergoing aortic arch replacement with frozen elephant trunk technique. A theranostic approach to patient blood management. J Clin Anesth 2020; 66:109910. [DOI: 10.1016/j.jclinane.2020.109910] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/04/2020] [Accepted: 05/22/2020] [Indexed: 11/18/2022]
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20
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Sharma S, Sonny A, Dalia AA, Karamchandani K. Acute heart failure after liver transplantation: A narrative review. Clin Transplant 2020; 34:e14079. [PMID: 32941661 DOI: 10.1111/ctr.14079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/06/2020] [Accepted: 08/27/2020] [Indexed: 11/27/2022]
Abstract
Acute heart failure (AHF) is an under recognized yet potentially lethal complication after liver transplantation (LT) surgery. The increase in incidence of liver transplantation amongst high-risk patients and the leniency in the criteria for transplantation, predisposes these patients to postoperative AHF and the antecedent morbidity and mortality. The inability of conventional preoperative cardiovascular testing to accurately identify patients at risk for post-LT AHF poses a considerable challenge to clinicians caring for these patients. Even if high-risk patients are identified, there is considerable ambiguity in the candidacy for transplantation as well as optimization strategies that could potentially prevent the development of AHF in the postoperative period. The intraoperative and postoperative management of patients who develop AHF is also challenging and requires a well-coordinated multidisciplinary approach. The use of mechanical circulatory support in patients with refractory heart failure has the potential to improve outcomes but its use in this complex patient population can be associated with significant complications and requires a stringent risk-benefit analysis on a case-by-case basis.
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Affiliation(s)
- Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Abraham Sonny
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
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21
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Frank SM, Lo BD, Yesantharao LV, Merkel KR, Qin CX, Cho BC, Lee KHK, Wintermeyer TL, Hebbar S, Burkhart RA, Goel R, Gehrie EA. Blood utilization and clinical outcomes in pancreatic surgery before and after implementation of patient blood management. Transfusion 2020; 60:2581-2590. [PMID: 32897635 DOI: 10.1111/trf.16063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/23/2020] [Accepted: 07/23/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Over the past decade, patient blood management (PBM) programs have been developed to reduce allogeneic blood utilization. This is particularly important in pancreatic surgery, which has historically been associated with high transfusion requirements and morbid event rates. This study investigated blood utilization and clinical outcomes in pancreatic surgery before, during, and after the implementation of PBM. STUDY DESIGN AND METHODS A total of 3482 pancreatic surgery patients were assessed in a 10-year retrospective cohort study (2009-2019) at a single academic center. Baseline patient characteristics, transfusion practices, postoperative morbidity (infectious, thrombotic, ischemic, respiratory, and renal complications), mortality, and length of stay were compared between patients in the pre-PBM (2009-2013), early-PBM (2014-2016), and mature-PBM (2017-2019) time periods. Multivariable analysis assessed the odds for composite morbidity/mortality. RESULTS Comparing the mature-PBM to pre-PBM cohorts, transfused units per 100 discharged patients decreased by 53% for erythrocytes (155 to 73; P < .0001), 81% for plasma (79 to 15; P < .038), and 75% for platelets (10 to 2.5; P < .005). Clinical outcomes improved as well, with composite morbid event rates decreasing by more than 50%, from 236 in 1438 patients (16.4%) to 85 in 1145 patients (7.4%) (P < .0001). Mortality and length of stay remained unchanged. Compared to the pre-PBM time period, early-PBM was associated with a risk-adjusted decrease in composite morbidity/mortality (OR 0.73; 95% CI 0.57-0.93; P = .010), while mature-PBM demonstrated a further incremental decrease (OR 0.44; 95% CI 0.33-0.57; P < .0001). CONCLUSIONS The implementation of PBM was associated with substantially decreased blood utilization in pancreatic surgery, without negatively impacting clinical outcomes.
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Affiliation(s)
- Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Health System Blood Management Program, Faculty, The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Brian D Lo
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Lekha V Yesantharao
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Kevin R Merkel
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Caroline X Qin
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Brian C Cho
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - K H Ken Lee
- Clinical and Value Analytics, The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Tyler L Wintermeyer
- Clinical and Value Analytics, The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Sachidanand Hebbar
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Richard A Burkhart
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ruchika Goel
- Department of Pathology (Transfusion Medicine), The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Eric A Gehrie
- Department of Pathology (Transfusion Medicine), The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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22
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Hensley NB, Frank SM, Prochaska MT. Intraoperative Transfusion Targets: Avoiding the Extremes. Anesth Analg 2020; 129:642-643. [PMID: 31425199 DOI: 10.1213/ane.0000000000004288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Nadia B Hensley
- From the Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Health System Blood Management Program, Faculty, Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Micah T Prochaska
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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Kim J, Nguyen TTT, Li Y, Zhang CO, Cha B, Ke Y, Mazzeffi MA, Tanaka KA, Birukova AA, Birukov KG. Contrasting effects of stored allogeneic red blood cells and their supernatants on permeability and inflammatory responses in human pulmonary endothelial cells. Am J Physiol Lung Cell Mol Physiol 2020; 318:L533-L548. [PMID: 31913681 DOI: 10.1152/ajplung.00025.2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Transfusion of red blood cells (RBCs) is a common life-saving clinical practice in severely anemic or hemorrhagic patients; however, it may result in serious pathological complications such as transfusion-related acute lung injury. The factors mediating the deleterious effects of RBC transfusion remain unclear. In this study, we tested the effects of washed long-term (RBC-O; >28 days) versus short-term (RBC-F; <14 days) stored RBCs and their supernatants on lung endothelial (EC) permeability under control and inflammatory conditions. RBCs enhanced basal EC barrier function as evidenced by an increase in transendothelial electrical resistance and decrease in permeability for macromolecules. RBCs also attenuated EC hyperpermeability and suppressed secretion of EC adhesion molecule ICAM-1 and proinflammatory cytokine IL-8 in response to LPS or TNF-α. In both settings, RBC-F had slightly higher barrier protective effects as compared with RBC-O. In contrast, supernatants from both RBC-F and RBC-O disrupted the EC barrier. The early phase of EC permeability response caused by RBC supernatants was partially suppressed by antioxidant N-acetyl cysteine and inhibitor of Src kinase family PP2, while addition of heme blocker and inhibition of NOD-like receptor family pyrin domain containing protein 3 (NLRP3), stress MAP kinases, receptor for advanced glycation end-products (RAGE), or Toll-like receptor-4 (TLR4) signaling were without effect. Morphological analysis revealed that RBC supernatants increased LPS- and TNF-α-induced breakdown of intercellular junctions and formation of paracellular gaps. RBC supernatants augmented LPS- and TNF-α-induced EC inflammation reflected by increased production of IL-6, IL-8, and soluble ICAM-1. These findings demonstrate the deleterious effects of RBC supernatants on EC function, which may have a major impact in pathological consequences associated with RBC transfusion.
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Affiliation(s)
- Junghyun Kim
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Trang T T Nguyen
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Yue Li
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Chen-Ou Zhang
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Boyoung Cha
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Yunbo Ke
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Anna A Birukova
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Konstantin G Birukov
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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24
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Smith MM, Kor DJ, Frank RD, Weister TJ, Dearani JA, Warner MA. Intraoperative Plasma Transfusion Volumes and Outcomes in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:1446-1456. [PMID: 32044241 DOI: 10.1053/j.jvca.2019.12.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/18/2019] [Accepted: 12/21/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Assess outcomes after intraoperative plasma transfusion in patients undergoing cardiac surgery. DESIGN Retrospective study of adult cardiac surgical between 2011 and 2015. Relationships between plasma transfusion volume, coagulation test values, and a primary outcome of early postoperative red blood cell (RBC) transfusion were assessed via multivariable regression analyses. Secondary outcomes included hospital mortality, intensive care unit and hospital-free days, intraoperative RBCs, estimated blood loss, and reoperation for bleeding. SETTING Academic tertiary referral center. PARTICIPANTS A total of 1,794 patients received intraoperative plasma transfusions during the study period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Higher plasma transfusion volumes were associated with worse clinical outcomes, with each 1-unit increase being associated with greater odds for postoperative RBCs [odds ratio (OR) 1.12 (confidence interval [CI] 1.04-1.20); p = 0.002], intraoperative [OR 1.85 (CI 1.69-2.03); p < 0.001], and fewer hospital-free days [mean -0.20 (-0.39, -0.01); p = 0.04]. Each 0.1 increase in pretransfusion International Normalized Ratio (INR) was associated with increased odds of postoperative and intraoperative RBCs, reoperation for bleeding, and fewer intensive care unit and hospital-free days. For given plasma volumes, patients achieving greater reduction in elevated pretransfusion INR values experienced more favorable outcomes. CONCLUSIONS In patients undergoing cardiac surgery who received intraoperative plasma transfusion, higher plasma transfusion volumes were associated with inferior clinical outcomes. Higher pretransfusion INR values also were associated with worse outcomes; however, those achieving a greater degree of INR correction after plasma transfusion demonstrated more favorable outcomes. Prospective studies related to plasma transfusion are needed to address this important topic.
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Affiliation(s)
- Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN.
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Ryan D Frank
- Department of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, MN
| | - Timothy J Weister
- Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Rochester, MN
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN
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Nordestgaard AT, Rasmussen LS, Sillesen M, Steinmetz J, Eid AI, Meier K, Kaafarani HMA, Velmahos GC. Red blood cell transfusion in surgery: an observational study of the trends in the USA from 2011 to 2016. Anaesthesia 2019; 75:455-463. [PMID: 31667830 DOI: 10.1111/anae.14900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2019] [Indexed: 01/28/2023]
Abstract
Guidelines recommend restrictive red blood cell transfusion strategies. We conducted an observational study to examine whether the rate of peri-operative red blood cell transfusion in the USA had declined during the period from 01 January 2011 to 31 December 2016. We included 4,273,168 patients from all surgical subspecialties. We examined parallel trends in rates of the following: pre-operative transfusion; prevalence of bleeding disorders and coagulopathy; and minimally invasive procedures. To account for changes in population and procedure characteristics, we performed multivariable logistic regression to assess whether the risk of receiving a transfusion had declined over the study period. Clinical outcomes included peri-operative myocardial infarction, stroke and all-cause mortality at 30 days. Peri-operative red blood cell transfusion rates declined from 37,040/441,255 (8.4%) in 2011 to 46,845/1,000,195 (4.6%) in 2016 (p < 0.001) across all subspecialties. Compared with 2011, the corresponding adjusted OR (95%CI) for red blood cell transfusion decreased gradually from 0.88 (0.86-0.90) in 2012 to 0.51 (0.50-0.51) in 2016 (p < 0.001). Pre-operative red blood cell transfusion rates and the prevalence of bleeding disorders decreased, whereas haematocrit levels and the proportion of minimally invasive procedures increased. Compared with 2011, the adjusted hazard ratios (95%CI) in 2012 and 2016 were 0.96 (0.90-1.02) and 1.05 (0.99-1.11) for myocardial infarction, 0.91 (0.83-0.99) and 0.99 (0.92-1.07) for stroke and 0.98 (0.94-1.02) and 0.99 (0.96-1.03) for all-cause mortality. Use of peri-operative red blood cell transfusion declined from 2011 to 2016. This was not associated with an increase in adverse clinical outcomes.
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Affiliation(s)
- A T Nordestgaard
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Anaesthesia, Centre of Head and Orthopaedics 4231, Rigshospitalet, University of Copenhagen, Denmark
| | - L S Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics 4231, Rigshospitalet, University of Copenhagen, Denmark
| | - M Sillesen
- Department of Surgical Gastroenterology and Institute for Inflammation Research, Rigshospitalet, University of Copenhagen, Denmark
| | - J Steinmetz
- Department of Anaesthesia, Centre of Head and Orthopaedics 4231, Rigshospitalet, University of Copenhagen, Denmark
| | - A I Eid
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - K Meier
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - H M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - G C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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26
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Transfusion-Associated Circulatory Overload and Transfusion-Related Acute Lung Injury. Hematol Oncol Clin North Am 2019; 33:767-779. [DOI: 10.1016/j.hoc.2019.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Abstract
Transfusion-related acute lung injury is a leading cause of death associated with the use of blood products. Transfusion-related acute lung injury is a diagnosis of exclusion which can be difficult to identify during surgery amid the various physiologic and pathophysiologic changes associated with the perioperative period. As anesthesiologists supervise delivery of a large portion of inpatient prescribed blood products, and since the incidence of transfusion-related acute lung injury in the perioperative patient is higher than in nonsurgical patients, anesthesiologists need to consider transfusion-related acute lung injury in the perioperative setting, identify at-risk patients, recognize early signs of transfusion-related acute lung injury, and have established strategies for its prevention and treatment.
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28
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McVey MJ, Lin Y, Young DK, Cserti-Gazdewich C. A case of recurrent transfusion-related acute lung injury despite lessons learned from antibody mitigation. Transfus Med 2019; 29:376-378. [PMID: 31429144 DOI: 10.1111/tme.12628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 07/02/2019] [Accepted: 07/31/2019] [Indexed: 11/29/2022]
Affiliation(s)
- M J McVey
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Medicine, SickKids, Toronto, Ontario, Canada
| | - Y Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Transfusion Medicine and Tissue Bank, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - D K Young
- Canadian Blood Services, Chair, and on behalf of the TRALI Medical Review Group
| | - C Cserti-Gazdewich
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine (Medical Oncology and Hematology), University Health Network, Blood Transfusion Laboratory (Laboratory Medicine Program), Toronto, Ontario, Canada
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29
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Warner MA, Hanson AC, Weister TJ, Higgins AA, Madde NR, Schroeder DR, Kreuter JD, Kor DJ. Changes in International Normalized Ratios After Plasma Transfusion of Varying Doses in Unique Clinical Environments. Anesth Analg 2019; 127:349-357. [PMID: 29596103 DOI: 10.1213/ane.0000000000003336] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Plasma transfusion is commonly performed for the correction of abnormal coagulation screening tests. The goal of this investigation was to assess the relationship between the dose of plasma administered and changes in coagulation test results in a large and diverse cohort of patients with varying levels of coagulation abnormalities and comorbid disease and in a variety of clinical settings. METHODS In this single-center historical cohort study, all plasma transfusion episodes in adult patients with abnormal coagulation screening tests were extracted between 2011 and 2015. The primary outcome was the proportion of patients attaining normal posttransfusion international normalized ratio (INR ≤ 1.1) with secondary outcomes including the proportion of patients attaining partial normalization of INR (INR ≤ 1.5) or at least 50% normalization in pretransfusion values with respect to an INR of 1.1. RESULTS In total, 6779 unique patients received plasma with a median (quartiles) pretransfusion INR of 1.9 (1.6-2.5) and a median transfusion volume of 2 (2-3) units. The majority (85%) of transfusions occurred perioperatively, with 20% of transfusions administered prophylactically before a procedure. The median decrease in INR was 0.4 (0.2-0.8). Complete INR normalization was obtained in 12%. Reductions in INR were modest with pretransfusion INR values <3. Patients receiving ≥3 units of plasma were more likely to achieve at least 50% normalization in INR than those receiving ≤2 units (68% vs 60%; P < .001). CONCLUSIONS Changes in INR after plasma transfusion were modest at typically used clinical doses, particularly in those with less severely deranged baseline coagulation screening tests. Further studies are necessary to assess the relationships between plasma-mediated changes in INR and clinical outcomes.
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Affiliation(s)
- Matthew A Warner
- From the Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.,Periprocedural Outcomes, Information and Transfusion Study Group, Mayo Clinic, Rochester, Minnesota
| | - Andrew C Hanson
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Timothy J Weister
- Periprocedural Outcomes, Information and Transfusion Study Group, Mayo Clinic, Rochester, Minnesota.,Department of Anesthesiology and Perioperative Medicine, Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Nageswar R Madde
- Periprocedural Outcomes, Information and Transfusion Study Group, Mayo Clinic, Rochester, Minnesota.,Department of Anesthesiology and Perioperative Medicine, Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Darrell R Schroeder
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Justin D Kreuter
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Daryl J Kor
- From the Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.,Periprocedural Outcomes, Information and Transfusion Study Group, Mayo Clinic, Rochester, Minnesota
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30
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Warner MA, Schaefer KK, Madde N, Burt JM, Higgins AA, Kor DJ. Improvements in red blood cell transfusion utilization following implementation of a single-unit default for electronic ordering. Transfusion 2019; 59:2218-2222. [PMID: 31002192 PMCID: PMC6610646 DOI: 10.1111/trf.15316] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The prevention of excessive allogeneic red blood cell (RBC) transfusion is an important component of patient blood management initiatives. In this investigation, changes in transfusion behaviors following modification of computerized physician order entry (CPOE) procedures for RBC transfusions to a single-unit default quantity were assessed. STUDY DESIGN AND METHODS This is an observational cohort study of adults for whom nonemergency allogeneic RBC transfusions were ordered in the 2 years before and 2 years after the date of modification of the CPOE system to a single-unit default (June 18, 2015). Changes in the frequency of single- versus multiunit RBC transfusion orders and other transfusion metrics were compared between preintervention and postintervention cohorts. RESULTS A total of 52,773 unique transfusion orders for 61,989 RBC units were included, of which 60,045 (96.9%) were transfused. Single-unit orders increased annually, from 10,404 (74.1%) in the first year to 11,645 (88.6%) in the last year, while multiunit orders decreased by more than half (p < 0.0001). The number of RBC units transfused decreased by 13.9% from 32,528 in the preintervention cohort to 27,497 in the post intervention cohort (p < 0.0001) with an estimated reduction in transfusion-related expenditures of nearly $4 million. The percentage of transfusions associated with a posttransfusion hemoglobin of10 g/dL or greater decreased by 34.5% (p < 0.0001). CONCLUSION Modification of the CPOE process such that nonemergency RBC transfusion orders were defaulted to a single unit was associated with decreased rates of multiunit RBC transfusion orders, lower transfusion volumes, and substantial cost savings.
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Affiliation(s)
- Matthew A. Warner
- Divison of Critical Care, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN
- Patient Blood Management Committee, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Kalli K. Schaefer
- Patient Blood Management Committee, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Nageswar Madde
- Patient Blood Management Committee, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jennifer M. Burt
- Patient Blood Management Committee, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Andrew A. Higgins
- Patient Blood Management Committee, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Daryl J. Kor
- Divison of Critical Care, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN
- Patient Blood Management Committee, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN
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32
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Transfusion-associated circulatory overload and transfusion-related acute lung injury. Blood 2019; 133:1840-1853. [PMID: 30808638 DOI: 10.1182/blood-2018-10-860809] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 12/10/2018] [Indexed: 01/18/2023] Open
Abstract
Transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI) are syndromes of acute respiratory distress that occur within 6 hours of blood transfusion. TACO and TRALI are the leading causes of transfusion-related fatalities, and specific therapies are unavailable. Diagnostically, it remains very challenging to distinguish TACO and TRALI from underlying causes of lung injury and/or fluid overload as well as from each other. TACO is characterized by pulmonary hydrostatic (cardiogenic) edema, whereas TRALI presents as pulmonary permeability edema (noncardiogenic). The pathophysiology of both syndromes is complex and incompletely understood. A 2-hit model is generally assumed to underlie TACO and TRALI disease pathology, where the first hit represents the clinical condition of the patient and the second hit is conveyed by the transfusion product. In TACO, cardiac or renal impairment and positive fluid balance appear first hits, whereas suboptimal fluid management or other components in the transfused product may enable the second hit. Remarkably, other factors beyond volume play a role in TACO. In TRALI, the first hit can, for example, be represented by inflammation, whereas the second hit is assumed to be caused by antileukocyte antibodies or biological response modifiers (eg, lipids). In this review, we provide an up-to-date overview of TACO and TRALI regarding clinical definitions, diagnostic strategies, pathophysiological mechanisms, and potential therapies. More research is required to better understand TACO and TRALI pathophysiology, and more biomarker studies are warranted. Collectively, this may result in improved diagnostics and development of therapeutic approaches for these life-threatening transfusion reactions.
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Roubinian N. TACO and TRALI: biology, risk factors, and prevention strategies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:585-594. [PMID: 30570487 PMCID: PMC6324877 DOI: 10.1182/asheducation-2018.1.585] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are the leading causes of transfusion-related morbidity and mortality. These adverse events are characterized by acute pulmonary edema within 6 hours of a blood transfusion and have historically been difficult to study due to underrecognition and nonspecific diagnostic criteria. However, in the past decade, in vivo models and clinical studies utilizing active surveillance have advanced our understanding of their epidemiology and pathogenesis. With the adoption of mitigation strategies and patient blood management, the incidence of TRALI and TACO has decreased. Continued research to prevent and treat these severe cardiopulmonary events is focused on both the blood component and the transfusion recipient.
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Affiliation(s)
- Nareg Roubinian
- Blood Systems Research Institute, San Francisco, CA; Kaiser Permanente Northern California Medical Center and Division of Research, Oakland, CA; and Department of Laboratory Medicine, University of California, San Francisco, CA
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34
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Thalji L, Thum D, Weister TJ, Weber WV, Stubbs JR, Kor DJ, Nemergut ME. Incidence and Epidemiology of Perioperative Transfusion-Related Pulmonary Complications in Pediatric Noncardiac Surgical Patients. Anesth Analg 2018; 127:1180-1188. [DOI: 10.1213/ane.0000000000003574] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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35
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Warner MA, Frank RD, Weister TJ, Smith MM, Stubbs JR, Kor DJ. Higher intraoperative plasma transfusion volumes are associated with inferior perioperative outcomes. Transfusion 2018; 59:112-124. [PMID: 30383908 DOI: 10.1111/trf.14988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/15/2018] [Accepted: 08/21/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intraoperative plasma transfusion is common, yet little is known regarding its effects on perioperative coagulation tests or clinical outcomes. STUDY DESIGN AND METHODS This is a retrospective cohort study of adults receiving intraoperative plasma transfusion at a single center from 2011 to 2015. Relationships between plasma transfusion volume, changes in coagulation test values, and clinical outcomes, including a primary outcome of early postoperative red blood cell (RBC) transfusion, were assessed with multivariable regression analyses. Secondary outcomes included hospital mortality, intensive care unit (ICU)- and hospital-free days, intraoperative RBC transfusions, and estimated blood loss. RESULTS A total of 3393 unique patients were included, with median (IQR) transfusion of 2 (2-4) units. In multivariable analyses, higher plasma volumes were associated with worse outcomes, with each 1 mL/kg increase associated with increased odds for postoperative (1.02 [1.01-1.03], p < 0.001) and intraoperative RBCs (1.17 [1.16-1.19], p < 0.001) and fewer ICU- and hospital-free days (mean difference [95% CI], -0.08 [-0.12 to -0.05], p < 0.001; and -0.09 [-0.13 to -0.06], p < 0.001, respectively). Greater decreases in international normalized ratio (INR) following plasma transfusion were associated with decreased odds of postoperative RBCs (0.35 [0.25-0.47], p < 0.001), decreased mortality (0.50 [0.31-0.83], p = 0.007), and increased mean ICU- (1.31 [0.41-2.21], p = 0.004) and hospital-free days (1.15 [0.19-2.10], p = 0.018). CONCLUSION In patients receiving intraoperative plasma transfusion, higher transfusion volumes were associated with inferior clinical outcomes; however, greater improvements in INR were associated with improved outcomes. Future prospective studies are necessary to better define these relationships and to explore plasma transfusion triggers beyond the limitations of INR.
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Affiliation(s)
- Matthew A Warner
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ryan D Frank
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Timothy J Weister
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Mark M Smith
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - James R Stubbs
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Daryl J Kor
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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36
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Friedman T, Javidroozi M, Lobel G, Shander A. Complications of Allogeneic Blood Product Administration, with Emphasis on Transfusion-Related Acute Lung Injury and Transfusion-Associated Circulatory Overload. Adv Anesth 2018; 35:159-173. [PMID: 29103571 DOI: 10.1016/j.aan.2017.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Tamara Friedman
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, TeamHealth Research Institute, 350 Engle Street, Englewood, NJ 07631, USA
| | - Mazyar Javidroozi
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, TeamHealth Research Institute, 350 Engle Street, Englewood, NJ 07631, USA
| | - Gregg Lobel
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, TeamHealth Research Institute, 350 Engle Street, Englewood, NJ 07631, USA
| | - Aryeh Shander
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, TeamHealth Research Institute, 350 Engle Street, Englewood, NJ 07631, USA.
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Intraoperative red blood cell transfusion, delayed graft function, and infection after kidney transplant: an observational cohort study. J Anesth 2018; 32:368-374. [DOI: 10.1007/s00540-018-2484-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/16/2018] [Indexed: 01/28/2023]
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38
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Mazzeffi MA, See JM, Williams B, Richards J, Zimmerman D, Galvagno S, Fontaine M, Tanaka K. Five-year trends in perioperative red blood cell transfusion from index cases in five surgical specialties: 2011 to 2015. Transfusion 2018. [PMID: 29542136 DOI: 10.1111/trf.14559] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Red blood cell (RBC) transfusion can be life-saving; however, the risks of RBC transfusion have been increasingly recognized, and current guidelines recommend restrictive transfusion in most patients. We hypothesized that RBC transfusions are decreasing in surgical patients. STUDY DESIGN AND METHODS A retrospective review of the National Surgical Quality Improvement Program database was performed from 2011 to 2015. Index cases in five surgical specialties were studied: neurosurgery, thoracic surgery, gynecologic surgery, orthopedic surgery, and vascular surgery. Patient characteristics, preoperative laboratory values, and surgery details were compared between years. The study's primary outcome was perioperative RBC transfusion, which was compared over the 5-year period for each specialty. Secondary outcomes were myocardial infarction and renal failure after surgery. In addition, trends in RBC transfusion between low-risk and high-risk patients and between emergency and elective surgery were examined. RESULTS RBC transfusion decreased in all surgical specialties except for thoracic and gynecologic surgery. RBC transfusion decreased substantially in orthopedic surgery, falling from 22.4% in 2011 to 6.3% in 2015 (p ≤ 0.0001). High-risk patients had greater reductions in the receipt of RBC transfusion than low-risk patients, and there were no increases in myocardial infarction or renal failure after surgery in any specialty. CONCLUSION RBC transfusion appears to be decreasing across multiple surgical specialties, with no apparent increase in myocardial infarctions or renal failure. This likely represents an important improvement in patient care. Continued efforts are needed to develop patient blood management programs and further reduce RBC transfusion.
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Affiliation(s)
- Michael A Mazzeffi
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - John M See
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Brittney Williams
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Justin Richards
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Darin Zimmerman
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Samuel Galvagno
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Magali Fontaine
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenichi Tanaka
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
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Alelign T, Ahmed MM, Bobosha K, Tadesse Y, Howe R, Petros B. Kidney Transplantation: The Challenge of Human Leukocyte Antigen and Its Therapeutic Strategies. J Immunol Res 2018; 2018:5986740. [PMID: 29693023 PMCID: PMC5859822 DOI: 10.1155/2018/5986740] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/30/2017] [Accepted: 12/03/2017] [Indexed: 12/16/2022] Open
Abstract
Kidney transplantation remains the treatment of choice for end-stage renal failure. When the immune system of the recipient recognizes the transplanted kidney as a foreign object, graft rejection occurs. As part of the host immune defense mechanism, human leukocyte antigen (HLA) is a major challenge for graft rejection in transplantation therapy. The impact of HLA mismatches between the donor and the potential recipient prolongs the time for renal transplantation therapy, tethered to dialysis, latter reduces graft survival, and increases mortality. The formation of pretransplant alloantibodies against HLA class I and II molecules can be sensitized through exposures to blood transfusions, prior transplants, and pregnancy. These preformed HLA antibodies are associated with rejection in kidney transplantation. On the other hand, the development of de novo antibodies may increase the risk for acute and chronic rejections. Allograft rejection results from a complex interplay involving both the innate and the adaptive immune systems. Thus, further insights into the mechanisms of tissue rejection and the risk of HLA sensitization is crucial in developing new therapies that may blunt the immune system against transplanted organs. Therefore, the purpose of this review is to highlight facts about HLA and its sensitization, various mechanisms of allograft rejection, the current immunosuppressive approaches, and the directions for future therapy.
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Affiliation(s)
- Tilahun Alelign
- College of Natural Sciences, Department of Microbial, Cellular and Molecular Biology, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia
- Department of Biology, Debre Berhan University, P.O. Box 445, Debre Berhan, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Momina M. Ahmed
- St. Paul's Hospital Millennium Medical College and Addis Ababa University, Addis Ababa, Ethiopia
| | - Kidist Bobosha
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Yewondwossen Tadesse
- School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Rawleigh Howe
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Beyene Petros
- College of Natural Sciences, Department of Microbial, Cellular and Molecular Biology, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia
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Farag E, Argalious M, Tetzlaff JE, Sharma D. Blood Products Transfusion. BASIC SCIENCES IN ANESTHESIA 2018. [PMCID: PMC7121298 DOI: 10.1007/978-3-319-62067-1_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Transfusion of blood products may be required during the perioperative period. Despite a well-established safety record, transfusion of blood and its components is not risk free. Indication for each of the blood components needs to be established based on the laboratory investigation and/or clinical picture. In general terms, when there is a clinical evidence of a deficiency in oxygen-carrying capacity, red cell transfusion should be considered; and in the situations of clinically significant coagulopathy, hemostatic blood products (frozen plasma, platelets, cryoprecipitate, factor concentrates) transfusion should be considered. Complications of blood administration range from rare but severe reactions (hemolytic transfusion reactions) to more common, and also associated with significant morbidity and mortality, such as transfusion-related acute lung injury (TRALI), transfusion-related circulatory overload (TACO), and changes in immune system (transfusion related immunomodulation [TRIM]).
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Affiliation(s)
- Ehab Farag
- Departments of General Anesthesia and Outcomes Research, Anesthesiology Institute, Cleveland Clinic Lerner College of Medicine, Case Western University, Cleveland, Ohio USA
| | - Maged Argalious
- Center for Anesthesiology Education, Anesthesiology Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio USA
| | - John E. Tetzlaff
- Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio USA
| | - Deepak Sharma
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington USA
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Frank SM, Thakkar RN, Podlasek SJ, Ken Lee KH, Wintermeyer TL, Yang WW, Liu J, Rotello LC, Fleury TA, Wachter PA, Ishii LE, Demski R, Pronovost PJ, Ness PM. Implementing a Health System-wide Patient Blood Management Program with a Clinical Community Approach. Anesthesiology 2017; 127:754-764. [PMID: 28885446 DOI: 10.1097/aln.0000000000001851] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient blood management programs are gaining popularity as quality improvement and patient safety initiatives, but methods for implementing such programs across multihospital health systems are not well understood. Having recently incorporated a patient blood management program across our health system using a clinical community approach, we describe our methods and results. METHODS We formed the Johns Hopkins Health System blood management clinical community to reduce transfusion overuse across five hospitals. This physician-led, multidisciplinary, collaborative, quality-improvement team (the clinical community) worked to implement best practices for patient blood management, which we describe in detail. Changes in blood utilization and blood acquisition costs were compared for the pre- and post-patient blood management time periods. RESULTS Across the health system, multiunit erythrocyte transfusion orders decreased from 39.7 to 20.2% (by 49%; P < 0.0001). The percentage of patients transfused decreased for erythrocytes from 11.3 to 10.4%, for plasma from 2.9 to 2.2%, and for platelets from 3.1 to 2.7%, (P < 0.0001 for all three). The number of units transfused per 1,000 patients decreased for erythrocytes from 455 to 365 (by 19.8%; P < 0.0001), for plasma from 175 to 107 (by 38.9%; P = 0.0002), and for platelets from 167 to 141 (by 15.6%; P = 0.04). Blood acquisition cost savings were $2,120,273/yr, an approximate 400% return on investment for our patient blood management efforts. CONCLUSIONS Implementing a health system-wide patient blood management program by using a clinical community approach substantially reduced blood utilization and blood acquisition costs.
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Affiliation(s)
- Steven M Frank
- From the Department of Anesthesiology and Critical Care Medicine (S.M.F., W.W.Y., P.J.P.), Department of Medicine (R.N.T., L.C.R.), Department of Pathology, Transfusion Medicine (S.J.P., J.L., T.A.F., P.M.N.), Armstrong Institute for Patient Safety and Quality (K.H.K.L., T.L.W., P.A.W., R.D., P.J.P.), and Department of Otolaryngology Head and Neck Surgery (L.E.I.), The Johns Hopkins Medical Institutions, Baltimore, Maryland
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Smith NK, Kim S, Hill B, Goldberg A, DeMaria S, Zerillo J. Transfusion-Related Acute Lung Injury (TRALI) and Transfusion-Associated Circulatory Overload (TACO) in Liver Transplantation: A Case Report and Focused Review. Semin Cardiothorac Vasc Anesth 2017; 22:180-190. [DOI: 10.1177/1089253217736298] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Liver transplantation (LT) is a complex procedure in a patient with multi-organ system dysfunction and coagulation defects. The surgical procedure involves dissection, major vessel manipulation, and pathophysiologic effects of graft storage and reperfusion. As a result, LT frequently involves significant hemorrhage. Subsequent massive transfusion carries high risk of transfusion-associated complications. Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are the leading causes of transfusion associated mortality. In this case report and focused review, we present data that suggest that patients undergoing liver transplantation may be at higher risk for TRALI and TACO than the general population. Anesthesiologists can play a role in decreasing these risks by increasing recognition and reporting of TRALI and TACO, using point of care testing with thromboelastography to guide and decrease transfusion, and considering alternatives to traditional blood products like solvent/detergent plasma.
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Affiliation(s)
- Natalie K. Smith
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Sang Kim
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Bryan Hill
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Andrew Goldberg
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Samuel DeMaria
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Jeron Zerillo
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
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A Randomized Clinical Trial of Red Blood Cell Transfusion Triggers in Cardiac Surgery. Ann Thorac Surg 2017; 104:1243-1250. [DOI: 10.1016/j.athoracsur.2017.05.048] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/19/2017] [Accepted: 05/15/2017] [Indexed: 11/23/2022]
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Otrock ZK, Liu C, Grossman BJ. Transfusion-related acute lung injury risk mitigation: an update. Vox Sang 2017; 112:694-703. [PMID: 28948604 DOI: 10.1111/vox.12573] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 07/11/2017] [Accepted: 08/11/2017] [Indexed: 02/04/2023]
Abstract
Transfusion-related acute lung injury (TRALI) is a life-threatening complication of transfusion. Greater understanding of the pathophysiology of this syndrome has much improved during the last two decades. Plasma-containing components from female donors with leucocyte antibodies were responsible for the majority of TRALI fatalities before mitigation strategies were implemented. Over the past 15 years, measures to mitigate risk for TRALI have been implemented worldwide and they continued to evolve with time. The AABB requires that all plasma containing components and whole blood for transfusion must be collected from men, women who have not been pregnant, or women who have tested negative for human leucocyte antigen antibodies. Although the incidence of TRALI has decreased following the institution of TRALI mitigation strategies, TRALI is still the most common cause of transfusion-associated death in the United States. In this review, we focus on TRALI risk mitigation strategies. We describe the measures taken by blood collection facilities to reduce the risk of TRALI in the United States, Canada and European countries. We also review the literature for the effectiveness of these measures.
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Affiliation(s)
- Z K Otrock
- Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, MI, USA
| | - C Liu
- Department of Pathology and Immunology, Barnes-Jewish Hospital, Washington University, St Louis, MO, USA
| | - B J Grossman
- Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, MI, USA
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Abuelkasem E, Hasan S, Mazzeffi MA, Planinsic RM, Sakai T, Tanaka KA. Reduced Requirement for Prothrombin Complex Concentrate for the Restoration of Thrombin Generation in Plasma From Liver Transplant Recipients. Anesth Analg 2017; 125:609-615. [DOI: 10.1213/ane.0000000000002106] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Winearls J, Reade M, Miles H, Bulmer A, Campbell D, Görlinger K, Fraser JF. Targeted Coagulation Management in Severe Trauma: The Controversies and the Evidence. Anesth Analg 2017; 123:910-24. [PMID: 27636575 DOI: 10.1213/ane.0000000000001516] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Hemorrhage in the setting of severe trauma is a leading cause of death worldwide. The pathophysiology of hemorrhage and coagulopathy in severe trauma is complex and remains poorly understood. Most clinicians currently treating trauma patients acknowledge the presence of a coagulopathy unique to trauma patients-trauma-induced coagulopathy (TIC)-independently associated with increased mortality. The complexity and incomplete understanding of TIC has resulted in significant controversy regarding optimum management. Although the majority of trauma centers utilize fixed-ratio massive transfusion protocols in severe traumatic hemorrhage, a widely accepted "ideal" transfusion ratio of blood to blood products remains elusive. The recent use of viscoelastic hemostatic assays (VHAs) to guide blood product replacement has further provoked debate as to the optimum transfusion strategy. The use of VHA to quantify the functional contributions of individual components of the coagulation system may permit targeted treatment of TIC but remains controversial and is unlikely to demonstrate a mortality benefit in light of the heterogeneity of the trauma population. Thus, VHA-guided algorithms as an alternative to fixed product ratios in trauma are not universally accepted, and a hybrid strategy starting with fixed-ratio transfusion and incorporating VHA data as they become available is favored by some institutions. We review the current evidence for the management of coagulopathy in trauma, the rationale behind the use of targeted and fixed-ratio approaches and explore future directions.
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Affiliation(s)
- James Winearls
- From the *Intensive Care Unit, Gold Coast University Hospital, Southport, Queensland, Australia; †Gold Coast University Hospital Critical Care Research Group, Queensland, Australia; ‡Joint Health Command, Australian Defence Force and Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Queensland, Australia; §Heart Foundation Research Centre, School of Medicine, Griffith University, Gold Coast, Queensland, Australia; ∥Trauma Department, Gold Coast University Hospital, Queensland, Australia; ¶Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany; #Tem International GmbH, Munich, Germany; and **Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
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Risk Factors and Clinical Outcomes Associated with Perioperative Transfusion-associated Circulatory Overload. Anesthesiology 2017; 126:409-418. [PMID: 28072601 DOI: 10.1097/aln.0000000000001506] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Transfusion-associated circulatory overload remains underappreciated in the perioperative environment. The authors aimed to characterize risk factors for perioperative transfusion-associated circulatory overload and better understand its impact on patient-important outcomes. METHODS In this case-control study, 163 adults undergoing noncardiac surgery who developed perioperative transfusion-associated circulatory overload were matched with 726 transfused controls who did not develop respiratory complications. Univariate and multivariable logistic regression analyses were used to evaluate potential risk factors for transfusion-associated circulatory overload. The need for postoperative mechanical ventilation, lengths of intensive care unit and hospital stay, and mortality were compared. RESULTS For this cohort, the mean age was 71 yr and 56% were men. Multivariable analysis revealed the following independent predictors of transfusion-associated circulatory overload: emergency surgery, chronic kidney disease, left ventricular dysfunction, previous β-adrenergic receptor antagonist use, isolated fresh frozen plasma transfusion (vs. isolated erythrocyte transfusion), mixed product transfusion (vs. isolated erythrocyte transfusion), and increasing intraoperative fluid administration. Patients who developed transfusion-associated circulatory overload were more likely to require postoperative mechanical ventilation (73 vs. 33%; P < 0.001) and experienced prolonged intensive care unit (11.1 vs. 6.5 days; P < 0.001) and hospital lengths of stay (19.9 vs. 9.6 days; P < 0.001). Survival was significantly reduced (P < 0.001) in transfusion recipients who developed transfusion-associated circulatory overload (1-yr survival 72 vs. 84%). CONCLUSIONS Perioperative transfusion-associated circulatory overload was associated with a protracted hospital course and increased mortality. Efforts to minimize the incidence of transfusion-associated circulatory overload should focus on the judicious use of intraoperative blood transfusions and nonsanguineous fluid therapies, particularly in patients with chronic kidney disease, left ventricular dysfunction, chronic β-blocker therapy, and those requiring emergency surgery.
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Rahmani F, Aghamohammadi A, Ochs HD, Rezaei N. Agammaglobulinemia: comorbidities and long-term therapeutic risks. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1330145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Farzaneh Rahmani
- Research Center for Immunodeficiencies, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Primary Immunodeficiency Diseases Network (PIDNet), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Hans D. Ochs
- Department of Pediatrics, University of Washington and Seattle Children’s Research Institute, Seattle, WA, USA
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Seattle, WA, USA
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Sheffield, UK
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Roubinian NH, Looney MR, Keating S, Kor DJ, Lowell CA, Gajic O, Hubmayr R, Gropper M, Koenigsberg M, Wilson GA, A Matthay M, Toy P, Murphy EL. Differentiating pulmonary transfusion reactions using recipient and transfusion factors. Transfusion 2017; 57:1684-1690. [PMID: 28470756 DOI: 10.1111/trf.14118] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 02/07/2017] [Accepted: 02/12/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND It is increasingly recognized that recipient risk factors play a prominent role in possible transfusion-related acute lung injury (pTRALI) and transfusion-associated circulatory overload (TACO). We hypothesized that both transfusion and recipient factors including natriuretic peptides could be used to distinguish TRALI from TACO and pTRALI. STUDY DESIGN AND METHODS We performed a post hoc analysis of a case-control study of pulmonary transfusion reactions conducted at the University of California at San Francisco and Mayo Clinic, Rochester. We evaluated clinical data and brain natriuretic peptides (BNP) levels drawn after transfusion in patients with TRALI (n = 21), pTRALI (n = 26), TACO (n = 22), and controls (n = 24). Logistic regression and receiver operating characteristics curve analyses were used to determine the accuracy of clinical and biomarker predictors in differentiating TRALI from TACO and pTRALI. RESULTS We found that pTRALI and TACO were associated with older age, higher fluid balance, and elevated BNP levels relative to those of controls and TRALI. The following variables were useful in distinguishing cases of pTRALI and TACO from TRALI: age more than 70 years, BNP levels more than 1000 pg/mL, 24-hour fluid balance of more than 3 L, and a lower number of transfused blood components. Using the above variables, our logistic model had a 91% negative predictive value in the differential diagnosis of TRALI. CONCLUSIONS Models incorporating readily available clinical and biomarker data can be used to differentiate transfusion-related respiratory complications. Additional studies examining recipient risk factors and the likelihood of TRALI may be useful in decision making regarding donor white blood cell antibody testing.
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Affiliation(s)
- Nareg H Roubinian
- Blood Systems Research Institute.,University of California at San Francisco, San Francisco, California
| | - Mark R Looney
- University of California at San Francisco, San Francisco, California
| | | | | | | | | | | | - Michael Gropper
- University of California at San Francisco, San Francisco, California
| | | | | | - Michael A Matthay
- University of California at San Francisco, San Francisco, California
| | - Pearl Toy
- University of California at San Francisco, San Francisco, California
| | - Edward L Murphy
- Blood Systems Research Institute.,University of California at San Francisco, San Francisco, California
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Jia R, Li N, Xu BY, Zhang W, Gu XP, Ma ZL. Incidence, influencing factors, and prognostic impact of intraoperative massive blood loss in adolescents with neuromuscular scoliosis: A STROBE-compliant retrospective observational analysis. Medicine (Baltimore) 2017; 96:e6292. [PMID: 28296737 PMCID: PMC5369892 DOI: 10.1097/md.0000000000006292] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Factors influencing massive blood loss for neuromuscular scoliosis (NMS) patients.Despite advances in surgical and anesthetic techniques, scoliosis surgery is still associated with intraoperative massive blood loss, which can result in postoperative mortality and morbidity. The aim of this study was to assess the incidence, influencing factors, and prognostic impact of intraoperative massive blood loss in adolescents with NMS.A retrospective review of adolescents who underwent posterior spinal instrumentation and fusion for NMS was performed. Perioperative variables and data were recorded. Massive blood loss was defined as an estimated blood loss that exceeds 30% of total blood volume.We obtained data for 114 patients, of whom 63 (55%) had intraoperative massive blood loss. Compared with those without, patients with massive blood loss were more likely to be older, have lower body mass indexes (BMIs), larger Cobb angles, more fused levels, more osteotomy procedures, and prolonged duration of operation. Logistic regression analysis identified the number of fused levels to be more than 12 (P = 0.003, odds ratio = 6.614, 95% confidence interval [CI]: 1.891-23.131), BMI lower than 16.8 kg/m (P = 0.025, odds ratio = 3.293, 95% CI: 1.159-9.357), age greater than 15 years (P = 0.014, odds ratio = 3.505, 95% CI: 1.259-9.761), and duration of operation longer than 4.4 hours (P = 0.016, odds ratio = 3.746, 95% CI: 1.428-9.822) as influencing factors. Patients with massive blood loss are associated with more intraoperative colloids infusion and blood transfusions (red blood cell and fresh frozen plasma), as well as postoperative drainage volume.In adolescents with NMS who underwent posterior spinal instrumentation and fusion operations, intraoperative massive blood loss is common. The number of fused levels, BMI, age, and duration of operation are factors influencing intraoperative massive blood loss.
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Affiliation(s)
- Rui Jia
- Department of Anesthesiology
| | - Na Li
- Department of Anesthesiology
| | - Bi-Yun Xu
- Department of Statistics, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
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