Red blood cell transfusion in the treatment and management of anaemia: the search for the elusive transfusion trigger

Comparison of liberal versus restrictive transfusion strategies after hip surgery in patients with coronary artery disease: a post hoc analysis of the FOCUS trial

BACKGROUND

There are no clear recommendations for optimal transfusion thresholds for patients with coronary artery disease who undergo noncardiac surgery. By comparing restrictive and liberal transfusion strategies for coronary artery disease combined with hip surgery, this study hopes to provide recommendations for transfusion strategies in this special population.

METHODS

A total of 805 patients from the FOCUS trial (Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair) with coronary artery disease combined with hip surgery were divided into two groups based on transfusion thresholds: restricted transfusion (a hemoglobin level of 8 g/deciliter) and liberal transfusion (a hemoglobin threshold of 10 g/deciliter). The primary outcome of this study was a composite endpoint including in-hospital death, myocardial infarction, unstable angina, and acute heart failure. The secondary endpoints included other in-hospital adverse events and 30- and 60-day follow-up events. Analyses were performed by intention to treat.

RESULTS

Except for the proportion of congestive heart failure patients, the baseline levels of the two groups were comparable. The median number of transfusion units in the liberal transfusion group was 2 units, and the median transfusion volume in the restricted transfusion group was 0 units. The primary outcome was not significantly different between the two groups (9.2% vs. 9.4%, p = 0.91). The incidence of in-hospital myocardial infarction events was lower in the liberal transfusion group than in the restricted transfusion group (3.2% vs. 6.2%) (OR = 0.51, P = 0.048). The remaining in-hospital endpoint events, except for myocardial infarction, were not significantly different between the two groups. The 30-day and 60-day endpoints of death and inability to walk independently were not significantly different between the two groups, with ORs (95% CI) of 1.00 (0.75-1.31) and 1.06 (0.80-1.41), respectively. We also found no interaction between transfusion strategies and factors such as age, sex, or multiple underlying comorbidities at the 60-day follow-up.

CONCLUSIONS

There was no significant difference in the in-hospital, 30-day or 60-day outcome endpoints between the two groups. However, this study demonstrated that a liberal transfusion strategy tends to reduce the incidence of in-hospital myocardial infarction events in patients with coronary artery disease combined with hip surgery compared to a restrictive transfusion strategy. More high-quality studies should be designed to investigate the optimal transfusion threshold in patients with coronary artery disease treated without cardiac surgery.

[Role of red blood cell (RBC) transfusions in patients with prolonged mechanical ventilation during weaning process]

AIM

Patients undergoing long-term ventilation often show anemia. The aim of the study was to investigate the duration and success of weaning from mechanical ventilation in patients with RBC transfusion.

METHODS

A retrospective analysis of patient data from a weaning unit was performed. Transfused and non-transfused patients were matched using a propensity score. Of the 249 patients in the database, 31 transfused and the same number of non-transfused cases with similar disease severity as measured by the Simplified Acute Physiology Score (SAPS) could be analyzed. Additional sensitivity analyses were performed.

RESULTS

In the group of transfused patients, the difference in weaning duration was longer than in non-transfused patients (1.35 days and 3.26 days, respectively). Weaning success also varied. The risk of weaning failure was twice as high in the group of transfused patients. The groups also differed in terms of mortality, 25.8% of the transfused patients died, while in the non-transfused patients the mortality rate was 6.5%. The risk of death was increased in patients who received RBC transfusion. The differences were not statistically significant.

CONCLUSION

A high proportion of patients with prolonged mechanical ventilation have anemia. RBC transfusion does not improve their prognosis. The need for transfusion is associated with higher mortality and longer duration of weaning in this population. The indication for RBC transfusion should therefore be restrictive.

Near-Infrared Spectroscopy to Guide and Understand Effects of Red Blood Cell Transfusion

This review is a summary of available evidence regarding the use of near-infrared spectroscopy (NIRS) to help better guide and understand the effects of red blood cell (RBC) transfusion in neonatal patients. We review recent literature demonstrating the changes that take place in regional tissue oxygen saturation (rSO2) resulting from RBC transfusion. We also discuss in detail if any correlation exists between rSO2 and hemoglobin values in neonates. Finally, we review studies that have evaluated the use of NIRS as a transfusion guide during neonatal intensive care.

Longitudinal hemoglobin trajectories and acute kidney injury in patients undergoing cardiac surgery: a retrospective cohort study

Object

The purpose of this study was to describe the longitudinal dynamic hemoglobin trajectories in patients undergoing cardiac surgery and to explore whether they provide a broader perspective in predicting AKI compared to traditional threshold values. Additionally, the interaction of red blood cell transfusion was also investigated.

Methods

The MIMIC-IV database was searched to identify patients undergoing cardiac surgery with cardiopulmonary bypass. Group-based trajectory modeling (GBTM) was used to determine the hemoglobin trajectories in the first 72 h after ICU admission. The correlation between hemoglobin trajectories and AKI was evaluated using multivariable logistic regression and inverse probability of treatment weighting. Receiver operating characteristic (ROC) curves were created in the dataset to further validate previously reported thresholds.

Results

A total of 4,478 eligible patients were included in this study. Three hemoglobin trajectories were identified by GBTM, which were significantly different in the initial hemoglobin level and evolution pattern. Compared to the "the lowest, rising, and then declining" trajectory, patients in the "the highest, declining" and "medium, declining" trajectory groups had significantly lower AKI risk (OR 0.56; 95% CI 0.48, 0.67) and (OR 0.70; 95% CI 0.55, 0.90), respectively. ROC analysis yielded a disappointing result, with an AUC of 0.552, sensitivity of 0.25, and specificity of 0.86 when the hemoglobin threshold was set at 8 g/dl in the entire cohort. In the subgroup analysis of red blood cell transfusion, hemoglobin levels above 10 g/dl predicted higher AKI risk, and there was no correlation between hemoglobin trajectories and AKI in the non-red blood cell transfusion subgroup.

Conclusion

This study identified a hemoglobin trajectory that is associated with an increased risk of AKI after cardiac surgery. It is noteworthy that fixed hemoglobin thresholds should not be applied to all patient types. In patients receiving red blood cell transfusion, maintaining hemoglobin levels above 10 g/dl through transfusion was associated with an increased risk of AKI.

Transfusion trigger after operations in high cardiac risk patients (TOP) trial protocol. Protocol for a multicenter randomized controlled transfusion strategy trial

BACKGROUND

There is substantial uncertainty regarding the effects of restrictive postoperative transfusion among patients who have underlying cardiovascular disease. The TOP Trial's objective is to compare adverse outcomes between liberal and restrictive transfusion strategies in patients undergoing vascular and general surgery operations, and with a high risk of postoperative cardiac events.

METHODS

A two-arm, single-blinded, randomized controlled superiority trial will be used across 15 Veterans Affairs hospitals with expected enrollment of 1520 participants. Postoperative transfusions in the liberal arm commence when Hb is <10 g/ dL and continue until Hb is greater than or equal to 10 g/dL. In the restrictive arm, transfusions begin when Hb is <7 g/dL and continue until Hb is greater than or equal to 7 g/dL. Study duration is estimated to be 5 years including a 3-month start-up period and 4 years of recruitment. Each randomized participant will be followed for 90 days after randomization with a mortality assessment at 1 year.

RESULTS

The primary outcome is a composite endpoint of all-cause mortality, myocardial infarction (MI), coronary revascularization, acute renal failure, or stroke occurring up to 90-days after randomization. Events rates will be compared between restrictive and liberal transfusion groups.

CONCLUSIONS

The TOP Trial is uniquely positioned to provide high quality evidence comparing transfusion strategies among patients with high cardiac risk. Results will clarify the effect of postoperative transfusion strategies on adverse outcomes and inform postoperative management algorithms.

TRIAL REGISTRATION

http://clinicaltrials.gov identifier: NCT03229941.

When Guideline-Concordant Standardized Care Results in Healthcare Disparities

AbstractClinical red blood cell transfusion guidelines have been widely adopted in clinical practice, resulting in standardized transfusion practices in hospitalized patients with anemia. Standardization of transfusion practice has been welcomed by clinicians and health systems as a mechanism for reducing unnecessary, harmful, and costly practice variation that results in healthcare disparities. However, overzealously applied guidelines can have deleterious consequences for individual patients, ultimately resulting in and/or exacerbating healthcare disparities, rather than resolving them. This article provides empirical examples of the adverse consequences from the well-meaning attempt to standardize transfusion practice based on clinical practice guidelines and discusses the ethical implications of standardized transfusion practice.

Haemoglobin value and red blood cell transfusions in prolonged weaning from mechanical ventilation: a retrospective observational study

INTRODUCTION

The role of haemoglobin (Hb) value and red blood cell (RBC) transfusions in prolonged weaning from mechanical ventilation (MV) is still controversial. Pathophysiological considerations recommend a not too restrictive transfusion strategy, whereas adverse effects of transfusions are reported. We aimed to investigate the association between Hb value, RBC transfusion and clinical outcome of patients undergoing prolonged weaning from MV.

METHODS

We performed a retrospective, single-centred, observational study including patients being transferred to a specialised weaning unit. Data on demographic characteristics, comorbidities, current and past medical history and the current course of treatment were collected. Weaning failure and mortality were chosen as primary and secondary endpoint, respectively. Differences between transfused and non-transfused patients were analysed. To evaluate the impact of different risk factors including Hb value and RBC transfusion on clinical outcome, a multivariate logistic regression analysis was used.

RESULTS

184 patients from a specialised weaning unit were analysed, of whom 36 (19.6%) failed to be weaned successfully. In-hospital mortality was 18.5%. 90 patients (48.9%) required RBC transfusion during the weaning process, showing a significantly lower Hb value (g/L) (86.3±5.3) than the non-transfusion group (95.8±10.5). In the multivariate regression analysis (OR 3.24; p=0.045), RBC transfusion was associated with weaning failure. However, the transfusion group had characteristics indicating that these patients were still in a more critical state of disease.

CONCLUSIONS

In our analysis, the need for RBC transfusion was independently associated with weaning failure. However, it is unclear whether the transfusion itself should be considered an independent risk factor or an additional symptom of a persistent critical patient condition.

Characteristics of thromboprophylaxis in elderly patients before and after orthopedic hip and knee surgery

Elderly patients with a hip fracture are at significantly higher risk for developing venous thromboembolism (VTE). The incidence of fatal pulmonary embolism (PE) occurs in 2-3% of patients after elective hip and knee surgery and about 6-7% after hip fracture surgery, with a higher risk in men (10,2%) than in women (4,7%). The use of pharmacological prophylaxis significantly reduces the incidence of symptomatic VTE. Pharmacological prophylaxis includes the use of antiplatelet drugs (aspirin), unfractionated heparin (UFH), low molecular weight heparins (LMWH), vitamin K antagonists (VKA), Fondaparinux and direct oral anticoagulants (DOAC). The use of low molecular weight heparins (LMWH) - enoxaparin, represents the gold standard of thromboprophylaxis in orthopedic surgery, and for now, they are the only drugs that are recommended for thromboprophylaxis in hip fracture surgery. Rivaroxaban is used in the prophylaxis of VTE in elective hip and knee surgeries at a fixed dose of 10 mg once daily, and apixaban at a dose of 2,5 mg twice daily in knee arthroplasty for at least 14 days, and after hip arthroplasty for at least 35 days. Early hip fracture surgery as soon as possible, preferably within 24 hours, and no later than 48 hours after admission to the hospital, significantly reduces the morbidity and mortality of elderly patients.

Transfusion thresholds for guiding red blood cell transfusion

BACKGROUND

The optimal haemoglobin threshold for use of red blood cell (RBC) transfusions in anaemic patients remains an active field of research. Blood is a scarce resource, and in some countries, transfusions are less safe than in others because of inadequate testing for viral pathogens. If a liberal transfusion policy does not improve clinical outcomes, or if it is equivalent, then adopting a more restrictive approach could be recognised as the standard of care.  OBJECTIVES: The aim of this review update was to compare 30-day mortality and other clinical outcomes for participants randomised to restrictive versus liberal red blood cell (RBC) transfusion thresholds (triggers) for all clinical conditions. The restrictive transfusion threshold uses a lower haemoglobin concentration as a threshold for transfusion (most commonly, 7.0 g/dL to 8.0 g/dL), and the liberal transfusion threshold uses a higher haemoglobin concentration as a threshold for transfusion (most commonly, 9.0 g/dL to 10.0 g/dL).

SEARCH METHODS

We identified trials through updated searches: CENTRAL (2020, Issue 11), MEDLINE (1946 to November 2020), Embase (1974 to November 2020), Transfusion Evidence Library (1950 to November 2020), Web of Science Conference Proceedings Citation Index (1990 to November 2020), and trial registries (November 2020). We  checked the reference lists of other published reviews and relevant papers to identify additional trials. We were aware of one trial identified in earlier searching that was in the process of being published (in February 2021), and we were able to include it before this review was finalised.

SELECTION CRITERIA

We included randomised trials of surgical or medical participants that recruited adults or children, or both. We excluded studies that focused on neonates. Eligible trials assigned intervention groups on the basis of different transfusion schedules or thresholds or 'triggers'. These thresholds would be defined by a haemoglobin (Hb) or haematocrit (Hct) concentration below which an RBC transfusion would be administered; the haemoglobin concentration remains the most commonly applied marker of the need for RBC transfusion in clinical practice. We included trials in which investigators had allocated participants to higher thresholds or more liberal transfusion strategies compared to more restrictive ones, which might include no transfusion. As in previous versions of this review, we did not exclude unregistered trials published after 2010 (as per the policy of the Cochrane Injuries Group, 2015), however, we did conduct analyses to consider the differential impact of results of trials for which prospective registration could not be confirmed.   DATA COLLECTION AND ANALYSIS: We identified trials for inclusion and extracted data using Cochrane methods. We pooled risk ratios of clinical outcomes across trials using a random-effects model. Two review authors independently extracted data and assessed risk of bias. We conducted predefined analyses by clinical subgroups. We defined participants randomly allocated to the lower transfusion threshold as being in the 'restrictive transfusion' group and those randomly allocated to the higher transfusion threshold as being in the 'liberal transfusion' group.

MAIN RESULTS

A total of 48 trials, involving data from 21,433 participants (at baseline), across a range of clinical contexts (e.g. orthopaedic, cardiac, or vascular surgery; critical care; acute blood loss (including gastrointestinal bleeding); acute coronary syndrome; cancer; leukaemia; haematological malignancies), met the eligibility criteria. The haemoglobin concentration used to define the restrictive transfusion group in most trials (36) was between 7.0 g/dL and 8.0 g/dL.  Most trials included only adults; three trials focused on children. The included studies were generally at low risk of bias for key domains including allocation concealment and incomplete outcome data. Restrictive transfusion strategies reduced the risk of receiving at least one RBC transfusion by 41% across a broad range of clinical contexts (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.53 to 0.66; 42 studies, 20,057 participants; high-quality evidence), with a large amount of heterogeneity between trials (I² = 96%). Overall, restrictive transfusion strategies did not increase or decrease the risk of 30-day mortality compared with liberal transfusion strategies (RR 0.99, 95% CI 0.86 to 1.15; 31 studies, 16,729 participants; I² = 30%; moderate-quality evidence) or any of the other outcomes assessed (i.e. cardiac events (low-quality evidence), myocardial infarction, stroke, thromboembolism (all high-quality evidence)). High-quality evidence shows that the liberal transfusion threshold did not affect the risk of infection (pneumonia, wound infection, or bacteraemia). Transfusion-specific reactions are uncommon and were inconsistently reported within trials. We noted less certainty in the strength of evidence to support the safety of restrictive transfusion thresholds for the following predefined clinical subgroups: myocardial infarction, vascular surgery, haematological malignancies, and chronic bone-marrow disorders.

AUTHORS' CONCLUSIONS

Transfusion at a restrictive haemoglobin concentration decreased the proportion of people exposed to RBC transfusion by 41% across a broad range of clinical contexts. Across all trials, no evidence suggests that a restrictive transfusion strategy impacted 30-day mortality, mortality at other time points, or morbidity (i.e. cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism, infection) compared with a liberal transfusion strategy. Despite including 17 more randomised trials (and 8846 participants), data remain insufficient to inform the safety of transfusion policies in important and selected clinical contexts, such as myocardial infarction, chronic cardiovascular disease, neurological injury or traumatic brain injury, stroke, thrombocytopenia, and cancer or haematological malignancies, including chronic bone marrow failure.  Further work is needed to improve our understanding of outcomes other than mortality. Most trials compared only two separate thresholds for haemoglobin concentration, which may not identify the actual optimal threshold for transfusion in a particular patient. Haemoglobin concentration may not be the most informative marker of the need for transfusion in individual patients with different degrees of physiological adaptation to anaemia. Notwithstanding these issues, overall findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds between the range of 7.0 g/dL and 8.0 g/dL. Some patient subgroups might benefit from RBCs to maintain higher haemoglobin concentrations; research efforts should focus on these clinical contexts.

Adherence to blood product transfusion guidelines-An observational study of the current transfusion practice in a medical intensive care unit

BACKGROUND

Blood transfusions though life-saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the 'Choosing Wisely campaign'. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost.

OBJECTIVES

In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre-transfusion haemoglobin (Hb) ≥7 g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions.

METHODS

We conducted a retrospective observational study in a 64-bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N = 957) requiring packed red blood cell transfusion between January 2015 and December 2015.

RESULTS

In total, 3140 units were transfused with a mean pre-transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty-four (30%) transfusion events occurred with a pre-transfusion Hb ≥7 g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre-transfusion Hb ≥7 g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.88; p = 0.02) and LOS in patients with chronic blood loss (β₁ .8.26, 95% CI 4.09-12.43; p < 0.01).

CONCLUSION

A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.

Association of Perioperative Red Blood Cell Transfusion With Symptomatic Venous Thromboembolism Following Total Hip and Knee Arthroplasty

BACKGROUND

Prior registry data suggest that perioperative red blood cell (RBC) transfusion may increase the incidence of venous thromboembolism (VTE) in patients status post surgery. However, there are limited data that explore VTE risk after perioperative transfusion in the setting of primary total joint arthroplasty (TJA). Our aim is to investigate the association between perioperative RBC transfusion and the development of symptomatic VTE after adjusting for confounding variables.

METHODS

We retrospectively reviewed all patients undergoing primary TJA at a single institution from 2001 to 2016. The primary outcome was development of symptomatic VTE (deep vein thrombosis or pulmonary embolism) up to 90 days following primary TJA. To identify the association between RBC transfusion and development of VTE, univariate and multivariate analyses were used, as well as a sensitivity analysis using propensity score matching based on patient comorbidities.

RESULTS

Of the 29,003 patients who underwent TJA, 2500 (8.62%) received RBC transfusion perioperatively and 302 (1.04%) developed a postoperative VTE within 90 days of surgery. While univariate analysis did suggest a slightly increased incidence of VTE in association with RBC transfusion (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.09-2.16), this difference was eliminated when multivariate analysis (OR, 0.42; 95% CI, 0.12-1.39) and propensity score matching (propensity-matched OR, 1.2; 95% CI, 0.7-1.8) were employed.

CONCLUSION

Perioperative RBC transfusion does not significantly increase the incidence of symptomatic VTE following primary TJA in the 90-day postoperative period after adjustment for host VTE risk scores and other confounding variables. Perioperative RBC transfusion may be safely administered if indicated following total hip and knee arthroplasty.

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.

Factors for Blood Transfusions Following Hemi Hip Arthroplasty for Patients With Femoral Neck Fracture

Background:

Hemi hip arthroplasty is one treatment option for femoral neck fractures; however, there has been limited evidence on factors associated with blood transfusions following hemi hip arthroplasty. Hence, the aim of this study was to identify the predictors of blood transfusion after hemi hip arthroplasty, which could lead to the establishment of proper guidelines for management protocols.

Materials and Methods:

This study was a retrospective cohort study, conducted in a single center of 323 femoral neck fracture patients having undergone hemi hip arthroplasty. Peri-operative factors and demographic data were extracted from the electronic medical records, from 2007 to 2019. A predictive model was developed by logistic regression (LR), and adjusted by multivariate logistic regression.

Result:

One hundred and twenty-six (39%) patients received blood transfusions. On multivariate analysis, those of a female gender (odds ratio (OR) 2.00, p = 0.037), having a body mass index lower than 18.5 kg/m² (OR 2.40, p = 0.028), lower preoperative hemoglobin levels (OR 0.52, p < 0.001) and given general anesthesia (OR 2.07, p = 0.028) were shown to be significantly associated with a higher risk of requiring a blood transfusion.

Conclusion:

The authors recommend that preparation of blood components coupled with the utilization of blood conserving methods for high risk patients, as studies have stated, in addition to the consideration of spinal anesthesia; if patients have no contraindication, should be implemented.

Effectiveness of Multi-Modal Blood Management in Bernese Periacetabular Osteotomy and Periacetabular Osteotomy with Proximal Femoral Osteotomy

Objective

Bernese periacetabular osteotomy (PAO), an effective treatment for patients with developmental dysplasia of the hip (DDH), is characterized by wide exposure, cancellous bone surgery, and difficult techniques. In addition, the hip joint is deep and of rich muscles and neurovascular supply, which significantly increases bleeding. For patients who had combined proximal femoral osteotomy (PFO), the blood loss may be tremendous. The blood management for PAO is still challenging. We aimed to evaluate the effectiveness of multi‐modal blood management for PAO and PAO combined with PFO.

Patients and Methods

We retrospectively evaluated patients who had PAO with or without combined procedures from June 2010 to December 2018 in our department. The multi‐modal blood management protocol included three parts: (i) pre‐operation – autologous component blood donation and iron supplement/erythropoietin; (ii) during operation – controlled hypotension anesthesia, intraoperative auto‐blood transfusion, tranexamic acid (20 mg/kg, IV / 0.5 g local), and standardized surgical procedure to shorten surgical time; and (iii) post‐operation – no drainage used, selective allo‐blood transfusion, and ice packing technique. As the lacking of the above standard blood management protocol during PAO or PAO + PFO initially, we divided all the patients into three groups: Group A (PAO) – before protocol started, 74 hips; Group B (PAO) – after protocol finalized, 178 hips; Group C (PAO + PFO) – after protocol finalized, 55 hips. The intraoperative blood loss, surgical time, allo‐transfusion rate, pre‐ and postoperative hemoglobin were compared among groups.

Results

Both the general characteristics and preoperative hemoglobin were comparable among the three groups (P < 0.001). The intraoperative blood loss was 797.1 ± 312.2, 381.7 ± 144.0 and 544.1 ± 249.1 mL, respectively. The surgical time was 109.6 ± 18.5, 80.2 ± 20.0 and 154.3 ± 44.7 min, respectively. The allo‐transfusion rate was 86.5%, 0%, and 2%, respectively. The mean decreased value of hemoglobin on the first postoperative day of group B and group C was greater than that of group A, which was associated with the higher allo‐transfusion rate of group A. However, on the third postoperative day, the mean decreased value of hemoglobin of group B was less than that of group A and group C.

Conclusion

Perioperative multi‐modal blood management for PAO or PAO + PFO can significantly decrease intraoperative blood loss, reduce allo‐transfusion rate from over 80% to 0%, and ensure the rapid recovery of postoperative hemoglobin level.

Clinical impact of red blood cell transfusion on adverse clinical events in acute heart failure patients with anemia

BACKGROUND

Anemia has been recognized as an important comorbidity in patients with acute heart failure (AHF) and is associated with adverse clinical events. However, the clinical impact of red blood cell (RBC) transfusion in such patients is unclear.

METHOD

This study was a retrospective single-center registry including AHF patients admitted to Kyorin University Hospital between 2007 and 2014. Anemia was defined as a hemoglobin level < 130 g/L in males or < 120 g/L in females. Those with major bleeding with a fall in hemoglobin concentration of >20 g/L were excluded. AHF readmission at 3 months and in-hospital and 2-year all-cause mortality were evaluated.

RESULTS

Of 501 AHF patients, 38 were excluded owing to major bleeding; finally, 463 (age, 77 ± 11 years; males, 58%) were evaluated. RBC transfusion during hospitalization was performed in 112 patients (24%). Hemoglobin level on admission was 105 ± 16 g/L (transfusion, 89 ± 17 g/L; no transfusion, 110 ± 12 g/L; p < 0.001). AHF readmission at 3 months and in-hospital and 2-year all-cause mortality were observed in 46 (10%), 16 (3%), and 121 (26%) patients, respectively. Univariate Cox regression analysis demonstrated that RBC transfusion was not associated with AHF readmission at 3 months (hazard ratio: 0.80; 95% confidence interval: 0.39-1.66) The association did not differ at any hemoglobin concentration or left ventricular ejection fraction value. Multivariate Cox regression analysis revealed similar results. Furthermore, RBC transfusion was not correlated with in-hospital and 2-year all-cause mortality.

CONCLUSIONS

RBC transfusion was not associated with AHF readmission or all-cause mortality.

Prescriptive analytics for reducing 30-day hospital readmissions after general surgery

INTRODUCTION

New financial incentives, such as reduced Medicare reimbursements, have led hospitals to closely monitor their readmission rates and initiate efforts aimed at reducing them. In this context, many surgical departments participate in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), which collects detailed demographic, laboratory, clinical, procedure and perioperative occurrence data. The availability of such data enables the development of data science methods which predict readmissions and, as done in this paper, offer specific recommendations aimed at preventing readmissions.

MATERIALS AND METHODS

This study leverages NSQIP data for 722,101 surgeries to develop predictive and prescriptive models, predicting readmissions and offering real-time, personalized treatment recommendations for surgical patients during their hospital stay, aimed at reducing the risk of a 30-day readmission. We applied a variety of classification methods to predict 30-day readmissions and developed two prescriptive methods to recommend pre-operative blood transfusions to increase the patient's hematocrit with the objective of preventing readmissions. The effect of these interventions was evaluated using several predictive models.

RESULTS

Predictions of 30-day readmissions based on the entire collection of NSQIP variables achieve an out-of-sample accuracy of 87% (Area Under the Curve-AUC). Predictions based only on pre-operative variables have an accuracy of 74% AUC, out-of-sample. Personalized interventions, in the form of pre-operative blood transfusions identified by the prescriptive methods, reduce readmissions by 12%, on average, for patients considered as candidates for pre-operative transfusion (pre-operative hematoctic <30). The prediction accuracy of the proposed models exceeds results in the literature.

CONCLUSIONS

This study is among the first to develop a methodology for making specific, data-driven, personalized treatment recommendations to reduce the 30-day readmission rate. The reported predicted reduction in readmissions can lead to more than $20 million in savings in the U.S. annually.

Effect of postoperative haemoglobin variation on major cardiopulmonary complications in high cardiac risk patients undergoing anatomical lung resections

OBJECTIVES

Recent evidence shows that permissive anaemia strategies are safe in different surgical settings. However, effects of variations in haemoglobin (Hb) levels could have a negative impact in high-risk patients. We investigated the combined effect of postoperative Hb concentration and cardiac risk status on major cardiopulmonary complications after anatomical lung resections.

METHODS

We retrospectively analysed the records, collected in a prospective clinical database, of 154 consecutive patients undergoing anatomical lung resections at our institution (February 2017-February 2019). Hb levels were displayed as preoperative concentration, nadir Hb level before onset of complications and delta Hb (ΔHb). Cardiac risk was stratified according to the Thoracic Revised Cardiac Risk Index (ThRCRI). Univariable and multivariable logistic regression analyses were used to test the associations between patients, surgical variables and cardiopulmonary complications according to the European Society of Thoracic Surgeons definitions.

RESULTS

Cardiopulmonary complications occurred in 63 patients (17%). In the fully adjusted multivariable model, higher values of ΔHb were associated with increased risk of complications [odds ratio (OR) 1.07; P < 0.001], along with higher ThRCRI classes (classes A-B versus C-D: OR 0.09; P < 0.001). Interaction terms with transfusion were not statistically significant, indicating that the harmful effect of ΔHb was independent. According to receiver operating characteristic curve analysis, a ΔHb of 29 g/l was found to be the best cut-off value for predicting complications.

CONCLUSIONS

In our series, ΔHb, rather than nadir Hb, was associated with an increased risk of complications, particularly in patients with higher cardiac risk. Restrictive transfusion strategies should be carefully applied in patients undergoing lung resections and balanced according to individual clinical status.

Review of current transfusion therapy and blood banking practices

Transfusion Medicine is a dynamically evolving field. Recent high-quality research has reshaped the paradigms guiding blood transfusion. As increasing evidence supports the benefit of limiting transfusion, guidelines have been developed and disseminated into clinical practice governing optimal transfusion of red cells, platelets, plasma and cryoprecipitate. Concepts ranging from transfusion thresholds to prophylactic use to maximal storage time are addressed in guidelines. Patient blood management programs have developed to implement principles of patient safety through limiting transfusion in clinical practice. Data from National Hemovigilance Surveys showing dramatic declines in blood utilization over the past decade demonstrate the practical uptake of current principles guiding patient safety. In parallel with decreasing use of traditional blood products, the development of new technologies for blood transfusion such as freeze drying and cold storage has accelerated. Approaches to policy decision making to augment blood safety have also changed. Drivers of these changes include a deeper understanding of emerging threats and adverse events based on hemovigilance, and an increasing healthcare system expectation to align blood safety decision making with approaches used in other healthcare disciplines.

To transfuse or not transfuse: an intensive appraisal of red blood cell transfusions in the ICU

PURPOSE OF REVIEW

This review is a critical appraisal of the current data comparing restrictive vs. liberal transfusion strategies for patients who are critically ill in ICUs. We focus on four subsets of critically ill patients: pediatric patients, patients with gastrointestinal bleeds, septic patients and patients undergoing cardiac surgery.

RECENT FINDINGS

Almost a decade after the TRICC trial, a randomized trial showing the safety of a restrictive transfusion threshold in critically ill patients, four large randomized controlled trials have shown that a restrictive transfusion strategy is safe in pediatric critically ill patients, patients with acute upper gastrointestinal bleeds, patients with septic shock and patients undergoing cardiac surgery. A large multicenter randomized trial is underway to determine the safety of a restrictive strategy in myocardial infarction.

SUMMARY

A restrictive transfusion threshold is recommended in nearly all critically ill patients. This is at least noninferior to more liberal transfusion practice; in addition, a restrictive threshold has shown improved outcomes in some patients and decreased chances of adverse events in patients. Judicious use of red cells improves patient outcome and protects the blood supply, a limited resource. More data are needed to determine appropriate transfusion threshold recommendations for patients with traumatic brain injury and acute coronary syndrome.

Preoperative Iron Supplementation and Restrictive Transfusion Strategy in Hip Fracture Surgery

Background

Hip fracture surgery (HFS) is often associated with perioperative blood loss, and it frequently necessitates transfusion. However, the hemoglobin (Hb) threshold for transfusion remains controversial in hip fracture patients. We evaluated the usefulness of the restrictive strategy and preoperative intravenous iron supplementation in HFS.

Methods

We retrospectively reviewed the medical records of 1,634 patients (> 60 years of age) who underwent HFS between May 2003 and June 2014 and were followed up for 1 year or more after surgery. We used the liberal transfusion strategy until May 2009 to determine the transfusion threshold; afterwards, we switched to the restrictive transfusion strategy. Patients with the restrictive transfusion strategy (restrictive group) received intravenous iron supplementation before surgery. We compared the transfusion rate, morbidity, and mortality of the restrictive group with those of the patients with the liberal transfusion strategy (liberal group).

Results

Preoperative intravenous iron supplementation was not associated with any adverse reactions. The transfusion rate was 65.3% (506/775) in the liberal group and 48.2% (414/859) in the restrictive group (p < 0.001). The mean hospital stay was shorter in the restrictive group (21.5 vs. 28.8 days, p < 0.001). There was no significant difference in the postoperative medical complications including myocardial infarction and cerebrovascular event. Mortality at postoperative 30, 60, and 90 days was similar between the two groups.

Conclusions

Our blood management protocol involving restrictive strategy combined with preoperative intravenous iron supplementation appears to be effective and safe in HFS of elderly patients.

Review of available evidence supporting different transfusion thresholds in different patient groups with anemia

In patients with anemia, transfusion of red blood cells (RBCs) can save lives and improve quality of life. The choice to transfuse should be cautiously made owing to risks of transfusion, economic costs, and limitations on the blood supply. Until the 1980s, the decision for RBC transfusion was guided by Hb threshold, with the aim of maintaining the patient's blood Hb level over 100 grams per liter. Since then, multiple randomized controlled trials and key systematic reviews have provided evidence-based guidelines as to appropriate transfusion thresholds in a number of clinical settings. Here, we aimed to address the outcome of defining different anemia criteria in specific clinical populations exclusively on the basis of the need for RBC transfusion based on Hb concentration. We focused on the patient populations, where there were the most available data on differing transfusion thresholds, which looked at transfusing to a higher or liberal transfusion threshold in comparison with a lower or restrictive transfusion threshold. These included patients in intensive care with or without septic shock, hip fracture surgery, cardiovascular surgery, and upper gastrointestinal bleeding, the pediatric population, and also those with malaria, by reviewing key randomized controlled trials and systematic reviews. Twenty-four randomized controlled studies and 12 systematic reviews have been included, and these are discussed below.

Counterintuitive results from observational data: a case study and discussion

OBJECTIVE

To explore the issue of counterintuitive data via analysis of a representative case in which the data obtained was unexpected and inconsistent with current knowledge. We then discuss the issue of counterintuitive data while developing a framework for approaching such findings.

DESIGN

The case study is a retrospective analysis of a cohort of coronary artery bypass graft (CABG) patients. Regression was used to examine the association between perceived pain in the intensive care unit (ICU) and selected outcomes.

SETTING

Medical Information Mart for Intensive Care-III, a publicly available, de-identified critical care patient database.

PARTICIPANTS

844 adult patients from the database who underwent CABG surgery and were extubated within 24 hours after ICU admission.

OUTCOMES

30 day mortality, 1 year mortality and hospital length of stay (LOS).

RESULTS

Increased pain levels were found to be significantly associated with reduced mortality at 30 days and 1 year, and shorter hospital LOS. A one-point increase in mean pain level was found to be associated with a reduction in the odds of 30 day and 1 year mortality by a factor of 0.457 (95% CI 0.304 to 0.687, p<0.01) and 0.710 (95% CI 0.571 to 0.881, p<0.01) respectively, and a 0.916 (95% CI -1.159 to -0.673, p<0.01) day decrease in hospital LOS.

CONCLUSION

The finding of an association between increased pain and improved outcomes was unexpected and clinically counterintuitive. In an increasingly digitised age of medical big data, such results are likely to become more common. The reliability of such counterintuitive results must be carefully examined. We suggest several issues to consider in this analytic process. If the data is determined to be valid, consideration must then be made towards alternative explanations for the counterintuitive results observed. Such results may in fact indicate that current clinical knowledge is incomplete or not have been firmly based on empirical evidence and function to inspire further research into the factors involved.

Long-Term Outcomes Among Patients Discharged From the Hospital With Moderate Anemia: A Retrospective Cohort Study

BACKGROUND

Randomized clinical trial findings support decreased red blood cell (RBC) transfusion and short-term tolerance of in-hospital anemia. However, long-term outcomes related to changes in transfusion practice have not been described.

OBJECTIVE

To describe the prevalence of anemia at and after hospital discharge and associated morbidity and mortality events.

DESIGN

Retrospective cohort study.

SETTING

Integrated health care delivery system with 21 hospitals serving 4 million members.

PARTICIPANTS

445 371 surviving adults who had 801 261 hospitalizations between January 2010 and December 2014.

MEASUREMENTS

Hemoglobin levels and RBC transfusion, rehospitalization, and mortality events within 6 months of hospital discharge. Generalized estimating equations were used to examine trends over time, accounting for correlated observations and patient-level covariates.

RESULTS

From 2010 to 2014, the prevalence of moderate anemia (hemoglobin levels between 7 and 10 g/dL) at hospital discharge increased from 20% to 25% (P < 0.001) and RBC transfusion declined by 28% (39.8 to 28.5 RBC units per 1000 patients; P < 0.001). The proportion of patients whose moderate anemia had resolved within 6 months of hospital discharge decreased from 42% to 34% (P < 0.001), and RBC transfusion and rehospitalization within 6 months of hospital discharge decreased from 19% to 17% and 37% to 33%, respectively (P < 0.001 for both). During this period, the adjusted 6-month mortality rate decreased from 16.1% to 15.6% (P = 0.004) in patients with moderate anemia, in parallel with that of all others.

LIMITATION

Possible unmeasured confounding.

CONCLUSION

Anemia after hospitalization increased in parallel with decreased RBC transfusion. This increase was not accompanied by a rise in subsequent RBC use, rehospitalization, or mortality within 6 months of hospital discharge. Longitudinal analyses support the safety of practice recommendations to limit RBC transfusion and tolerate anemia during and after hospitalization.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute.

Korean clinical practice guideline for perioperative red blood cell transfusion from Korean Society of Anesthesiologists

Background

Considering the functional role of red blood cells (RBC) in maintaining oxygen supply to tissues, RBC transfusion can be a life-saving intervention in situations of severe bleeding or anemia. RBC transfusion is often inevitable to address intraoperative massive bleeding; it is a key component in safe perioperative patient management. Unlike general medical resources, packed RBCs (pRBCs) have limited availability because their supply relies entirely on voluntary donations. Additionally, excessive utilization of pRBCs may aggravate prognosis or increase the risk of developing infectious diseases. Appropriate perioperative RBC transfusion is, therefore, crucial for the management of patient safety and medical resource conservation. These concerns motivated us to develop the present clinical practice guideline for evidence-based efficient and safe perioperative RBC transfusion management considering the current clinical landscape.

Methods

This guideline was obtained after the revision and refinement of exemplary clinical practice guidelines developed in advanced countries. This was followed by rigorous evidence-based reassessment considering the healthcare environment of the country.

Results

This guideline covers all important aspects of perioperative RBC transfusion, such as preoperative anemia management, appropriate RBC storage period, and leukoreduction (removal of white blood cells using filters), reversal of perioperative bleeding tendency, strategies for perioperative RBC transfusion, appropriate blood management protocols, efforts to reduce blood transfusion requirements, and patient monitoring during a perioperative transfusion.

Conclusions

This guideline will aid decisions related to RBC transfusion in healthcare settings and minimize patient risk associated with unnecessary pRBC transfusion.

Recommendations on RBC Transfusion in Infants and Children With Acquired and Congenital Heart Disease From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative

OBJECTIVES

To present the recommendations and supporting literature for RBC transfusions in critically ill children with acquired and congenital heart disease developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

DESIGN

Consensus conference series of 38 international, multidisciplinary experts in RBC transfusion management of critically ill children.

METHODS

Experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations and research priorities for RBC transfusions in critically ill children. The cardiac disease subgroup included three experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA appropriateness method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.

RESULTS

Twenty-one recommendations were developed and reached agreement. For children with myocardial dysfunction and/or pulmonary hypertension, there is no evidence that transfusion greater than hemoglobin of 10 g/dL is beneficial. For children with uncorrected heart disease, we recommended maintaining hemoglobin greater than 7-9.0 g/dL depending upon their cardiopulmonary reserve. For stable children undergoing biventricular repairs, we recommend not transfusing if the hemoglobin is greater than 7.0 g/dL. For infants undergoing staged palliative procedures with stable hemodynamics, we recommend avoiding transfusions solely based upon hemoglobin, if hemoglobin is greater than 9.0 g/dL. We recommend intraoperative and postoperative blood conservation measures. There are insufficient data supporting shorter storage duration RBCs. The risks and benefits of RBC transfusions in children with cardiac disease requires further study.

CONCLUSIONS

We present RBC transfusion management recommendations for the critically ill child with cardiac disease. Clinical recommendations emphasize relevant hemoglobin thresholds, and research recommendations emphasize need for further understanding of physiologic and hemoglobin thresholds and alternatives to RBC transfusion in subpopulations lacking pediatric literature.

Impact and management of iron deficiency and iron deficiency anemia in women's health

INTRODUCTION

Iron deficiency and iron deficiency anemia are highly prevalent among women throughout their lives. Some females are particularly vulnerable to iron deficiency/iron deficiency anemia, including those with heavy menstrual bleeding (HMB) and pregnant/postpartum women. Despite the high prevalence of iron deficiency/iron deficiency anemia in women, the condition is still underdiagnosed and therefore undertreated, with serious clinical consequences. Areas covered: The following review examines the impact of iron deficiency and iron deficiency anemia on clinical outcomes and quality of life in women from adolescence to post-menopause, paying particular attention to guidelines and current recommendations for diagnostic tests and management. Expert commentary: There are numerous adverse health consequences of an iron-deficient state, affecting all aspects of the physical and emotional health and well-being of women. Guidelines must be developed to help clinicians better identify and treat women at risk of iron deficiency or iron deficiency anemia, particularly those with HMB, or who are pregnant or postpartum. Replacement therapy with oral or intravenous iron preparations is the mainstay of treatment for iron deficiency/iron deficiency anemia, with red blood cell transfusion reserved for emergency situations. Each iron therapy type is associated with benefits and limitations which impact their use.

A simple and low-cost portable paper-based ABO blood typing device for point-of-care testing

ABO blood group is the most important blood type system for transfusion medicine. A paper-based analytical device (PAD) for ABO blood typing has been proposed. The device was composed of Whatman No. 113 paper, an absorbent gel pad, and a 3D-printing cassette. The 3D-printing cassette contained two circular holes for display of letters "A" and "B" on the PAD. Whole blood was dropped onto hydrophilic letters A and B on the PAD, in which the anti-A and anti-B were pre-immobilized, respectively. An absorbent gel pad was used to adsorb excess blood sample and washing solution during the washing step. The particle size of agglutinated red blood cells (RBCs) could not be eluted out of the paper by the elution solution. In contrast, non-agglutinated RBCs were washed out by means of elution solution. The devices could be used for real blood samples in a wide range of hematocrit levels, 21-59%. Unknown blood group samples (n = 500) were identified by the developed device and the results were compared with the conventional method, revealing 100% accuracy. Because of its compact size with low-cost fabrication, the portable ABO blood typing device has great potential for point-of-care testing, particularly in developing countries.

Emergency Medicine Evaluation and Management of Anemia

Anemia is a common condition and is diagnosed on laboratory assessment. It is defined by abnormally low hemoglobin concentration or decreased red blood cells. Several classification systems exist. Laboratory markers provide important information. Acute anemia presents with symptoms owing to acute blood loss; chronic anemia may present with worsening fatigue, dyspnea, lightheadedness, or chest pain. Specific treatments depend on the underlying anemia and etiology. Iron is an alternative treatment for patients with microcytic anemia owing to iron deficiency. Hyperbaric oxygen is an option for alternative rescue therapy. Most patients with chronic anemia may be discharged with follow-up if hemodynamically stable.

Impact of Anemia and Transfusion on Readmission and Length of Stay After Spinal Surgery: A Single-center Study of 1187 Operations

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine whether receipt of blood transfusion and preoperative anemia are associated with increased rates of 30-day all-cause readmission, and secondarily with a prolonged hospital stay after spinal surgery.

SUMMARY OF BACKGROUND DATA

Increased focus on health care quality has led to efforts to determine postsurgical readmission rates and predictors of length of postoperative hospital stay. Although there are still no defined outcome measures specific to spinal surgery to which providers are held accountable, efforts to identify appropriate measures and to determine modifiable risk factors to optimize quality are ongoing.

METHODS

Records from 1187 consecutive spinal surgeries at Northwestern Memorial Hospital in 2010 were retrospectively reviewed and data were collected that described the patient, surgical procedure, hospital course, complications, and readmissions. Presence or absence of transfusion during the surgery and associated hospital course was treated as a binary variable. Multivariate negative binomial regression and logistic regression were used to model length of stay and readmission, respectively.

RESULTS

Nearly one fifth (17.8%) of surgeries received transfusions, and the overall readmission rate was 6.1%. After controlling for potential confounders, we found that the presence of a transfusion was associated with a 60% longer hospital stay [adjusted incidence rate ratio=1.60 (1.34-1.91), P<0.001], but was not significantly associated with an increased rate of readmission [adjusted odds ratio=0.81 (0.39-1.70), P=0.582]. Any degree of preoperative anemia was associated with increased length of stay, but only severe anemia was associated with an increased rate of readmission.

CONCLUSIONS

Both receipt of blood transfusion and any degree of preoperative anemia were associated with increased length of hospital stay after controlling for other variables. Severe anemia, but not receipt of blood transfusion, was associated with increased rate of readmission. Our findings may help define actions to reduce length of stay and decrease rates of readmission.

Preoperative blood transfusion is a predictor of worse short-term postoperative outcomes after colectomy

BACKGROUND

Both anemia and blood transfusion are associated with poor outcomes. The aim of this study was to evaluate the effect of preoperative blood transfusion on postoperative outcomes after colectomy, stratified by severity of anemia.

METHODS

Patients undergoing colectomy from 2012-2014 were selected from the National Surgical Quality Improvement Program targeted colectomy database. Patients were divided into 2 groups based on receipt of preoperative transfusion and then stratified by hematocrit. Univariate and multivariate analyses were used to compare 30-day outcomes between the 2 groups.

RESULTS

A total of 60,785 patients were included in the study, with an overall preoperative transfusion rate of 3.4% (n = 2,073). On univariate analysis, transfusion was associated with significantly greater rates of postoperative morbidity. The risk-adjusted, multivariate model confirmed increased risk of complications with preoperative transfusion (odds ratio 1.32, 95% confidence interval, 1.18-1.48). Furthermore, transfusion did not improve outcomes even in the setting of moderate anemia (odds ratio 1.35, 95% confidence interval, 1.14-1.60) or severe anemia (odds ratio 0.97, 95% confidence interval, 0.66-1.41).

CONCLUSIONS

Preoperative transfusion is an independent predictor of complications in patients with mild and moderate anemia. Furthermore, these retrospective data suggest that even severely anemic patients do not benefit from preoperative transfusion and empiric transfusion therefore should be avoided. Alternatives to preoperative optimization of this high-risk surgical population should be sought.

Reflections on Cultural Preferences and Internal Medicine: The Case of Jehovah's Witnesses and the Changing Thresholds for Blood Transfusions

Jehovah's witnesses oppose receiving blood transfusions based on religious grounds. This refusal raises complex medical, legal and ethical issues for the treating medical staff. In the past physicians attempted to force patients and children to accept transfusions when deemed medically necessary through the use of court orders. However, in recent years the threshold for blood transfusion has been gradually raised by medical experts as expressed in consensus guidelines, which means that Jehovah's witnesses' aversion to transfusion would have been partially justified medically. This article will further discuss these current trends.

Local Administration of Tranexamic Acid During Prostatectomy Surgery: Effects on Reducing the Amount of Bleeding

BACKGROUND

One of the issues in prostatectomy surgery is bleeding. Although tranexamic acid (TRA) is an antifibrinolytic agent for reducing bleeding, controversies surround its use.

OBJECTIVES

In this study, the effect of local administration of TRA on reducing bleeding during prostatectomy surgery was evaluated.

METHODS

A total of 186 patients who underwent prostatectomy surgery were assessed in this clinical trial study. Patients were divided randomly into two groups. After prostate removal, TRA (500 mg TRA with 5 mL total volume) to the intervention group and normal saline to the control group were sprayed with the same volume. At the end of surgery, the prescribed blood bags were measured and recorded. Hemoglobin and platelet levels were recorded 6 hours after the test. Moreover, the amounts of blood inside the blood bags in the first 24 hours, the second 24 hours, and the total length of hospital stay were recorded and compared in each group.

RESULTS

By comparing the measured values before and after surgery, we found that the amounts of hemoglobin, hematocrit, and platelet decreased. The mean blood loss in the intervention group was recorded at 340 mL and that in the control group was 515 mL. The maximum bleeding in the control group was almost twice as much as that in the intervention group. Blood loss in the intervention group with the administration of TRA was significantly lesser than that in the control group (P = 0.01). The decrease in platelet level in the intervention group was significantly lower than that in the control group (P = 0.03).

CONCLUSIONS

The present study showed that local administration of TRA significantly reduces bleeding after prostatectomy surgery and is effective in preventing postoperative hemoglobin decrease.

Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion

BACKGROUND

There is considerable uncertainty regarding the optimal haemoglobin threshold for the use of red blood cell (RBC) transfusions in anaemic patients. Blood is a scarce resource, and in some countries, transfusions are less safe than others because of a lack of testing for viral pathogens. Therefore, reducing the number and volume of transfusions would benefit patients.

OBJECTIVES

The aim of this review was to compare 30-day mortality and other clinical outcomes in participants randomized to restrictive versus liberal red blood cell (RBC) transfusion thresholds (triggers) for all conditions. The restrictive transfusion threshold uses a lower haemoglobin level to trigger transfusion (most commonly 7 g/dL or 8 g/dL), and the liberal transfusion threshold uses a higher haemoglobin level to trigger transfusion (most commonly 9 g/dL to 10 g/dL).

SEARCH METHODS

We identified trials by searching CENTRAL (2016, Issue 4), MEDLINE (1946 to May 2016), Embase (1974 to May 2016), the Transfusion Evidence Library (1950 to May 2016), the Web of Science Conference Proceedings Citation Index (1990 to May 2016), and ongoing trial registries (27 May 2016). We also checked reference lists of other published reviews and relevant papers to identify any additional trials.

SELECTION CRITERIA

We included randomized trials where intervention groups were assigned on the basis of a clear transfusion 'trigger', described as a haemoglobin (Hb) or haematocrit (Hct) level below which a red blood cell (RBC) transfusion was to be administered.

DATA COLLECTION AND ANALYSIS

We pooled risk ratios of clinical outcomes across trials using a random-effects model. Two people extracted the data and assessed the risk of bias. We conducted predefined analyses by clinical subgroups. We defined participants randomly allocated to the lower transfusion threshold as 'restrictive transfusion' and to the higher transfusion threshold as 'liberal transfusion'.

MAIN RESULTS

A total of 31 trials, involving 12,587 participants, across a range of clinical specialities (e.g. surgery, critical care) met the eligibility criteria. The trial interventions were split fairly equally with regard to the haemoglobin concentration used to define the restrictive transfusion group. About half of them used a 7 g/dL threshold, and the other half used a restrictive transfusion threshold of 8 g/dL to 9 g/dL. The trials were generally at low risk of bias .Some items of methodological quality were unclear, including definitions and blinding for secondary outcomes.Restrictive transfusion strategies reduced the risk of receiving a RBC transfusion by 43% across a broad range of clinical specialties (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.49 to 0.65; 12,587 participants, 31 trials; high-quality evidence), with a large amount of heterogeneity between trials (I² = 97%). Overall, restrictive transfusion strategies did not increase or decrease the risk of 30-day mortality compared with liberal transfusion strategies (RR 0.97, 95% CI 0.81 to 1.16, I² = 37%; N = 10,537; 23 trials; moderate-quality evidence) or any of the other outcomes assessed (i.e. cardiac events (low-quality evidence), myocardial infarction, stroke, thromboembolism (high-quality evidence)). Liberal transfusion did not affect the risk of infection (pneumonia, wound, or bacteraemia).

AUTHORS' CONCLUSIONS

Transfusing at a restrictive haemoglobin concentration of between 7 g/dL to 8 g/dL decreased the proportion of participants exposed to RBC transfusion by 43% across a broad range of clinical specialities. There was no evidence that a restrictive transfusion strategy impacts 30-day mortality or morbidity (i.e. mortality at other points, cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism, infection) compared with a liberal transfusion strategy. There were insufficient data to inform the safety of transfusion policies in certain clinical subgroups, including acute coronary syndrome, myocardial infarction, neurological injury/traumatic brain injury, acute neurological disorders, stroke, thrombocytopenia, cancer, haematological malignancies, and bone marrow failure. The findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds above 7 g/dL to 8 g/dL.