Evidence of content validity of the "Blood Transfusion Reaction" (code 0700) nursing outcome from the nursing outcomes classification

OBJECTIVE

The objective of study was to present evidence of the content validity of conceptual and operational definitions of the "Blood Transfusion Reaction (code 0700)" nursing outcome from the Nursing Outcomes Classification (NOC).

METHOD

A methodological study was implemented in four phases. The first phase consisted of a narrative literature review in which the main indicators related to blood transfusion were identified: 25 new indicators that were not present in NOC, in addition to 14 existing indicators, for a total of 39 to be studied. In the second phase, conceptual and operational definitions, and magnitude of NOC indicators were developed. The third phase consisted of analysis of evidence of content validity of conceptual and operational definitions of indicators, through assessment by experts. In the fourth phase, a pilot test was applied to 40 electronic medical records of patients who received blood components and presented with a transfusion reaction.

RESULTS

A total of 27 articles were analyzed and served as support to develop conceptual and operational definitions, and magnitude of indicators, considered for the outcome under study. It was assessed by a group of 10 experts, requiring three rounds to reach the established critical content validity ratio in which four of these indicators were excluded, leaving 35 indicators in the final version. A pilot test on 40 records revealed the presence of 13 indicators, of which six were present in the classification.

CONCLUSION

The conceptual and operational definitions and magnitude developed for the "Blood Transfusion Reaction (code 0700)" nursing outcome demonstrated adequate evidence of content validity in the 21 indicators found in the literature, along with 14 indicators already present in NOC, and 13 of these indicators were present in patients receiving blood components who presented a transfusion reaction.

IMPLICATIONS FOR PRACTICE

Nurses can use this nursing outcome as a clinical assessment tool for monitoring blood transfusion recipients' clinical signs.

Cresp®: transforming the landscape of chemotherapy-induced anemia - a comprehensive retrospective real-world analysis in 523 Indian patients

Introduction

Anemia, a frequently encountered issue among cancer patients undergoing chemotherapy, is regrettably underappreciated despite its prevalence and profound impact on their well-being. Chemotherapy-induced anemia (CIA) diminishes the quality of life, causing fatigue, breathlessness, and a decline in the performance status. However, correcting anemia can lead to notable improvements in these parameters. Notably, darbepoetin alpha (DA) has shown efficacy in addressing anemia in this context. This real-world study aims to evaluate the efficacy of DA in the treatment of CIA among Indian cancer patients.

Methods

This single-center retrospective study assessed the effectiveness of DA in treating CIA among advanced/metastatic solid tumor patients on palliative myelosuppressive therapy. The study measured the change in hemoglobin levels after DA administration as the primary outcome, with secondary outcomes including impact on blood transfusion dependence, changes in anemia-related symptoms, and occurrence of adverse events.

Results

A total of 523 patients, with a median age of 55, were included in the study. Patients were categorized based on cancer site, type of chemotherapy, response to therapy, and DA doses. A significant mean increase of 2.28 gm/dl in hemoglobin (Hb) levels from baseline to post-DA administration was observed (8.56±0.45 to 10.84±0.92; 26.6%; P<.001). Each sub-group revealed a significant enhancement of mean hemoglobin from baseline to the end of treatment. Significant improvements were noted from baseline in fatigue, and dyspnea. Adverse drug reactions included hypertension (5.4%), deep vein thrombosis (2.9%), and arrhythmias (0.8%).

Discussion

DA demonstrates impressive efficacy and safety in managing CIA, leading to substantial improvements in mean hemoglobin levels in palliative setting. This has the potential to reduce the need for blood transfusions and enhance the quality of life for patients.

Impact of anemia requiring transfusion or erythropoiesis-stimulating agents on new-onset cardiovascular events and mortality after continuous renal replacement therapy

Anemia is common in critically ill patients undergoing continuous renal replacement therapy (CRRT). We investigated the impact of anemia requiring red blood cell (RBC) transfusion or erythropoiesis-stimulating agents (ESAs) on patient outcomes after hospital discharge in critically ill patients with acute kidney injury (AKI) requiring CRRT. In this retrospective cohort study using the Health Insurance Review and Assessment database of South Korea, 10,923 adult patients who received CRRT for 3 days or more between 2010 and 2019 and discharged alive were included. Anemia was defined as the need for RBC transfusion or ESAs. Outcomes included cardiovascular events (CVEs) and all-cause mortality after discharge. The anemia group showed a tendency to be older with more females and had more comorbidities compared to the control group. Anemia was not associated with an increased risk of CVEs (adjusted hazard ratio [aHR]: 1.05; 95% confidence interval [CI]: 0.85-1.29), but was associated with an increased risk of all-cause mortality (aHR: 1.41; 95% CI 1.30-1.53). For critically ill patients with AKI requiring CRRT, anemia, defined as requirement for RBC transfusion or ESAs, may increase the long-term risk of all-cause mortality.

Development and validation of a prediction tool for intraoperative blood transfusion in brain tumor resection surgery: a retrospective analysis

Early identification of a patient with a high risk of blood transfusion during brain tumor resection surgery is difficult but critical for implementing preoperative blood-saving strategies. This study aims to develop and validate a machine learning prediction tool for intraoperative blood transfusion in brain tumor resection surgery. A total of 541 patients who underwent brain tumor resection surgery in our hospital from January 2019 to December 2021 were retrospectively enrolled in this study. We incorporated demographics, preoperative comorbidities, and laboratory risk factors. Features were selected using the least absolute shrinkage and selection operator (LASSO). Eight machine learning algorithms were benchmarked to identify the best model to predict intraoperative blood transfusion. The prediction tool was established based on the best algorithm and evaluated with discriminative ability. The data were randomly split into training and test groups at a ratio of 7:3. LASSO identified seven preoperative relevant factors in the training group: hemoglobin, diameter, prothrombin time, white blood cell count (WBC), age, physical status of the American Society of Anesthesiologists (ASA) classification, and heart function. Logistic regression, linear discriminant analysis, supporter vector machine, and ranger all performed better in the eight machine learning algorithms with classification errors of 0.185, 0.193, 0.199, and 0.196, respectively. A nomogram was then established, and the model showed a better discrimination ability [0.817, 95% CI (0.739, 0.895)] than hemoglobin [0.663, 95% CI (0.557, 0.770)] alone in the test group (P = 0.000). Hemoglobin, diameter, prothrombin time, WBC, age, ASA status, and heart function are risk factors of intraoperative blood transfusion in brain tumor resection surgery. The prediction tool established using the logistic regression algorithm showed a good discriminative ability than hemoglobin alone for predicting intraoperative blood transfusion in brain tumor resection surgery.

Investigation of the patients with recurrent acute transfusion reactions: A single tertiary medical centre experience

OBJECTIVE

To assess the spectrum of patients who developed recurrent acute transfusion reactions (TRs) and to characterize these recurrent TRs.

METHODS

This retrospective study included patients who developed ≥2 acute TRs between April 2017 and March 2020 in a tertiary medical centre.

RESULTS

Among 216 TRs that occurred after 2024 transfusions in 87 patients, 66 (75.9%) patients reported a history of transfusions before the first TR and 70 (80.5%) patients received further transfusions after the last TR; with the same type of TR and reaction to the same type of blood product observed in 59 (67.8%) patients and 56 (64.4%) patients, respectively. TRs were most commonly associated with packed red blood cell (PRBC) transfusions and a febrile non-haemolytic transfusion reaction (FNHTR) was the most common type of TR. However, leukocyte reduced (LR) PRBCs were less common than LR platelets among transfusions with TR (22.7% [27/119] versus 75.0% [57/76], respectively) and premedication was prescribed before 196 of 216 (90.7%) transfusions with TR.

CONCLUSION

Most patients with recurrent TRs received repeated transfusions in addition to transfusions with TR. Instead of considering premedication, an increase in the use of LR might be the strategy to reduce the recurrence of TR.

Development and validation of a nomogram for blood transfusion during intracranial aneurysm clamping surgery: a retrospective analysis

PURPOSE

Intraoperative blood transfusion is associated with adverse events. We aimed to establish a machine learning model to predict the probability of intraoperative blood transfusion during intracranial aneurysm surgery.

METHODS

Patients, who underwent intracranial aneurysm surgery in our hospital between January 2019 and December 2021 were enrolled. Four machine learning models were benchmarked and the best learning model was used to establish the nomogram, before conducting a discriminative assessment.

RESULTS

A total of 375 patients were included for analysis in this model, among whom 108 received an intraoperative blood transfusion during the intracranial aneurysm surgery. The least absolute shrinkage selection operator identified six preoperative relative factors: hemoglobin, platelet, D-dimer, sex, white blood cell, and aneurysm rupture before surgery. Performance evaluation of the classification error demonstrated the following: K-nearest neighbor, 0.2903; logistic regression, 0.2290; ranger, 0.2518; and extremely gradient boosting model, 0.2632. A nomogram based on a logistic regression algorithm was established using the above six parameters. The AUC values of the nomogram were 0.828 (0.775, 0.881) and 0.796 (0.710, 0.882) in the development and validation groups, respectively.

CONCLUSIONS

Machine learning algorithms present a good performance evaluation of intraoperative blood transfusion. The nomogram established using a logistic regression algorithm showed a good discriminative ability to predict intraoperative blood transfusion during aneurysm surgery.

Adverse transfusion reactions and what we can do

INTRODUCTION

Transfusions of blood and blood components have inherent risks and the ensuing adverse reactions. It is very important to understand the adverse reactions of blood transfusion comprehensively for ensuring the safety of any future transfusions.

AREAS COVERED

According to the time of onset, adverse reactions of blood transfusion are divided into immediate and delayed transfusion reactions. In acute transfusion reactions, timely identification and immediate cessation of transfusion is critical. Vigilance is required to distinguish delayed responses or reactions that present non-specific signs and symptoms. In this review, we present the progress of mechanism, clinical characteristics and management of commonly encountered transfusion reactions.

EXPERT OPINION

The incidence of many transfusion-related adverse events is decreasing, but threats to transfusion safety are always emerging. It is particularly important for clinicians and blood transfusion staff to recognize the causes, symptoms and treatment methods of adverse blood transfusion reactions to improve the safety. In the future, at-risk patients will be better identified and can benefit from more closely matched blood components.

The Effects of Preoperative Administration of Erythropoietin in Pediatric Patients Undergoing Cranial Vault Remodeling for Craniosynostosis

BACKGROUND AND PURPOSE

Over 90% of patients undergoing cranial vault remodeling for craniosynostosis receive blood transfusions to compensate for intraoperative blood loss. However, transfusions are not without risk and can lead to allergic and immune transfusion reactions as well as rare cases of infectious transmissions. Preoperative use of erythropoietin in cranial vault remodeling has been demonstrated to be safe and to reduce transfusion requirements in prior studies. This study's purpose is to add to the body of data supporting the safe use of a protocolized erythropoietin alfa regimen before cranial vault remodeling and strip craniectomy procedures with decreased blood transfusion requirements and other favorable outcomes.

METHODS

A retrospective chart review was performed on patients who underwent cranial vault remodeling between 2006 and 2021 at our tertiary care center. Two groups were identified: in the first, preoperative erythropoietin was administered under protocol; and in the second, preoperative erythropoietin was not administered. The groups were compared with respect to age, perioperative hemoglobin levels, estimated blood loss during surgery, packed red blood cell transfusion volume, length of hospital stay, and length of surgery.

RESULTS

Demographics were not significantly different in terms of age, weight, diagnosis, gender, and type of procedure. Patients who were administered preoperative erythropoietin were found to have significantly increased preoperative hemoglobin levels (13.6 versus 12.3 g/dL), as well as decreased estimated intraoperative blood loss (376 versus 1099 mL), the volume of packed red blood cells transfused (316 versus 897 mL), length of hospital stay, and length of surgery. Postoperative hemoglobin levels were not found to be significantly different.

CONCLUSIONS

In this study, preoperative administration of erythropoietin with elemental iron was beneficial for patients undergoing cranial vault remodeling for craniosynostosis. Specifically, it decreased the need for red blood cell transfusion, intraoperative blood loss, and length of hospital stay. No adverse events were recorded in the treatment arm. Further studies may include a separate group administered iron alone.

Allogeneic lymphocytes immunotherapy in female infertility: Lessons learned and the road ahead

The endometrium is an essential tissue in the normal immunologic dialogue between the mother and the conceptus, which is necessary for the proper establishment and maintenance of a successful pregnancy. It's become evident that the maternal immune system plays a key role in the normal pregnancy's initiation, maintenance, and termination. In this perspective, the immune system contributes to regulating all stages of pregnancy, thus immunological dysregulation is thought to be one of the major etiologies of implantation failures. Many researchers believe that immune therapies are useful tactics for improving the live births rate in certain situations. Lymphocyte immunotherapy (LIT) is an active form of immunotherapy that, when used on the relevant subgroups of patients, has been shown in multiple trials to dramatically enhance maternal immunological balance and pregnancy outcome. The primary goal of LIT is to regulate the immune system in order to create a favorable tolerogenic immune milieu and tolerance for embryo implantation. However, there are a plethora of influential factors influencing its therapeutic benefits that merit to be addressed. The objective of our study is to discuss the mechanisms and challenges of allogeneic LIT.

Effect of Human or Mouse IL-7 on the Homeostasis of Porcine T Lymphocytes

Due to the inconsistent fluctuation of blood supply for transfusion, much attention has been paid to the development of artificial blood using other animals. Although mini-pigs are candidate animals, contamination of mini-pig T cells in artificial blood may cause a major safety concern. Therefore, it is important to analyze the cross-reactivity of IL-7, the major survival factor for T lymphocytes, between human, mouse, and mini-pig. Thus, we compared the protein sequences of IL-7 and found that porcine IL-7 was evolutionarily different from human IL-7. We also observed that when porcine T cells were cultured with either human or mouse IL-7, these cells did not increase the survival or proliferation compared to negative controls. These results suggest that porcine T cells do not recognize human or mouse IL-7 as their survival factor.

Preventing adverse reactions in pediatric transfusions using washed platelet concentrate

Blood transfusion is an important form of supportive care in children; however, transfusion-associated adverse reactions (TARs) are a problem. As with adults, allergic transfusion reactions (ATRs) and febrile non-hemolytic transfusion reactions (FNHTRs) are major TARs, and the frequency of ATRs caused by platelet concentrate (PC) tends to be particularly high. The plasma component of the blood product is thought to be a major factor in the onset of TARs such as ATR and FNHTR. By contrast, in children, age, underlying disease, and number of blood transfusions may be relevant patient-related factors. Although acetaminophen or diphenhydramine may be used prophylactically to prevent TARs, there is no clear evidence of their effectiveness. Volume-reduced PC is used to prevent TARs; however, it may be difficult to maintain the quality of platelets. Plasma-replaced PC stored with platelet additive solution raises the concern that TARs cannot be completely prevented by residual plasma. Washed PC removes most of the plasma, so it can effectively prevent ATR and FNHTR. The recent development of platelet additive solution [M-sol, bicarbonate Ringer's solution supplemented with acid-citrate-dextrose formula A (BRS-A)] in Japan has enabled the maintenance of the quality of platelets for long periods. The clinical use of washed PC in Japan has therefore progressed. Washed PC with M-sol or BRS-A for pediatric patients can effectively prevent TARs without diminishing the transfusion effect. The supply of washed PC has begun from the Japanese Red Cross Society, and it has become possible to use washed PC at all medical institutions in Japan.

Advancement of echocardiography for surveillance of iron overload cardiomyopathy: comparison to cardiac magnetic resonance imaging

The prevalence of iron overload cardiomyopathy (IOC) is increasing. Patients with transfusion-dependent anemias or conditions associated with increased iron absorption over time are at a significant risk for the development of iron-overloaded states such as IOC. Current guidelines regarding the diagnostic evaluation and follow-up of patients at risk for IOC exist, and are composed of multiple components, including such as echocardiography, genetic testing, magnetic resonance imaging of liver, and cardiac magnetic resonance imaging (CMR). While these are considered reliable for the evaluation of patients at risk for an iron-overloaded state, there is an access challenge associated with initial and serial CMR scanning in this patient population. Furthermore, there are other limiting factors, such as patient characteristics that may preclude the use of CMR as a viable diagnostic imaging modality for these patients. On the other hand, recent evidence in the literature suggests that transthoracic echocardiography, which has had significant technological advances, can equal or even outperform CMR to identify cardiac functional abnormalities such as subclinical left ventricular strain and left atrial functional abnormalities in iron overload conditions. Therefore, there is a potential role of more frequent use of echocardiography for surveillance of the development of IOC. Our purpose with this narrative review is to describe recent advances in echocardiography and propose a potential increased use of echocardiography in the surveillance of the development of IOC.

Identifying and Understanding Transfusion Reactions in the Oncology Population

OBJECTIVES

To provide an overview of transfusion reactions, their underlying pathophysiology, clinical presentation, and recommendations for nursing management.

DATA SOURCES

We researched peer-reviewed journal articles, book chapters, Internet, and lecture proceedings.

CONCLUSION

Transfusion reactions are adverse reactions to blood products frequently seen in the oncology population and can significantly vary in severity and etiology. Oncology nurses are in a critical position to assist with prevention, early detection, and time-sensitive treatment of transfusion reactions.

IMPLICATIONS FOR NURSING PRACTICE

The oncology nurse's comprehensive understanding of possible transfusion reactions and management recommendations is key for optimal care of the oncology patient.

Management and Clinical Outcome of Posterior Reversible Encephalopathy Syndrome in Pediatric Oncologic/Hematologic Diseases: A PRES Subgroup Analysis With a Large Sample Size

This study investigated the management and clinical outcomes along with associated factors of posterior reversible encephalopathy syndrome (PRES) in childhood hematologic/oncologic diseases. We present data from children with hematologic/oncologic diseases who developed PRES after treatment of the primary disease with chemotherapy and hematopoietic stem cell transplantation (HSCT) at 3 medical centers in Changsha, China from 2015 to 2020, and review all previously reported cases with the aim of determining whether this neurologic manifestation affects the disease prognosis. In the clinical cohort of 58 PRES patients, hypertension [pooled odds ratio (OR) = 4.941, 95% confidence interval (CI): 1.390, 17.570; P = 0.001] and blood transfusion (OR = 14.259, 95% CI: 3.273, 62.131; P = 0.001) were significantly associated with PRES. Elevated platelet (OR = 0.988, 95% CI: 0.982, 0.995; P < 0.001), hemoglobin (OR = 0.924, 95% CI: 0.890, 0.995; P < 0.001), and blood sodium (OR = 0.905, 95% CI: 0.860, 0.953; P < 0.001), potassium (OR = 0.599, 95% CI: 0.360, 0.995; P = 0.048), and magnesium (OR = 0.093, 95% CI: 0.016, 0.539; P = 0.008) were protective factors against PRES. Data for 440 pediatric PRES patients with hematologic/oncologic diseases in 21 articles retrieved from PubMed, Web of Science, and Embase databases and the 20 PRES patients from our study were analyzed. The median age at presentation was 7.9 years. The most common primary diagnosis was leukemia (62.3%), followed by solid tumor (7.7%) and lymphoma (7.5%). Most patients (65.0%) received chemotherapy, including non-induction (55.2%) and induction (44.8%) regimens; and 86.5% used corticosteroids before the onset of PRES. Although 21.0% of patients died during follow-up, in most cases (93.2%) this was not attributable to PRES but to severe infection (27.3%), underlying disease (26.1%), graft-vs.-host disease (14.8%), multiple organ dysfunction syndrome (8.0%), and respiratory failure (3.4%). PRES was more common with HSCT compared to chemotherapy and had a nearly 2 times higher mortality rate in patients with oncologic/hematologic diseases than in those with other types of disease. Monitoring neurologic signs and symptoms in the former group is therefore critical for ensuring good clinical outcomes following treatment of the primary malignancy.

Noninvasive Cellular Oxygenation Measurement During Graded Hypoxia Using Visible-Near-Infrared Spectroscopy

In critically ill patients, direct knowledge of intracellular pO₂ would allow for identification of cellular hypoxia, which when prolonged leads to organ failure. We have developed a visible-near-infrared optical system that noninvasively measures myoglobin saturation, which is directly related to intracellular pO₂, from the surface of the skin. We used an animal model of graded hypoxia from low levels of inspired oxygen (n = 5) and verified that low intracellular pO₂ is correlated with high steady-state serum lactate values. In addition, the pO₂ gradient between arterial blood and inside muscle cells was 83 mm Hg at 21% O₂, but fell to 24 mm Hg at 8% O₂. Continuous myoglobin saturation measurement in skeletal muscle displayed the same trends as cerebral oxygenation with no lag in changes over time, demonstrating its relevance as a measure of systemic oxygenation.

Early recognition of possible transfusion reactions using an electronic automatic notification system for changes in vital signs in patients undergoing blood transfusions

BACKGROUND

The study was designed to evaluate the ability of a novel electronic automatic notification system (EANS) to detect significant changes in transfusion-associated vital signs (VSs) during transfusion and to determine whether the EANS improved acute transfusion reaction (ATR) detection rates and suspected ATR reporting rates.

STUDY DESIGN AND METHODS

VSs were measured three times per unit or batch product transfused:-before, 15 minutes after commencement, and at the completion of the transfusion-and recorded on the EANS. Significant changes in VSs were defined as increased temperature (≥38°C or ≥1°C change in baseline temperature), 20 mm Hg or 20% increase or decrease in systolic blood pressure, or 20% increase in pulse rate. The 6-month periods preceding and after the introduction of the EANS were defined as "before" and "after." Data from these periods were used for comparison and evaluation.

RESULTS

During the after period, 945 notifications were reported from the EANS and 521 suspected ATR were detected. The suspected ATR reporting rates for the before and after were 0.29% (73/25 213) and 2.06% (521/25 304, P < .001) and the ATR detection rates before and after were 0.13% (33/25 213) and 0.49% (116/25 304, P < .001), respectively. Among 116 ATR cases, 49.1% could be detected only by significant changes in VSs.

CONCLUSION

The EANS was very effective in detecting ATRs that could have been overlooked by medical staff. Further data are needed to demonstrate the extent to which the introduction of an EANS may improve the safety of transfused patients.

Blood transfusion in children at a university hospital in a middle-income country: The need to reinforce adherence to current guidelines

OBJECTIVES

Blood component transfusion is a common procedure used during hospital admissions; however, it is not risk-free. The evaluation of correct use of blood products (BP) is of vast importance considering the risks and costs implied in their use. Our principal objective was to evaluate the adherence to national guidelines for blood transfusion in pediatric patients at a third level university hospital.

MATERIAL AND METHODS

A prospective and retrospective descriptive analytical study was conducted to report the incidence of incorrect use of BP in pediatric patients (1 month to 16 years of age). In a timeline period of 4 years, 579 medical records were randomly selected from a total of 6575 transfusions realized to create a statistically significant sample. The variables studied were volume, infusion time, and transfusion criteria. Indications were evaluated in patient's medical records according to national guidelines.

RESULTS

Of the transfusions analyzed, 54% were classified as incorrect mainly due to lack of transfusion criteria fulfillment. Blood transfusion indications in pediatric patients adhered poorly to national guidelines.

CONCLUSION

The implementation of effective programs for education and information on the use of BP are needed to increase compliance with current guidelines.

Current practices in menstrual management in adolescents with cancer: A national survey of pediatric oncology providers

BACKGROUND

Adolescents and young adult (AYA) women with cancer are at risk of heavy menstrual bleeding (HMB) due to thrombocytopenia, coagulopathy, and/or disruption of the hypothalamic-pituitary-gonadal axis. Currently, little is known about current practices to help prevent and treat HMB in AYA women with cancer.

METHODS

We surveyed providers from 100 pediatric oncology centers. Face and content validity were assessed prior to distribution. Descriptive statistics, Chi-squared and Fisher exact tests were used for analysis.

RESULTS

Ninety-four percent of respondents have recommended preventative menstrual suppression. More than half of respondents agreed that patients with the following types of cancers should receive preventative menstrual suppression: sarcomas, acute leukemias, lymphomas, and germ cell tumors. The most preferred form of menstrual suppression was GnRH agonists. Almost 95% of respondents felt that it is important to consider menstrual suppression and that a formal guideline about initiation of menstrual suppression would be helpful. Only 46% felt comfortable personally managing menstrual suppression.

CONCLUSIONS

The vast majority of pediatric oncologists who responded to this national survey have used preventative menstrual suppression and feel that it is important to consider in many types of AYA cancers. Although pediatric oncologists are most often managing menstrual suppression, they do not feel comfortable doing so and desire guidelines to help with management. Future studies to assess which patients require menstrual suppression and which menstrual suppression is best tolerated and efficacious is needed.

Preoperative Immune Response is Associated with Perioperative Transfusion Requirements in Glioma Surgery

Immunosuppression induced by transfusion causes postoperative adverse events including poor prognosis in cancer, but data on influence of the immune response on blood transfusion requirements during perioperative period are limited. The aim of this study was to investigate whether the preoperative immune response is associated with perioperative blood cell transfusion in a glioma surgical patient population. The authors identified 321 cases of surgery for treatment of glioma. Patient variables, preoperative laboratory variables (hemoglobin, platelet count, activated partial thromboplastin time, prothrombin time, hematocrit, red and white blood cell count), and transfusions were registered. Plasma concentration of Th-associated cytokines was measured by flow cytometry. Multivariable regression analysis and receiver operating characteristic curve were undertaken to identify predictors of transfusion. Of 321 patients, 157 (48.90%) received red blood cells transfusion. The mean age is significantly higher in transfusion group compared to no transfusion group, while postoperative hospital stay, preoperative hemoglobin, prothrombin time, activated partial thromboplastin time, platelet count, red and white blood cell count and hematocrit of patients did not differ significantly between the two groups. No significant differences of IL-2, -4, -6, -10 and INF-γ concentration were observed between transfusion and no transfusion group. The concentration of TNF and IL-17A was significantly lower in transfusion patients than in the no transfusion subjects. Low plasma TNF and IL-17A levels predicted high perioperative transfusion rate, the combination of them enlarged the prognostic accuracy of testing. Our study demonstrates that the preoperative immune response influences transfusion requirements, and TNF and IL-17 are important predictive risk factors for perioperative use of blood components in glioma patients.

Vaccine immune response, autoimmunity and morbidity after neonatal blood exchange transfusion

INTRODUCTION

A blood exchange transfusion (BET) is most commonly performed to treat severe neonatal haemolytic disease. A distinct form of blood transfusion adverse reaction is transfusion-related immunomodulation. The purpose of our retrospective single-centre case-control cohort study was to investigate whether a blood exchange transfusion in the neonatal period provokes immunomodulation and affects humoral immune response to vaccination, morbidity and occurrence of autoantibodies.

METHODS

Study subjects were 74 apparently healthy children, who were born at term as appropriate for gestational age and received four doses of diphtheria and tetanus toxoid vaccine. Forty-one received BET due to neonatal hemolytic disease and no other blood product afterwards, while 33 did not receive any blood products. Analysis of diphtheria, tetanus and autoimmune antibodies was performed and their medical records were analyzed for infectious, allergic, cancerous and autoimmune diseases.

RESULTS

A clearly exaggerated immune response to diphtheria (1.016 IU/mL, 95% confidence interval (CI) 0.662-1.369 IU/mL vs. 0.515 IU/mL, 95% CI 0.363 to 0.626 IU/mL, P = 0.011) and slightly exaggerated immune response to tetanus vaccine (1.798 IU/mL, 95% CI 1.180-2.416 IU/mL vs. 1.036 IU/mL, 95% CI 0.398-1.673 IU/mL, P = non-specific) were observed in BET subjects. A propensity towards autoimmunity (25.8% vs. 12.5%, P = non-specific) was observed in BET subjects. However, BET in the neonatal period did not influence the occurrence of bacterial, childhood viral diseases with exception of varicella (43.9% vs. 21.2%, P = 0.040), autoimmune and cancer diseases.

CONCLUSION

BET impacted humoral immune response to diphtheria and tetanus vaccine and occurrence of autoimmune antibodies, but did not affect morbidity and the occurrence of autoimmune diseases. These effects could be related to massive antigenic load of BET and an accelerated priming of immune cells and consequent immunomodulation.

Comparison of Local Injection of Fresh Frozen Plasma to Traditional Methods of Hemostasis in Minimally Invasive Procedures

RATIONALE AND OBJECTIVES

To evaluate different techniques for reducing hemorrhagic complications in coagulopathic patients with elevated international normalized ratio having an image-guided percutaneous invasive procedure; techniques included systemic transfusion of fresh frozen plasma (FFP), local injection of FFP, percutaneous injection of gelatin sponge, and percutaneous placements of angiographic coils.

MATERIALS AND METHODS

Retrospective review of 232 consecutive patients with known coagulopathy undergoing image-guided minimally invasive procedures were selected. Ninety-one patients had local FFP injected, 40 patients underwent local synthetic gelatin injection, 16 patients had percutaneous coil embolization, and 85 patients received systemic FFP. The number of bleeds, complications related to bleeds, and systemic complications were recorded. A 30 cc threshold was used to delineate significant bleeding.

RESULTS

No patients experienced clinically significant or insignificant bleeding with local FFP injection (P value <.05). Other local hemostatic methods (Gelfoam, systemic FFP, and coil embolization) were associated with higher levels of bleeding (12.5%, 17.1%, 37.5%, respectively) and complications (7.5%, 31.4%, 37.5%, respectively). Systemic FFP infusion was associated with respiratory, infectious, and mortal complications.

CONCLUSIONS

Local injection of blood products provides a safe and efficacious hemostatic agent to reduce the incidence of postprocedural bleeding. The technique is associated with lower rates of bleeding and systemic complications when compared to other local and systemic techniques. Further randomized prospective studies with a larger patient cohort need to be performed to corroborate these initial findings.

Efficacy and safety of ferric carboxymaltose versus ferrous sulfate for iron deficiency anemia during pregnancy: subgroup analysis of Korean women

Background

We performed a post-hoc subgroup analysis in Korean women who participated in the Phase III FER-ASAP (FERric carboxymaltose-Assessment of SAfety and efficacy in Pregnancy) study to compare the efficacy and safety of ferric carboxymaltose (FCM) with oral ferrous sulfate (FS).

Methods

Pregnant Korean women (gestational weeks 16–33) with iron-deficiency anemia (IDA) were randomized 1:1 to FCM (n = 46; 1000–1500 mg iron) or FS (n = 44; 200 mg iron/day) group for 12 weeks. The primary objective was to compare the mean hemoglobin (Hb) increase at week 3; secondary objectives included change in iron parameters, quality of life (QoL), and safety.

Results

Baseline characteristics of the Korean subgroup were consistent with those of non-Korean FER-ASAP population except for lower body-mass index and higher maternal age. Hb level increases were comparable between the two treatment groups in Korean women at week 3 (FCM 1.23 ± 0.89 g/dL vs FS 1.14 ± 1.72 g/dL). Iron parameters improved over time as secondary endpoints were significantly in favor of FCM. In terms of QoL, FCM treatment significantly improved the mental and physical components as well as vitality prior to delivery. Both treatments were well tolerated.

Conclusions

FCM provided significantly greater improvements in iron parameters and QoL compared to FS in the Korean subgroup. FCM may be a preferable alternative to currently available treatments for IDA during pregnancy.

Transfusion Medicine and Molecular Genetic Methods

Transfusion procedures are always complicated by potential genetic mismatching between donor and recipient. Compatibility is determined by several major antigens, such as the ABO and Rhesus blood groups. Matching for other blood groups (Kell, Kidd, Duffy, and MNS), human platelet antigens, and human leukocyte antigens (HLAs) also contributes toward the successful transfusion outcomes, especially in multitransfused or highly immunized patients. All these antigens of tissue identity are highly polymorphic and thus present great challenges for finding suitable donors for transfusion patients. The ABO blood group and HLA markers are also the determinants of transplant compatibility, and mismatched antigens will cause graft rejection or graft-versus-host disease. Thus, a single and comprehensive registry covering all of the significant transfusion and transplantation antigens is expected to become an important tool in providing an efficient service capable of delivering safe blood and quickly locating matching organs/stem cells. This review article is intended as an accessible guide for physicians who care for transfusion-dependent patients. In particular, it serves to introduce the new molecular screening methods together with the biology of these systems, which underlies the tests.

Cell-free nucleic acids are present in blood products and regulate genes of innate immune response

BACKGROUND

Extracellular nucleic acids circulate in plasma. They are expected to be present in manufactured blood products eligible for transfusion, but little is known about their biological activity on human cells. The aim of this study is to investigate whether cell-free nucleic acids (CFNAs) are present and biologically active in red blood cell units (RBCUs), fresh frozen plasmas, and platelet concentrates.

STUDY DESIGN AND METHODS

CFNAs were extracted from RBCUs, fresh frozen plasma, and platelet concentrates. Their nature and structure were analyzed by regular methods of nucleic acid detection/quantification. A normalized polymerase chain reaction combining amplification of a CFNA marker (Alu 115) and amplification of an internal nonhuman DNA control spiked in all samples (phiX 174) was developed to study CFNA release after RBCU storage. The impact of CFNAs on gene regulation was tested by microarray after coculture with peripheral blood mononuclear cells and macrophages.

RESULTS

Extracellular double-stranded DNA was present in all blood products, with higher amounts found in cellular suspensions (RBCUs and platelet concentrates). Storage up to 40 days did not influence release from RBCUs, and CFNA amount varied considerably from one unit to another. Microarray experiments showed that exposition of macrophages to CFNA increased the expression of genes involved in the innate immune response including chemokines, chemokine receptors, and receptors of the innate response.

CONCLUSION

CFNAs are present in blood products. Immunoregulatory properties of CFNA are shown in vitro, providing new insights on biologically active components of blood products besides those for intended therapeutic use.

Transfusion-associated hazards: A revisit of their presentation

As a therapy or a support to other therapies, despite being largely beneficial to patients in general, transfusion it is not devoid of some risks. In a moderate number of cases, patients may manifest adverse reactions, otherwise referred to as transfusion-associated hazards (TAHs). The latest French 2016 haemovigilance report indicates that 93% of TAHs are minor (grade 1), 5.5% are moderate (grade 2) and 1.6% are severe (grade 3), with only five deaths (grade 4) being attributed to transfusion with relative certainty (imputability of level [or grade] 1 to 3). Health-care providers need to be well aware of the benefits and potential risks (to best evaluate and discuss the benefit-risk ratio), how to prevent TAHs, the overall costs and the availability of alternative therapeutic options. In high-income countries, most blood establishments (BEs) and hospital blood banks (HBBs) have developed tools for reporting and analysing at least severe transfusion reactions. With nearly two decades of haemovigilance, transfusion reaction databases should be quite informative, though there are four main caveats that prevent it from being fully efficient: (ai) reporting is mainly declarative and is thus barely exhaustive even in countries where it is mandatory by law; (aii) it is often difficult to differentiate between the different complications related to transfusion, diseases, comorbidities and other types of therapies in patients suffering from debilitating conditions; (aiii) there is a lack of consistency in the definitions used to describe and report some transfusion reactions, their severity and their likelihood of being related to transfusion; and (aiv) it is difficult to assess the imputability of a particular BC given to a patient who has previously received many BCs over a relatively short period of time. When compiling all available information published so far, it appears that TAHs can be analysed using different approaches: (bi) their pathophysiological nature; (bii) their severity; (biii) the onset scheme; (biv) a quality assessment (preventable or non-preventable); (bv) their impact on ongoing therapy. Moreover, TAHs can be reported either in a non-integrative or in an integrative way; in the latter case, presentation may also differ when issued by a blood establishment or a treating ward. At some point, a recapitulative document would be useful to gain a better understanding of TAHs in order to decrease their occurrence and severity and allow decision makers to determine action plans: this is what this review attempts to make. This review attempts to merge the different aspects, with a focus on the hospital side, i.e., how the most frequent TAHs can be avoided or mitigated.

The Non-Hemostatic Aspects of Transfused Platelets

Platelets transfusion is a safe process, but during or after the process, the recipient may experience an adverse reaction and occasionally a serious adverse reaction (SAR). In this review, we focus on the inflammatory potential of platelet components (PCs) and their involvement in SARs. Recent evidence has highlighted a central role for platelets in the host inflammatory and immune responses. Blood platelets are involved in inflammation and various other aspects of innate immunity through the release of a plethora of immunomodulatory cytokines, chemokines, and associated molecules, collectively termed biological response modifiers that behave like ligands for endothelial and leukocyte receptors and for platelets themselves. The involvement of PCs in SARs—particularly on a critically ill patient’s context—could be related, at least in part, to the inflammatory functions of platelets, acquired during storage lesions. Moreover, we focus on causal link between platelet activation and immune-mediated disorders (transfusion-associated immunomodulation, platelets, polyanions, and bacterial defense and alloimmunization). This is linked to the platelets’ propensity to be activated even in the absence of deliberate stimuli and to the occurrence of time-dependent storage lesions.

Adverse Reactions to Transfusion of Blood Products and Best Practices for Prevention

Transfusion, a common practice in critical care, is not without complication. Acute adverse reactions to transfusion occur within 24 hours and include acute hemolytic transfusion reaction, febrile nonhemolytic transfusion reaction, allergic and anaphylactic reactions, and transfusion-related acute lung injury, transfusion-related infection or sepsis, and transfusion-associated circulatory overload. Delayed transfusion adverse reactions develop 48 hours or more after transfusion and include erythrocyte and platelet alloimmunization, delayed hemolytic transfusion reactions, posttransfusion purpura, transfusion-related immunomodulation, transfusion-associated graft versus host disease, and, with long-term transfusion, iron overload. Clinical strategies may reduce the likelihood of reactions and improve patient outcomes.

Frequency and pattern of noninfectious adverse transfusion reactions at a tertiary care hospital in Korea

Background

Although transfusion is a paramount life-saving therapy, there are multiple potential significant risks. Therefore, all adverse transfusion reaction (ATR) episodes require close monitoring. Using the computerized reporting system, we assessed the frequency and pattern of non-infectious ATRs.

Methods

We analyzed two-year transfusion data from electronic medical records retrospectively. From March 2013 to February 2015, 364,569 units of blood were transfused. Of them, 334,582 (91.8%) records were identified from electronic nursing records. For the confirmation of ATRs by blood bank physicians, patients' electronic medical records were further evaluated.

Results

According to the nursing records, the frequency of all possible transfusion-related events was 3.1%. After the blood bank physicians' review, the frequency was found to be 1.2%. The overall frequency of febrile non-hemolytic transfusion reactions (FNHTRs) to red blood cells (RBCs), platelet (PLT) components, and fresh frozen plasmas (FFPs) were 0.9%, 0.3%, and 0.2%, respectively, and allergic reactions represented 0.3% (RBCs), 0.9% (PLTs), and 0.9% (FFPs), respectively. The pre-storage leukocyte reduction significantly decreased the frequency of FNHTRs during the transfusion of RBCs (P<0.01) or PLTs (P≒0.01).

Conclusions

The frequency of FNHTRs, allergic reactions, and "no reactions" were 22.0%, 17.0%, and 60.7%, respectively. Leukocyte-reduction was associated with a lower rate of FNHTRs, but not with that of allergic reactions. The development of an effective electronic reporting system of ATRs is important in quantifying transfusion-related adverse events. This type of reporting system can also accurately identify the underlying problems and risk factors to further the quality of transfusion care for patients.

The infectious risks in blood transfusion as of today - A no black and white situation

Transfusion has been tainted with the risk of contracting an infection - often severe - and fears about this risk are still prevailing, in sharp contrast with the actual risk in Western countries. Those actual risks are rather immunological, technical (overload) or metabolic. Meanwhile, in developing countries and particularly in Africa, transfusion transmitted infections (TTIs) are still frequent, because of both the scarcity of volunteer blood donors and resources and the high incidence and prevalence of infections. Global safety of blood components has been declared as a goal to be attained everywhere by the World Heath Organization (WHO). However, this challenge is difficult to meet because of several intricate factors, of which the emergence of infectious agents, low income and breaches in sanitation and hygiene. This review aims at encompassing the situation of TTIs in different settings and means that can be deployed to improve the situation where this can possibly be.

Role of Leukoreduction of Packed Red Blood Cell Units in Trauma Patients: A Review

Hemorrhagic shock is a leading cause of mortality within the trauma population, and blood transfusion is the standard of care. Leukoreduction filters remove donor leukocytes prior to transfusion of blood products. While the benefits of leukocyte depletion are well documented in scientific literature, these benefits do not translate directly to the clinical setting. This review summarizes current research regarding leukoreduction in the clinical arena, as well as studies performed exclusively in the trauma population.

Transfusion-related acute lung injury: transfusion, platelets and biological response modifiers

Transfusion-related acute lung injury (TRALI) may be induced by plasma, platelet concentrates and red blood cell concentrates. The mechanism leading to TRALI is thought to involve two steps. The priming step consists of previous inflammatory pathological conditions or external factors attracting leukocytes to lung vessels and creating conditions favorable for the second step, in which anti-HLA or anti-HNA antibodies or biologically active lipids, usually in transfused blood products, stress leukocytes and inflame lung epithelia. Platelets may be involved in the pathogenesis of TRALI because of their secretory potential and capacity to interact with other immune cells. There is no drug based-prophylaxis, but transfusion strategies are used to mitigate the risk of TRALI.

Pulmonary Protection Strategies in Cardiac Surgery: Are We Making Any Progress?

Pulmonary dysfunction is a common complication of cardiac surgery. The mechanisms involved in the development of pulmonary dysfunction are multifactorial and can be related to the activation of inflammatory and oxidative stress pathways. Clinical manifestation varies from mild atelectasis to severe respiratory failure. Managing pulmonary dysfunction postcardiac surgery is a multistep process that starts before surgery and continues during both the operative and postoperative phases. Different pulmonary protection strategies have evolved over the years; however, the wide acceptance and clinical application of such techniques remain hindered by the poor level of evidence or the sample size of the studies. A better understanding of available modalities and/or combinations can result in the development of customised strategies for the different cohorts of patients with the potential to hence maximise patients and institutes benefits.