TACO and TRALI: biology, risk factors, and prevention strategies

Prehospital Whole Blood Administration Not Associated with Increased Transfusion Reactions: The Experience of a Metropolitan EMS Agency

OBJECTIVES

Low titer O+ whole blood (LTO+WB) has been shown to improve outcomes in trauma patients and use is increasingly common. Studies on prehospital use and efficacy have been published throughout the literature, but few of these fully address the risks of transfusion reactions and other side effects. The focus of this study is to look at prehospital LTO+WB transfusions in trauma patients and review for transfusion reactions.

METHODS

This was a retrospective review of consecutive trauma patients who received prehospital LTO+WB over a 4.5-year period. We used EMS agency transfusion records and institutional blood bank data from two urban level I trauma centers for records on blood transfusion reactions. Excluded from the study were patients declared dead on arrival to the hospital, patients transfused for non-traumatic complaints, patients for whom hospital records were unavailable, and any transfusion reaction that occurred more than 10 days after the prehospital transfusion. Descriptive statistics were used for data analysis.

RESULTS

Of 1126 prehospital transfusions 572 met inclusion criteria. There were 2 (0.35%) suspected transfusion reactions, none of which were determined to be hemolytic reactions. There was 1 febrile non-hemolytic reaction on hospital day 1 and there was 1 allergic reaction with hives and shortness of breath that occurred on hospital day 1.

CONCLUSIONS

Prehospital LTO+WB is safe to use and has a similar rate of transfusion reaction as when given in-hospital. Concerns about transfusion reactions caused by LTO+WB should not preclude its use prehospital. Regardless of the low incidence of transfusion reactions, prehospital personnel should be trained in their recognition and management. Limitations include retrospective study design and the inability to distinguish transfusion reactions from prehospital LTO+WB versus reaction to blood products transfused at the trauma center.

An in silico simulation of the frequency of administering HLA-incompatible low titer group O whole blood units when the donor pool includes unscreened female donors

BACKGROUND

As low titer group O whole blood (LTOWB) increases in popularity, blood centers are finding innovative ways of maintaining the supply. One potential way is collecting LTOWB from parous female donors without testing for HLA antibodies. This in silico simulation predicted the risk of an LTOWB unit containing an HLA antibody and the subsequent risk for an HLA-incompatible transfusion.

METHODS

An LTOWB blood bank with 1 million units was simulated consisting of male, nulliparous, and parous female donors. The proportion of each donor type was modeled after the sex distribution at US blood centers. The parity of female donors was calculated based on the average number of live births per female depending on her age. HLA-alloimmunization risk was determined by her parity status. The HLA haplotypes of the simulated recipients were derived from the 100 most common HLA haplotypes in the US National Marrow Registry Program database. The proportion of different race/ethnic groups in the US was used to simulate 100,000 LTOWB recipients to whom between 1 and 10 units were administered.

RESULTS

Overall, the risk of an LTOWB unit containing at least one HLA antibody was 12.2% and the rate of receiving an HLA-incompatible unit was 21.3%. The risk of receiving an HLA-incompatible unit rose from 4.8% after receipt of one unit to 36.5% after 10 units.

CONCLUSION

Blood collectors and hospitals should evaluate the potential TRALI risk against the benefit of a potentially expanded inventory of LTOWB before collecting plasma-containing products from non-HLA-tested parous female donors.

[Red Blood Cell Transfusion - Indications, Informed Consent and Associated Risks]

The aim of red blood cell (RBC) transfusion is to prevent or treat anemic tissue hypoxia in acute or chronic anemia. In 2022, approximately 3.2 million red blood cell transfusions were conducted in Germany. Most blood products are transfused in surgical medicine. RBC units should be used appropriately, based on recent evidence about their indications, profound knowledge on handling, correct documentation as well as possible associated risks of transfusion-associated adverse events and their respective treatments. Blood loss in particular increases the risk of an imbalance between oxygen supply and oxygen demand. Targeted, rational (restrictive) blood transfusion based on physiological transfusion triggers makes it possible to avoid organ injury due to anemic hypoxia.

Nonlinear relationship between Hemoglobin-to-Age Ratio and all-cause mortality in patients with septic shock: A retrospective cohort study in the MIMIC-IV database

BACKGROUND

Previous studies have shown that both age and hemoglobin are closely associated with the prognosis of septic shock. A recent study found that hemoglobin may change with age. Hemoglobin-to-Age Ratio (HAR) takes both age and hemoglobin into consideration as essential factors. So far, the effect of HAR on the prognosis of septic shock is still unclear. This research aimed to investigate the association between the HAR and the prognosis of patients with septic shock.

METHODS

Cox proportional hazards regression analysis, restricted cubic spline, Kaplan-Meier survivor analysis and stratified interaction analysis were used to elucidate the relationship between the HAR and prognosis of patients with septic shock.

RESULTS

There is a nonlinear association between the HAR and mortality within 28 days after intensive care unit admission. When the HAR was lower than 0.13, mortality within 28 days after ICU admission decreased significantly as the HAR increased. When the HAR was higher than 0.13, the HAR was not a protective factor for mortality within 28 days after ICU admission. In patients with septic shock, the HAR was more effective in reducing the risk of death in patients with atrial fibrillation than in patients without atrial fibrillation.

CONCLUSION

There is a nonlinear association between the HAR and mortality within 28 days after intensive care unit admission. When the HAR was at a low level, mortality within 28 days after ICU admission decreased significantly as the HAR increased. When the HAR was at high levels, the HAR might not be a protective factor for mortality within 28 days after ICU admission. In patients with septic shock, the HAR was more effective in reducing the risk of death in patients with atrial fibrillation than in patients without atrial fibrillation.

Successful implementation of a patient blood management programme in a lower middle-income state

BACKGROUND AND OBJECTIVES

Transfusions are common, but their use is decreasing in some countries as a result of increased risk awareness and the implementation of patient blood management (PBM), an evidence-based approach to optimize patient outcomes. This study aimed to detail the implementation of PBM in a Brazilian state and its impact on transfusion rates and associated costs.

MATERIALS AND METHODS

The PBM implementation involved several strategies: medical education, haematology consultation services, provision of intravenous iron and other medications, establishment of PBM and perioperative anaemia clinics, cell salvage and acute normovolaemic haemodilution, anaemia reference laboratories and rotational thromboelastometry. The program's implementation was assessed through quality indicators and cost analysis.

RESULTS

Since 2016, there have been reductions in transfusion rates, mainly in red blood cell (RBC) transfusion. Quality indicators showed an increase in single-RBC transfusions from 53% in December 2015 to 85.9% in June 2024 and a decrease in transfusions for patients with Hb ≥7 g/dL from 5.9% in March 2021 to 2.7% in May 2024. The PBM programme led to an estimated annual cost saving of R$2.63 million (US $487,000), if considered RBC direct costs, and from R$9.69 million to R$16.145 million (US $1.79-$2.99 million) in activity-based costs, considering only the reduction in RBC transfusions.

CONCLUSION

The PBM programme in Ceará successfully reduced transfusion rates and associated costs through a multidisciplinary approach, medical education and government support. This model demonstrates the potential for significant healthcare improvements and cost savings and can serve as a benchmark for other regions and countries, especially in low- and middle-income settings.

Transfusion-related acute lung injury/transfusion-associated circulatory overload in a child with non-transfusion dependent thalassemia and aplastic crisis due to acute parvovirus B19 infection

We present a never-transfused girl with thalassemia intermedia who was admitted for febrile aplastic crisis due to human parvovirus B19. After a first transfusion of packed red blood cells, she developed pulmonary oedema. She improved with supportive care including the use of intravenous diuretics. Due to severe anaemia, she received a second blood transfusion, antibiotics for febrile neutropenia and intravenous γ globulin for control of the parvovirus infection. She had an uneventful recovery. The first of her male blood donors had an antibody against a patient's human leukocyte antigens type II antigen with a high mean fluorescent intensity. Our patient had clinical features and supportive laboratory evidence for mild transfusion-related acute lung injury (TRALI). However, she also met the criteria for transfusion-associated circulatory overload (TACO). We conclude that our patient likely suffered from TRALI/TACO, a consensus term proposed in 2019 for patients in whom TRALI cannot be distinguished from TACO or in whom both conditions occur simultaneously.

Developments in Transfusion Medicine: Pulmonary Transfusion Reactions and Novel Blood Cell Labeling Techniques

Staying updated on advancements in transfusion medicine is crucial, especially in critical care and perioperative setting, where timely and accurate transfusions can be lifesaving therapeutic interventions. This narrative review explores the landscape of transfusion-related adverse events, focusing on pulmonary transfusion reactions such as transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI). TACO and TRALI are the leading causes of transfusion-related morbidity and mortality; however, specific treatments are lacking. Understanding the current incidence, diagnostic criteria, pathogenesis, treatment, and prevention strategies can equip clinicians to help reduce the incidence of these life-threatening complications. The review discusses emerging pathogenic mechanisms, including the possible role of inflammation in TACO and the mechanisms of reverse TRALI and therapeutic targets for TACO and TRALI, emphasizing the need for further research to uncover preventive and treatment modalities. Despite advancements, significant gaps remain in our understanding of what occurs during transfusions, highlighting the necessity for improved monitoring methods. To address this, the review also presents novel blood cell labeling techniques in transfusion medicine used for improving monitoring, quality assessment, and as a consequence, potentially reducing transfusion-related complications. This article aims to provide an update for anesthesiologists, critical care specialists, and transfusion medicine professionals regarding recent advancements and developments in the field of transfusion medicine.

Transfusion-related acute lung injury (TRALI) following intravenous immunoglobulin infusion in a rituximab immunosuppressed patient with long-shedding SARS-CoV-2

BACKGROUND

Transfusion-related acute lung injury (TRALI) is a rare life-threatening complication of blood product transfusion. Intravenous immunoglobulin (IVIG)-related TRALI is scarcely reported.

CASE PRESENTATION

A 63-year-old male patient suffering from multiple sclerosis treated with half-yearly rituximab infusions, was hospitalized due to dry cough, daily fever and shivering for seven days despite antibiotic therapy. Because of the history of COVID-19 one month prior without the symptoms having improved since, persistent bilateral multifocal areas of ground glass opacities in chest computed tomography and positive SARS-CoV-2 PCR from bronchoalveolar lavage with a cycling time of 30.1 COVID-19 due to long-shedding SARS-CoV-2 under immunosuppression with rituximab was diagnosed. He received treatment with nirmatrelvir und ritonavir and because of diagnosed IgG deficiency additionally a single dose of 20 g IVIG. During the IVIG infusion, the patient acutely developed tachycardia, hypotension, fever, chills, and hypoxemic respiratory failure due to pulmonary edema. TRALI was promptly diagnosed, and the patient was transferred to the intensive care unit for non-invasive ventilation for less than 24 h. The patient was discharged home from regular ward 72 h later in a good general condition and no remaining symptoms of TRALI.

CONCLUSION

IVIG-related TRALI is a rare but life-threating condition and prompt recognition is lifesaving. Due to an increased use of IVIG not only in long-shedding SARS-CoV-2, an increase of TRALI incidence is expected.

Transfusion-related acute lung injury and treatment with high-flow oxygen therapy in a pediatric patient: a case report

Transfusion-Related Acute Lung Injury (TRALI) is an immune-inflammatory lung pathology that manifests within the first 6-72 hours after administration of blood products. However, due to reduced awareness of TRALI, it continues to be an underreported and often underdiagnosed complication of transfusion therapy. We report a case of a 6-year-old girl with myelodysplastic syndrome and TRALI developed in the first hour after platelet transfusion. Diagnosis of TRALI is based on the exclusion of etiologic factors such as volume overload and cardiogenic pulmonary edema following transfusion. Symptoms responded to high-flow oxygen therapy, so intubation was not attempted and full recovery was achieved.

Objective indexes for comparing platelet usage among peer hospitals during the COVID-19 pandemic: A cross-sectional study

Background and Aims

Besides hospital size, clinical diagnosis and severity of patient cases determine the total platelet usage. Therefore, the appropriateness of platelet usage could not be compared simply with the total units of platelet usage in each hospital. This study aimed to objectively monitor and analyze platelet usage after implementing a single-unit issuing policy for each platelet transfusion in our hospital in October 2020.

Materials and Methods

We used three objective indices, X, Y, and Z, to monitor platelet usage and compared it with other hospitals. Three indices were generated by dividing the annual total units of platelet usage by the total annual reimbursement, total number of admissions, and average total reimbursement per admission for each hospital.

Results

The new indices X and Y alleviated hospital size-dependent differences. Index Y was preferred over X because its value fluctuated less during the COVID-19 pandemic. The Z index was adjusted for the average total reimbursement per admission, and the results showed that more patients with higher disease complexity did not have increased platelet usage during the COVID-19 pandemic. In our hospital (H1), index Z decreased from 2019 to 2021 due to a policy of issuing a single unit for each platelet transfusion.

Conclusion

These three objective indices are suitable for peer comparison and monitoring platelet usage in hospitals, irrespective of their size. They could be applied to promote patient blood management and provide an early response to the gradual shortage of blood resources owing to the aging population and declining birth rate in Taiwan.

Experiences in the use of multiple doses of convalescent plasma in critically ill patients with COVID-19: An early phase 1 descriptive study

Background

At the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, transfusion of coronavirus disease 2019 (COVID-19) convalescent plasma (CCP) emerged as a potential therapeutic strategy to help patients severely afflicted by COVID-19. The efficacy of CCP has been controversial as it depends on many variables pertaining to the plasma donor and the patient with COVID-19, for example, time of convalescence or symptoms onset. This feasibility and descriptive study aimed to assess the safety of multiple doses of CCP in mechanically ventilated, intubated patients with respiratory failure due to COVID-19.

Methods

A cohort of 30 patients all experiencing severe respiratory failure and undergoing invasive mechanical ventilation in an intensive care unit, received up to five doses of 300-600 mL of CCP on alternate days (0, 2, 4, 6, and 8) until extubation, futility, or death.

Results

Nineteen patients received five doses, seven received four, and four received two or three doses. At 28-day follow-up mark, 57% of patients recovered and were sent home, and the long-term mortality rate was 27%. Ten severe adverse events reported in the study were unrelated to CCP transfusion. Independent of the number of transfused doses, most patients had detectable levels of total and neutralizing antibodies in plasma.

Conclusion

This study suggests that transfusion of multiple doses of CCP is safe. This strategy may represent a viable option for future studies, given the potential benefit of CCP transfusions during the early stages of infection in unvaccinated populations and in settings where monoclonal antibodies or antivirals are contraindicated or unavailable.

Incidence and Role of Recipient-Specific Antibodies in Allogeneic Hematopoietic Cell Transplantation from Mismatched Related Donors

High titer of donor-specific antibodies (DSAs) increases the risk of graft rejection after mismatched related hematopoietic cell transplantation (HCT). There are no data regarding the incidence of anti-HLA recipient-specific antibodies (RSAs) and their role after transplantation. Here we aimed to identify the incidence of RSAs in a mismatched related hematopoietic cell donor population and their possible impact on immune-mediated complications, such as acute graft-versus-host disease (aGVHD), and complications resulting from endothelial injury, such as transplantation-associated thrombotic microangiopathy (TA-TMA) and veno-occlusive disease (VOD). We prospectively analyzed the incidence of anti-HLA antibodies in 28 mismatched related pairs of recipients and their donors who underwent HCT at our center between 2020 and 2022. In positive samples screened for anti-HLA class I and/or II antibodies, the specificity of the HLA antibodies was analyzed. All recipients had a hematologic malignancy and received a myeloablative conditioning regimen and immunosuppression consisting of post-transplantation cyclophosphamide, tacrolimus, and mycophenolate mofetil. Patients were tested for TA-TMA and aGVHD development during routine post-transplantation visits up to 100 days post-transplantation. We used modified Jodele criteria for TA-TMA diagnosis, and based aGVHD grading on the MAGIC criteria. VOD was assessed using the European Society for Blood and Marrow Transplantation. Anti-HLA antibodies were detected in 12 donors (43%) and in 9 recipients (32%). There were no significant differences between donors and recipients according to age (median, 42 years [range, 17 to 69 years] versus 39 years [range, 8 to 68 years]), sex, or pregnancy history. No transfusion history was noted in the donor group (P < .05). RSA antibodies were present more often than DSAs and were detected in 9 out of 12 (75%) anti-HLA-positive donors and in only 2 out of 9 (22%) recipients, respectively (P < .05). During the follow-up, 11 patients (39%) developed aGVHD, including grade I-II in 9 (32%) and grade III-IV in 2 (7%). Twelve patients (43%) met the criteria for TA-TMA, and only 1 patient (3.5%) was diagnosed with VOD by day 100 post-HCT. RSAs were detected significantly more often in the TA-TMA group; among 12 patients diagnosed with TA-TMA, 7 (58%) had RSAs (P < .05). We did not find a correlation between RSAs and aGVHD. The patient with VOD did not have an RSA-positive donor. There was no difference in membrane attack complex (MAC) concentration in the RSA-positive group on day 30 and day 60 post-HCT; however, there was a trend toward higher MAC concentration in the RSA-positive group on day 100 (median, 912 ng/mL [range, 788 to 1120 ng/mL] versus 616 ng/mL [range, 352 to 1244 ng/mL]; P = .055). Patients with RSA suffered more often from platelet and red blood cell decreases or transfusion refractoriness, and increased lactate dehydrogenase activity was observed in all RSA-positive cases. The donor immune status and the presence of RSA may be associated with higher rates of TA-TMA in mismatched HCT recipients. Antibody-mediated complement activation might be an additional factor influencing TA-TMA occurrence.

Clinical outcomes in hospitalized plasma and platelet transfusion recipients prior to and following widespread blood donor SARS-CoV-2 infection and vaccination

BACKGROUND

The safety of transfusion of SARS-CoV-2 antibodies in high plasma volume blood components to recipients without COVID-19 is not established. We assessed whether transfusion of plasma or platelet products during periods of increasing prevalence of blood donor SARS-CoV-2 infection and vaccination was associated with changes in outcomes in hospitalized patients without COVID-19.

METHODS

We conducted a retrospective cohort study of hospitalized adults who received plasma or platelet transfusions at 21 hospitals during pre-COVID-19 (3/1/2018-2/29/2020), COVID-19 pre-vaccine (3/1/2020-2/28/2021), and COVID-19 post-vaccine (3/1/2021-8/31/2022) study periods. We used multivariable logistic regression with generalized estimating equations to adjust for demographics and comorbidities to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Among 21,750 hospitalizations of 18,584 transfusion recipients without COVID-19, there were 697 post-transfusion thrombotic events, and oxygen requirements were increased in 1751 hospitalizations. Intensive care unit length of stay (n = 11,683) was 3 days (interquartile range 1-5), hospital mortality occurred in 3223 (14.8%), and 30-day rehospitalization in 4144 (23.7%). Comparing the pre-COVID, pre-vaccine and post-vaccine study periods, there were no trends in thromboses (OR 0.9 [95% CI 0.8, 1.1]; p = .22) or oxygen requirements (OR 1.0 [95% CI 0.9, 1.1]; p = .41). In parallel, there were no trends across study periods for ICU length of stay (p = .83), adjusted hospital mortality (OR 1.0 [95% CI 0.9-1.0]; p = .36), or 30-day rehospitalization (p = .29).

DISCUSSION

Transfusion of plasma and platelet blood components collected during the pre-vaccine and post-vaccine periods of the COVID-19 pandemic was not associated with increased adverse outcomes in transfusion recipients without COVID-19.

Short-Term Mortality Among Pediatric Patients With Heart Diseases Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation serves as a crucial mechanical circulatory support for pediatric patients with severe heart diseases, but the mortality rate remains high. The objective of this study was to assess the short-term mortality in these patients.

METHODS AND RESULTS

We systematically searched PubMed, Embase, and Cochrane Library for observational studies that evaluated the short-term mortality of pediatric patients undergoing veno-arterial extracorporeal membrane oxygenation. To estimate short-term mortality, we used random-effects meta-analysis. Furthermore, we conducted meta-regression and binomial regression analyses to investigate the risk factors associated with the outcome of interest. We systematically reviewed 28 eligible references encompassing a total of 1736 patients. The pooled analysis demonstrated a short-term mortality (defined as in-hospital or 30-day mortality) of 45.6% (95% CI, 38.7%-52.4%). We found a significant difference (P<0.001) in mortality rates between acute fulminant myocarditis and congenital heart disease, with acute fulminant myocarditis exhibiting a lower mortality rate. Our findings revealed a negative correlation between older age and weight and short-term mortality in patients undergoing veno-arterial extracorporeal membrane oxygenation. Male sex, bleeding, renal damage, and central cannulation were associated with an increased risk of short-term mortality.

CONCLUSIONS

The short-term mortality among pediatric patients undergoing veno-arterial extracorporeal membrane oxygenation for severe heart diseases was 45.6%. Patients with acute fulminant myocarditis exhibited more favorable survival rates compared with those with congenital heart disease. Several risk factors, including male sex, bleeding, renal damage, and central cannulation contributed to an increased risk of short-term mortality. Conversely, older age and greater weight appeared to be protective factors.

Extracorporeal Membrane Oxygenation Patient Outcomes Following Restrictive Blood Transfusion Protocol

OBJECTIVES

To investigate the effect of a restrictive blood product utilization protocol on blood product utilization and clinical outcomes.

DESIGN

We retrospectively reviewed all adult extracorporeal membrane oxygenation (ECMO) patients from January 2019 to December 2021. The restrictive protocol, implemented in March 2020, was defined as transfusion of blood products for a hemoglobin level less than 7, platelet levels less than 50, and/or fibrinogen levels less than 100. Subgroup analysis was performed based on the mode of ECMO received: venoarterial ECMO, venovenous ECMO, and ECMO support following extracorporeal cardiopulmonary resuscitation (ECPR).

SETTING

M Health Fairview University of Minnesota Medical Center.

PATIENTS

The study included 507 patients.

INTERVENTIONS

One hundred fifty-one patients (29.9%) were placed on venoarterial ECMO, 70 (13.8%) on venovenous ECMO, and 286 (56.4%) on ECPR.

MEASUREMENTS AND MAIN RESULTS

For patients on venoarterial ECMO (48 [71.6%] vs. 52 [63.4%]; p = 0.374), venovenous ECMO (23 [63.9%] vs. 15 [45.5%]; p = 0.195), and ECPR (54 [50.0%] vs. 69 [39.2%]; p = 0.097), there were no significant differences in survival on ECMO. The last recorded mean hemoglobin value was also significantly decreased for venoarterial ECMO (8.10 [7.80-8.50] vs. 7.50 [7.15-8.25]; p = 0.001) and ECPR (8.20 [7.90-8.60] vs. 7.55 [7.10-8.88]; p < 0.001) following implementation of the restrictive transfusion protocol.

CONCLUSIONS

These data suggest that a restrictive transfusion protocol is noninferior to ECMO patient survival. Additional, prospective randomized trials are required for further investigation of the safety of a restrictive transfusion protocol.

CE: Recognizing Transfusion-Associated Circulatory Overload

ABSTRACT

Transfusion-associated circulatory overload (TACO) is the leading cause of transfusion-related deaths in the United States, accounting for more than 30% of fatalities reported to the Food and Drug Administration between 2016 and 2020. However, TACO is widely considered to be an underdiagnosed and underreported complication of blood transfusions, and its exact incidence is unknown. One of the reasons for this is a lack of recognition of TACO and its signs and symptoms, especially as the definition of TACO has been updated twice since 2018 without full dissemination to nurses, who are responsible for bedside care of patients during and following blood transfusions. This article seeks to bridge this gap by discussing the updated definitions and signs and symptoms of TACO, as well as the management of this treatable blood transfusion reaction.

Convalescent plasma therapy in critically İll COVID-19 patients: A retrospective cohort study

Background

Convalescent plasma (CP) therapy can be defined as a passive immunity transfer approach involving the administration of plasma for therapeutic purposes to inpatients hospitalized due to an active virus infection. Passive immunity antibodies can reduce target organ damage and directly neutralize the responsible pathogens. A limited number of studies on the use of CP have reported that critically ill patients can benefit from CP therapy.

Aim

We aimed in this study as the outcomes of CP therapy in critically ill coronavirus disease 2019 (COVID-19) patients in intensive care unit (ICU) and determine the differences between the recovery and mortality groups.

Patients and Methods

This retrospective design study involved critically ill patients who were diagnosed with COVID-19 pneumonia or who were suspected of having COVID-19 in the ICU between April 1, 2020, and June 1, 2020. Comorbidity of patients, respiratory findings, hemodynamic data, laboratory data, and poor prognostic measures were compared between mortality and recovery group.

Results

Convalescent plasma (CP) therapy was supplied for 41 (13.58%) patients in total of 302 COVID-19 patients. Twenty-nine patients were died in total of 41 COVID-19 patients who supplied CP therapy. The mortality rate is 70.73% in CP therapy. There was a significantly higher incidence (P < 0.021) of invasive mechanical ventilation (IMV) and significantly lower mean arterial pressure (MAP) values in mortality group (P < 0.05). There were significantly higher NLR values (P < 0.05), lower platelet count (P < 0.05), lower of glomerular filtration rate (GFR) level (P < 0.05), higher creatinine values (P < 0.05), higher lactate dehydrogenase (LDH) levels (P < 0.05), higher D-dimer levels (P < 0.05), higher level of pro-brain natriuretic peptide (BNP) (P = 0.000), rate of fever (P = 0.031), arrythmia (P = 0.024), and transfusion-associated circulatory overload (TACO) (P = 0.008) were more often in mortality group.

Conclusion

Convalescent plasma therapy seems not useful in critically ill COVID-19 patients.

Extracellular vesicles: effectors of transfusion-related acute lung injury

Respiratory transfusion reactions represent some of the most severe adverse reactions related to receiving blood products. Of those, transfusion-related acute lung injury (TRALI) is associated with elevated morbidity and mortality. TRALI is characterized by severe lung injury associated with inflammation, pulmonary neutrophil infiltration, lung barrier leak, and increased interstitial and airspace edema that cause respiratory failure. Presently, there are few means of detecting TRALI beyond clinical definitions based on physical examination and vital signs or preventing/treating TRALI beyond supportive care with oxygen and positive pressure ventilation. Mechanistically, TRALI is thought to be mediated by the culmination of two successive proinflammatory hits, which typically comprise a recipient factor (1st hit-e.g., systemic inflammatory conditions) and a donor factor (2nd hit-e.g., blood products containing pathogenic antibodies or bioactive lipids). An emerging concept in TRALI research is the contribution of extracellular vesicles (EVs) in mediating the first and/or second hit in TRALI. EVs are small, subcellular, membrane-bound vesicles that circulate in donor and recipient blood. Injurious EVs may be released by immune or vascular cells during inflammation, by infectious bacteria, or in blood products during storage, and can target the lung upon systemic dissemination. This review assesses emerging concepts such as how EVs: 1) mediate TRALI, 2) represent targets for therapeutic intervention to prevent or treat TRALI, and 3) serve as biochemical biomarkers facilitating TRALI diagnosis and detection in at-risk patients.

Novel computational methods on electronic health record yields new estimates of transfusion-associated circulatory overload in populations enriched with high-risk patients

BACKGROUND

Transfusion-associated circulatory overload (TACO) is a severe adverse reaction (AR) contributing to the leading cause of mortality associated with transfusions. As strategies to mitigate TACO have been increasingly adopted, an update of prevalence rates and risk factors associated with TACO using the growing sources of electronic health record (EHR) data can help understand transfusion safety.

STUDY DESIGN AND METHODS

This retrospective study aimed to provide a timely and reproducible assessment of prevalence rates and risk factors associated with TACO. Novel natural language processing methods, now made publicly available on GitHub, were developed to extract ARs from 3178 transfusion reaction reports. Other patient-level data were extracted computationally from UCSF EHR between 2012 and 2022. The odds ratio estimates of risk factors were calculated using a multivariate logistic regression analysis with case-to-control matched on sex and age at a ratio of 1:5.

RESULTS

A total of 56,208 patients received transfusions (total 573,533 units) at UCSF during the study period and 102 patients developed TACO. The prevalence of TACO was estimated to be 0.2% per patient (102/total 56,208). Patients with a history of coagulopathy (OR, 1.36; 95% CI, 1.04-1.79) and transplant (OR, 1.99; 95% CI, 1.48-2.68) were associated with increased odds of TACO.

DISCUSSION

While TACO is a serious AR, events remained rare, even in populations enriched with high-risk patients. Novel computational methods can be used to find and continually surveil for transfusion ARs. Results suggest that patients with history or presence of coagulopathy and organ transplant should be carefully monitored to mitigate potential risks of TACO.

Transfusion-related acute lung injury under general anesthesia successfully treated with extracorporeal membrane oxygenation: A case report

Transfusion-related acute lung injury (TRALI) is a serious complication of blood transfusion and can also develop severe hypoxemia. In TRALI cases with difficult blood oxygenation on mechanical ventilation support, temporary veno-venous extracorporeal membrane oxygenation support appears to maintain oxygen levels.

Severe COVID-19: Drugs and Clinical Trials

By January of 2023, the COVID-19 pandemic had led to a reported total of 6,700,883 deaths and 662,631,114 cases worldwide. To date, there have been no effective therapies or standardized treatment schemes for this disease; therefore, the search for effective prophylactic and therapeutic strategies is a primary goal that must be addressed. This review aims to provide an analysis of the most efficient and promising therapies and drugs for the prevention and treatment of severe COVID-19, comparing their degree of success, scope, and limitations, with the aim of providing support to health professionals in choosing the best pharmacological approach. An investigation of the most promising and effective treatments against COVID-19 that are currently available was carried out by employing search terms including "Convalescent plasma therapy in COVID-19" or "Viral polymerase inhibitors" and "COVID-19" in the Clinicaltrials.gov and PubMed databases. From the current perspective and with the information available from the various clinical trials assessing the efficacy of different therapeutic options, we conclude that it is necessary to standardize certain variables-such as the viral clearance time, biomarkers associated with severity, hospital stay, requirement of invasive mechanical ventilation, and mortality rate-in order to facilitate verification of the efficacy of such treatments and to better assess the repeatability of the most effective and promising results.

Usefulness of palliative radiotherapy in reducing the frequency of red blood cell transfusion in patients with malignant tumor bleeding

Objective

We aimed to evaluate the usefulness of palliative radiotherapy in reducing the frequency of red blood cell (RBC) transfusions in patients with malignant tumor bleeding as a quantitative value to evaluate the hemostatic effect.

Materials and Methods

In this study, we conducted a retrospective review of patients visiting our department between June 2013 and April 2021. All patients underwent RBC transfusions for 30 days before the initiation of radiotherapy. We determined the overall survival (OS) time and RBC transfusion-free (RBCTF) time using statistical tests.

Results

In total, 21 patients were enrolled in our study, including 13 women and 8 men; the median patient age was 63 years (range: 32-82 years). After radiotherapy, 19 of the 21 patients had a decreased frequency of requirement for RBC transfusion compared to that before radiotherapy. Fourteen patients had achieved an RBCTF state 1 month after radiotherapy. The estimated 1-year OS and RBCTF rates were 36.3% (95% confidence interval [CI]: 14.2%) and 66.7% (95% CI: 42.5%-42.5%), respectively.

Conclusion

The present study revealed a reduction in RBC transfusion after palliative radiotherapy in patients with malignant tumor bleeding. We believe that reducing the frequency of blood transfusions in patients with terminal conditions would have significant clinical benefits.

Transfusion-Related Acute Lung Injury in an Alcoholic Hepatic Cirrhosis Patient: A Case Report

Transfusion-related acute lung injury (TRALI) is one of the leading causes of transfusion-related mortality in the United States. It is a rare, potentially fatal complication of blood product transfusion, often seen in one in 5000 transfusion cases. On average, studies show a reported estimated fatality rate of 5-24% with a mortality rate of 12%. In the US, TRALI has been responsible for 30% of transfusion-related deaths. In this report, we discuss a case of a 51-year female with a past medical history of alcohol dependence and depression who presented complaining of dizziness and lightheadedness for 1 week. Subsequent diagnostic assessment and therapeutic interventions included various imaging studies, serial hematological evaluations, and eventual administration of blood transfusions, intravenous corticosteroids, supplemental oxygenation, and diuresis for clinical management. The occurrence of TRALI is often underreported due to a lack of timely recognition resulting in delayed treatment. Overall, we were able to not only diagnose TRALI in this patient but also effectively comprehend the significance of guiding appropriate management strategies due tohuman leukocyte antigen (HLA) TRALI-mediating antibodies to potentially reduce the overall incidence of such transfusion reactions.

Noninfectious Pulmonary Complications after Hematopoietic Stem Cell Transplantation

Pulmonary complications after hematopoietic stem cell transplantation (HSCT) are important sources of morbidity and mortality. Improvements in infection-related complications have made noninfectious pulmonary complications an increasingly significant driver of transplantation-related mortality. Broadly, these complications can be characterized as either early or late complications, with idiopathic pneumonia syndrome and bronchiolitis obliterans syndrome the most prevalent early and late complications, respectively. Outcomes with historical treatment consisting mainly of corticosteroids are often poor, highlighting the need for a deeper understanding of these complications' underlying disease biology to guide the adoption of novel therapies that are being increasingly used in the modern era.

A systematic review of the safety and efficacy of convalescent plasma or immunoglobulin treatment for people with severe respiratory viral infections due to coronaviruses or influenza

OBJECTIVE

Evaluate the safety and effectiveness of convalescent plasma (CP) or hyperimmune immunoglobulin (hIVIG) in severe respiratory disease caused by coronaviruses or influenza, in patients of all ages requiring hospital admission.

METHODS

We searched multiple electronic databases for all publications to 12th October 2020, and RCTs only to 28th June 2021. Two reviewers screened, extracted, and analysed data. We used Cochrane ROB (Risk of Bias)1 for RCTs, ROBINS-I for non-RCTs, and GRADE to assess the certainty of the evidence.

RESULTS

Data from 30 RCTs and 2 non-RCTs showed no overall difference between groups for all-cause mortality and adverse events in four comparisons. Certainty of the evidence was downgraded for high ROB and imprecision. (1) CP versus standard care (SoC) (20 RCTS, 2 non-RCTs, very-low to moderate-high certainty); (2) CP versus biologically active control (6 RCTs, very-low certainty); (3) hIVIG versus SoC (3 RCTs, very-low certainty); (4) early CP versus deferred CP (1 RCT, very-low certainty). Subgrouping by titre improved precision in one outcome (30-day mortality) for the 'COVID high-titre' category in Comparison 1 (no difference, high certainty) and Comparison 2 (favours CP, very-low certainty). Post hoc analysis suggests a possible benefit of CP in patients testing negative for antibodies at baseline, compared with those testing positive.

CONCLUSION

A minimum titre should be established and ensured for a positive biological response to the therapy. Further research on the impact of CP/hIVIG in patients who have not yet produced antibodies to the virus would be useful to target therapies at groups who will potentially benefit the most.

Restrictive and liberal transfusion strategies in extracorporeal membrane oxygenation: A retrospective observational study

BACKGROUND

To compare the outcomes of patients requiring extracorporeal membrane oxygenation (ECMO) support who had a restrictive transfusion strategy with those who had a liberal strategy.

STUDY DESIGN AND METHODS

We retrospectively reviewed all adult patients from 2010 to 2019 who received a minimum of one packed red blood cell (pRBC) during ECMO. Hemoglobin values before each transfusion were retrieved. Restrictive transfusion strategy was defined as a transfusion threshold ≤8.5 g/dl in all transfusion episodes for a single patient, while liberal transfusion strategy was defined as a transfusion threshold >8.5 g/dl in any transfusion episode.

RESULTS

The analysis included 763 patients, with 138 (18.1%) patients in the restrictive and 625 (81.9%) in the liberal transfusion strategy group. The median hemoglobin level, taking into account all measured hemoglobin values, during ECMO support was 8.3 and 9.9 g/dl, and the average units of pRBC received per day were 0.7 (0.3-1.8) and 1.2 (0.6-2.3), respectively. There were no significant differences in intensive care unit (ICU) mortality (adjusted odds ratio (OR), 0.86; 95% CI 0.56-1.30; p = .47), hospital mortality (adjusted OR, 0.79; 95% CI 0.52-1.21; p = .28), and 90-day mortality (adjusted OR, 0.84; 95% CI 0.55-1.28; p = .42) between the two groups. Among subgroup analyses, a restrictive transfusion strategy was associated with decreased risk of ICU mortality in patients on veno-venous ECMO (adjusted OR, 0.36; 95% CI 0.17-0.73; p = .005). There was no heterogeneity on outcomes across patients stratified by age, APACHE IV score, or need for large volume transfusion.

DISCUSSION

Our data suggested it may be safe to adopt a restrictive red cell transfusion threshold of 8.5 g/dl in patients on ECMO, and highlighted the need for prospective trials in this heavily-transfused population.

Transfusion-related acute lung injury (TRALI): a retrospective review of reported cases in Queensland, Australia over 20 years

BACKGROUND

Transfusion-related acute lung injury (TRALI) is a rare but potentially fatal transfusion reaction. An effective haemovigilance programme is important in implementing successful and targeted risk reduction strategies. We aim to provide a summary of TRALI cases referred for investigation in Queensland (QLD) Australia from 1999 to 2019, describing the epidemiological and laboratory features of local TRALI cases.

MATERIALS AND METHODS

A retrospective audit evaluated all cases reported to the QLD Australian Red Cross Lifeblood over the 20-year study period. Cases were categorised according to the 2004 Canadian consensus criteria.

RESULTS

Of the 91 cases referred for investigation, expert review confirmed 30 of TRALI and 18 of possible TRALI. A total of 238 donors and 110 blood products were assessed in confirmed cases. TRALI affected patients of all ages. Most patients had underlying haematological malignancies (25%), surgery (15%) or liver disease (13%). TRALI incidence was measured at 1 in 130,000 per issued product in QLD. Red cells were transfused in 32 cases, platelets in 18 and plasma products in 21, with 16 cases involving multiple products. Following laboratory assessment, 23% of cases had findings supportive of antibody mediated TRALI and 21% as likely non-antibody mediated. Possible TRALI was identified in 37.5% of cases of which 25% were antibody mediated and 12.5% non-antibody mediated. Nine (18.5%) cases were uncategorised due to insufficient immunologic investigations.

DISCUSSION

Rates of TRALI incidence measured are lower than those seen in many international studies. A reduction in confirmed cases has been noted over recent years, supporting the implementation of risk-reduction strategies. We report a relatively higher proportion of non-antibody mediated TRALI and possible TRALI cases in more recent years, suggesting the need to further understand the role of product age and biological risk modifiers.

Biological investigations of transfusion reactions: contribution of symptom-based decisional algorithms

OBJECTIVES

While transfusion is a common and safe therapeutic procedure in health care facilities, transfusion reactions can occur, whether acute or delayed, mild or life-threatening. In face of these reactions, the biological analysis laboratory plays a central role in their diagnosis. The objective of this article is to develop decisional algorithms for laboratory tests to be performed according to the clinical symptoms developed by the patient during or after transfusion.

METHODS

Based on the information collected by reviewing the literature and the procedures used in our hospital, we then developed biological investigation algorithms according to the symptoms presented by the patient, rather than the presumed reaction.

RESULTS AND CONCLUSION

We have developed symptom-based algorithms for acute transfusion reactions management that streamline laboratory testing and simplify the differential diagnosis.

Transfusion-Related Acute Lung Injury (TRALI) in Postoperative Anesthesia Care Unit (PACU) After One Unit of Platelets: A Case Report

Transfusion-related acute lung injury (TRALI) following transfusion of all plasma-containing blood products is a rare but serious syndrome characterized by the acute onset of non-cardiogenic pulmonary edema with severe hypoxemia with or without symptoms of hypotension, pinkish frothy secretions, fever, and cyanosis. In this report, we present a case of a 66-year-old female with a medical history significant for hypertension, hyperlipidemia, hepatitis C, liver cirrhosis, tobacco use disorder, metastatic spindle cell carcinoma of the lung status post chemotherapy who developed TRALI after administration of one unit of platelets. Although a rare occurrence, there can be a considerable risk of TRALI following transfusion of all plasma-containing blood products and there is great importance in considering each patient’s risk factors for TRALI development prior to blood product administration.

What Is Different in Acute Hematologic Malignancy-Associated ARDS? An Overview of the Literature

Background and Objectives: Acute hematologic malignancies are a group of heterogeneous blood diseases with a high mortality rate, mostly due to acute respiratory failure (ARF). Acute respiratory distress syndrome (ARDS) is one form of ARF which represents a challenging clinical condition. The paper aims to review current knowledge regarding the variable pathogenic mechanisms, as well as therapeutic options for ARDS in acute hematologic malignancy patients. Data collection: We provide an overview of ARDS in patients with acute hematologic malignancy, from an etiologic perspective. We searched databases such as PubMed or Google Scholar, including articles published until June 2022, using the following keywords: ARDS in hematologic malignancy, pneumonia in hematologic malignancy, drug-induced ARDS, leukostasis, pulmonary leukemic infiltration, pulmonary lysis syndrome, engraftment syndrome, diffuse alveolar hemorrhage, TRALI in hematologic malignancy, hematopoietic stem cell transplant ARDS, radiation pneumonitis. We included relevant research articles, case reports, and reviews published in the last 18 years. Results: The main causes of ARDS in acute hematologic malignancy are: pneumonia-associated ARDS, leukostasis, leukemic infiltration of the lung, pulmonary lysis syndrome, drug-induced ARDS, radiotherapy-induced ARDS, diffuse alveolar hemorrhage, peri-engraftment respiratory distress syndrome, hematopoietic stem cell transplantation-related ARDS, transfusion-related acute lung injury. Conclusions: The short-term prognosis of ARDS in acute hematologic malignancy relies on prompt diagnosis and treatment. Due to its etiological heterogeneity, precision-based strategies should be used to improve overall survival. Future studies should focus on identifying the relevance of such etiologic-based diagnostic strategies in ARDS secondary to acute hematologic malignancy.

Chronicle of Hypoxemia: Transfusion-Associated Circulatory Overload Versus Transfusion-Related Acute Lung Injury

The preeminent causes of blood transfusion-related morbidity and mortality are transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI). These occur within hours of blood transfusion and lead to acute respiratory distress. The differentiation between TACO and TRALI has always been a great challenge in the context of underlying etiology, whether it is volume overload or lung injury, or both. This is a case report of a 64-year-old female with multiple comorbidities, who was brought to the emergency department with generalized weakness. She was hemodynamically unstable and encephalopathic. Her hemoglobin was 6.5 gm/dl with no active evidence of bleeding. She was started on a norepinephrine drip and one unit of packed red blood cells was transfused. A few hours post-transfusion, she became extremely tachypneic and hypoxic. A chest x-ray post-transfusion showed diffuse bilateral fluffy alveolar infiltrates and the N-terminal (NT)-pro hormone Brain Natriuretic Peptide (NT-proBNP) was significantly elevated. The transfusion reaction workup was negative. Due to worsening hypoxia, she required a rapid transition from non-invasive to invasive mechanical ventilation. The chronology of this case report depicts a unique presentation of acute respiratory distress and the course of hypoxemia. 

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.

Transfusion-Related Acute Lung Injury During Liver Transplantation: A Scoping Review

Liver transplantation is associated with significant blood loss, often requiring massive blood product transfusion. Transfusion-related acute lung injury (TRALI) is a devastating cause of transfusion-related deaths. While reports have investigated the general incidence of TRALI, the incidence of TRALI specifically following transfusion during liver transplant remains unclear. This scoping review summarizes existing literature regarding TRALI during the liver transplantation perioperative period. Databases were searched for all articles and abstracts reporting on TRALI after liver transplantation. Data collected included number of patients studied, patient characteristics, incidences of TRALI, TRALI characteristics, and patient outcomes. The primary outcome investigated was the incidence of TRALI in the setting of liver transplantation. Thirteen full-text citations were included in this review. The incidence of TRALI post-liver transplant was 0.68% (65 of 9,554). Based on reported transfusion data, patients diagnosed with TRALI received an average of 10.92 ± 10.81 units of packed red blood cells (pRBC), 20.05 ± 15.72 units of fresh frozen plasma, and 5.75 ± 10.00 units of platelets. Common interventions following TRALI diagnosis included mechanical ventilation with positive end-expiratory pressure, inhaled high-flow oxygen, inhaled pulmonary vasodilator, and pharmacologic treatment using pressors or inotropes, corticosteroids, or diuretics. Based on reported mortality data, 26.67% of patients (12 of 45) diagnosed with TRALI died during the postoperative period. This scoping review underscores the importance of better understanding the incidence and presentation of TRALI after liver transplant surgery. The clinical implications of these results warrant the development of identification and management strategies for liver transplant patients at increased risk for developing TRALI.

Plasma Transfusion in Septic Shock—A Secondary Analysis of a Retrospective Single-Center Cohort

In sepsis, both beneficial and detrimental effects of fresh frozen plasma (FFP) transfusion have been reported. The aim of this study was to analyze the indication for and effect of FFP transfusion in patients with septic shock. We performed a secondary analysis of a retrospective single-center cohort of all patients treated for septic shock at the interdisciplinary surgical intensive care unit (ICU) of the Heidelberg University Hospital. Septic shock was defined according to sepsis-3 criteria. To assess the effects of FFP administration in the early phase of septic shock, we compared patients with and without FFP transfusion during the first 48 h of septic shock. Patients who died during the first 48 h of septic shock were excluded from the analysis. Primary endpoints were 30- and 90-day mortality. A total of 261 patients were identified, of which 100 (38.3%) received FFP transfusion within the first 48 h after septic shock onset. The unmatched analysis showed a trend toward higher 30- and 90-d mortality in the FFP group (30 d: +7% p = 0.261; 90 d: +11.9% p = 0.061). In the propensity-matched analysis, 30- and 90-day mortality were similar between groups. Plasma administration did not influence fluid or vasopressor need, lactate levels, ICU stay, or days on a ventilator. We found no significant harm or associated benefit of FFP use in the early phase of septic shock. Finally, plasma should only be used in patients with a strong indication according to current recommendations, as a conclusive evaluation of the risk-benefit ratio for plasma transfusion in septic shock cannot be made based on the current data.

SLC44A2 Frequency, a New TaqMan Real-Time Polymerase Chain Reaction Method for HNA-3A/3B Genotyping, and a New Application of Droplet Digital PCR

Background: Human neutrophil antigen-3A (HNA-3A) and human neutrophil antigen-3B (HNA-3B) are generated by a single-nucleotide polymorphism (rs2288904, c.461G &gt; A) in exon 7 of the choline transporter-like protein-2 gene (CTL2, also known as SLC44A2). Antibodies to HNA-3 can be generated following blood transfusion or other factors resulting in exposure to HNA-3 antigens. These antibodies can cause transfusion-related acute lung injury (TRALI) or neonatal alloimmune neutropenia (NAIN). This study describes a sensitive and specific TaqMan real-time polymerase chain reaction (PCR) method to screen for the HNA-3 genotype using specific primers and probes designed to detect allelic polymorphisms. Considering the high sensitivity and accuracy of droplet digital PCR (ddPCR) in the identification of the rare SLC44A2*2 allele, we used this technique to identify blood donors with the rare HNA-3B antigen and calculate the allele frequency of SLC44A2 in mixed populations with different proportions.

Methods: DNA samples purified from 208 donors in northwest China were subjected to TaqMan real-time PCR to detect allelic polymorphisms in SLC44A2. The results were confirmed by Sanger sequencing. The rare HNA-3B antigen was detected by ddPCR. SLC44A2 frequency was determined by two-channel ddPCR.

Results: The genotypes of all DNA samples were detected by the TaqMan real-time PCR using specific probes for HNA-3, and the results were consistent with the Sanger sequencing results in respect to the HNA-3A and HNA-3B polymorphisms. The allele frequencies of SLC44A2*1 and SLC44A2*2 in the 208 donors in northwest China were 64.9% (95% confidence interval [CI], 59%–70.8%) and 35.1% (95% CI, 29.2%–41%), respectively. The ratio of SLC44A2*2 alleles was accurately detected in all blood pools by ddPCR but not by TaqMan real-time PCR. This allowed for the SLC44A2 frequency in the population to be accurately inferred.

Conclusion: This new method of detecting SLC44A2 alleles was highly sensitive and specific, as confirmed by Sanger sequencing. ddPCR using the designed probes resulted in successful detection of the rare HNA-3B antigen. Furthermore, we successfully detected the rare HNA-3B antigen and inferred the SLC44A2 frequency by ddPCR using the probes that we designed.

Modified Bentall procedure: A 15-year single-center clinical experience

OBJECTIVE

Bentall procedure is a standard technique for complete aortic root replacement but a huge challenge is postoperative bleeding. Many modifications have been proposed and the "button technique" is commonly used. With a 15-year experience, this study was to evaluate outcomes of this modified Bentall procedure.

METHODS

A retrospective study was performed with all patients who underwent the Bentall procedure with a button technique between 2005 and 2020. Commercially available composite grafts were used in 38 patients and self-assembled composite graft was used in 74 patients. Safety outcome was postoperative complications and long-term outcomes included overall and reoperation-free survivals.

RESULTS

Among 112 patients, the mean age was 46.3 years and 69.6% were men. Indications for the Bentall procedure were ascending aortic aneurysm and valve regurgitation (59.8%), aortic dissection (19.6%), Marfan syndrome (17%), and endocarditis (3.6%). Three patients (2.7%) died in hospital. During a median follow-up period of 42 months, 11 patients died and 7 patients required reoperation. Overall survival and reoperation-free survival were 86.1% and 83.4% at 5 years and 86.1% and 72.6% at 10 years, respectively.

CONCLUSIONS

The Bentall procedure with a button technique is safe and effective for aortic root replacement. Further investigations are required to improve the feasibility and effectiveness of the procedure.

Changes in the incidence of transfusion reactions in hematological patients over the past 30 years

BACKGROUND

Patients with hematological diseases are polytransfused and often immunocompromised, therefore susceptible to transfusion reactions (TR). This study aims to document the incidence of TRs in adult hematological patients and assess the effect of changes in the production of blood components and transfusion practice on their occurrence.

STUDY DESIGN AND METHODS

Retrospective observational analysis of TRs reported from 1993 to 2019 was performed. For the analysis of the effect of changes on the incidence of TRs, the evaluated time was divided into two periods: the 1st period before the introduction of changes in production, when leukoreduced blood components were used only selectively, and the 2nd period, when semi-automated method of production and universal leukoreduction was introduced.

RESULTS

The decrease in the incidence of TRs was observed for both red blood cell (RBC) and platelet concentrate (PC) transfusions in the 2nd period. Since platelet additive solution has been used, a further decrease in the incidence was reported. The decrease in incidence was also observed for delayed hemolytic/serological transfusion reactions and for transfusion-transmitted bacterial infections. Four cases of incorrect blood transfusions were uniquely related to the hematological patients, caused by antigen loss and transfusion ordering after ABO-incompatible hematopoietic stem cell transplantation.

DISCUSSION

Our results provided evidence that the introduction of tools offered by modern transfusion medicine: universal leukodepletion, plasma replacement with additive solutions, sensitive laboratory techniques, prophylactic antigen matching policy, informatization, and automatization, decreased the incidence of TRs and improved transfusion safety.

A Systematic Review on the Management of Transfusion-Related Acute Lung Injury in Transfusion-Dependent Sickle Cell Disease

The onset of respiratory distress and acute lung injury (ALI) following a blood transfusion is known as transfusion-related acute lung injury (TRALI), although its pathophysiology remains unknown. Even though sickle cell disease (SCD) has been studied for more than a century, few therapeutic and management strategies adequately address the emergence of TRALI. TRALI, an immune-mediated transfusion response that can result in life-threatening consequences, is diagnosed based on clinical signs and symptoms. Early detection and treatment increase the chances of survival and, in most cases, result in a complete recovery. Our objective is to provide a firm grasp of the present status of SCD-related TRALI care and therapy. After exploring multiple databases, this study offers evidence-based guidelines to aid clinicians and other healthcare professionals make decisions concerning transfusion assistance for SCD and the management of transfusion-related complications. Other risk factors for acute lung injury including sepsis aspiration should be ruled out throughout the diagnostic process. Several recent studies have shown that immunotherapy or immunological targets can effectively prevent these complications. Red cell transfusions, red cell antigen matching optimization, and iron chelation can also help reduce negative consequences. It is to be noted that poor clinical outcomes can be avoided by early detection and treatment of hemolytic transfusion reactions. Finally, preventing the onset of TRALI may be the most effective therapeutic strategy for SCD patients who rely on blood transfusions for survival.

High-Dose Convalescent Plasma for Treatment of Severe COVID-19

To assess whether high-dose coronavirus disease (COVID-19) convalescent plasma (CCP) transfusion may benefit patients with severe COVID-19, we conducted a multicenter randomized trial in Brazil. Patients with severe COVID-19 who were within 10 days of initial symptom onset were eligible. Patients in the CCP group received 3 daily doses of CCP (600 mL/d) in addition to standard treatment; control patients received standard treatment only. Primary outcomes were death rates at days 30 and 60 of study randomization. Secondary outcomes were ventilator-free days and hospital-free days. We enrolled 107 patients: 36 CCP and 71 control. At day 30, death rates were 22% for CCP and 25% for the control group; at day 60, rates were 31% for CCP and 35% for control. Needs for invasive mechanical ventilation and durations of hospital stay were similar between groups. We conclude that high-dose CCP transfused within 10 days of symptom onset provided no benefit for patients with severe COVID-19.

Coagulopathies in Intensive Care Medicine: Balancing Act between Thrombosis and Bleeding

Patient Blood Management advocates an individualized treatment approach, tailored to each patient's needs, in order to reduce unnecessary exposure to allogeneic blood products. The optimization of hemostasis and minimization of blood loss is of high importance when it comes to critical care patients, as coagulopathies are a common phenomenon among them and may significantly impact morbidity and mortality. Treating coagulopathies is complex as thrombotic and hemorrhagic conditions may coexist and the medications at hand to modulate hemostasis can be powerful. The cornerstones of coagulation management are an appropriate patient evaluation, including the individual risk of bleeding weighed against the risk of thrombosis, a proper diagnostic work-up of the coagulopathy's etiology, treatment with targeted therapies, and transfusion of blood product components when clinically indicated in a goal-directed manner. In this article, we will outline various reasons for coagulopathy in critical care patients to highlight the aspects that need special consideration. The treatment options outlined in this article include anticoagulation, anticoagulant reversal, clotting factor concentrates, antifibrinolytic agents, desmopressin, fresh frozen plasma, and platelets. This article outlines concepts with the aim of the minimization of complications associated with coagulopathies in critically ill patients. Hereditary coagulopathies will be omitted in this review.

Transfusion Reactions and Adverse Events

Blood transfusions are generally safe but can carry considerable risks. This review summarizes the different types of transfusion reactions and ways to diagnose and manage them. Symptoms are often overlapping and nonspecific. When a reaction is suspected, it is critical to stop the transfusion immediately and report the reaction to the blood bank, as this can affect the patient's outcome. New evidence-based algorithms of transfusion, newer blood screening methods and donor policies and deferrals, new laboratory testing, electronic verification systems, and improved hemovigilance lead to the avoidance of unnecessary transfusions and decrease the incidence of serious transfusion reactions.

The recipe for TACO: A narrative review on the pathophysiology and potential mitigation strategies of transfusion-associated circulatory overload

Transfusion associated circulatory overload (TACO) is one of the leading causes of transfusion related morbidity and mortality. TACO is the result of hydrostatic pulmonary edema following transfusion. However, up to 50% of all TACO cases appear after transfusion of a single unit, suggesting other factors, aside from volume, play a role in its pathophysiology. TACO follows a two-hit model, in which the first hit is an existing disease or comorbidity that renders patients volume incompliant, and the second hit is the transfusion. First hit factors include, amongst others, cardiac and renal failure. Blood product factors, setting TACO apart from crystalloid overload, include colloid osmotic pressure effects, viscosity, pro-inflammatory mediators and storage lesion byproducts. Differing hemodynamic changes, glycocalyx injury, endothelial damage and inflammatory reactions can all contribute to developing TACO. This narrative review explores pathophysiological mechanisms for TACO, discusses related therapeutic and preventative measures, and identifies areas of interest for future research.

Effect of Intra- and Post-Operative Fluid and Blood Volume on Postoperative Pulmonary Edema in Patients with Intraoperative Massive Bleeding

In patients with intraoperative massive bleeding, the effects of fluid and blood volume on postoperative pulmonary edema are uncertain. Patients with intraoperative massive bleeding who had undergone a non-cardiac surgery in five hospitals were enrolled in this study. We evaluated the association of postoperative pulmonary edema risk and intra- and post-operatively administered fluid and blood volumes in patients with intraoperative massive bleeding. In total, 2090 patients were included in the postoperative pulmonary edema analysis, and 300 patients developed pulmonary edema within 72 h of the surgery. The postoperative pulmonary edema with hypoxemia analysis included 1660 patients, and the condition occurred in 161 patients. An increase in the amount of red blood cells transfused per hour after surgery increased the risk of pulmonary edema (hazard ratio: 1.03; 95% confidence interval: 1.01–1.05; p = 0.013) and the risk of pulmonary edema with hypoxemia (hazard ratio: 1.04; 95% confidence interval: 1.01–1.07; p = 0.024). An increase in the red blood cells transfused per hour after surgery increased the risk of developing pulmonary edema. This increase can be considered as a risk factor for pulmonary edema.

Transfusion-Associated Circulatory Overload and Transfusion-Related Acute Lung Injury

OBJECTIVES

To review the new current diagnostic criteria of transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI) from the literature while highlighting distinguishing features. We provide comprehensive understanding of the importance of hemovigilance and its role in appropriately identifying and reporting these potentially fatal transfusion reactions.

METHODS

A review of the English language literature was performed to analyze TACO and TRALI while providing further understanding of the rationale behind the historical underrecognition and underreporting.

RESULTS

Our review demonstrates the new 2018 and 2019 case definitions for TACO and TRALI, respectively. With more comprehensive diagnostic strategies, adverse transfusion events can be better recognized from mimicking events and underlying disease. In addition, there are mitigation strategies in place to help prevent complications of blood product transfusion, with emphasis on the prevention of TACO and TRALI.

CONCLUSIONS

TACO and TRALI are potentially fatal adverse complications of blood transfusion. Both have been historically underrecognized and underreported due to poor defining criteria and overlapping symptomatology. Developing a thorough clinical understanding between these two entities can improve hemovigilance reporting and can contribute to risk factor identification and preventative measures.

Why Does the Precautionary Principle Suffice for Blood Regulation?

Traditional approaches to blood regulation emphasise the precautionary principle and pursue zero-risk for viral transmission; these traditional approaches have usually followed tragedy, such as the HIV and hepatitis C infections that followed the use of factor VIII concentrates. However, a much more haphazard haemovigilance system operates for general adverse events. Such imprecise assessment of hazards prevents sound benefit-risk assessment, and for blood products this is further confounded by the fact that their efficacy has attracted little systematic study. The ongoing COVID-19 pandemic has now prompted the proposal of a convalescent plasma (CP) blood product. Clearly, mere freedom from infectious agents will not suffice in assessing CP, and an objective measure of efficacy, so as to permit formal benefit-risk analysis, is essential. This is both a scientific and an ethical demand, as has been the case for other experimental COVID-19 treatments. With special reference to COVID-19 CP, the well-recognized adverse events of transfusion-associated lung injury (TRALI) and transfusion-associated circulatory overload (TACO) will be important. Furthermore, not only efficacy but also product quality attributes (e.g., antibody titre) will have to be defined. Both of these are outside the traditional regulatory philosophy for blood products and are needed to truly assess the benefit-risk of this putative therapeutic product.

Convalescent plasma therapy - a silver lining for COVID-19 management?

The COVID-19 pandemic has pushed the world towards social, economic, and medical challenges. Scientific research in medicine is the only means to overcome novel and complex diseases like COVID-19. To sum up the therapeutic wild-goose chase, many available antivirals and repurposed drugs have failed to show successful clinical evidence in patient recovery, several vaccine candidates are still waiting in the trial pipelines and a few have become available to the common public for administration in record time. However, with upcoming evidence of coronavirus mutations, available vaccines may thrive on the spirit of doubt about efficacy and effectiveness towards these new strains of Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV2). In all these collective uncertainties, plasma therapy has shown a ray of hope for critically ill patients. To date, with very few published case studies of convalescent plasma in COVID-19, there are two school of thought process in the scientific community regarding plasma therapy efficiency and this leads to confusion due to the lack of optimal randomized and controlled studies. Without undertaking any robust scientific studies, evidence or caution, accepting any therapy unanimously may cause more harm than good, but with a clearer understanding of SARS-CoV2 immunopathology and drug response, plasma therapy might be the silver lining against COVID-19 for the global community.