How do we forecast tomorrows' transfusion: Non-transfusional hemotherapy

Hemotherapy is the treatment of diseases by the use of blood or blood products from blood donation (by others of for oneself). It is clear that blood components transfusion represents the most important part of the activities of the professionals (doctors, nurses, technicians…) working in hemotherapy. But there are others forms of hemotherapy that are steadily growing, that we will discuss: plasma exchange, mononuclear cells collections for cellular therapies, extracorporeal photoapheresis, ABO antigen specific immunoadsorption and autologous platelet lysate.

Implications of Hepatitis E Virus in Blood Transfusions, Hemodialysis, and Solid Organ Transplants

Hepatitis E Virus (HEV) is emerging as the primary cause of acute viral hepatitis in humans. The virus is commonly transmitted by the fecal-oral route via contaminated water in endemic regions or through the consumption of inadequately cooked swine products or game meats in industrialized regions. HEV genotypes 1 and 2 are predominantly associated with waterborne transmission in developing countries, whereas HEV3 and HEV4 are mainly zoonotically transmitted in industrialized countries. Seroprevalence in populations determined by detecting anti-HEV antibodies and serum HEV RNA is commonly used to analyze the presence of HEV. Although HEV RNA-based detection is now standardized, there is a lack of agreement between the assaying methods used for gathering seroprevalence data. Since 2004, HEV has been considered as a transmissible infectious agent through blood transfusion. Recent seroprevalence studies in European countries indicate an underestimated risk for blood transfusion and hence warrant testing the blood supply. HEV infection is usually self-limiting and spontaneously cleared. However, in about 60% of recipients of solid organ transplants, HEV progresses to chronic hepatitis. Immunosuppressive drugs such as tacrolimus are a major cause of chronic hepatitis and reducing its dosage results in viral clearance in about 30% of patients. In hemodialysis patients, the parenteral route is implicated as an important mechanism of transmission. In this review, we explore the clinical and epidemiological characteristics of various HEV genotypes in blood donors, hemodialysis patients, and transplant recipients.

Increased Use of Blood Transfusions to Manage Urological Conditions during the COVID-19 Pandemic

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to an extensive reorganization of the healthcare system in Italy, with significant deferment of the treatment of urology patients. We aimed to assess the impact of deferred treatment during the SARS-CoV-2 pandemic on the need for blood transfusions in 3 Italian urology departments.

Methods

We reviewed hospital chart data on blood transfusions at the urology units of 3 academic centers in the north of Italy from March to April 2020. Data were compared with values from the same time frame in 2019 (March to April 2019).

Results

We observed significant reductions of the number of patients admitted to the urology units from March to April 2020 (373 vs. 119) and the number of performed surgeries (242 vs. 938) compared to 2019. Though, the number of transfused blood units was comparable between the 2 years (182 vs. 252), we found a greater mean number of blood units transfused per admission in 2020 (0.49 vs. 0.22; p < 0.0001). As a whole, the transfusion rate for hematuria was higher in 2020 than in 2019 (36 vs. 7.9%; p < 0.0001).

Discussion/Conclusion

The observed increased number of blood transfusions needed throughout the SARS-CoV-2 era could have had a negative impact on both patients and the healthcare system. It is possible to speculate that this is the consequence of a delayed diagnosis and deferred treatment of acute conditions.

Impact of Anesthetics, Analgesics, and Perioperative Blood Transfusion in Pediatric Cancer Patients: A Comprehensive Review of the Literature

Cancer is the leading cause of death by disease in developed countries. Children and adolescents with cancer need surgical interventions (ie, biopsy or major surgery) to diagnose, treat, or palliate their malignancies. Surgery is a period of high vulnerability because it stimulates the release of inflammatory mediators, catecholamines, and angiogenesis activators, which coincides with a period of immunosuppression. Thus, during and after surgery, dormant tumors or micrometastasis (ie, minimal residual disease) can grow and become clinically relevant metastasis. Anesthetics (ie, volatile agents, dexmedetomidine, and ketamine) and analgesics (ie, opioids) may also contribute to the growth of minimal residual disease or disease progression. For instance, volatile anesthetics have been implicated in immunosuppression and direct stimulation of cancer cell survival and proliferation. Contrarily, propofol has shown in vitro anticancer effects. In addition, perioperative blood transfusions are not uncommon in children undergoing cancer surgery. In adults, an association between perioperative blood transfusions and cancer progression has been described for some malignancies. Transfusion-related immunomodulation is one of the mechanisms by which blood transfusions can promote cancer progression. Other mechanisms include inflammation and the infusion of growth factors. In the present review, we discuss different aspects of tumorigenesis, metastasis, angiogenesis, the immune system, and the current studies about the impact of anesthetics, analgesics, and perioperative blood transfusions on pediatric cancer progression.

Increased Transfusion Requirements with Pharmacologic Thromboembolism Prophylaxis During Inflammatory Bowel Disease Exacerbation

BACKGROUND

Inflammatory bowel disease (IBD) exacerbation requiring hospitalization increases the risk of venous thromboembolism (VTE), and current guidelines recommend pharmacologic VTE prophylaxis (PVTEP).

AIMS

Bleeding risks with PVTEP in this population are poorly defined, and no study has investigated packed red blood cell (PRBC) transfusion requirements in this population.

METHODS

We conducted a chart review of all adult hospitalizations for IBD exacerbation within the Northwell Healthcare system. Patient characteristics recorded included demographics, disease type ulcerative colitis or Crohn's disease, severe disease defined by inpatient corticosteroid or biologic use, and admission hemoglobin. Inpatient use of PVTEP and anti-platelet therapies were identified. The primary outcome was the occurrence of any packed red blood cell (PRBC) transfusion.

RESULTS

In total, 717 patients met inclusion criteria, accounting for 891 admissions. PVTEP was used during 60.4% of admissions, and 11.1% of patient admissions included a transfusion event. Severe disease patients receiving PVTEP had an 18.6% transfusion risk, versus 11.1% for those not receiving PVTEP, OR 1.82, CI (1.04-3.17). One multivariable analysis transfusion was associated with PVTEP, OR 2.11, 95% CI 1.18, 3.77, p = 0.0120, disease severity OR 3.17, 95% CI 1.81,5.54, p < 0.0001, anti-platelet therapies OR 2.46, 95% CI 1.23-4.90, p = 0.0107, bowel resection OR 3.88, 95% CI 1.97,7.63, p < 0.0001 and decreased admission hemoglobin OR 2.01, 95% CI 1.73-2.32, p < 0.0001, but not disease type ulcerative colitis OR 0.71, 95% CI 0.42-1.20.

CONCLUSION

PVTEP during IBD exacerbation is associated with increased PRBC transfusions. Our findings do not constitute a contraindication to PVTEP, but may be incorporated into patient counseling during inpatient IBD management.

Improved hemostasis with major hepatic resection in the current surgical era

BACKGROUND

Major hepatic resection, predominantly performed for oncologic intent, is a complex procedure with the potential for severe intraoperative hemorrhage. The current surgical era has the ability to improve hemostasis throughout the performance of major hepatic resections which decreases blood transfusions and the detrimental effects associated with transfusion. We evaluated hemostasis and outcomes in the current surgical era of performing hepatic resections.

METHODS

Utilizing the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database all major hepatic resections performed between 2012 and 2016 were analyzed in regards to hemostasis. Hemostasis was evaluated by the need for and magnitude of blood transfusions. Additional perioperative variables (including operative time, length of hospital stay, and mortality rates) were analyzed to assess for outcomes with hemostasis. The NSQIP results were compared to previous publications involving major hepatic resections to detect improvement in hemostasis and outcomes in the current surgical era.

RESULTS

A total of 22777 major hepatic resections met the inclusion criteria for analysis in the NSQIP database. An additional 21198 cases were compiled within the selected publications for comparative analysis. The transfusion rate in the current surgical era was 13.3% versus 38.7% in the previous era (P = 0.0001). When a transfusion was required in the current surgical era there was a two-fold reduction in the number of units transfused (1.5 U vs. 3.8 U, P = 0.0001). Statistically significant improvements in operative time and length of hospital stay were presented within the current surgical era (P = 0.0001). When a transfusion was required there was an increased relative risk score of 7 for mortality (4.9% vs. 0.7%, P = 0.0001), however, improvement in mortality rates did not reach statistical significance across surgical eras (1.3% vs. 4.0%, P = 0.0001).

CONCLUSIONS

The conduction of major hepatic resection in the current surgical era is more hemostatic. Correlated with improved hemostasis are better outcomes for both clinical and financial endpoints. These findings should encourage continued and increased performance of major hepatic resections.

Transfusion practice in the non-bleeding critically ill: an international online survey-the TRACE survey

BACKGROUND

Over the last decade, multiple large randomized controlled trials have studied alternative transfusion strategies in critically ill patients, demonstrating the safety of restrictive transfusion strategies. Due to the lack of international guidelines specific for the intensive care unit (ICU), we hypothesized that a large heterogeneity in transfusion practice in this patient population exists. The aims of this study were to describe the current transfusion practices and identify the knowledge gaps.

METHODS

An online, anonymous, worldwide survey among ICU physicians was performed evaluating red blood cell, platelet and plasma transfusion practices. Furthermore, the presence of a hospital- or ICU-specific transfusion guideline was asked. Only completed surveys were analysed.

RESULTS

Nine hundred forty-seven respondents filled in the survey of which 725 could be analysed. Hospital transfusion protocol available in their ICU was reported by 53% of the respondents. Only 29% of respondents used an ICU-specific transfusion guideline. The reported haemoglobin (Hb) threshold for the general ICU population was 7 g/dL (7-7). The highest reported variation in transfusion threshold was in patients on extracorporeal membrane oxygenation or with brain injury (8 g/dL (7.0-9.0)). Platelets were transfused at a median count of 20 × 109 cells/L IQR (10-25) in asymptomatic patients, but at a higher count prior to invasive procedures (p < 0.001). In patients with an international normalized ratio (INR) > 3, 43% and 57% of the respondents would consider plasma transfusion without any upcoming procedures or prior to a planned invasive procedure, respectively. Finally, doctors with base specialty in anaesthesiology transfused critically ill patients more liberally compared to internal medicine physicians.

CONCLUSION

Red blood cell transfusion practice for the general ICU population is restrictive, while for different subpopulations, higher Hb thresholds are applied. Furthermore, practice in plasma and platelet transfusion is heterogeneous, and local transfusion guidelines are lacking in the majority of the ICUs.

Towards the future of blood transfusion - the South African National Blood Service's perspectives on cellular therapeutic services and products

Blood transfusion services are the cornerstone of the healthcare delivery system, and need to stay abreast of advances in technology to ensure relevance to the needs of the country. In this review, we examine the current status of blood transfusion systems and discuss their possible future role in cellular therapies.

Profound Intraoperative Hypotension Associated With Transfusion via the Belmont Fluid Management System

This retrospective observational case series conducted at 2 large academic centers over a 4-year period consists of 15 cases of profound hypotension in surgical patients immediately after initiation of the Belmont Fluid Management System for rapid transfusion of blood products. Halting the infusion and administering vasoactive agents led to resolution of hypotension. Repeat transfusion with the Belmont system resulted in repeat hypotension unless counteracted with vasopressors. No etiology was elucidated. This represents the largest documented association of acute hypotensive transfusion reaction with any rapid infusion system in surgical patients.

Restrictive Transfusion Strategy Is More Effective in Massive Burns: Results of the TRIBE Multicenter Prospective Randomized Trial

OBJECTIVES

Studies suggest that a restrictive transfusion strategy is safe in burns, yet the efficacy of a restrictive transfusion policy in massive burn injury is uncertain. Our objective: compare outcomes between massive burn (≥60% total body surface area (TBSA) burn) and major (20-59% TBSA) burn using a restrictive or a liberal blood transfusion strategy.

METHODS

Patients with burns ≥20% were block randomized by age and TBSA to a restrictive (transfuse hemoglobin <7 g/dL) or liberal (transfuse hemoglobin <10 g/dL) strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes.

RESULTS

Three hundred and forty-five patients received 7,054 units blood, 2,886 in massive and 4,168 in restrictive. Patients were similar in age, TBSA, and inhalation injury. The restrictive group received less blood (45.57 ± 47.63 vs. 77.16 ± 55.0, p < 0.03 massive; 11.0 ± 16.70 vs. 16.78 ± 17.39, p < 0.001) major). In massive burn, the restrictive group had fewer ventilator days (p < 0.05). Median ICU days and LOS were lower in the restrictive group; wound healing, mortality, and infection did not differ. No significant outcome differences occurred in the major (20-59%) group (p > 0.05).

CONCLUSIONS

A restrictive transfusion strategy may be beneficial in massive burns in reducing ventilator days, ICU days and blood utilization, but does not decrease infection, mortality, hospital LOS or wound healing.

Advantages of early intervention with arterial embolization for intra-abdominal solid organ injuries in children

PURPOSE

Active bleeding due to abdominal trauma is an important cause of mortality in childhood. The aim of this study is to demonstrate the advantages of early percutaneous transcatheter arterial embolization (PTAE) procedures in children with intra-abdominal hemorrhage due to blunt trauma.

METHODS

Children with blunt abdominal trauma were retrospectively included. Two groups were identified for inclusion: patients with early embolization (EE group, n=10) and patients with late embolization (LE group, n=11). Both groups were investigated retrospectively and statistically analyzed with regard to lengths of stay in the intensive care unit and in the hospital, first enteral feeding after trauma, blood transfusion requirements, and cost.

RESULTS

The duration of stay in the intensive care unit was greater in the LE group than in the EE group (4 days vs. 2 days, respectively). The duration of hospital stay was greater in the LE group than in the EE group (14 days vs. 6 days, respectively). Blood transfusion requirements (15 cc/kg of RBC packs) were greater in the LE group than in the EE group (3 vs. 1, respectively). The total hospital cost was higher in the LE group than in the EE group (4502 USD vs. 1371.5 USD, respectively). The time before starting enteral feeding after first admission was higher in the LE group than in the EE group (4 days vs. 1 day, respectively).

CONCLUSION

Early embolization with PTAE results in shorter intensive care and hospitalization stays, earlier enteral feeding, and lower hospital costs for pediatric patients with intra-abdominal hemorrhage due to blunt trauma.

Closed suction drainage following routine primary total joint arthroplasty is associated with a higher transfusion rate and longer postoperative length of stay: a retrospective cohort study

BACKGROUND

In an enhanced recovery after surgery program, not placing a closed suction drain following routine primary total joint arthroplasty (TJA) is becoming more acceptable. However, the influence of drain use on transfusion rate and postoperative length of stay (PLOS) in TJA remains controversial. Therefore, we aimed to compare drain use with no drain in routine primary TJA to determine the differences in transfusion rate and PLOS.

METHODS

We analyzed the data from 12,992 patients undergoing primary unilateral TJA: 6325 total knee arthroplasties (TKA) and 6667 total hip arthroplasties (THA). Patients were divided into two groups according to whether they received a drain postoperatively following TKA and THA. We extracted information for transfusion and PLOS from patients' electronic health records and analyzed the data by logistic and linear regression analyses.

RESULTS

The transfusion rate and PLOS were 15.07% and 7.75 ± 3.61 days, respectively, in the drain group and 6.72% and 6.54 ± 3.32 days, respectively, in the no-drain group following TKA. The transfusion rate and PLOS were 20.53% and 7.00 ± 3.35 days, respectively, in the drain group and 13.57% and 6.07 ± 3.06 days, respectively, in the no-drain group following THA. After adjusting for the following variables: age, gender, body mass index, orthopedic diagnoses, hypertension, type 2 diabetes, coronary heart disease, chronic obstructive pulmonary disease, preoperative hemoglobin, albumin, analgesic use, anesthesia, American Society of Anesthesiologists class, tranexamic acid use, intraoperative bleeding, operative time, and tourniquet use (for TKA), drain use correlated significantly with a higher transfusion rate (risk ratio = 2.812, 95% confidence interval (CI) 2.224-3.554, P < 0.001 for TKA and risk ratio = 1.872, 95% CI 1.588-2.207, P < 0.001 for THA) and a longer PLOS (partial regression coefficient (B) = 1.099, 95% CI 0.879-1.318, P < 0.001, standard regression coefficient (B') = 0.139 for TKA; B = 0.973, 95% CI 0.695-1.051, P < 0.001, and B' = 0.115 for THA). Two groups showed no significant difference in wound complications.

CONCLUSIONS

Our findings indicated that drain use was associated with a higher transfusion rate and a longer PLOS in patients undergoing routine primary TJA. The routine use of postoperative drainage is not recommended in primary unilateral TJA.

[Serological screening in donors in Mexico: advances and technology]

The residual risk of transfusion-related infections has decreased dramatically in countries that have routinely implemented serological screening. Most of the donation in Mexico is from replacement practice, a risk factor for positive serology. In Mexico, the altruistic donation is only 2.7%. The heterogeneity of technical factors, regional factors and internal policies of each center influences the variability of data on the prevalence of positive screening, as well as the prevalence of confirmed cases. The main advantage of nucleic acid technology is the detection of donors in the period of serological window or occult infections, being occult hepatitis reports in Mexican donors from 1 to 3.4%. The limitation of available technology, the scope of the clinic and perspectives, invites us to improve technology and health policies in the interest of transfusion safety.

Risk factors for heart disease in transfusion-dependent thalassemia: serum ferritin revisited

Heart disease remains a leading cause of morbidity and mortality in transfusion-dependent thalassemia (TDT), which can be attributed to several factors but primarily develops in the setting of iron overload. This was a retrospective cohort study utilizing Webthal^® patient data from five major centers across Italy. Patients without heart disease were followed-up for 10 years (2000-2010) and data were collected for demographics, splenectomy status, serum ferritin and hemoglobin levels, and comorbidities associated with heart disease. Among 379 patients analyzed (mean age 22.9 ± 5.1 years, 47.8% men), 44 (cumulative incidence: 11.6%) developed heart disease during the period of observation. Splenectomy (p = 0.002) and serum ferritin level (p < 0.001) were the only risk factors with significant association with heart disease. A serum ferritin threshold of ≥ 3000 ng/mL was the best predictor for the development of heart disease (86.4% sensitivity and 92.8% specificity, AUC: 0.912, 95% CI 0.852-0.971, p < 0.001). On multivariate analysis, only a serum ferritin level ≥ 3000 ng/mL remained significantly and independently associated with increased risk of heart disease (HR: 44.85, 95% CI 18.85-106.74), with a 5- and 10-year heart disease-free survival of 58 and 39%. The association between iron overload and heart disease in patients with TDT is confirmed, yet a new serum ferritin level of 3000 ng/mL to flag increased risk is suggested.

Trends and Gaps in National Blood Transfusion Services - 14 Sub-Saharan African Countries, 2014-2016

Ensuring availability of safe blood products through recruitment of voluntary, nonremunerated, blood donors (VNRDs) and prevention of transfusion-transmissible infections (TTIs), including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis, is important for public health (1,2). During 2004-2016, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) provided approximately $468 million in financial support and technical assistance* to 14 sub-Saharan African countries^† with high HIV prevalence to strengthen national blood transfusion services (NBTSs)^§ and improve blood safety and availability. CDC analyzed these countries' 2014-2016 blood safety surveillance data to update previous reports (1,2) and summarize achievements and programmatic gaps as some NBTSs begin to transition funding and technical support from PEPFAR to local ministries of health (MOHs) (2,3). Despite a 60% increase in blood supply since 2004 and steady declines in HIV prevalence (to <1% among blood donors in seven of the 14 countries), HIV prevalence among blood donors still remains higher than that recommended by the World Health Organization (WHO) (4). PEPFAR support has contributed to significant reductions in HIV prevalence among blood donors in the majority of PEPFAR-supported countries, and linking donors who screen HIV-positive to confirmatory testing and indicated treatment, as well as further reducing TTIs, remains a public health priority (5).

Whole Blood Transfusion

Whole blood is the preferred product for resuscitation of severe traumatic hemorrhage. It contains all the elements of blood that are necessary for oxygen delivery and hemostasis, in nearly physiologic ratios and concentrations. Group O whole blood that contains low titers of anti-A and anti-B antibodies (low titer group O whole blood) can be safely transfused as a universal blood product to patients of unknown blood group, facilitating rapid treatment of exsanguinating patients. Whole blood can be stored under refrigeration for up to 35 days, during which it retains acceptable hemostatic function, though supplementation with specific blood components, coagulation factors or other adjuncts may be necessary in some patients. Fresh whole blood can be collected from pre-screened donors in a walking blood bank to provide effective resuscitation when fully tested stored whole blood or blood components are unavailable and the need for transfusion is urgent. Available clinical data suggest that whole blood is at least equivalent if not superior to component therapy in the resuscitation of life-threatening hemorrhage. Low titer group O whole blood can be considered the standard of care in resuscitation of major hemorrhage.

Are Allogeneic Transfusions Decreasing in Total Knee Arthroplasty Patients? National Inpatient Sample 2009-2013

BACKGROUND

Allogeneic transfusions are commonly used for substantial blood loss in total knee arthroplasty (TKA), but have been associated with adverse effects and increased costs. The purpose of this study is to provide a detailed description of (1) trends of allogeneic blood transfusion; (2) risk factors and adverse events; and (3) discharge disposition, length-of-stay (LOS), and cost/charge analysis for primary TKA patients who received an allogeneic blood transfusion from 2009-2013.

METHODS

A cohort of 3,217,056 primary TKA patients was identified from the National Inpatient Sample database from 2009-2013. Demographic, clinical, economic, and discharge data were analyzed for patients who received allogeneic blood products, and for those who did not receive any type of blood transfusion. Other parameters analyzed include risk factors, adverse events, discharge disposition, and costs/charges.

RESULTS

There was a significant decline in use of allogeneic transfusion from 2009-2013 incidence (13.9%-7.3%; P < .001). All comorbidities examined were associated with significantly increased risk of receiving allogeneic transfusion with exception of patients with AIDS, metastatic cancer, and peptic ulcer disease. Allogeneic transfusion was associated with worse outcomes during hospitalization. Patients also had a greater likelihood of discharge to short-term care, greater LOS, and greater median costs/charges. Among TKA patients who received an allogeneic transfusion, costs varied based on hospital ownership and characteristics, primary-payer, region, and bed-size.

CONCLUSION

Given the poor outcomes and higher costs associated with allogeneic transfusions, efforts must be undertaken to minimize this risky practice. With the projected increase in demand for TKAs, orthopedists must understand effective blood management strategies.

Trends in Red Blood Cell, Plasma, and Platelet Transfusions in the United States, 1993-2014

This study uses National Inpatient Sample survey data to characterize trends in red blood cell, plasma, and platelet transfusions in the United States between 1993 and 2014, a period of time during which trials were demonstrating the safety of restrictive red blood cell transfusion strategies.

Anemia and blood transfusion in the critically ill patient with cardiovascular disease

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2017. Other selected articles can be found online at http://ccforum.com/series/annualupdate2017 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .

[Geriatric medicine]

In 2016, consequences, contributing factors, and prevention of inappropriate drug prescribing were investigated. Two studies lift the veil on unexplained falls and syncope. A meta-analysis questions the need to adapting transfusion's threshold to comorbidities, and another one the performance of screening for swallowing disorders. The Framingham Heart Study reports the declining of the incidence of vascular dementia. The role played by microbleeds in cognitive deterioration was investigated and aducanumab showed encouraging effect in Alzheimer's disease. When vaccination against influenza for health workers in nursing home was challenged by a meta-analysis this recommendation must be followed. Vaccines against shingles are effective and safe, and a study confirms the efficacy of the HZ7su among 70+.

Hemoglobin-Based Oxygen Carrier (HBOC) Development in Trauma: Previous Regulatory Challenges, Lessons Learned, and a Path Forward

Historically, hemoglobin-based oxygen carriers (HBOCs) were being developed as "blood substitutes," despite their transient circulatory half-life (~ 24 h) vs. transfused red blood cells (RBCs). More recently, HBOC commercial development focused on "oxygen therapeutic" indications to provide a temporary oxygenation bridge until medical or surgical interventions (including RBC transfusion, if required) can be initiated. This included the early trauma trials with HemAssist ^® (BAXTER), Hemopure ^® (BIOPURE) and PolyHeme ^® (NORTHFIELD) for resuscitating hypotensive shock. These trials all failed due to safety concerns (e.g., cardiac events, mortality) and certain protocol design limitations. In 2008 the Food and Drug Administration (FDA) put all HBOC trials in the US on clinical hold due to the unfavorable benefit:risk profile demonstrated by various HBOCs in different clinical studies in a meta-analysis published by Natanson et al. (2008). During standard resuscitation in trauma, organ dysfunction and failure can occur due to ischemia in critical tissues, which can be detected by the degree of lactic acidosis. SANGART'S Phase 2 trauma program with MP4OX therefore added lactate >5 mmol/L as an inclusion criterion to enroll patients who had lost sufficient blood to cause a tissue oxygen debt. This was key to the successful conduct of their Phase 2 program (ex-US, from 2009 to 2012) to evaluate MP4OX as an adjunct to standard fluid resuscitation and transfusion of RBCs. In 2013, SANGART shared their Phase 2b results with the FDA, and succeeded in getting the FDA to agree that a planned Phase 2c higher dose comparison study of MP4OX in trauma could include clinical sites in the US. Unfortunately, SANGART failed to secure new funding and was forced to terminate development and operations in Dec 2013, even though a regulatory path forward with FDA approval to proceed in trauma had been achieved.

An Operative Complexity Index Shows Higher Volume Hospitals and Surgeons Perform More Complex Adult Spine Deformity Operations

BACKGROUND

Though previous studies have shown improved outcomes associated with higher volume surgeons and hospitals, this may not be replicated in ASDS due to case complexity variation. We hypothesized that high-volume surgeons perform more complex surgeries. Therefore, we defined an Operative Complexity Index (OCI), specifically for the National Inpatient Samples (NIS) data, which provides information on in-hospital postoperative complications, to assess rates of adult spine deformity surgery (ASDS) cases as they relate to surgeon and hospital operative volume.

METHODS

The 2001 to 2010 NIS was queried for patients greater than 21 years of age with in-hospital stays, including a spine arthrodesis for a diagnosis of scoliosis. Surgeon and hospital identifiers were used to allocate records into volume quartiles by number of surgeries per year. The OCI was devised considering the number of fusion levels, surgical approach, revision status, and use of osteotomy. The index was validated using blood-loss-related diagnostic and procedural codes. One-way ANOVA assessed continuous measures. Chi-square assessed categorical measures.

RESULTS

141,357 ASDS cases met the inclusion criteria. High-volume surgeons performed a higher rate of longfusions (> 8 levels), revision surgeries, and surgeries requiring osteotomy. The OCI showed weak, but significant, correlation with blood loss values: acute blood loss anemia (r = 0.21) and treatment with blood products (r = 0.12) (p < 0.001). High OCI also was also associated with increased length of stay (r = 0.27) and total charges (r = 0.41) (p < 0.001).

CONCLUSIONS

The operative complexity index (OCI) for ASDS increases with high-volume surgeons and centers, indicating it can be useful to adjust for surgical invasiveness in the NIS database. Operative complexity must be considered when evaluating patient safety and quality indices among hospitals and surgeons.

[INFLUENCED ARBEPOETINALFA TO REDUCE THE NUMBER OF BLOOD TRANSFUSION IN CHILDREN WITH NON-SYNDROMIC CRANIOSYNOSTOSIS.]

BACKGROUND

According to the literature, the prevalence of non-syndromic forms of craniosynostosis in children is very high. Given that the treatment of this pathology and surgery performed only at an early age of the child, the need for transfusion arise very often.

THE AIM

To study the efficacy ofpreoperative use of darbepoetin alfa in combination with intraoperative normovolemic hemodilution to reduce the number of blood transfusions during surgery and in the early postoperative period.

MATERIALS AND METHODS

The study included 70 children between the ages of 6 months up to 12 months, divided into two groups: a control group (n=34) without stimulation of erythropoiesis and the study group (n =36) using apre-stimulation oferythropoiesis darbepoetin alfa.

RESULTS

In the control group, blood transfusion was performed in 79% of cases, compared with the test group-22% of cases. Also, the patients ofthe study group determined a statistically significant (p<0. 05) increase the level of red blood cells, hemoglobin and reticulocytes.

CONCLUSION

In children up to a year with various forms ofnon-syndromic craniosynostosis preoperative stimulation of erythropoiesis in conjunction with normovolemic hemodilution reduces the number of blood transfusions 3 times, or to opt out of its holding.

One size will never fit all: the future of research in pediatric transfusion medicine

There is concern at the National Heart, Lung, and Blood Institute (NHLBI) and among transfusion medicine specialists regarding the small number of investigators and studies in the field of pediatric transfusion medicine (PTM). Accordingly, the objective of this article is to provide a snapshot of the clinical and translational PTM research considered to be of high priority by pediatricians, neonatologists, and transfusion medicine specialists. Included is a targeted review of three research areas of importance: (i) transfusion strategies, (ii) short- and long-term clinical consequences, and (iii) transfusion-transmitted infectious diseases. The recommendations by PTM and transfusion medicine specialists represent opportunities and innovative strategies to execute translational research, observational studies, and clinical trials of high relevance to PTM. With the explosion of new biomedical knowledge and increasingly sophisticated methodologies over the past decade, this is an exciting time to consider transfusion medicine as a paradigm for addressing questions related to fields such as cell biology, immunology, neurodevelopment, outcomes research, and many others. Increased awareness of PTM as an important, fertile field and the promotion of accompanying opportunities will help establish PTM as a viable career option and advance basic and clinical investigation to improve the health and wellbeing of children.

[Quality assurance at the interface between anesthesia and transfusion medicine]

BACKGROUND

The current situation in hospitals is characterized by financial limitations and simultaneously by increasing demands on quality and safety. The operative interface between anesthesia and transfusion medicine affects both factors.

AIM

A detailed analysis was performed to evaluate the process quality at this operative interface at the University Hospital of Göttingen. The aim of the project was to revise und develop the structures and responsibilities at this interface, to dispose of weak points and to realize the optimization potential in the supply of blood products.

MATERIAL AND METHODS

A databank-based electronic data processing solution was established with the clear definition of responsibilities for the various workflow procedures and the written documentation of these definitions in standard operating protocols. In order to guarantee the necessary transparency a routine reporting system to the department of surgery was established. In addition, a continuous further development of the blood supply standard based on electronic report data was implemented.

RESULTS

By implementing the above named measures the rate of supplied to transfused blood products could be increased from 43.1 % to 55.7 %. The compliance with the blood supply standard improved continually over the first 18 months from 60.3 % to 92.3 %. The rate of supplied blood product deliveries without subsequent operation could be reduced from 9.0 % to 4.6  %. As a result of this optimization the supply costs in the internal cost allocation were reduced from 9,406 <euro> to 3,544 <euro>.

CONCLUSION

The measures described are appropriate to cost-effectively improve quality and patient safety. The optimization measures presented in this article can be implemented in other hospitals to increase quality and safety after individual adjustment to the local circumstances.

Engineering a fail-safe health system. Memorial Hermann wants to eliminate health care errors (really)

Memorial Hermann Healthcare System is on an all-out mission to eliminate health care-acquired infections. Despite a bit of physician resistance, the results so far are astonishing.

Challenges in the management of the blood supply

Although blood suppliers are seeing short-term reductions in blood demand as a result of initiatives in patient blood management, modelling suggests that during the next 5-10 years, blood availability in developed countries will need to increase again to meet the demands of ageing populations. Increasing of the blood supply raises many challenges; new approaches to recruitment and retainment of future generations of blood donors will be needed, and care will be necessary to avoid taking too much blood from these donors. Integrated approaches in blood stock management between transfusion services and hospitals will be important to minimise wastage--eg, by use of supply chain solutions from industry. Cross-disciplinary systems for patient blood management need to be developed to lessen the need for transfusion--eg, by early identification and reversal of anaemia with haematinics or by reversal of the underlying cause. Personalised medicine could be applied to match donors to patients, not only with extended blood typing, but also by using genetically determined storage characteristics of blood components. Growing of red cells or platelets in large quantities from stem cells is a possibility in the future, but challenges of cost, scaling up, and reproducibility remain to be solved.

Massive transfusion: an evidence-based review of recent developments

The design and implementation of massive transfusion protocols with ratio-based transfusion of blood and blood products are important and active areas of investigation. A significant yet controversial body of literature exists to support the use of hemostatic resuscitation in massive transfusion and new data to support the use of adjuncts, such as recombinant factor VIIa and tranexamic acid. We review the developments in massive transfusion research during the past 5 years, including protocol implementation, hemostatic resuscitation, the use of tranexamic acid, and goal-directed therapy for coagulopathy. Furthermore, we provide a level of evidence analysis of the data surrounding the use of component therapy and recombinant factor VIIa in massive transfusion, summary recommendations for the various agents of resuscitation, and new methods of goal-directed therapy.

[The state of art, problems and future of transfusiology]

The article specifies the main areas of modern transfusiology: blood services, transfusion immunology, clinical and industrial transfusiology. Our research work and the analysis of published data made it possible to specify a new paradigm of transfusion medicine--the transition from the doctrine of blood components transfusion to molecular transfusiology, which comprises medicamentary transfusiology based on the use of gene engineering and biotechnology components as well as blood components preparations, high-tech methods of extracorporeal molecular hemocorrection and highly specific laboratory technology. In view of this concept we develop and introduce modern methods of transfusion medicine and laboratory technologies, aimed at providing the safety of transfusion manipulations and optimizing their use in clinical practice. Transfusion immunology is a part of Transfusion Medicine, studying and implementing in practice the immunological safety and efficacy of transfusions. The article also specifies the main criteria for blood donation and blood components transfusion in patients with hereditary abnormalities of blood; a new approach to evaluation of blood donors potential in endemic foci of inherited abnormalities of blood. The results of the research work formed the basis for protocols of donors examination and the treatment of patients needing hemo transfusion, optimized the tactics of decreed research during the examination of blood donors and patients needing blood transfusion.

Ex-vivo red blood cells generation: a step ahead in transfusion medicine?

Blood transfusion and especially red blood cell (RBC) transfusion is an essential therapeutic act because it might be life-saving in several situations such as massive bleeding or as prolonged quality-of-life therapies in patients with chronic anemic disorders. Although the need for blood is thereby widespread, there is however a major imbalance between demand and supply of donors, so that there is a mounting research to develop suitable surrogates for human donated blood. Functional RBCs have already been generated from a variety of cellular progenitors (i.e., somatic stem cells, human embryonic stem cells and induced pluripotent stem cells) and synthetic biomaterials. Although these types of "artificial blood" carry several advantages over donated blood, including larger supply, lower risk of blood-borne pathogens transmission, no risk of immune incompatibility using group O, RhD-negative RBCs, and extended survival of stored RBCs, their efficacy has not been extensively tested thus far in clinical trials. Therefore, while it seems premature at this point in time to conclude that ex-vivo manufacturing of blood might be the definitive solution to the current shortage of blood supply, it represents however a valuable starting point for translational research in transfusion medicine.

Comparison of blood transfusion free pancreaticoduodenectomy to transfusion-eligible pancreaticoduodenectomy

Even though the surgical techniques and perioperative care have improved, blood transfusions are still often required for the patients undergoing pancreaticoduodenectomy (PD). But complications from blood transfusions, poor prognosis of blood transfused patients, cost, and availability of blood products demand transfusion free (TF) surgery in the PD patients. The purpose of this study is to compare clinical outcome of TF pancreaticoduodenectomy with transfusion-eligible (TE) PD. We had investigated the possibility of blood TF treatments for the patients who underwent PD from December 2005 to August 2007. There were 41 cases of PD performed by one surgeon with the same method: 14 patients of the TF group and 27 patients of the TE group. Most of the TF group patients received perioperative blood augmentation and intraoperative acute normovolemic hemodilution. The results of statistical analysis between TF and TE group showed that there were no statistical differences in intraoperative data and postoperative outcomes, except preoperative hemoglobin levels, type of operations, and transfusion amount. To our best knowledge, this is the first successful PD program in selected patients as a series of operations without blood transfusion. TF PD can be done successfully in selected patients without severe complications.

Transfusion-related acute lung injury (TRALI): A Canadian blood services research and development symposium

Since the first description of transfusion-related acute lung injury (TRALI) more than 2 decades ago, we have only recently begun to learn how this disorder may occur and how to prevent it. Scientists from around the world have made great strides in identifying the possible causes of this condition. Blood banks and transfusion services have risen to the challenges of prevention. Recent introduction of restricting most plasma products to those obtained from male donors only has greatly reduced the incidence of TRALI worldwide. Scientists have recently identified the gene and protein for the human neutrophil antigen-3a associated with most mortality due to TRALI, and this presents an opportunity for a screening assay to prevent future TRALI-associated deaths. Finally, animal models of TRALI have provided insight into the possible mechanisms of this disorder and can be used to explore potential treatment modalities.