Risk of vaso-occlusive episodes in patients with sickle cell disease exposed to systemic corticosteroids: a comprehensive review.

INTRODUCTION: Sickle cell disease (SCD) is the most frequent inherited disorder in the world. It is caused by a single amino acid mutation on the beta-globin chain, which lead to red blood cell deformation, haemolysis, and chronic inflammation. Clinical consequences are vaso-occlusives crisis, acute chest syndrome, thrombosis, infection, and chronic endothelial injury. AREAS COVERED: Corticosteroids are an old therapeutic class, that are inexpensive and widely available, which can be administered in different forms. Their adverse effects are numerous and well-known. This class could appear to be useful in SCD treatment due to its anti-inflammatory effect. Moreover, corticosteroids remain an essential therapeutic class for many indications, besides SCD. Although specific adverse effects of corticosteroids have been suspected in SCD patients for decades, recent papers has reported strong evidence of specific and severe adverse effects in this population. Based on a literature review, we will discuss pathophysiological considerations, consequences, and practical use of corticosteroids in SCD. EXPERT OPINION: High corticosteroid doses, for any indication , induce vaso-occlusive crises, acute chest syndrome, and re-hospitalization in patients with SCD. There is no evidence of any benefits of corticosteroid use in the SCD acute events. Prevention by hydroxyurea and/or red blood cell transfusion or exchange should be discussed when corticosteroid use is indispensable.

Pedipacks in the transfusion of pediatric patients to reduce wastage of blood components: an observational study from a tertiary center.

BACKGROUND: Pedipacks prevent wastage of blood components but they are not used efficiently in pediatric clinics. METHODS: Red cell concentrate (RCC) and platelet concentrate volumes transfused in the last eight months in the pediatric clinics were screened. To calculate the wastage of blood components, the number of transfused pedipacks, whole unit RCC, and platelet units were screened from transfusion laboratory digital records to show the number of whole RCC units or platelets units used instead of pedipacks. The study results were shared with physicians and transfusion laboratory staff and they were trained on the subject in meetings. Two years later, the transfusion laboratory records were assessed again to evaluate pedipack usage. A google questionnaire was also submitted to the transfusion laboratories of other hospitals to assess the use of pedipacks. RESULTS: RCC and platelets were used in 82.9% of the transfusions, and 31.2% of RCC and 18.4 % of platelets were transfused to patients ≤12 months. During the study period, 569 pedipacks and 117 random donor or apheresis platelets separated into satellite packs would be required. But only 48 pedipacks of RCCs and 24 units of random donor platelets/apheresis platelets separated into satellite packs were used. After two years, in RCC transfusions of 0-12 month-old patients, the transfusion laboratory release of pedipacks increased to 67.9% from 13.5%. Other centers were not also using pedipacks efficiently. The main reasons were unawareness of the subject, the blood bank delivering two units of pedipacks even when only one unit was ordered and the risk of not using the second pedipack before the expiry date, and the short expiry date of irradiated pedipacks. CONCLUSIONS: By increasing awareness of the subject, the collaboration of the clinic and laboratory and solving bureaucratic problems, rational use of blood components can be achieved.

Safety and Feasibility of Ultra-Restrictive Transfusion Protocol as a Blood-Preservation Strategy During Shortage Crises.

BACKGROUND: We hypothesized that implementation of new ultra-restrictive transfusion protocol in adult surgical intensive care units (SICU) was safe and feasible during pandemic-associated shortage crises. METHODS: Retrospective analysis two months pre- and post-implementation of ultra-restrictive transfusion protocol in March 2020 with hemoglobin cutoff of 6 g/dL (6.5 g/dL if ≥ 65 years old) for patients without COVID, active bleeding, or myocardial ischemia. RESULTS: We identified 16/93 and 27/168 patients PRE and POST meeting standard transfusion threshold (7 g/dL); within POST, 12 patients met ultra-restrictive cutoffs. There was no significant difference between PRE and POST in the rate of mortality, ischemic complications, or the number of transfusions per patient, however, the overall incidence of transfusion was lower in the POST group (7.1 vs 17.2%, p = 0.02). Patients received a mean (SD) of 4(3.8) and 2.4(1.5) PRBC transfusions pre- and post-implementation. Odds ratio of mortality in POST group was 0.62 (95%CI: 0.08-5.12) adjusted for age, sex, and SOFA score. CONCLUSIONS: Implementation of an ultra-restrictive transfusion protocol was feasible and effective as a blood- preservation strategy.

2021: Perioperative and critical care year in review for the cardiothoracic surgery team.

For yet another year, our lives have been dominated by a pandemic. This year in review, we feature an expert panel opinion regarding extracorporeal support in the context of COVID-19, challenging previously held standards. We also feature survey results assessing the impact of the pandemic on cardiac surgical volume. Furthermore, we focus on a single center experience that evaluated the use of pulmonary artery catheters and the comparison of transfusion strategies in the Restrictive and Liberal Transfusion Strategies in Patients With Acute Myocardial Infarction (REALITY) trial. Additionally, we address the impact of acute kidney injury on cardiac surgery and highlight the controversy regarding the choice of fluid resuscitation. We close with an evaluation of dysphagia in cardiac surgery and the impact of prehabilitation to optimize surgical outcomes.

Hospital red blood cell and platelet supply and utilization from March to December of the first year of the COVID-19 pandemic: The BEST collaborative study.

BACKGROUND: At the start of the coronavirus disease 2019 (COVID-19) pandemic, widespread blood shortages were anticipated. We sought to determine how hospital blood supply and blood utilization were affected by the first wave of COVID-19. STUDY DESIGN AND METHODS: Weekly red blood cell (RBC) and platelet (PLT) inventory, transfusion, and outdate data were collected from 13 institutions in the United States, Brazil, Canada, and Denmark from March 1st to December 31st of 2020 and 2019. Data from the sites were aligned based on each site's local first peak of COVID-19 cases, and data from 2020 (pandemic year) were compared with data from the corresponding period in 2019 (pre-pandemic baseline). RESULTS: RBC inventories were 3% lower in 2020 than in 2019 (680 vs. 704, p < .001) and 5% fewer RBCs were transfused per week compared to 2019 (477 vs. 501, p < .001). However, during the first COVID-19 peak, RBC and PLT inventories were higher than normal, as reflected by deviation from par, days on hand, and percent outdated. At this time, 16% fewer inpatient beds were occupied, and 43% fewer surgeries were performed compared to 2019 (p < .001). In contrast to 2019 when there was no correlation, there was, in 2020, significant negative correlations between RBC and PLT days on hand and both percentage occupancy of inpatient beds and percentage of surgeries performed. CONCLUSION: During the COVID-19 pandemic in 2020, RBC and PLT inventories remained adequate. During the first wave of cases, significant decreases in patient care activities were associated with excess RBC and PLT supplies and increased product outdating.

Passive order auditing associated with reductions in red blood cell utilization: National blood shortage experience.

BACKGROUND: Decreased blood collection during the Coronavirus Disease 2019 (COVID-19) pandemic resulted in long-term red blood cell (RBC) shortages in the United States. In an effort to conserve RBCs, the existing passive alert system for auditing inpatient transfusions was modified to activate at a lower hemoglobin threshold (6.5 g/dL instead of 7.0 g/dL for stable, nonbleeding inpatients) during a 9-month shortage at an academic medical center. Hemoglobin levels prior to RBC transfusions were compared for inpatients receiving RBC transfusions to determine whether RBC utilization changed during the intervention. STUDY DESIGN AND METHODS: This retrospective study compared the number of single-unit RBC transfusions and hemoglobin levels prior to RBC transfusion among inpatients during the 9 months of the intervention (Period 2, 06/01/2021-2/28/2022) to the same period of the previous year (Period 1, 06/01/2020-2/28/2021). RESULTS: Overall full unit RBC transfusions to inpatients decreased by 15% from 5182 to 4421. Of all transfusions, 50.3% and 49.8% were single-unit RBC transfusions in Period 1 and Period 2, respectively. The incidence rate difference and incidence rate ratio of single RBC units transfused per 1000 patient days were significantly decreased (p = 0.0007). The average pre-transfusion hemoglobin level significantly decreased from 7.18 g/dL to 7.05 g/dL (p = 0.0002), largely due to significant decreases in hemoglobin transfusion triggers for adult inpatient ward transfusions. DISCUSSION: Modification of the passive alert system was associated with significantly decreased RBC utilization during a long-term RBC shortage. Modification of transfusion criteria recommended by passive alerts may be a feasible option to decrease RBC utilization at centers during long-term RBC shortages.

Predictors of Red Blood Cell Transfusion in Elderly COVID-19 Patients in Korea.

Background: Patients who experience clinical deterioration from coronavirus disease (COVID-19) require blood transfusion support. We analyzed blood component usage in COVID-19 patients and identified the predictors of red blood cell (RBC) transfusion in elderly (≥65 years) patients. Methods: Blood component usage in 882 COVID-19 patients hospitalized between January 24, 2020 and April 30, 2021 was analyzed. Elderly patients were categorized into transfused and non-transfused groups according to their RBC transfusion history; their demographic and clinical characteristics, disease severity, and outcomes were compared. Associations were determined using multiple logistic regression. Results: The overall transfusion rate was 8.3% (73/882), and the transfusion rate was 2.7% (14/524) in patients aged <65 years and 16.5% (59/358) in those aged ≥65 years. Among the 358 elderly patients, 344 patients, including 50 who received transfusion and 294 who did not, were enrolled for the analysis. The prevalence of diabetes mellitus (DM), white blood cell count, absolute neutrophil count, and neutrophil-to-lymphocyte ratio (NLR) on admission were significantly higher in the transfused group, whereas Hb and platelet counts were significantly lower. Disease severity in the transfused group was relatively high on admission and increased thereafter. DM, intensive care unit entrance on admission, Hb, platelet count, and NLR on admission were independently associated with RBC transfusion. Conclusions: This study presents transfusion rates in COVID-19 patients according to age groups and predictors of RBC transfusion in elderly patients. The results provide a basis for developing a strategy for the medical treatment of infectious diseases emerging during pandemics.

Hyperhemolysis in a patient with sickle cell disease and recent SARS-CoV-2 infection, with complex auto- and alloantibody work-up, successfully treated with tocilizumab.

BACKGROUND: Hyperhemolysis syndrome (HHS) is a severe delayed hemolytic transfusion reaction seen in sickle cell disease (SCD) patients, characterized by destruction of donor and recipient RBCs. It results in a drop in hemoglobin to below pretransfusion levels and frequently reticulocytopenia. CASE REPORT: We report a case of a man in his thirties with SCD with a recent hospitalization 2 weeks prior for COVID-19. His red cell antibody history included anti-Fy(a) and warm autoantibody. At that time, he was given 2 units of RBC and discharged with a hemoglobin of 10.2 g/dl. He returned to the hospital approximately 1.5 weeks later with hemoglobin 6.0 g/dl and symptoms concerning for acute chest syndrome. Pretransfusion testing now showed 4+ pan-agglutinin in both gel-based and tube-based testing. Alloadsorption identified an anti-N and a strong cold agglutinin. Three least incompatible units were transfused to this patient over several days, with evidence of hemolysis. Further reference lab work revealed anti-Fya , anti-Fyb , anti-Lea , anti-Leb , and an anti-KN system antibody. The patient's hemoglobin nadired at 4.4 g/dl. The patient was treated with a single dose of tocilizumab, his hemoglobin stabilized, and he was discharged. DISCUSSION: We present a case of HHS proximate to recent SARS-CoV-2 infection with multiple allo and autoantibodies identified. Information on the relationship between SARS-CoV-2 infection and HHS is limited; however, it is possible that inflammation related to COVID-19 could predispose to HHS. Tocilizumab is an approved treatment for COVID-19. Additionally, tocilizumab appears to be a promising treatment option for patients with HHS.

Multisystem Inflammatory Syndrome in a Pediatric Patient With Sickle Cell Disease and COVID-19: A Case Report.

To this day, there are limited data about the effects and management of coronavirus disease infection in pediatric patients with sickle cell disease. We present the management and successful clinical course of an 8-year-old female with homozygous sickle cell disease (SS) and severe acute chest syndrome secondary to coronavirus disease 2019 infection, complicated by cortical vein thrombosis.

Blood supply, transfusion demand and mortality in Italian patients hospitalised during nine months of COVID-19 pandemic.

BACKGROUND: We describe blood supply and usage from March to December 2020 in two research medical hospitals in the Apulia region of Italy: Research Hospital "Casa Sollievo della Sofferenza" (Centre 1) and University Hospital of Bari (Centre 2). MATERIALS AND METHODS: We performed a retrospective observational study of blood component transfusions in the first eight months of the pandemic: 1st March-31st December 2020. We assessed the number of hospitalised patients who were transfused, the number and type of blood components donated and the number and type of blood components transfused in different care settings. RESULTS: Blood donations were lower in 2020 than in 2019, with a significant reduction in red blood cells (RBC) transfused (-29% in 2020 vs 2019) and fewer transfusions in 2020 in the Internal Medicine departments (-67% and -44% in Centres 1 and 2, respectively) and Intensive Care Units (ICUs) (-53% and -54% in Centres 1 and 2, respectively). The overall number of fatalities was significantly lower in 2020 than in 2019; the proportion of fatalities in men was significantly higher in 2020 than in 2019 (53.9% and 41.5%, respectively; p=0.000). Among COVID-19 patients (n=645), 427 (66.2%) were transfused in Infectious Disease departments and the remaining in ICUs. The fatality rate was 14.3% in COVID patients transfused in Infectious Disease departments and 22.5% in those transfused in ICUs. Kaplan-Meier analysis showed 30- and 60-day mortality was significantly higher in patients transfused in 2020 compared to those transfused in 2019. Fatalities were mostly observed in COVID-19 patients. DISCUSSION: Present data may be helpful in understanding the trend of collection and use of blood supplies during periods of pandemic. The implementation of a Patient Blood Management programme is essential to maintain sufficient blood supplies and to keep track of clinical outcomes that represent the most important goal of transfusion.

Severe autoimmune hemolytic anemia following receipt of SARS-CoV-2 mRNA vaccine.

BACKGROUND: Large clinical trials have demonstrated the overall safety of vaccines for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, reports have emerged of autoimmune phenomena, including vaccine-associated myocarditis, immune thrombocytopenia, and immune thrombotic thrombocytopenia. CASE PRESENTATION: Here we present a novel case of a young woman who developed life-threatening autoimmune hemolytic anemia (AIHA) after her first dose of a SARS-CoV-2 mRNA vaccine. Notably, initial direct antiglobulin testing was negative using standard anti-IgG reagents, which are "blind" to certain immunoglobulin (IgG) isotypes. Further testing using an antiglobulin reagent that detects all IgG isotypes was strongly positive and confirmed the diagnosis of AIHA. The patient required transfusion with 13 units of red blood cells, as well as treatment with corticosteroids, rituximab, mycophenolate mofetil, and immune globulin. CONCLUSION: As efforts to administer SARS-CoV-2 vaccines continue globally, clinicians must be aware of potential autoimmune sequelae of these therapies.

Measures to reduce red cell use in patients with sickle cell disease requiring red cell exchange during a blood shortage.

The COVID-19 pandemic has created major disruptions in health care delivery, including a severe blood shortage. The inventory of Rh and K antigen-negative red cell units recommended for patients with hemoglobinopathies became alarmingly low and continues to be strained. Because patients with sickle cell disease requiring chronic red cell exchange (RCE) incur a large demand for red cell units, we hypothesized that implementation of 2 measures could reduce blood use. First, obtaining the pretransfusion hemoglobin S (HbS) results by procedure start time would facilitate calculation of exact red cell volume needed to achieve the desired post-RCE HbS. Second, as a short-term conservation method, we identified patients for whom increasing the targeted end procedure hematocrit up to 5 percentage points higher than the pretransfusion level (no higher than 36%) was not medically contraindicated. The goal was to enhance suppression of endogenous erythropoiesis and thereby reduce the red cell unit number needed to maintain the same target HbS%. These 2 measures resulted in an 18% reduction of red cell units transfused to 50 patients undergoing chronic RCE during the first 6 months of the COVID-19 pandemic. Despite reduction of blood use, pretransfusion HbS% target goals were maintained and net iron accumulation was low. Both strategies can help alleviate a shortage of Rh and K antigen-negative red cells, and, more generally, transfusing red cell units based on precise red cell volume required can optimize patient care and judicious use of blood resources.

COVID-19 related callback in blood donors; Outcomes in blood donors and patients.

Call back as a procedure to report post donation symptoms or illness by donors has been established since 2009 in Iranian Blood Transfusion Organization (IBTO). During the first phase of COVID-19 outbreak, all blood donors were requested to report any respiratory infection symptoms after donation. The study investigated the callback data of COVID-19 in Tehran Blood Center during the first 3 months of the outbreak in Iran. The purpose of this study was to estimate the frequency of post donation COVID-19 related call back reports and determine its implications for blood donors and patients. A telephone interview was conducted with donors who had reported COVID-19 symptoms. Some questions were asked to evaluate donor's health at the time of blood donation. The donors categorized into three groups: laboratory-confirmed, suspected, and COVID-19 irrelevant based on their answers. In cases that the blood component obtained from a laboratory-confirmed donor had been released, the hospital was notified and asked to follow up the recipient for COVID-19. The results showed 30 donors (0.08 %) had callback related to COVID-19 and 76.63 % of the obtained component was disposed. The results also showed that only one donor had a laboratory-confirmed result with the RBC unit processed from her whole blood released for transfusion. The RBC unit recipient did not show any signs or symptoms of infection during a 46-day follow-up. Concluded that callback system was effective to remove most of the components obtained from the donors who reported to be COVID-19 suspected or confirmed. Moreover, the result did not support virus transmission through blood transfusion.

Intra-operative autologous blood donation for cardiovascular surgeries in Japan: A retrospective cohort study.

Intra-operative autologous blood donation is a blood conservation technique with limited evidence. We evaluated the association between intra-operative autologous blood donation and decrease in peri-operative transfusion in cardiovascular surgery based on evidence from a Japanese administrative database. We extracted the data of patients who had undergone cardiovascular surgery from the Diagnosis Procedure Combination database in Japan (2016-2019). Based on the surgery type, we examined the association of intra-operative autologous blood donation with the transfusion rate and amount of blood used in cardiac and aortic surgeries using multilevel propensity score matching. We enrolled 32,433 and 4,267 patients who underwent cardiac and aortic surgeries and received 5.0% and 6.7% intra-operative autologous blood donation with mean volumes of 557.68 mL and 616.96 mL, respectively. The red blood cell transfusion rates of the control and intra-operative autologous blood donation groups were 60.6% and 38.4%, respectively, in the cardiac surgery cohort (p < .001) and 91.4%, and 83.8%, respectively, in the aortic surgery cohort (p = .037). The transfusion amounts for the control and intra-operative autologous blood donation groups were 5.9 and 3.5 units of red blood cells, respectively, for cardiac surgery patients (p < .001) and 11.9 and 7.9 units, respectively, for aortic surgery patients (p < .001). Intra-operative autologous blood donation could reduce the transfusion rate or amount of red blood cells and fresh frozen plasma for patients undergoing index cardiovascular surgery and could be an effective blood transfusion strategy in cardiovascular surgery for Japanese patients.

A COVID-19 pregnant patient with thrombotic thrombocytopenic purpura: a case report.

BACKGROUND: Pregnancy seems to increase the risk of thrombotic thrombocytopenic purpura (TTP) relapses and make the TTP more severe in any of the pregnancy trimesters, or even during the postpartum period. CASE PRESENTATION: This study highlights details of treating a COVID-19 pregnant patient who survived. This 21-year addicted White woman was admitted at her 29th week and delivered a stillbirth. She was transferred to another hospital after showing signs of TTP, which was caused by a viral infection. CONCLUSION: This viral infection caused fever and dyspnea, and the patient was tested positive for COVID-19 infection. A chest computed tomography scan showed diffuse multiple bilateral consolidations and interlobar septal thickening. She stayed at the Intensive Care Unit for 20 days and treated with plasmapheresis. As far as we know, this is the first report of a TTP pregnant patient with COVID-19 infection.