Red blood cell transfusion threshold after pediatric cardiac surgery: A systematic review and meta-analysis.

BACKGROUND: Restrictive red blood cell transfusion strategy is implemented to minimize risk following allogeneic blood transfusion in adult cardiac surgery. However, it is still unclear if it can be applied to pediatric cardiac patients. The purpose of this systematic review and meta-analysis was to determine the effect of postoperative restrictive transfusion thresholds on clinical outcomes based on up-to-date results of randomized controlled trials (RCTs) and observational studies in pediatric cardiac surgery. METHOD: We searched for RCTs and observational studies in the following databases: the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ClinicalTrials.gov from their inception to October 26, 2017. We also searched reference lists of published guidelines, reviews, and relevant articles, as well as conference proceedings. No language restrictions were applied and no observational study met the inclusion criteria. RESULTS: Four RCTs on cardiac surgery involving 454 patients were included. There were no differences in the pooled fixed effects of intensive care unit (ICU) stay between the liberal and restrictive transfusion thresholds (standardized mean difference SMD, 0.007; 95% confidence interval CI, -0.18-0.19; P = .94). There were also no differences in the length of hospital stay (SMD, -0.062; 95% CI, -0.28-0.15; P = .57), ventilation duration (SMD, -0.015; 95% CI, -0.25-0.22; P = .90), mean arterial lactate level (SMD, 0.071; 95% CI, -0.22-0.36; P = .63), and mortality (risk ratio, 0.49; 95% CI, 0.13-1.94; P = .31). There was no inter-trial heterogeneity for any pooled analysis. Publication bias was tested using Egger, Begg, or the trim-and-fill test, and the results indicated no significant publication bias. CONCLUSION: Evidence from RCTs in pediatric cardiac surgery, though limited, showed non-inferiority of restrictive thresholds over liberal thresholds in length of ICU stay and other outcomes following red blood cell transfusion. Further high-quality RCTs are necessary to confirm the findings.

Ionised calcium levels in major trauma patients who received blood en route to a military medical treatment facility.

BACKGROUND: Hypocalcaemia is a common metabolic derangement in critically ill patients. Blood transfusion can also contribute to depleted calcium levels. The aims of this study were to identify the incidence of hypocalcaemia in military trauma patients receiving blood products en route to a deployed hospital facility and to determine if intravenous calcium, given during the prehospital phase, has an effect on admission calcium levels. METHODS: This was a retrospective review of patients transported by the UK Medical Emergency Response Team in Afghanistan between January 2010 and December 2014 who were treated with blood products in the prehospital setting. Total units of blood products administered, basic demographics, Injury Severity Score and trauma type were collected. Ionised serum calcium levels on admission to hospital were compared between those who received blood products without prehospital intravenous calcium supplemental therapy (non-treatment) and patients who were treated with 10 mL of intravenous calcium chloride (10%) concurrently with blood products (treatment). RESULTS: The study included 297 patients; 237 did not receive calcium and 60 did. The incidence of hypocalcaemia in the non-treatment group was 70.0% (n=166) compared with 28.3% (n=17) in the treatment group. Serum calcium levels were significantly different between the groups (1.03 mmol/L vs 1.25 mmol/L, difference 0.22 mmol/L, 95% CI 0.15 to 0.27). In the non-treatment group, 26.6% (n=63) had calcium levels within the normal range compared with 41.7% (n=25) in those who received calcium. There was a dose response of calcium level to blood products with a significant decrease in calcium levels as the volume of blood products increased. CONCLUSION: Trauma patients who received blood products were at high risk of hypocalcaemia. Aggressive management of these patients with intravenous calcium during transfusion may be required.

In Trauma, Conventional ROTEM and TEG Results Are Not Interchangeable But Are Similar in Clinical Applicability.

BACKGROUND: There is growing interest in viscoelastic hemostatic assays rotational thromboelastometry (ROTEM) and thromboelastography (TEG) for trauma. Despite shared features, it is unknown whether their results are interchangeable and whether one is clinically superior in predicting mortality, blood transfusion, and diagnosing early trauma coagulopathy. METHODS: We conducted a prospective observational study comparing equivalent ROTEM and TEG parameters. Severely injured patients expected to receive massive transfusion were included. Assays were performed simultaneously on admission and repeated over subsequent 12 hours. International normalized ratio ≥1.2 or fibrinogen <1 g/L defined coagulopathy. TEG used kaolin as coagulation initiator and ROTEM used tissue factor (conventional). Spearman nonparametric analysis and Bland-Altman difference mean plot revealed parameter association. Logistic regression and receiver operating characteristic curves measured predictive values. RESULTS: 33 patients (74 ROTEM, 74 TEG) were included; 79% were male, mean Injury Severity Score was 23.5 ± 14, admission international normalized ratio was 1.33 ± 0.4, and 63.4% received blood transfusions. Overall, parameter agreement fell outside acceptable limits, with weak or no association. Clinically, ROTEM maximum clot firmness and TEG maximum amplitude showed reasonable predictive accuracy for mortality, strong accuracy for any or massive blood transfusion, reasonable for plasma transfusion and similar poor predictive accuracy for diagnosing coagulopathy. CONCLUSIONS: ROTEM and TEG results are not interchangeable, arguably due to different coagulation triggers. Assays had similar clinical performance.

Transfusión según cifras de hemoglobina o de acuerdo con objetivos terapéuticos / Transfusion according to haemoglobin levels or therapeutic objectives

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How to Assist Intensive Care Units in Improving Healthcare Quality. Development of Actionable Quality Indicators on Blood use.

Previously developed quality indicators (QIs) for the intensive care did not give clues for quality improvement. We will improve this by developing new QIs that are actionable, reliable, valid and easy to register. Using a modified RAND technique we developed in three rounds new QIs for blood use at Dutch intensive care units (ICUs). The final set of QIs will be part of the National Intensive Care Evaluation quality registry and evaluated in a randomized controlled trial. In addition, a web-based feedback tool containing strategies for quality improvement will be developed. With the results of this project we hope to improve and maintain good quality of care at the Dutch ICUs .

Audit of pediatric transfusion practices in a tertiary care hospital.

OBJECTIVE: To perform a retrospective audit of transfusion practices, in order to study the appropriate and inappropriate usage of different blood components in pediatric population. METHODS: The present study, conducted over a period of 3 mo analyzed all the episodes of transfusions and divided them into appropriate and inappropriate according to the type of blood components, the requesting departments and the clinical indication of transfusion. Data was reviewed according to the British Committee for Standards in Hematology and American Association of Blood Bank guidelines. RESULTS: A total of 2,145 units of hemocomponents were transfused to children, including 1,181 units of red cell concentrates, 566 units of platelet concentrates/platelet rich plasma, 118 units of whole blood and 280 units of fresh frozen plasma in 1,819 episodes. Appropriate usage of blood components was 59.65%. Whole blood was most appropriately transfused (82.9%). Appropriate indications outnumbered inappropriate requisitions in Department of Pediatric Medicine (70.38 %), Nursery (82.54 %) and Thalassemia day care centre (55.63%). Red cell concentrate was most appropriately indicated in anemias (73.14%) and inappropriately in cases of surgeries (53.6%). Platelets were used more appropriately in all clinical indications. Whole blood was transfused most appropriately (100%) in double venous exchange therapy. Most appropriate indication of fresh frozen plasma usage was coagulopathy (42.57%). CONCLUSIONS: As the appropriate usage (59.65%) of blood components was low in the present study, regular auditing of transfusion practices from time to time is indicated. This not only helps guide their judicious use but also serves to evaluate and decrease their inappropriate usage.

Influence of autologous and homologous blood transfusion on interleukins and tumor necrosis factor-α in peri-operative patients with esophageal cancer.

OBJECTIVE: To explore the influence of different ways of blood transfusion on the expression levels of interleukins (IL) and tumor necrosis factor-α (TNF-α) inperi-operative patients with esophageal cancer. MATERIALS AND METHODS: A total of 80 patients with esophageal cancer who underwent radical operations were selected as study patients and randomly divided into an observation group (treated with autologous blood transfusion) and control group (with homologous blood transfusion). Changes of intra-operative indexes and peri-operative blood indexes, from hemoglobin (Hb) and hematocrit value (Hct), to levels of inflammatory factors like interleukins-6 (IL-6), IL-8, IL-10 and tumor necrosis factor-α (TNF-α) were compared. RESULTS: Operations for patients in both groups were successfully conducted, and no significant differences in mean surgical duration and intra-operative hemorrhage volume, fluid infusion volume and blood transfusion volume were detected (p>0.05). Compared with values before surgery, Hb and Hct levels decreased significantly while white blood cell count (WBC) increased 1, 5 and 7 d after operation (p<0.05, p<0.01). In addition, WBC was apparently higher in observation group than in control group 5 and 7 d after operation (p<0.01). Compared with before surgery, in the observation group, levels of IL-6, IL-8 and IL-10 had no significant differences after operation (P>0.05), but TNF-α level increased y (p<0.01), whereas in control group, IL-6 level had no significant difference (p>0.05), IL-8 level decreased obviously (p<0.05), IL-10 level increased markedly first and then decreased gradually as time passed but its level remained elevated (p<0.01), and TNF-α level increased first and then decreased, and there was no significant difference 7 d after operation (p>0.05). CONCLUSIONS: Decreased IL-8 and increased IL-10 levels are two important reasons forimmunosuppression after homologous blood transfusion, whereas autologous blood transfusion can alleviate this while increasing the TNF-α level, which also has potential to improve anti-tumor immunity in the human body.

[The different types of therapeutic plasma are equivalent?]. / Les différents types de plasmas thérapeutiques sont-ils équivalents ?

In France, three varieties of therapeutic plasma are being processed, distributed and delivered, currently; however, many more varieties are in use worldwide, which go by the property of labile blood component or plasma derived medicines. For one type of component (one given name), several devices and bags and so on are used to concur to its process, which makes that one type of therapeutic plasma may significantly differ from one production setting to one other. This may affect (more or less) the component properties as well as the possibly reported adverse events. This review aims thus, firstly at stressing on the difficulty in comparing data obtained in different contexts, and secondly at making the point on future directions to process therapeutic plasma.

The definition of massive transfusion in trauma: a critical variable in examining evidence for resuscitation.

OBJECTIVES: 'Massive' transfusion is a poorly defined inclusion criteria for studies examining the blood and blood product that are used during trauma resuscitation. We aimed to compare the traditional definition of massive transfusion (≥10 units in 24 h) to a more acute definition of at least 5 units in 4 h. METHODS: Multitrauma patients were subgrouped according to the traditional definition and compared with the acute definition. Demographics, presenting vital signs and blood results, management including transfusion practice and outcomes were retrospectively studied. Associations of transfused fresh frozen plasma:packed red blood cells (PRBC) ratios with mortality were studied. RESULTS: There were 927 patients who received PRBCs in the first 24 h, with 314 patients identified using the traditional definition and 303 patients using the acute definition. The patients identified using the traditional definition received 18 (12-29) units of PRBC in 24 h, significantly higher than those identified using the acute definition [15 (9-29) units, P<0.001]. The traditional definition excluded a significant proportion of patients who died in the emergency department. By using the acute definition to select a study sample, there seems to be an increase in mortality with fresh frozen plasma:PRBC ratio of 1 : 1 ratio compared with a 1 : 2 ratio. CONCLUSION: The traditional 'massive' transfusion definition not only 'dilutes' the potential study samples with a less acute group of patients, but also further excludes patients who die early. This latter group is most likely to be benefitted from any change to resuscitation practice. An acute definition of massive transfusion should be adopted when examining clinical practice during initial trauma resuscitation.

The EASTR study: a new approach to determine the reasons for transfusion in epidemiological studies.

Previous studies of blood use have used different methods to obtain and classify transfusion indications. Before undertaking a national study of transfusion recipients, a pilot study was performed over 2 months at two teaching and two district general hospitals to match information from hospital transfusion laboratories with clinical coding data from the hospital's Patients Administration System to determine the indication for transfusion in 2468 recipients. Data analysis revealed major limitations in the conventional use of primary diagnostic International Statistical Classification of Disease and Related Health Problems 10th Revision (ICD-10) or procedure Office of Population, Censuses and Surveys - Classification of Surgical Operations and Procedures - 4th Revision (OPCS-4) codes alone in allocating transfusion indications. A novel algorithm was developed, using both types of code, to select the probable indication for transfusion for each patient. A primary OPCS-4 code was selected for recipients transfused in relation to surgery (43%) and either the primary (36%) or the secondary (12%) ICD-10 code was chosen for recipients transfused for medical reasons. The remaining patients were unclassified. Selected codes were then collated into Epidemiology and Survival of Transfusion Recipients (EASTR) casemix groups (E-CMGs). The most frequent E-CMGs were haematology (15% of recipients), musculoskeletal (14%), digestive system (12%) and cardiac (10%). The haematology E-CMG includes patients with malignant and non-malignant blood disorders and recipients transfused for anaemia where no cause was listed. Recipients undergoing hip and knee replacement and coronary artery bypass grafting are within the musculoskeletal and cardiac E-CMGs. The digestive E-CMG includes recipients transfused for gastrointestinal (GI) bleeds and those undergoing GI surgery. This methodology provides a more useful means of establishing the probable indication for transfusion and arranging recipients into clinically relevant groups.

Technology. Beyond bar codes.

Just as the Food and Drug Administration orders the use of bar codes on most prescription drugs and blood products meant for transfusion, there is a push for an even more potent technology--radio frequency identification.

Transfusión perioperatoria en histerectomías abdominales y vaginales electivas / Perioperative transfusion in elective abdominal and vaginal hysterectomies

Objetivos: Analizar la transfusión perioperatoria de concentrados de hematíes en histerectomías abdominales y vaginales e identificar el test de reserva de sangre idóneo. Tipo de estudio: Estudio descriptivo y comparativo de la transfusión en ambos procedimientos. Se estudió prospectivamente a 278 pacientes consecutivas: 173 operadas de histerectomía abdominal y 105 de histerectomía vaginal. Resultados: Recibió transfusión un 12,1 por ciento de las pacientes en las que se realizó histerectomía abdominal y un 7,6 por ciento de aquellas en las que se realizó histerectomía vaginal; el cociente reserva/transfusión fue de 9,7 y 16,1, respectivamente. En el 73 por ciento de las transfusiones el criterio de indicación utilizado fue la existencia de hemorragia activa. Se encontró una relación significativa entre la existencia de anemia preoperatoria y la transfusión. Conclusiones: a) La frecuencia de transfusión fue similar en ambos procedimientos; b) la reserva de sangre fue inadecuada por exceso en ambos grupos; así, la tipificación y el escrutinio constituyeron el test de reserva de sangre preoperatorio de elección; c) el criterio más utilizado de transfusión fue la existencia de hemorragia activa, y d) la corrección de la anemia preoperatoria podría evitar un tercio de las transfusiones (AU)

Emergency coronary artery bypass graft surgery in abciximab-treated patients.

BACKGROUND: Although the platelet antiaggregant abciximab is frequently used with percutaneous coronary interventions, results of emergency coronary artery bypass graft operations in patients recently treated with abciximab are poorly characterized. METHODS: During a 29-month period, 12 patients required emergency coronary artery bypass grafting within 12 hours (mean, 1.9 hours) of abciximab therapy. Our full standard heparin dose regimen was used (mean heparin dose, 53,000 U per patient). Each patient received a single platelet transfusion dose after protamine administration, and further blood products were transfused as necessary. Clinical outcome and transfusion requirements were compared with predicted results based on risk-adjusted historical patients. RESULTS: No patients died and none were returned to the operating room for coagulopathy-related bleeding. Per patient transfusion requirements were as follows: red blood cells, 3.6 units; apheresis platelets, 1.4 units; and fresh frozen plasma, 1.5 units. As compared with predicted values, there was no excessive incidence of mortality, stroke, or red blood cell transfusion requirements. CONCLUSIONS: Emergency coronary artery bypass graft operations using full-dose heparin can be performed successfully in acutely ischemic abciximab-treated patients. Prophylactic transfusion of platelets after protamine administration appears to be useful.

Alternativas no transfusionales

Por numerosas razones existe la necesidad de contar con soluciones diferentes a la sangre y sus derivados durante la práctica clínica diaria. Se necesitan soluciones que restauren la volemia pero también sustancias que tengan la posibilidad de transportar oxígeno para así sobrepasar las dificultades y riesgos de la terapia transfusional. Contamos con soluciones cristaloiedes y coloides que tienen características, ventajas y desventajas diferentes, para hacer restituciones iniciales del líquido vascular: A pesar de que en las últimas décadas se ha hecho gran inversión en búsqueda de un transportador de oxígeno diferente al glóbulo rojo, las sustancias con lasque contamos hoy en día, es decir, las soluciones de hemoglobina y las perflourocarbonados, aún no reúnen los requisitos suficientes para ser unos adecuados sustitutos de la sangre

Hemoderivados en pediatría / Hemoderivates in the pediatric patients

Objetivo. Determinar las indicaciones, efectos colaterales y tipos de hemoderivados utilizados en una unidad de cuidados intensivos de pediatría. Diseño. Estudio prospectivo, descriptivo.Población. Quinientas noventa y dos transfusiones de hemoderivados. Metodología. Se revisaron los expedientes clínicos de 183 pacientes ingresados a la Unidad de Cuidado Intensivo por un período de 5 meses (abril-agosto 1998). Se incluyeron todos los pacientes que necesitaron algun hemoderivado y se excluyeron los que tenían trastornos hematológicos crónicos. El estudio incluyó una encuesta con precisas concretas sobre conocimientos básicos del uso de hemoderivados al personal médico. Resultados. Todos los entrevistados (n=56) han indicado y transfundido en alguna ocasión derivados de sangre. El 91 de los pacientes tratados en la UTIP fueron transfundidos; 58.6 de los cuales recibió glóbulos empacados. La sangre completa fue utilizada exclusivamente para exanguinotransfusiones totales. Cada paciente recibió en promedio 3.2 transfusiones. El 65 de pacientes egresó vivo del servicio y se reportaron 0.5 de complicaciones inmediatas. El 22.2 de las transfusiones estaban correctamente justificadas. Conclusiones. El estudio determinó que no hay uniformidad de conocimientos y criterios en el uso de hemoderivados y que no existe un protocolo establecido para su uso