Blood transfusions in non-major burns patients

BACKGROUND

Blood transfusions are essential to treating anaemia of burn injuries. It has recently been observed that patients with non-major burns < 20%TBSA may also develop anaemia requiring transfusion of blood products. Due to the morbidity and mortality rate associated with blood transfusions better understanding of risk factors may guide clinical practices to improve patient care.

OBJECTIVE

To determine risk factors for transfusion of blood products in patients with non-major burn injuries and assess transfusion practices to establish impact on patient outcome.

METHOD

Our study included 182 adult patients with non-major burn injuries, < 20%TBSA admitted over a 3-year period at the Department of Plastic Surgery and Burns Unit of the Emergency County Hospital Cluj-Napoca. We analysed patient and injury characteristics: age, gender, %TBSA burn, %FT burn, burn site, mechanism of injury, inhalation injury, Hb lab determinations throughout admission and surgical management. Charlson comorbidities index has been determined based on cardiovascular, neurological, gastrointestinal and renal comorbidities as well as diabetes mellitus. We selected blood transfusions, wound infections and length of hospital stay as outcome for our analysis.

RESULTS

37.9% of patients included in our study developed anaemia throughout admission and 7.7% underwent blood transfusions. Mean Hb levels triggering blood transfusions have been recorded at 7.4 (IQR=8.8-9.9) g/dL. Patients who received transfusions were older, presented with higher %TBSA and associated a higher comorbidity index. They also tended to develop coagulopathy and underwent more surgical procedures to achieve wound closure. In transfused patients who associate comorbidities we observed a higher rate of wound infections and longer hospital stay.

CONCLUSIONS

Patient related comorbidities correlate with higher transfusion rates in non-major burn injuries. Due to the risk associated with the use of blood products decision to transfuse should adhere to current guideline practices and be tailored to specific patient requirements.

Reducing Blood Loss in a Burn Care Unit: A Review of Its Key Determinants

Patients with a major burn injury differ considerably from the typical critical ill and trauma population. Very often, burn patients suffer from anemia throughout their hospital stay. This is caused both by combination of persistent blood loss with decreased erythropoiesis. Therefore, burn patients do have major transfusion requirements. However, transfusion is not devoid of risks or costs. We hereby review the best surgical techniques and medical approaches, aiming to reduce blood loss in a burn patient and optimize red cell production, so that we can reduce the need of RBC transfusion. The implementation of a combination of surgical techniques aiming to reduce blood loss and medical care approaches to prevent anemia, rather than single attitudes, should be adopted in burn care. There is an urgent need for clear guidelines that can easily be accepted, applied, and spread across different burn units to methodically implement measures to reduce blood loss and transfusion needs, and ultimately improve burn patients' outcome and the health care financial status.

Experience of outreach in a resource-constrained environment: 10 years of outcomes in burn care

OBJECTIVE

The objective of this work was to describe an efficient and sustainable outreach model in a resource-constrained environment, with a multifaceted approach focusing on national policy change, telemedicine, injury prevention, education and treatment of burns.

SUMMARY BACKGROUND DATA

Burn injury constitutes a significant portion of morbidity and mortality worldwide, particularly in children, and in low- and middle-income countries.

METHODS

We reviewed the impact of ten-years of a burn outreach program. Our focus was on clinical data on burn care within one region of Ukraine. We assessed knowledge of burn prevention/first aid utilizing a large survey, analyzed clinical data from our outreach clinic and telemedicine program, and analyzed data within a newly created burn repository within Ukraine.

RESULTS

A national burn prevention policy has been implemented through our efforts along with a burn prevention program. Educational efforts have led to improvements of major complication rates (wound infection [7% vs. 16%], pneumonia [2.4% vs. 0.3%], sepsis [1.6% vs. 0.6%], UTI [2% vs. 0.6%], and cellulitis [11% vs. 3.4%]), respiratory support of acutely ill patients [1.3% vs. 0.4%], and blood transfusion triggers.

CONCLUSIONS

Broadly, our model could be an example of building sustainable outreach programs in resource-constrained environments. Through collaboration with local healthcare providers, we have developed and implemented an outreach program in a resource-constrained environment.

Plasma TNFα and Unknown Factor/s Potentially Impede Erythroblast Enucleation Obstructing Terminal Maturation of Red Blood Cells in Burn Patients

INTRODUCTION

In this study, using burn patient's peripheral blood mononuclear cells (PBMCs), we have shown that the Epo independent stage of terminal enucleation to reticulocyte formation is impeded in the presence of autologous plasma (BP). Furthermore, substitution with allogeneic control plasma (CP) from the healthy individual in place of BP rectified this enucleation defect. The exclusive role of burn microenvironment in late-stage erythropoiesis defect was further demarcated through control healthy human bone marrow cells cultured in the presence of CP, BP, and cytokines.

METHODS

PBMCs and human bone marrow (huBM) were differentiated ex vivo to enucleated reticulocytes in the presence of required growth factors and 5% CP or BP. Effect of systemic mediators in burn microenvironment like IL-6, IL-15, and TNFα was also explored. Neutralization experiments were carried out by adding varying concentrations (25 ng-400 ng/mL) of Anti-TNFα Ab to either CP+TNFα or BP.

RESULTS

Reticulocyte proportion and maturation index were significantly improved upon substituting BP with CP during differentiation of burn PBMCs. In the huBM ex vivo culture, addition of IL-6 and IL-15 to CP inhibited the proliferation stages of erythropoiesis, whereas TNFα supplementation caused maximum diminution at erythroblast enucleation stage. Supplementation with anti-TNFα in the BP showed significant but partial restoration in the enucleation process, revealing the possibility of other crucial microenvironmental factors that could impact RBC production in burn patients.

CONCLUSION

Exogenous TNFα impairs late-stage erythropoiesis by blocking enucleation, but neutralization of TNFα in BP only partially restored terminal enucleation indicating additional plasma factor(s) impair(s) late-stage RBC maturation in burn patients.

Increased risk of blood transfusion in patients with diabetes mellitus sustaining non-major burn injury

BACKGROUND

Due to the increased mortality and morbidity associated with blood transfusion, identifying modifiable predictors of transfusion are vital to prevent or minimise blood use. We hypothesised that burn patients with diabetes mellitus were more likely to be prescribed a transfusion. These patients tend to have increased age, number of comorbidities, infection risk and need for surgery which are all factors reported previously to be associated with blood use.

OBJECTIVE

To determine whether patients with diabetes mellitus who have sustained a burn ≤20% total body surface area (TBSA) are at higher risk of receiving red blood cell transfusion compared to those without diabetes mellitus.

METHOD

This was a retrospective cohort study including patients admitted to the major Burns Unit in Western Australia for management of a burn injury. Only the first hospital admission between May 2008 to February 2017 were included.

RESULTS

Among 2101 patients with burn injuries ≤20% TBSA, 48 (2.3%) received packed red blood cells and 169 (8.0%) had diabetes. There were 13 (7.7%) diabetic patients that were transfused versus 35 (1.8%) non-diabetic patients. Patients with diabetes were 5.2 (p = 0.034) times more likely to receive packed red blood cells after adjusting for percentage TBSA, haemoglobin at admission or prior to transfusion, number of surgeries, total comorbid burden and incidence of infection. As percentage TBSA increases, the probability of packed red blood cell transfusion increases at a higher rate in DM patients.

CONCLUSIONS

This study showed that diabetic patients with burn injuries ≤20% TBSA have a higher probability of receiving packed red blood cell transfusion compared to patients without diabetes. This effect was compounded in burns with higher percentage TBSA.

Trends and outcomes in multicomponent blood transfusion: an 11-year cohort study of a large multisite academic center

BACKGROUND

Most studies reporting on blood component utilization overlook patients transfused with more than one type of blood product (multicomponent transfusion). These patients are of importance, as they are large consumers of blood products and likely have different characteristics and outcomes than nontransfused patients and patients transfused with only one blood component type. Our study aimed to determine the prevalence of multicomponent transfusion at a large multisite academic center, as well as the patient characteristics and outcomes associated with multicomponent transfusion.

METHODS

A retrospective cohort study of transfused adult inpatients at the Ottawa Hospital between 2007 and 2017 was performed. Eligible transfusions were red blood cells (RBCs), platelets, plasma, cryoprecipitate, and/or fibrinogen concentrate. Descriptive analyses were done to determine multicomponent transfusion prevalence. Patient characteristics and outcomes associated with multicomponent transfusion were assessed using multivariable regressions.

RESULTS

Of 55,719 adult transfused inpatient admissions, 25% received a multicomponent transfusion. Multicomponent transfusion prevalence was highest in hematology (51%), cardiac surgery (45%), and critical care (40%) patients. Multivariable regression analysis showed that compared to RBC-only transfusion, multicomponent transfusion was associated with increased odds of in-hospital mortality (odds ratio, 3.48; 95% confidence interval [CI], 3.26-3.73), greater odds of institutional discharge as opposed to discharge home (odds ratio, 1.22; 95% CI, 1.15-1.30), and a 1.58 time increase in duration of hospitalization (95% CI, 1.54-1.62).

CONCLUSION

Multicomponent transfusion recipients make up a large proportion of transfused patients and have poorer outcomes. It is necessary to continue studying these patients, including outcomes and transfusion appropriateness, to inform best practices.

Metagenomics in pooled plasma, with identification of potential emerging infectious pathogens

BACKGROUND

Many emerging infectious pathogens are well known for existing in healthy blood donors and could be transmitted via blood transfusion or plasma derivatives usage. Therefore, there is an urgent need to discover the pathogens in qualified blood donation to avoid potential threats to blood safety.

STUDY DESIGN AND METHODS

The objective of this study was to investigate the microbiome that existed in pooled plasma from different manufacturers in Chengdu and Guiyang. Random polymerase chain reaction, large-scale clone sequencing, and bioinformatics were used to investigate the metagenomics and microbiome structure of pooled plasma. Among detected microbiomes, potential pathogens were subsequently identified.

RESULT

After host DNA cleaning, 551 clones were classified as bacteria; 88 clones were classified as viruses, and four clones were considered to be parasites, respectively. Thirteen kinds of bacteria and two kinds of parasites that might potentially threaten blood safety were identified along with six kinds of nonpathogenic viruses. The infection status of one identified pathogen Coxiella burnetii was evaluated in 1638 plasma samples. The reactive rate of immunoglobulin (Ig)G1 was 1.10% (18/1638), the reactive rate of IgG2 was 0.85% (14/1638), and the reactive rate of IgM was 0.98% (16/1638).

CONCLUSION

Some pathogens that were already considered as threats to blood safety were discovered in those pooled plasma such as C. burnetii, Orientia tsutsugamushi, and Plasmodium sp. As a result, we should initiate some specific tests in the endemic area on plasma donors to enhance the blood safety in China.

Discrete β-adrenergic mechanisms regulate early and late erythropoiesis in erythropoietin-resistant anemia

BACKGROUND

Anemia of critical illness is resistant to exogenous erythropoietin. Packed red blood cells transfusions is the only treatment option, and despite related cost and morbidity, there is a need for alternate strategies. Erythrocyte development can be divided into erythropoietin-dependent and erythropoietin-independent stages. We have shown previously that erythropoietin-dependent development is intact in burn patients and the erythropoietin-independent early commitment stage, which is regulated by β1/β2-adrenergic mechanisms, is compromised. Utilizing the scald burn injury model, we studied erythropoietin-independent late maturation stages and the effect of β1/β2, β-2, or β-3 blockade in burn mediated erythropoietin-resistant anemia.

METHODS

Burn mice were randomized to receive daily injections of propranolol (nonselective β1/β2 antagonist), nadolol (long-acting β1/β2 antagonist), butoxamine (selective β2 antagonist), or SR59230A (selective β3 antagonist) for 6 days after burn. Total bone marrow cells were characterized as nonerythroid cells, early and late erythroblasts, nucleated orthochromatic erythroblasts and enucleated reticulocyte subsets using CD71, Ter119, and Syto-16 by flow cytometry. Multipotential progenitors were probed for MafB expressing cells.

RESULTS

Although propranolol improved early and late erythroblasts, only butoxamine and selective β3-antagonist administrations were positively reflected in the peripheral blood hemoglobin and red blood cells count. While burn impeded early commitment and late maturation stages, β1/β2 antagonism increased the early erythroblasts through commitment stages via β2 specific MafB regulation. β3 antagonism was more effective in improving overall red blood cells through late maturation stages.

CONCLUSION

The study unfolds novel β2 and β3 adrenergic mechanisms orchestrating erythropoietin resistant anemia after burn, which impedes both the early commitment stage and the late maturation stages, respectively.

Blood transfusions in severe burn patients: Epidemiology and predictive factors

BACKGROUND

Blood is a vital resource commonly used in burn patients; however, description of blood transfusions in severe burns is limited. The purpose of this study was to describe the epidemiology of blood transfusions and determine factors associated with increased transfusion quantity.

METHODS

This is a retrospective study of total 133 patients with >40% total body surface area (TBSA) burns admitted to the burn center of Changhai hospital from January 2008 to December 2013. The study characterized blood transfusions in severe burn patients. Univariate and Multivariate regression analyses were used to evaluate the association of clinical variables with blood transfusions.

RESULTS

The overall transfusion rate was 97.7% (130 of 133). The median amount of total blood (RBC and plasma), RBC and plasma transfusions was 54 units (Interquartile range (IQR), 20-84), 19 units (IQR, 4-37.8) and 28.5 units (IQR, 14.8-51.8), respectively. The number of RBC transfusion in and outside operation room was 7 (0, 14) and 11 (2, 20) units, and the number of plasma was 6 (0.5, 12) and 21 (11.5, 39.3) units. A median of one unit of blood was transfused per TBSA and an average of 4 units per operation was given in the series. The consumption of plasma is higher than that of RBC. On multivariate regression analysis, age, full-thickness TBSA and number of operations were significant independent predictors associated with the number of RBC transfusion, and coagulopathy and ICU length showed a trend toward RBC consumption. Predictors for increased plasma transfusion were female, high full-thickness TBSA burn and more operations.

CONCLUSIONS

Severe burn patients received an ample volume of blood transfusions. Fully understanding of predictors of blood transfusions will allow physicians to better optimize burn patients during hospitalization in an effort to use blood appropriately.