A new perspective on best transfusion practices

Risk Factors Analysis and Nomogram Model Establishment of Hidden Blood Loss in Overweight and Obese Elderly Patients After Total Hip Arthroplasty

Background

Total hip arthroplasty (THA) has become the first-choice treatment for elderly patients with end-stage hip disease. The high amount of hidden blood loss (HBL) in overweight and obese patients after THA not only affects rapid recovery, but also results in a greater economic burden. We aimed to identify risk factors that contribute to elevated HBL in overweight and obese patients after THA by retrospective analysis, and establish a nomogram prediction model for massive HBL in overweight and obese patients after THA.

Methods

A total of 505 overweight and obese patients treated with THA were included and randomly divided into modeling and validation sets according to a 7:3 ratio. The demographic and relevant clinical data of the patients were collected. The independent risk factors affecting HBL after THA in overweight and obese patients were obtained by Pearson, independent sample T-test, and multiple linear regression analyses. R software was used to establish a nomogram prediction model for postoperative HBL, as well as a receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

Results

HBL was 911±438 mL, accounting for 79.5±13.1% of the total perioperative blood loss (1104±468 mL). A multiple linear regression analysis showed that HBL was associated with necrosis of the femoral head, absence of hypertension, longer operative time, higher preoperative erythrocytes, and higher preoperative D-dimer levels. The areas under the ROC curve (AUC) for the modeling and validation sets were 0.751 and 0.736, respectively, while the slope of the calibration curve was close to 1. The DCA curve demonstrated a better net benefit at a risk of HBL ≥1000 ml in both the training and validation groups.

Conclusion

HBL was an important component of total blood loss (TBL) after THA in overweight and obese patients. Necrosis of the femoral head, absence of hypertension, longer operative time, higher preoperative erythrocytes, and higher preoperative D-dimer levels were independent risk factors for postoperative HBL in these patients. The predictive model constructed based these data had better discriminatory power and accuracy, and could result in better net benefit for patients.

Critical Assessment of Transfusional Practices in the Obstetrics and Gynecology Department At the University Hospital of Kinshasa

Introduction

Gynecology and obstetrics are among the specialties where blood transfusion is most practiced. This situation requires the use of good transfusion practices. The objective of this study was to assess the quality of transfusion practice in the Gynecology and Obstetrics Department of the University Hospital of Kinshasa (UHK).

Methods

This is a prospective, evaluative and descriptive study performed at the Department of Gyneco-Obstetrics of the University Hospital of Kinshasa from February 25 to June 25, 2020; which dealt with patients who received at least one blood transfusion.

Results

About 498 patients, 54 patients were transfused and their average age was 36.4 years, with the extremes of 14 and 60 years, the transfusion rate was 10.8%. Most of patients (n=36: 2/3) were transfused during weekend days, sachets were used as delivery materials of blood product in 57.4% of cases (n = 31). Among the prescribers of blood products, 70.4% were nurses. All transfusions were carried out in type-specific and cross-matched Rh. All the transfused patients were not aware of the disadvantages of transfusion. Compatibility tests at the patient's bedside were not performed in 61.1% of cases and the concordance control between the patient and the blood component to be transfused was not performed in 70.4% of cases. Close monitoring of blood transfusion in the first ten minutes was not performed in 59.3% of cases.

Conclusion

Transfusion encounters real practical problems in the gyneco-obstetrical environment of countries with limited resources. However, an assessment and multidisciplinary collaboration would be necessary to improve transfusion practice in medical field.

Impact of restrictive versus liberal transfusion and clinical outcomes in critically ill children: A retrospective observational study

Background and Aims

Critically ill children with anemia often requires blood transfusion, which can cause several complications. It is important to decide when to start the red blood cell (RBC) transfusion; however, the guidelines is still lacking. The aim of this study was to compare restrictive and liberal transfusion strategy.

Methods

This is an observational retrospective study of critically-ill children who receive RBC transfusion. Subjects categorized into two groups by initial hemoglobin (Hb), that is, restrictive (Hb ≤ 7 g/dl) and liberal (Hb ≤ 9.5 g/dl) strategy. In each group, subjects categorized based on: (1) Hb increment: high (increased ≥2.5 g/dl) and low (increase <2.5 g/dl) and (2) final Hb level: low (<7.0 mg/dl), moderate (7.0-10.0 mg/dl), and high (>10.0 mg/dl). Patient with hematologic or congenital disorder, severe malnutrition, chronic infection-related anemia, and transfusion in Hb level ≥9.5 g/dl were exclude. Each patients were evaluated for the clinical outcome, which is: intensive care length of stay (IC-LOS), length of mechanical ventilation (LoMV), and mortality rate.

Results

Clinical outcome and mortality rates of both transfusion strategies are similar. The mortality rates were lower in higher Hb increment and final Hb level (p = 0.04 and p = 0.01, respectively). Multivariate analysis in all groups revealed mortality rate had moderate correlation with Hb increment (odds ratio [OR] = 0.694, 95% confidence interval [CI] 0.549-0.878; p = 0.002) and moderate correlation (OR = 0.642, 95% CI 0.519-0.795; p = 0.000) with final Hb level. The similar results was found after categorization based on transfusion strategy.

Conclusion

We conclude the restrictive and liberal transfusion strategy have a similar effect to IC-LOS, LoMV, and mortality rate. High Hb increment (≥2.5 g/dl) and moderate-high final Hb (≥7.0 g/dl) after transfusion reduce the mortality rate.

Characterising differences in red blood cell usage patterns between healthcare sectors in South Africa: 2014-2019

BACKGROUND

South Africa aims to transition from a two-tiered healthcare system (public and private) to universal health coverage. Data on red blood cell (RBC) product usage reveal disparities between the sectors. Blood transfusion services further need to understand differing disease profiles and transfusion prescribing practices between the sectors to ensure blood security should the transition to a two-tiered health system come to fruition.

MATERIALS AND METHODS

Operational data for public and private healthcare RBC requests between 1 January 2014 and 31 March 2019, obtained from the South African National Blood Service (SANBS), were retrospectively analysed. Sector-specific demographic and utilisation trends were compared for the dominant clinical disciplines. Pre-transfusion haemoglobin (Hb) patterns were also delineated for 2018.

RESULTS

Between 2014 and 2019, 2,356,411 public and private sector RBC transfusion events resulted in the issue of 4,020,094 RBC units (1,553,159 transfusion events and 2,495,054 units within the public sector versus 803,282 transfusion events and 1,525,040 units in private). The dominant clinical disciplines within the public sector were Medical (32.9%), Gynaecology/Obstetrics (27.3%), General Surgery (13.6%), and Paediatrics (including Paediatric Surgery) (6.5%), compared to Intensive Care Units (33.2%), Medical (28.3%), General Surgery (10.4%), and Haematology/Oncology (8.3%) in the private sector. Median pre-transfusion Hb values for 2018 were lower in the public than in the private sector: 6.9 g/dL public sector versus 8 g/dL private sector.

DISCUSSION

Clinical drivers of RBC usage within the public and private healthcare sectors in South Africa differ significantly. Disparate pre-transfusion Hb between the sectors are likely due to differing disease profiles and severity, as well as differences in practice in prescribing transfusions. Implementation of a nationally co-ordinated Patient Blood Management programme may help to address these disparities and help ensure a sustainable blood transfusion system.

Patient Blood Management: transfusion appropriateness in the post-operative period

BACKGROUND

Within the context of Patient Blood Management (PBM) policy for the peri-operative period, the transfusion medicine unit of our institution adopted a series of strategies to support and enhance red blood cell (RBC) transfusion best practices. This study aimed to evaluate the appropriateness of RBC transfusion therapy in the post-operative period, before and after starting a multifactorial PBM policy.

MATERIALS AND METHODS

A 2-phase observational study was conducted on patients who underwent major surgery. The study was designed as follows: 3 months of preliminary audit, followed by multifactorial PBM policy, and a final audit. The policy comprised seminars, teaching lessons, periodic consultations and the insertion of Points of Care. RBC transfusion appropriateness was evaluated in both audits.

RESULTS

The preliminary audit, performed on 168 patients, showed that 37.7% of the patients were appropriately transfused. The final audit, performed on 205 patients, indicated a significant increase of RBC transfusion appropriateness to 65.4%.

DISCUSSION

In our experience, our multifactorial PBM policy improved the RBC transfusion appropriateness in the post-operative period. We believe that our multifactorial PBM policy, which comprises the insertion of Points of Care, supported the healthcare workers in the transfusion decision-making process. This enhancement of transfusion appropriateness implies clinical and managerial advantages, such as reduced transfusion-related risks, optimisation of health care resources, and reduction in costs.

Discharge Hemoglobin Association with Long-Term Outcomes of ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

Background

Anemia following acute myocardial infarction (AMI) is associated with poor outcomes. While previous studies in patients with AMI have focused on anemia at admission, we hypothesized that hemoglobin (Hb) decline during hospitalization and lower discharge Hb would be associated with greater long-term mortality in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).

Methods

We analyzed records of 983 STEMI patients who were treated with primary PCI. The primary end point was all-cause mortality at 1 year and 2 years. The relationship between discharge Hb levels, decline in Hb levels, bleeding event classification, and all-cause mortality was determined.

Results

Overall, 16.4% of patients had bleeding events, which were classified by the Thrombolysis in Myocardial Infarction (TIMI) score as 7% minimal, 8.6% minor, and 0.9% major. No significant gastrointestinal bleed and cerebral hemorrhage occurred in hospitals among these patients. The incidence rate of the 2-year all-cause mortality increased with severity of the bleeding event score (8.78% for no bleeding vs. 11.59% for minimal bleeding vs. 20.24% for minor bleeding vs. 55.56% for major bleeding, P < 0.001). Discharge Hb was significantly associated with 2-year mortality in an unadjusted model (hazard ratio (HR) per 1 g/L decrease in discharge Hb = 1.020, 95% confidence interval (CI): 1.006–1.034, P < 0.001). Discharge Hb was significantly associated with 2-year mortality in an unadjusted model (hazard ratio (HR) per 1 g/L decrease in discharge Hb = 1.020, 95% confidence interval (CI): 1.006–1.034, P < 0.001). Discharge Hb was significantly associated with 2-year mortality in an unadjusted model (hazard ratio (HR) per 1 g/L decrease in discharge Hb = 1.020, 95% confidence interval (CI): 1.006–1.034,

Conclusions

In this population of patients hospitalized for STEMI, all-cause mortality increased with lower discharge Hb, and discharge Hb was a significant predictor of mortality risk.

Knowledge of Blood Transfusion in Medical And Biology Students

Introduction: Blood transfusion (hemotherapy) is a therapeutic intervention used in treatment strategies of multiple diseases, thus, proper education is of utmost importance. Since currently there are no specified educational programs, undergraduate students were evaluated for the knowledge gained during university courses.

Purpose: To evaluate and compare the level of knowledge of students of the faculty of Health Science, Department of Medicine (DM), and Department of Molecular Biology-Genetics (DMB&Gs) on issues related to the transfusion of blood products.

Methods: A cross-sectional observational study was carried out with 123 students from the aforementioned departments of the Democritus University of Thrace, from the third year to the last year of study. A questionnaire was used, weighted, and was based on the European Commission's Guide to the Preparation, Use and Quality Assurance for Blood Components. Statistical tests such as chi-square (χ2), t-test, analysis of variance (ANOVA), and linear regression were used to investigate the factors that affect the overall score.

Results: The mean score of the students was 42.55 while the standard deviation (SD) was 12.27. The difference in the scores between the students of the DM (M = 44.63, SD = 13.2) and those of the DMB&Gs (mean = 38.25, SD = 9.05) was statistically significant in the univariable analysis (t= 3.1, p = 0.0), but in the multivariable analysis, it was not statistically significant (β = -4.1, p = 0.1.). The results of the multiple regression model indicated that the year of study, the professional status of the father, and the grade in the hematology course were associated with the total score.

Conclusions: The level of knowledge regarding blood product transfusion among students of the faculty of Health Science is insufficient.

Choosing Wisely: Decreasing the incidence of perioperative blood transfusions in gynecologic oncology

OBJECTIVE

To evaluate the efficacy and economic impact of a transfusion reduction initiative for patients undergoing gynecologic surgery.

METHODS

We conducted a prospective healthcare improvement study to align transfusion practices with the American Society of Hematology's Choosing Wisely® campaign. Baseline transfusion rates were determined retrospectively for all major gynecologic surgical cases from 3/1/14 to 6/30/14. Data for the post-intervention period from 5/15/15 to 5/16/16 were captured prospectively. The primary outcome was transfusion within 72 h of surgery. Secondary outcomes included perioperative morbidity, mortality, number of units ordered per transfusion episode and cost.

RESULTS

We identified 1281 surgical cases, 334 in the baseline and 947 in the post-implementation cohort. The baseline cohort was noted to have a higher median estimated blood loss (100 v. 75 mL, P < 0.01). Otherwise, there were no differences in clinical or perioperative characteristics between the two cohorts. The perioperative transfusion rate decreased from 24% to 11% (adjusted OR 0.27, 95% CI 0.16 to 0.45; P < 0.001). The perioperative laparotomy transfusion rate decreased from 48% to 23% (adjusted OR 0.21, 95% CI 0.12, 0.37; P < 0.001). The number of occurrences in which more than one unit of blood was ordered at a time decreased from 65% to 23%, P < 0.001. The incidence of surgical site infections declined in the post-intervention group, otherwise there were no differences in 30-day mortality, cardiac, venous thromboembolism or readmission rates between the groups. The projected cost savings was $161,112 over the 12-month intervention period.

CONCLUSIONS

Implementation of an educational based transfusion reduction program was associated with substantial reductions in perioperative transfusions and cost without significant changes in morbidity or mortality.

In Vitro Evaluation of a Novel Image Processing Device to Estimate Surgical Blood Loss in Suction Canisters

BACKGROUND

Clinicians are tasked with monitoring surgical blood loss. Unfortunately, there is no reliable method available to assure an accurate result. Most blood lost during surgery ends up on surgical sponges and within suction canisters. A novel Food and Drug Administration-cleared device (Triton system; Gauss Surgical, Inc, Los Altos, CA) to measure the amount of blood present on sponges using computer image analysis has been previously described. This study reports on performance of a complementary Food and Drug Administration-cleared device (Triton Canister System; Gauss Surgical, Inc, Los Altos, CA) that uses similar image analysis to measure the amount of blood in suction canisters.

METHODS

Known quantities of expired donated whole blood, packed red blood cells, and plasma, in conjunction with various amounts of normal saline, were used to create 207 samples representing a wide range of blood dilutions commonly seen in suction canisters. Each sample was measured by the Triton device under 3 operating room lighting conditions (bright, medium, and dark) meant to represent a reasonable range, resulting in a total of 621 measurements. Using the Bland-Altman method, the measured hemoglobin (Hb) mass in each sample was compared to the results obtained using a standard laboratory assay as a reference value. The analysis was performed separately for samples measured under each lighting condition. It was expected that under each separate lighting condition, the device would measure the various samples within a prespecified clinically significant Hb mass range (±30 g per canister).

RESULTS

The limits of agreement (LOA) between the device and the reference method for dark (bias: 4.7 g [95% confidence interval {CI}, 3.8-5.6 g]; LOA: -8.1 g [95% CI, -9.7 to -6.6 g] to 17.6 g [95% CI, 16.0-19.1 g]), medium (bias: 3.4 g [95% CI, 2.6-4.1 g]; LOA: -7.4 g [95% CI, -8.7 to -6.1 g] to 14.2 g [95% CI, 12.9-15.5 g]), and bright lighting conditions (bias: 4.1 g [95% CI, 3.2-4.9 g]; LOA: -7.6 g [95% CI, -9.0 to -6.2 g] to 15.7 g [95% CI, 14.3-17.1 g]) fell well within the predetermined clinically significant limits of ±30 g. Repeated measurements of the samples under the various lighting conditions were highly correlated with intraclass correlation coefficient of 0.995 (95% CI, 0.993-0.996; P < .001), showing that lighting conditions did not have a significant impact on measurements. Hb mass bias was significantly associated with hemolysis level (Spearman ρ correlation coefficient, -0.137; P = .001) and total canister volume (Spearman ρ correlation coefficient, 0.135; P = .001), but not ambient illuminance.

CONCLUSIONS

The Triton Canister System was able to measure the Hb mass reliably with clinically acceptable accuracy in reconstituted blood samples representing a wide range of Hb concentrations, dilutions, hemolysis, and ambient lighting settings.

An international consensus statement on the management of postoperative anaemia after major surgical procedures

Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.

Red blood cell transfusion policy: a critical literature review

The issue of the most appropriate red blood cell transfusion policy has been addressed by a number of randomised controlled trials, conducted over the last decades, comparing the effects on patients' outcome of restrictive blood transfusion strategies (transfusing when the haemoglobin concentration is less than 7 g/dL to 8 g/dL) vs more liberal ones (transfusing when the haemoglobin concentration is less than 9 g/dL to 10 g/dL) in a variety of clinical settings. In parallel, various systematic reviews and meta-analyses have tried to perform pooled analyses of the data from these randomised controlled trials and their results have been utilised by scientific societies to provide recommendations and guidelines on red blood cell transfusion thresholds. All these aspects will be critically discussed in this narrative review.

Optimizing Blood Transfusion Practices Through Bundled Intervention Implementation in Patients With Gynecologic Cancer Undergoing Laparotomy

OBJECTIVE

To examine blood transfusion practices and develop a standardized bundle of interventions to address the high rate of perioperative red blood cell transfusion among patients with ovarian and endometrial cancer.

METHODS

This was a retrospective cohort study. Our primary aim was to determine whether an implemented bundled intervention was associated with a reduction in perioperative red blood cell transfusions among cases of laparotomy for cancer. Secondary aims included comparing perioperative demographic, surgical, complication, and cost data. Interventions included blood transfusion practice standardization using American Society of Anesthesiologists guidelines, an intraoperative hemostasis checklist, standardized intraoperative fluid status communication, and evidence-based use of tranexamic acid. Prospective data from women undergoing laparotomy for ovarian or endometrial cancer from September 28, 2015, to May 31, 2016, defined the study cohort and were compared with historical controls (September 1, 2014, to September 25, 2015). Outcomes were compared in the full unadjusted cohorts and in propensity-matched cohorts.

RESULTS

In the intervention and historical cohorts, respectively, 89 and 184 women underwent laparotomy for ovarian cancer (n=74 and 152) or advanced endometrial cancer (n=15 and 32). Tranexamic acid was administered in 54 (60.7%) patients. The perioperative transfusion rate was lower for the intervention group compared with historical controls (18.0% [16/89] vs 41.3% [76/184], P<.001), a 56.4% reduction. This improvement in the intervention group remained significant after propensity matching (16.2% [13/80] vs 36.2% [29/80], P=.004). The hospital readmission rate was also lower for the intervention group compared with historical controls (1.1% [1/89] vs 12.5% [23/184], P=.002); however, this improvement did not attain statistical significance after propensity matching (1.2% [1/80] vs 7.5% [6/80], P=.12). Cost analysis demonstrated that this intervention was cost-neutral during index hospitalization plus 30-day follow-up.

CONCLUSION

Application of a standardized bundle of evidence-based interventions was associated with reduced blood use in our gynecologic oncology practice.

Blood transfusion strategies for acute upper gastrointestinal bleeding: are we back where we started?

Blood transfusion practices for acute upper gastrointestinal hemorrhage have changed over time. Restrictive strategies, which gave way to more liberal approaches for the greater part of the 20^th century, have again gained traction as emerging research suggests restricting transfusion is associated with similar, or possibly better outcomes in UGI bleeding. In a large, retrospective cohort study from an integrated health care system in Taiwan, Chen, et al., report the association between early blood transfusion and clinical outcomes in patients presenting to the emergency department with UGI bleeding, and these findings are discussed in the context of current knowledge and practice.

Transfusion practice in anemic, non-bleeding patients: Cross-sectional survey of physicians working in general internal medicine teaching hospitals in Switzerland

Background

Transfusion practice might significantly influence patient morbidity and mortality. Between European countries, transfusion practice of red blood cells (RBC) greatly differs. Only sparse data are available on transfusion practice of general internal medicine physicians in Switzerland.

Methods

In this cross-sectional survey, physicians working in general medicine teaching hospitals in Switzerland were investigated regarding their self-reported transfusion practice in anemic patients without acute bleeding. The definition of anemia, transfusion triggers, knowledge on RBC transfusion, and implementation of guidelines were assessed.

Results

560 physicians of 71 hospitals (64%) responded to the survey. Anemia was defined at very diverging hemoglobin values (by 38% at a hemoglobin <130 g/L for men and by 57% at <120 g/L in non-pregnant women). 62% and 43% respectively, did not define anemia in men and in women according to the World Health Organization. Fifty percent reported not to transfuse RBC according to international guidelines. Following factors were indicated to influence the decision to transfuse: educational background of the physicians, geographical region of employment, severity of anemia, and presence of known coronary artery disease. 60% indicated that their knowledge on Transfusion-related Acute Lung Injury (TRALI) did not influence transfusion practice. 50% of physicians stated that no local transfusion guidelines exist and 84% supported the development of national recommendations on transfusion in non-acutely bleeding, anemic patients.

Conclusion

This study highlights the lack of adherence to current transfusion guidelines in Switzerland. Identifying and subsequently correcting this deficit in knowledge translation may have a significant impact on patient care.

Real-time evaluation of an image analysis system for monitoring surgical hemoglobin loss

Monitoring blood loss is important for management of surgical patients. This study reviews a device (Triton) that uses computer analysis of a photograph to estimate hemoglobin (Hb) mass present on surgical sponges. The device essentially does what a clinician does when trying to make a visual estimation of blood loss by looking at a sponge, albeit with less subjective variation. The performance of the Triton system is reported upon in during real-time use in surgical procedures. The cumulative Hb losses estimated using the Triton system for 50 enrolled patients were compared with reference Hb measurements during the first quarter, half, three-quarters and full duration of the surgery. Additionally, the estimated blood loss (EBL) was calculated using the Triton measured Hb loss and compared with values obtained from both visual estimation and gravimetric measurements. Hb loss measured by Triton correlated with the reference method across the four measurement intervals. Bias remained low and increased from 0.1 g in the first quarter to 3.7 g at case completion. The limits of agreement remained narrow and increased proportionally from the beginning to the end of the cases, reaching a maximum range of -15.3 to 22.7 g. The median (IQR) difference of EBL derived from the Triton system, gravimetric method and visual estimation versus the reference value were 13 (74), 389 (287), and 4 (230) mL, respectively. Use of the Triton system to measure Hb loss in real-time during surgery is feasible and accurate.

Continuous Noninvasive Hemoglobin Monitoring: A Measured Response to a Critical Review

Supplemental Digital Content is available in the text.

Published ahead of print March 5, 2015

Perioperative Hemoglobin Trajectory in Adult Cardiac Surgical Patients

Preoperative anemia and nadir hemoglobin (Hb) during cardiopulmonary bypass (CPB) have been identified as significant risk factors for blood transfusion during cardiac surgery. The aim of this study was to confirm the association between preoperative anemia, perioperative fluid management, and blood transfusion. In addition, the proportion of elective cardiac surgery patients presenting for surgery with anemia was identified to examine whether the opportunity exists for timely diagnosis and intervention. Data from referral until hospital discharge were comprehensively reviewed over a 12-month period for all nonemergency cardiac surgical patients operated on in our institution. Of the 342 patients identified, elective cases were referred a median of 35 days before preoperative clinic and operated on a median of 14 days subsequently. Subacute cases had a median of 3 days from referral to surgery. As per the World Health Organization (WHO) criteria for anemia, 24.2% of elective and 29.6% of subacute patients were anemic. Blood transfusion was administered to 46.2% of patients during their admission. Transfusion was more likely in patients who were female (odds ratio [OR]: 2.45, 95%confidence interval [CI]: 1.28-4.70), had a low body mass index (BMI) (OR: .89, 95% CI: .84-.94), preoperative anemia (OR: 5.15, 95% CI: 2.59-10.24), or renal impairment (OR: 5.44, 95% CI: 2.42-12.22). Hemodilution minimization strategies reduced the Hb fall during CPB, but not transfusion rates. This study identifies a high prevalence of preoperative anemia with sufficient time for elective referrals to undergo appropriate diagnosis and interventions. It also confirms that low red cell mass (anemia and low BMI) and renal impairment are predictors of perioperative blood transfusion. Perfusion strategies to reduce hemodilution are effective at minimizing the intraoperative fall in Hb concentration but did not influence transfusion rate.

Biochemical storage lesions occurring in nonirradiated and irradiated red blood cells: a brief review

Red blood cells undergo a series of biochemical fluctuations during 35-42-day storage period at 1°C to 6°C. The sodium/potassium pump is immobilised causing a decrease in intracellular potassium with an increase in cytoplasmic sodium levels, glucose levels decline, and acidosis occurs as a result of low pH levels. The frailty of stored erythrocytes triggers the formation of haemoglobin-containing microparticles and the release of cell-free haemoglobin which may add to transfusion difficulties. Lipid peroxidation, oxidative stress to band 3 structures, and other morphological and structural molecular changes also occur leading to spheroechinocytes and osmotic fragility. These changes that transpire in the red cells during the storage period are referred to as "storage lesions." It is well documented that gamma irradiation exacerbates storage lesions and the reports of increased potassium levels leading to adverse reactions observed in neonates and infants have been of particular concern. There are, however, remarkably few systematic studies comparing the in vitro storage lesions of irradiated and nonirradiated red cell concentrates and it has been suggested that the impact of storage lesions on leucocyte reduced red blood cell concentrate (RBCC) is incomplete. The review examines storage lesions in red blood cells and their adverse effects in reference to blood transfusion.

Red blood cell transfusion strategies and Maximum surgical blood ordering schedule

Blood transfusion is one of the practices that is in vogue because it expands blood volume and purportedly improves the oxygen carrying capacity. Despite this supposed physiological benefit, paradoxically, both anaemia and transfusion are independently associated with organ injury and increased morbidity. Historically, transfusion was used to maintain blood haemoglobin concentration above 10 g/dL and a haematocrit above 30%. There is now a greater emphasis on interventions to reduce the use of transfusion as it is a scarce and expensive resource with many serious adverse effects. Institutional maximum surgical blood ordering schedule algorithm developed with data analysis and consensus of surgeons, anaesthesiologists and blood banks can reduce the overuse of blood. A PubMed search was performed with search words/combination of words 'erythrocyte transfusion, adverse effects, economics, mortality, therapy, therapeutic use and utilisation'. Search yielded a total of 1541 articles that were screened for clinical relevance for the purpose of this review.

Indications for blood and blood product transfusion

Transfusion of blood products carries certain inherent risks and hence it should be undertaken only if it improves patient outcome. A review of the literature was carried out to find the indications and effects of transfusion on morbidity and mortality of patients. There is high-quality evidence showing that restrictive blood transfusion with a transfusion trigger of haemoglobin of 7-8 g/dl or the presence of symptoms of anaemia is safe and not associated with increased mortality compared with liberal transfusion. Thus, restrictive strategy is strongly recommended in surgical and critically ill-patients. There is moderate evidence for the use of plasma and platelet transfusion in patients receiving massive blood transfusion. There is not enough evidence to support the use of plasma, platelets and cryoprecipitate in any other clinical setting. Retrospective studies show improved survival after high plasma and platelet to red blood cell ratio of 1:1:1, but this has not been confirmed in randomised trials.

Blood transfusion practices in obstetric anaesthesia

Blood transfusion is an essential component of emergency obstetric care and appropriate blood transfusion significantly reduces maternal mortality. Obstetric haemorrhage, especially postpartum haemorrhage, remains one of the major causes of massive haemorrhage and a prime cause of maternal mortality. Blood loss and assessment of its correct requirement are difficult in pregnancy due to physiological changes and comorbid conditions. Many guidelines have been used to assess the requirement and transfusion of blood and its components. Infrastructural, economic, social and religious constraints in blood banking and donation are key issues to formulate practice guidelines. Available current guidelines for transfusion are mostly from the developed world; however, they can be used by developing countries keeping available resources in perspective.