Essential Role of Patient Blood Management in a Pandemic: A Call for Action

Association between routine cell salvage use for lower segment caesarean section and post-operative iron infusion and anemia

PURPOSE

Intraoperative cell salvage is central to Patient Blood Management including for lower segment caesarean section. Prior to April 2020, we initiated intraoperative cell salvage during caesarean section based on risk assessment for hemorrhage and patient factors. As the pandemic broadened, we mandated intraoperative cell salvage to prevent peri-partum anemia and potentially reduce blood product usage. We examined the association of routine intraoperative cell salvage on maternal outcomes.

METHODS

We conducted a single-center non-overlapping before-after study of obstetric patients undergoing lower segment caesarean section in the 2 months prior to a change in practice ('usual care = selective intraoperative cell salvage', n = 203) and the 2 months following ('mandated intraoperative cell salvage', n = 228). Recovered blood was processed when a minimal autologous reinfusion volume of 100 ml was expected. Post-operative iron infusion and length of stay were modelled using logistic or linear regression, using inverse probability weighting to account for confounding.

RESULTS

More emergency lower-segment caesarean sections occurred in the Usual Care group. Compared to the Usual Care group, post-operative hemoglobin was higher and anemia cases fewer in the Mandated intraoperative cell salvage group. Rates of post-partum iron infusion were significantly lower in the Mandated intraoperative cell salvage group (OR = 0.31, 95% CI = 0.12 to 0.80, P = 0.016). No difference was found for length of stay.

CONCLUSION

Routine cell salvage provision during lower segment caesarean section was associated with a significant reduction in post-partum iron infusions, increased post-operative hemoglobin and reduced anemia prevalence.

Delayed surgery for acute type A aortic dissection: a retrospective review of an alternative surgical strategy in the COVID-19 era

BACKGROUND

During the coronavirus disease (COVID-19) pandemic, medical resources have often been limited to emergency surgeries. This study aimed to evaluate our experience with delayed surgery for acute type A aortic dissections (ATAADs).

METHODS

A retrospective study was conducted on 33 patients who underwent surgery for ATAADs between January 2020 and December 2021. The patients were divided into two groups: patients treated within 12 h of arrival (E group; N = 21) and those treated > 12 h after arrival (D group; N = 12) with strict antihypertensive therapy until surgery.

RESULTS

The plasma fibrinogen levels on arrival were lower in the D group than in the E group (174.3 ± 109.1 vs 293.4 ± 165.4, p = 0.038). The time to surgery from symptom onset was longer in the D group than in the E group (4 ± 1 h vs. 86 ± 108 h, p < 0.001). There was one case (3%) of mortality and seven cases (21%) of cerebral infarctions in the E group. There was no significant difference in the intraoperative data and quantity of blood transfused between the two groups.

CONCLUSION

Thus, delayed surgery for ATAAD with appropriate preoperative management may be an alternative surgical strategy in the COVID-19 era.

Implementation of a Bleeding Management Algorithm in Liver Transplantation: A Pilot Study

Objectives

The aims of the study were to compare the consumption of blood products before and after the implementation of a bleeding management algorithm in patients undergoing liver transplantation and to determine the feasibility of a multicentre, randomized study.

Background

Liver transplantation remains the only curative therapy for patients with end-stage liver disease, but it carries a high risk of surgical bleeding.

Materials and Methods

Retrospective study of patients treated before (group 1) and after (group 2) implementation of a haemostatic algorithm guided by viscoelastic testing, including use of lyophilized coagulation factor concentrates (prothrombin complex and fibrinogen concentrates). Primary outcome was the number of units of blood products transfused in 24 h after surgery. Secondary outcomes included hospital stay, mortality, and cost.

Results

Data from 30 consecutive patients was analysed; 14 in group 1 and 16 in group 2. Baseline data were similar between groups. Median total blood product consumption 24 h after surgery was 33 U (IQR: 11-57) in group 1 and 1.5 (0-23.5) in group 2 (p = 0.028). Significantly fewer units of red blood cells, fresh frozen plasma, and cryoprecipitate were transfused in group 2 versus group 1. There was no significant difference in complications, hospital stay, or in-hospital mortality between groups. The cost of haemostatic therapy was non-significantly lower in group 2 versus group 1 (7,400 vs. 15,500 USD; p = 0.454).

Conclusion

The haemostatic management algorithm was associated with a significant reduction in blood product use during 24 h after liver transplantation. This study demonstrated the feasibility and provided a sample size calculation for a larger, randomized study.

Prediction of Mid-term Platelet Transfusion in Stable Trauma Patients Using Rotational Thromboelastometry

Background

Rotational thromboelastometry (ROTEM; TEM International GmbH, Munich, Germany) is a global coagulation test that guides evidence-based platelet transfusion in trauma patients. We evaluated ROTEM parameters for predicting mid-term (five days) platelet transfusion in trauma patients.

Methods

Maximum clot firmness and clot amplitudes after 5, 10, and 15 mins (A5, A10, and A15, respectively) of fibrin-specific ROTEM (FIBTEM) and extrinsically activated ROTEM (EXTEM) were retrospectively collected from 82 hospitalized, stable, non-bleeding trauma patients after successful initial resuscitation. Platelet-specific ROTEM (PLTEM) was calculated by subtracting FIBTEM from EXTEM. Platelet transfusions were reviewed for five days after ROTEM.

Results

The areas under the curve for FIBTEM, EXTEM, and PLTEM predicting platelet concentrate transfusion of >12 U at mid-term were 0.915-0.923, 0.878-0.896, and 0.551-0.735, respectively. FIBTEM and EXTEM parameters were comparable to those of fibrinogen, fibrin/fibrinogen degradation products, D-dimer, and antithrombin III. Strong correlations (r>0.7) were noted between platelet count and EXTEM (A5, A10, and A15) or PLTEM (A5), platelet function (per platelet count) and EXTEM (A10 and A15), and fibrinogen levels and all FIBTEM parameters.

Conclusions

FIBTEM and EXTEM can reliably predict mid-term platelet transfusion in trauma patients. FIBTEM, EXTEM, and PLTEM parameters correlate with conventional coagulation tests (platelets and fibrinogen).

The Year in Coagulation and Transfusion: Selected Highlights from 2022

This is an annual review to cover highlights in transfusion and coagulation in patients undergoing cardiovascular surgery. The goal of this article is to provide readers with a focused summary of the most important transfusion and coagulation topics published in 2022. This includes a discussion covering the management of anemia and red blood cell transfusion, the management of factor Xa inhibitors, updates in coagulation testing, updates in the use of factor concentrates, advances in platelet therapy, advances in anticoagulation management of patients on extracorporeal membrane oxygenation and other forms of mechanical circulatory support, and advances in the diagnosis and management of heparin-induced thrombocytopenia.

Platelet Function Testing Using Sonoclot and TEG6s as a Platelet Transfusion Prediction Tool in Open Heart Surgery

Introduction The point-of-care test (POCT) is useful for blood coagulation management during cardiovascular surgery. Although thromboelastography (TEG6s) has been reported to have targeted benefits for blood transfusion in cardiac surgery, Sonoclot analysis has not yet been fully validated. In this study, we evaluated the accuracy of Sonoclot, especially platelet function (PF) as a platelet concentrate (PC) transfusion parameter, compared to TEG6s in cardiovascular surgery. Methods This single-center, prospective, randomised trial was conducted at a university hospital. Forty-two adult patients who underwent elective cardiac surgery requiring cardiopulmonary bypass were included in this study between 2017 and 2021. The participants were randomly assigned to the Sonoclot (S) or Sonoclot and TEG6s (ST) groups. The amount of intraoperative PC was determined according to the POCT parameter values at the time of protamine administration. In addition, we investigated the correlation between PF parameters of POCT and platelet count at the end of surgery. Results There was no statistically significant difference in the intraoperative PC volume between the two groups. The Sonoclot PF parameter, PF, was moderately correlated with platelet count at the end of surgery (r=0.5449, p=0.009), and the TEG6s PF parameter showed a strong correlation with platelet count at the end of surgery (r=0.7744, p<0.001). Conclusion There was no statistically significant difference in platelet transfusion volume between the Sonoclot and TEG6s in this study. The correlation between the PF of the Sonoclot and platelet count was moderate. This study suggests that PF of Sonoclot may be a potentiating indicator of PF.

German Patient Blood Management Network: effectiveness and safety analysis in 1.2 million patients

BACKGROUND

Patient Blood Management (PBM) is a patient-centred, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood whilst promoting patient safety and empowerment. The effectiveness and safety of PBM over a longer period have not yet been investigated.

METHODS

We performed a prospectively designed, multicentre follow-up study with non-inferiority design. Data were retrospectively extracted case-based from electronic hospital information systems. All in-hospital patients (≥18 yr) undergoing surgery and discharged between January 1, 2010 and December 31, 2019 were included in the analysis. The PBM programme focused on three domains: preoperative optimisation of haemoglobin concentrations, blood-sparing techniques, and guideline adherence/standardisation of allogeneic blood product transfusions. The outcomes were utilisation of blood products, composite endpoint of in-hospital mortality and postoperative complications (myocardial infarction/ischaemic stroke/acute renal failure with renal replacement therapy/sepsis/pneumonia), anaemia rate at admission and discharge, and hospital length of stay.

RESULTS

A total of 1 201 817 (pre-PBM: n=441 082 vs PBM: n=760 735) patients from 14 (five university/nine non-university) hospitals were analysed. Implementation of PBM resulted in a substantial reduction of red blood cell utilisation. The mean number of red blood cell units transfused per 1000 patients was 547 in the PBM cohort vs 635 in the pre-PBM cohort (relative reduction of 13.9%). The red blood cell transfusion rate was significantly lower (P<0.001) with odds ratio 0.86 (0.85-0.87). The composite endpoint was 5.8% in the PBM vs 5.6% in the pre-PBM cohort. The non-inferiority aim (safety of PBM) was achieved (P<0.001).

CONCLUSIONS

Analysis of >1 million surgical patients showed that the non-inferiority condition (safety of Patient Blood Management) was fulfilled, and PBM was superior with respect to red blood cell transfusion.

CLINICAL TRIAL REGISTRATION

NCT02147795.

Lessons learned from patient outcomes when lowering hemoglobin transfusion thresholds during COVID-19 blood shortages

OBJECTIVES

This study examines whether patient outcomes were affected when the hemoglobin (Hb) transfusion threshold was lowered by 1 g/dL during COVID-19-related blood shortages.

METHODS

Outcomes of lowered Hb thresholds (from <7 to <6 g/dL) were defined by 14-month intervals in 2 patient groups (prepandemic [January 2019-February 2020] and pandemic [April 2020-May 2021]). We evaluated patient admissions, pretransfusion (if transfused) or nadir admission (if not transfused) Hb levels between 5.0 and 8.0 g/dL, and total red blood cell (RBC) transfusions during admission (if transfused). Baseline variables and outcomes were selected from electronic health records. Primary COVID-19-related admissions were excluded. Regression analysis was conducted to determine outcomes.

RESULTS

Those in the prepandemic group (1976) and pandemic group (1547) were transfused. Fewer RBCs (2186, vs 3337) were used in the prepandemic group than in the pandemic group, respectively. Those in the prepandemic group had significantly higher rates of hypertension and diabetes as well as more smokers. Significant differences were observed when comparing the number of procedures and incidence of sepsis between the patient groups. Similar patterns were observed for the not transfused and transfused subgroups.

CONCLUSIONS

Patient outcomes were not affected after implementing lower Hb pretransfusion thresholds. Although confounding factors were mitigated, some may have been associated with procedures or sepsis. Proactive patient blood management strategies during COVID-19-related blood shortages may include adopting lower Hb thresholds.

Postoperative Transfusions after Administration of Delayed Cold-stored Platelets versus Room Temperature Platelets in Cardiac Surgery: A Retrospective Cohort Study

BACKGROUND

Delayed cold storage of room temperature platelets may extend shelf life from 5 to 14 days. The study hypothesized that the use of delayed cold-stored platelets in cardiac surgery would be associated with decreased postoperative platelet count increments but similar transfusion and clinical outcomes compared to room temperature-stored platelets.

METHODS

This is an observational cohort study of adults transfused with platelets intraoperatively during elective cardiac surgery between April 2020 and May 2021. Intraoperative platelets were either room temperature-stored or delayed cold-stored based on blood bank availability rather than clinical features or provider preference. Differences in transfusion and clinical outcomes, including a primary outcome of allogenic transfusion exposure in the first 24 h postoperatively, were compared between groups.

RESULTS

A total of 713 patient encounters were included: 529 (74%) room temperature-stored platelets and 184 (26%) delayed cold-stored platelets. Median (interquartile range) intraoperative platelet volumes were 1 (1 to 2) units in both groups. Patients receiving delayed cold-stored platelets had higher odds of allogeneic transfusion in the first 24 h postoperatively (81 of 184 [44%] vs. 169 of 529 [32%]; adjusted odds ratio, 1.65; 95% CI, 1.13 to 2.39; P = 0.009), including both erythrocytes (65 of 184 [35%] vs. 135 of 529 [26%]; adjusted odds ratio, 1.54; 95% CI, 1.03 to 2.29; P = 0.035) and platelets (48 of 184 [26%] vs. 79 of 529 [15%]; adjusted odds ratio, 1.91; 95% CI, 1.22 to 2.99; P = 0.005). There was no difference in the number of units administered postoperatively among those transfused. Platelet counts were modestly lower in the delayed cold-stored platelet group (-9 × 109/l; 95% CI, -16 to -3]) through the first 3 days postoperatively. There were no significant differences in reoperation for bleeding, postoperative chest tube output, or clinical outcomes.

CONCLUSIONS

In adults undergoing cardiac surgery, delayed cold-stored platelets were associated with higher postoperative transfusion utilization and lower platelet counts compared to room temperature-stored platelets without differences in clinical outcomes. The use of delayed cold-stored platelets in this setting may offer a viable alternative when facing critical platelet inventories but is not recommended as a primary transfusion approach.

EDITOR’S PERSPECTIVE

Evaluation of Anemia and Iron Deficiency in French Surgical Departments: The National Multicenter Observational PERIOPES Study

BACKGROUND

Assessment of anemia and iron deficiency before surgery is pivotal for patient blood management (PBM), but few data on current practices are available in the French context. The objective of this study was to describe anemia and iron deficiency management and blood transfusion use in surgical departments in France.

METHODS

This was a national multicenter cross-sectional study in 13 public hospitals and 3 private ones (all with an interest for PBM). Data of consecutive surgical patients from different specialties were retrieved from their chart between July 30, 2019, and December 31, 2021. Data included hemoglobin, iron workup, treatment with oral/intravenous iron or erythropoiesis-stimulating agent, and transfusions.

RESULTS

Data from 2345 patients (median age, 68 years; women, 50.9%; American Society of Anesthesiologists [ASA] physical status III-IV, 35.4%) were obtained. Only 5 centers had a formalized PBM program. At preoperative anesthesia visit, hemoglobin (Hb) level was assessed in 2112 (90.1%) patients and anemia diagnosed in 722 of them (34.2%). Complete iron workup was performed in 715 (30.5%) of the 2345 patients. Iron deficiency anemia was present in 219 (30.3%) of the 722 anemic patients. Among patients with anemia, only 217 (30.1%) of them were treated. A total of 479 perioperative blood transfusions were reported in 315 patients. Restrictive transfusion was not applied in 50% of transfusion episodes, and the single-unit red blood cell transfusion was also not frequent (37.2%).

CONCLUSIONS

Our observational study showed that preoperative anemia was frequent, but iron deficiency was often not assessed and few patients were treated. There is an urgent need for PBM implementation in these centers.

Re-examine the transfusion transmitted risk of SARS-CoV-2 virus during a major COVID-19 outbreak in 2022

INTRODUCTION

Although no case of COVID-19 transmission through transfusion has been reported, blood transfusion service (BTS) continues to implement pre-donation and post-donation measures to minimise the risk. In year 2022, when local healthcare system was badly impacted by a major outbreak, it opened an opportunity to re-examine the viraemia risk in these asymptomatic donors.

MATERIALS AND METHODS

Records were retrieved from blood donors who reported COVID-19 after donation and follow-up was also made for recipients who received their blood. Blood samples at donation were tested for SARS-CoV-2 viraemia by single-tube nested real-time RT-PCR assay designed to detect most SARS-CoV-2 variants including the prevailing delta and omicron variants.

RESULTS

From 1 January to 15 August 2022, the city with 7.4 M inhabitants recorded 1 187 844 COVID-19 positive cases and 125 936 successful blood donations were received. 781 donors reported to the BTS after donation with 701 being COVID-19 related (including close contact and symptoms respiratory tract infection). 525 COVID-19 were positive at the time of call back or follow-up. Of the 701 donations, they were processed into 1480 components with 1073 discarded upon donors' call back. For remaining 407 components, no recipient was found to have adverse event or COVID-19 positive. 510 samples from the above 525 COVID-19 positive donors were available and all tested negative for SARS-CoV-2 RNA.

DISCUSSION

With the negative SARS-CoV-2 RNA in blood donation samples and follow up data in transfusion recipients, the risk of transfusion transmitted COVID-19 appears negligible. However, current measures remains important in securing blood safety with ongoing surveillance of their effectiveness.

Management of hemotherapy services in the context of the COVID-19 pandemic

This study aimed to analyze the management of hemotherapy services (HS) in the context of the COVID-19 pandemic from the perspective of municipal managers in different regions of Brazil. A qualitative approach with semi-structured interviews was applied to HS managers in the three Brazilian capitals, from different regions of Brazil, during the period between September 2021 and April 2022. The textual content of the interviews was submitted to lexicographic textual analysis using the free access software, Iramuteq. The managers' perceptions resulted from the descending hierarchical classification (DHC) analysis, which generated six classes: availability of resources for the development of work; installed capacity of services; strategies and challenges for attracting blood donors; risks and worker protection; measures for crisis management; and communication strategies for the adhesion of candidates for donation. The analysis highlighted several strategies used by the management, as well as pointed out limits and challenges for HS organization and management, exacerbated in the context of the pandemic.

Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management

BACKGROUND

Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas.

METHODS

We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension.

AIMS

Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery.

RESULTS

Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes.

CONCLUSIONS

The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.

Impact of the COVID-19 Pandemic on the Usage of Blood for Transfusions: A 2-Year Experience from a Tertiary Center in Korea

The coronavirus disease (COVID-19) outbreak affected the utilization and management of blood products in hospitals. Blood shortages occurred owing to social distancing policies and reduction in blood donors. However, only a few studies examined whether these changes affected blood usage and transfusion patterns. We retrospectively reviewed blood component usage according to hospital departments and phases of surgery in transfused patients admitted between 1 March 2019 and 28 February 2021, in a single center in Anyang, Korea. We also analyzed the length of hospital stay and mortality to determine prognosis. In 2020, 32,050 blood components were transfused to 2877 patients, corresponding to 15.8% and 11.8% less than the rates in 2019, respectively. Postoperative usage of blood products significantly decreased in 2020 (3.87 ± 6.50) compared to 2019 (7.12 ± 21.71) (p = 0.047). The length of hospital stay of the patients who underwent postoperative transfusion in 2019 (n = 197) was 13.97 ± 11.95 days, which was not significantly different from that in 2020 (n = 167), i.e., 16.44 ± 17.90 days (p = 0.118). Further, 9 of 197 postoperative transfusion patients died in 2019, while 8 of 167 patients died in 2020 (p = 0.920). The COVID-19 pandemic resulted in limited blood supply and reduced postoperative transfusions; however, patient prognosis was not affected.

Effect of a Patient Blood Management Program on the Appropriateness of Red Blood Cell Transfusion and Clinical Outcomes in Elderly Patients Undergoing Hip Fracture Surgery

BACKGROUND

Elderly patients with hip fractures frequently receive perioperative transfusions, which are associated with increased morbidity and mortality. This study aimed to evaluate the impact of a patient blood management (PBM) program on the appropriateness of red blood cell (RBC) transfusion and clinical outcomes in geriatric patients undergoing hip fracture surgery.

METHODS

In 2018, the revised PBM program was implemented at the Korea University Anam Hospital, Seoul, Republic of Korea. Elderly patients aged ≥ 65 years who underwent hip fracture surgery from 2017 to 2020 were evaluated. Clinical characteristics and outcomes were analyzed according to the timing of PBM implementation (pre-PBM, early-PBM, and late-PBM). Multiveriate regression analysis was used to evaluate the risk factors of the adverse outcomes, such as in-hospital mortality or 30-day readmission.

RESULTS

A total of 884 elderly patients were included in this study. The proportion of patients who received perioperative RBC transfusions decreased significantly (43.5%, 40.1%, and 33.2% for pre-PBM, early-PBM, and late-PBM, respectively; P = 0.013). However, the appropriateness of RBC transfusion significantly increased (54.0%, 60.1%, and 94.7%, respectively; P < 0.001). The duration of in-hospital stay and 30-day readmission rates significantly decreased. Multivariable regression analysis revealed that RBC transfusion (odds ratio, 1.815; 95% confidence interval, 1.137-2.899; P = 0.013) was significantly associated with adverse outcomes.

CONCLUSION

Implementing the PBM program increased the appropriateness of RBC transfusion without compromising transfusion quality and clinical outcomes. Therefore, adopting the PBM program may improve the clinical management of elderly patients following hip fracture surgery.

Association between anaemia and hospital readmissions in patients undergoing major surgery requiring postoperative intensive care

Anaemia is a common sequela of surgery, although its relationship with patient recovery is unclear. The goal of this investigation was to assess the associations between haemoglobin concentrations at the time of hospital discharge following major surgery and early post-hospitalisation outcomes, with a primary outcome of 30 day unanticipated hospital readmissions. This investigation includes data from two independent population-based observational cohorts of adult surgical patients (aged ≥ 18 years) requiring postoperative intensive care unit admission between 1 January 2010 and 31 December 2019 in hospitals in Olmsted County, Minnesota, and between 1 July 2010 and 30 June 2017 in the Kaiser Permanente Northern California integrated healthcare system, California. Cox proportional hazards models assessed the associations between discharge haemoglobin concentrations (per 10 g.l-1 ) and outcomes, with prespecified multivariable adjustment. A total of 3260 patients were included from Olmsted County hospitals and 29,452 from Kaiser Permanente Northern California. In adjusted analyses, each 10 g.l-1 decrease in haemoglobin at hospital discharge was associated with a 9% (hazard ratio 1.09, 95%CI 1.02-1.18; p = 0.014) and 8% increase (hazard ratio 1.08, 95%CI 1.06-1.11; p < 0.001) in the hazard for readmission within 30 days in Olmsted County and Kaiser Permanente Northern California, respectively. In a sensitivity analysis exploring relationships across varying levels of pre-operative anaemia severity, these associations remained consistent, with lower discharge haemoglobin concentrations associated with higher readmissions irrespective of pre-operative anaemia severity. Anaemia at hospital discharge in surgical patients requiring postoperative intensive care is associated with increased rates of hospital readmission in two large independent cohorts. Future studies are necessary to evaluate strategies to prevent and/or treat anaemia in these patients for the improvement of post-hospitalisation outcomes.

Profile and characteristics of the adequacy of blood transfusions in Trauma Intensive Care. A cross sectional multicenter study

Introduction

Major trauma is one of the major health care problems facing modern society, trauma systems require careful planning to achieve an ideal level of coverage for the population. The Patient Blood Management Program is an integrated and global strategy to provide patient care that aims to assess and address, when possible, the etiology of blood abnormalities rather than transfuse without treating the underlying cause. We aimed to describe the factors that are associated with the clinical decision to transfuse polytraumatized patients admitted to the Intensive Care Unit (ICU).

Method

We performed a cross sectional multicenter study of patients admitted to ICUs for trauma in 14 Spanish hospitals from September 2020 to December 2021.

Results

A total of 69 patients were treated in the emergency room due to polytrauma, 46% of them were considered serious in the initial triage. Thirty were caused by a fall from considerable height (43.47%), followed by 39 patients admitted due to trac accidents (56.52%). The location of the trauma was mainly cranioencephalic, followed by thoracic trauma. Of the 69 patients, 25 received a blood transfusion during their ICU stay (36.23%).

Discussion

No significant differences were observed between transfused and non-transfused patients, except for the severity scales, where transfused patients have a higher score on all the scales assessed in the ICU except for the Revised Trauma Score. As we can see, the incidence of kidney failure was also different between the groups analyzed, reaching 44.00% in transfused patients and 13.64% in the group of patients without blood transfusion, p = 0.005. In this sense, 92.00% of the transfusions performed were inadequate according to the criteria of Hb in blood prior to the decision to transfuse (Hb < 9). Our data support the need to consider clinical practice guidelines regarding blood transfusion and its practices.

Extension of patient safety initiatives to perioperative care

PURPOSE OF REVIEW

Patient safety has significantly improved during the intraoperative period thanks to the anesthesiologists, surgeons, and nurses. Nowadays, it is within the perioperative period where most of the preventable harm happened to the surgical patient. We aim to highlight the main issues and efforts to improve perioperative patient safety focusing and the relation to intraoperative safety strategies.

RECENT FINDINGS

There is ongoing research on perioperative safety strategies aiming to initiate multidisciplinary interventions on early stages of the perioperative period as well as an increasing focus on preventing harm from postoperative complications.

SUMMARY

Any patient safety strategy to be implemented needs to be framed beyond the operating room and include in the intervention the whole perioperative period.

Towards optimized red blood cells ordering prior to cardiac surgery: a single center retrospective study

Background: Cardiac surgery is associated with a high rate of intraoperative transfusion, requiring pre- ordering or ordering of packed red blood cell (PRBC) before surgery. Our institutional strategy is based on a systematic type and screen (T/S) ordering of 3 PRBCs at the blood bank then stored in a dedicated refrigerator in the operating room for each patient scheduled for cardiac surgery. However, these PRBC units are not always transfused and are therefore at risk of destruction if temperature fluctuations are detected during transport and storage processes. In addition, these orders represent a burden for the blood bank. Therefore, it is relevant to move towards a more tailored PRBC order before cardiac surgery and challenge the systematic ordering protocol. Methods: The Transfusion Understanding Scoring Tool (TRUST) and the Transfusion Risk and Clinical Knowledge (TRACK) Score are designed to stratify blood transfusion needs in cardiac surgery. We retrospectively performed both scores for each patient scheduled for cardiac surgery. Then, we compared their performance to predict PRBC transfusion and determined the optimal threshold to optimize the preoperative PRBC order reflecting the needs of our population managed with our local standards. Results: Receiver operating characteristic (ROC) curves for prediction of PRBC transfusion using the two scores were computed for the whole cohort (n=1249). Both scores performed well (areas under ROC curves: 0.81 and 0.82 (95% CI) using the TRACK Score and the TRUST, respectively). A TRUST < 3 identified a subgroup of patients (53.6%) at low risk of transfusion. The availability of 1 T/S PRBC in the OR would cover the needs of the majority (92.5%) of this group. Conclusions: In our institution, the use of the TRUST preoperatively could offer a more tailored T/S PRBC order for the intraoperative period, especially in the low-risk transfusion group.

Factors affecting need for blood transfusion in paediatric patients undergoing open surgery for hip dysplasia

BACKGROUND AND OBJECTIVES

The management of intraoperative blood loss in the surgical treatment of paediatric hip dysplasia is resource intensive. There are numerous clinical factors that impact the need for intraoperative transfusion. Identification of patient and surgical factors associated with increased blood loss may reduce the unnecessary use of resources. This study aimed to identify factors predictive of intraoperative transfusion in children undergoing hip dysplasia surgery.

MATERIALS AND METHODS

This is a single-centre retrospective review of patients undergoing surgery for hip dysplasia from 1 January 2012 to 15 April 2021. Patient demographic factors, anaesthetic, surgical and transfusion histories were reviewed. Multivariable logistic regression analysis was performed to identify factors predictive of allogeneic red blood cell transfusion requirements during the intraoperative period.

RESULTS

This study includes 595 patients who underwent open surgery for hip dysplasia, including 297 (52.6%) classified as developmental dysplasia (DD) and 268 (47.3%) as neuromuscular (NM) with a mean age of 9.1 years (interquartile range 3-14). Intraoperative allogeneic transfusion was identified in 26/297 (8.8%) DD and 73/268 (27.2%) NM patients. Adjusted factors associated with increased odds of intraoperative transfusion were NM (odds ratio [OR] = 2.96, 95% confidence interval [CI] [1.76, 5.00]) and the number of osteotomies performed (OR = 1.82/osteotomy, 95% CI [1.40, 2.35]). Adjusted factors that reduced the odds of transfusion were the use of antifibrinolytics (OR = 0.35, 95% CI [0.17, 0.71]) and regional anaesthesia (OR = 0.52, 95% CI [0.29, 0.94]).

CONCLUSION

For children undergoing surgery for hip dysplasia, the number of osteotomies performed is predictive of the need for allogeneic blood transfusion. Antifibrinolytics and regional anaesthesia are associated with reduced risk for allogeneic blood transfusion. Blood management initiatives, such a preoperative optimization of haemoglobin and the use of antifibrinolytics, could target patients at increased risk of intraoperative bleeding and transfusion.

Effect of a Patient Blood Management system on perioperative transfusion practice and short-term outcomes of colorectal cancer surgery

BACKGROUND

Patients undergoing colorectal cancer surgery may require a blood transfusion. However, blood transfusions are associated with postoperative complications and long-term oncologic outcomes. Patient blood management (PBM) is an evidence-based multimodal approach for blood transfusion optimisation. We sought to investigate the effects of PBM implementation in blood transfusion practice and on short-term postoperative outcomes.

MATERIALS AND METHODS

This study retrospectively reviewed data from 2,080 patients who had undergone colorectal cancer surgery at a single centre from 2015 to 2020. PBM was implemented in 2018, and outcomes were compared between the pre-PBM (2015-2017) and the post-PBM (2018-2020) periods.

RESULTS

A total of 951 patients in the pre-PBM group and 1,129 in the post-PBM group were included. The transfusion rate of the total number of packed red blood cells (PRBCs) used decreased after PBM implementation (16.3 vs 8.3%; p<0.001). The rate of appropriately transfused PRBCs increased from the pre-PBM period to the post-PBM period (42 vs 67%; p<0.001). There was no significant difference in rates of complications between the two groups (23.0 vs 21.5%; p=0.412); however, a reduction in both anastomosis leakage (5.8 vs 3.7%; p=0.026) and the length of stay after surgery (LOS) (10.3±11.2 vs 8.2±5.7 days; p<0.001) was reported after PBM implementation.

DISCUSSION

The PBM programme optimised the transfusion rate in patients undergoing colorectal cancer surgery. Implementation of the PBM programme had a positive effect on postoperative length of stay and anastomosis leakage while no increase in the risk of other complications was reported.

Perioperative Pediatric Erythrocyte Transfusions: Incorporating Hemoglobin Thresholds and Physiologic Parameters in Decision-making

This article presents current literature and scientific evidence on hemoglobin thresholds and physiologic parameters to guide decisions regarding perioperative erythrocyte transfusions in pediatric patients based on the most up-to-date studies and expert consensus recommendations.

Patient blood management and patient safety

PURPOSE OF REVIEW

The particular fields within patient blood management (PBM) and patient safety reviewed here include novel insights into bleeding therapy, autologous cell salvage, and perioperative anemia therapy.

RECENT FINDING

World Health Organization has published that implementation of PBM is important but has not yet been performed in all hospitals. Two antibodies that mimic the function of FVIII, Emicizumab, and Mim8 have been developed. Tranexamic acid (TXA) has been investigated further in patients with hip surgery and shows reduction of bleeding. Thrombocytopenia in patients undergoing cardiac surgery is a particular concern that has been investigated in another trial. The use of autologous cell salvage was updated in form of a review and meta-analysis. And last but not least, intravenous iron in preoperative anemia therapy can reduce the number of transfusions, but especially iron carboxymaltose can cause hypophosphatemia.

SUMMARY

PBM should be further implemented in more hospitals. Emicizumab and Mim8 are indicated in acquired hemophilia or hemophilia A with inhibitors. TXA was confirmed to reduce bleeding. Autologous cell salvage is state of the art to reduce transfusion requirements in major cardiac and noncardiac surgery. Serum phosphate concentrations should be monitored after administration of intravenous iron compounds.

Blood conservation strategies at United States hospitals during the COVID‐19 pandemic: Findings from a multi‐institutional analysis

Background

Due to the coronavirus disease 2019 (COVID‐19) pandemic, the transfusion medicine community has experienced unprecedented blood supply shortages since March 2020. As such, numerous changes to everyday practice have occurred with a specific emphasis on blood conservation. We sought to determine the strategies used to mitigate blood shortages and promote blood conservation during the pandemic.

Methods

An anonymous, 37‐question survey was developed using Research Electronic Data Capture and distributed via e‐mail to transfusion medicine specialists across the US obtained via publicly available databases.

Results

Amongst surveyed [41.1% response rate (51/124 institutions)], 98.0% experienced a product shortage, with the greatest number reporting red blood cell (RBC) shortages (92.0%). This led to 35.3% of institutions altering the composition and/or number of blood product suppliers, including a 100% increase in the number of institutions acquiring blood from organizations that connect hospital transfusion services with blood collection centers (e.g., Blood Buy) compared to before March 2020. Prospective triaging of blood products was the most common blood conservation strategy (68.1%), though 35.4% altered their RBC exchange or transfusion program for patients receiving chronic RBC transfusion/exchange. As a result of these changes, 78.6% of institutions reported that these changes resulted in a reduction in blood product usage, and 38.1% reported a decrease in product wastage.

Conclusions

Most hospitals experienced the effects of the supply shortage, and many of them implemented blood conserving measures. Conservation strategies were associated with decreased blood utilization and waste, and future studies could evaluate whether these changes persist.

Patients' Choice, Consent, and Ethics in Patient Blood Management

The goal of patient blood management (PBM) is to optimize clinical outcomes for individual patients by managing their blood as a precious and unique resource to be safeguarded and managed judiciously. A corollary to successful PBM is the minimization or avoidance of blood transfusion and stewardship of donated blood. The first is achieved by a multidisciplinary approach with personalized management plans shared and decided on with the patient or their substitute. It follows that the physician-patient relationship is an integral component of medical practice and the fundamental link between patient and doctor based on trust and honest communication. Central to PBM is accurate and timely diagnosis based on sound physiology and pathophysiology as the bedrock on which scientifically based medicine is founded. PBM in all disease contexts starts with the questions, "What is the status of the patient's blood?" "If there are specific abnormalities in the blood, how should they be managed?" and "If allogeneic blood transfusion is considered, is there no reasonable alternative therapy?" There are compelling scientific reasons to implement a nontransfusion default position when there is clinical uncertainty and questionable evidence of clinical efficacy for allogeneic blood transfusion due to known potential hazards. Patients must be informed of their diagnosis, the nature, severity and prognosis of the disease, and treatment options along with risks and benefits. They should be involved in decision-making regarding their management. However, as part of this process, there are multifaceted medical, legal, ethical, and economic issues, encompassing shared decision-making, patient choice, and informed consent. Furthermore, variability in patient circumstances and preferences, the complexity of medical science, and the workings of health care systems in which consent takes place can be bewildering, not only for the patient but also for clinicians obtaining consent. Adding "patient" to the concept of blood management differentiates it from "donor" blood management to avoid confusion and the perception that PBM is a specific medical intervention. Personalized PBM is tailoring the PBM to the specific characteristics of each patient. With this approach, there should be no difficulty addressing the informed consent and ethical aspects of PBM. Patients can usually be reassured that there is nothing out of order with their blood, in which case the focus of PBM is to keep it that way. In some circumstances, a hematologist may be involved as a patient's blood advocate when abnormalities require expert involvement while the primary disease is being managed.

Patient Blood Management: Improving Outcomes for Millions While Saving Billions. What Is Holding It Up?

Patient blood management (PBM) offers significantly improved outcomes for almost all medical and surgical patient populations, pregnant women, and individuals with micronutrient deficiencies, anemia, or bleeding. It holds enormous financial benefits for hospitals and payers, improves performance of health care providers, and supports public authorities to improve population health. Despite this extraordinary combination of benefits, PBM has hardly been noticed in the world of health care. In response, the World Health Organization (WHO) called for its 194 member states, in its recent Policy Brief, to act quickly and decidedly to adopt national PBM policies. To further support the WHO's call to action, this article addresses 3 aspects in more detail. The first is the urgency from a health economic perspective. For many years, growth in health care spending has outpaced overall economic growth, particularly in aging societies. Due to competing economic needs, the continuation of disproportionate growth in health care spending is unsustainable. Therefore, the imperative for health care leaders and policy makers is not only to curb the current spending rate relative to the gross domestic product (GDP) but also to simultaneously improve productivity, quality, safety of patient care, and the health status of populations. Second, while PBM meets these requirements on an exceptional scale, uptake remains slow. Thus, it is vital to identify and understand the impediments to broad implementation. This includes systemic challenges such as the so-called "waste domains" of failure of care delivery caused by malfunctions of health care systems, failure of care coordination, overtreatment, and low-value care. Other impediments more specific to PBM are the misperception of PBM and deeply rooted cultural patterns. Third, understanding how the 3Es-evidence, economics, and ethics-can effectively be used to motivate relevant stakeholders to take on their respective roles and responsibilities and follow the urgent call to implement PBM as a standard of care.

Exploring Blood Donation Challenges and Mobilization Mechanisms in North China During the COVID-19 Pandemic: A Qualitative Study

Purpose

The coronavirus disease 2019 (COVID-19) pandemic disrupted the supply of blood globally, resulting in numerous studies focusing on the challenges in maintaining blood supply, and the responses to it, in countries with a mixed blood donation model. This study explored blood donation challenges and mobilization mechanisms in North China, which employs a non-remunerative donation model, during the COVID-19 pandemic’s first wave.

Materials and Methods

A qualitative approach was adopted to investigate blood donation practices in Chengde from April to June 2020. Data were collected from eight blood donors, six potential donors, three blood donation station leaders, and two government officials, through semi-structured interviews.

Results

The major challenge for blood supply was decreased blood donations, owing to lockdown restrictions, and individual and familial apprehensions. Mobilization mechanisms included bureaucratic and ideological mobilization. However, although group blood donation alleviates the pressure on supply chains during emergencies, it is detrimental to the cultivation of civic engagement in the long run.

Conclusion

This study contributes to the understanding of how countries with uncompensated blood donation models respond to public health emergencies. It suggests that striking a balance between the society’s and the state’s perception of blood donation would allow the state to incorporate the different “voices” of society, and devise an inclusive blood donation policy.

A Cohort Study in Intensive Care Units: Health Decisions Related to Blood Transfusion during the COVID-19 Pandemic

Critically ill polytrauma patients with hemorrhage require a rapid assessment to initiate hemostatic resuscitation in the shortest possible time with the activation of a massive transfusion or a critical hemorrhage management protocol. The hospital reality experienced during the COVID-19 pandemic in all countries was critical, as it was in Spain; according to the data published daily by the Ministry of Health on its website, during the period of this study, the occupancy rate of intensive care units (ICUs) by patients diagnosed with the novel coronavirus disease (COVID-19) rose to 23.09% in Spain, even reaching 45.23% at the end of January 2021. We aimed to analyze the changes observed during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic period regarding the effectiveness of Spanish ICUs in terms of mortality reduction. We present a cross-sectional study that compares two cohorts of patients admitted to ICUs across all autonomous communities of Spain with a diagnosis of polytrauma. Results: Only age was slightly higher at admission during the first wave of the pandemic (47.74 ± 18.65 vs. 41.42 ± 18.82 years, p = 0.014). The transfusion rate during the pandemic increased by 10.4% compared to the previous stage (p = 0.058). Regarding hemostatic components, the use of tranexamic acid increased from 1.8% to 10.7% and fibrinogen concentrates from 0.9% to 1.9%. In the case of prothrombin complex concentrates, although there was a slight increase in their use, there were no significant differences during the pandemic compared to the previous period. Conclusion: Mortality showed no difference before and during the pandemic, despite the observed change in the transfusion policy. In summary, the immediate and global implementation of patient blood management (PBM) based on clinical transfusion algorithms should be mandatory in all hospitals in our country.

The Immunological Effect of Oxygen Carriers on Normothermic Ex Vivo Liver Perfusion

Introduction

Normothermic ex vivo liver perfusion (NEVLP) is an organ preservation method that allows liver graft functional assessment prior to transplantation. One key component of normothermic perfusion solution is an oxygen carrier to provide oxygen to the liver to sustain metabolic activities. Oxygen carriers such as red blood cells (RBCs) or hemoglobin-based oxygen carriers have an unknown effect on the liver-resident immune cells during NEVLP. In this study, we assessed the effects of different oxygen carriers on the phenotype and function of liver-resident immune cells.

Methods

Adult Lewis rat livers underwent NEVLP using three different oxygen carriers: human packed RBCs (pRBCs), rat pRBCs, or Oxyglobin (a synthetic hemoglobin-based oxygen carrier). Hourly perfusate samples were collected for downstream analysis, and livers were digested to isolate immune cells. The concentration of common cytokines was measured in the perfusate, and the immune cells underwent phenotypic characterization with flow cytometry and quantitative reverse transcription polymerase chain reaction (qRT-PCR). The stimulatory function of the liver-resident immune cells was assessed using mixed lymphocyte reactions.

Results

There were no differences in liver function, liver damage, or histology between the three oxygen carriers. qRT-PCR revealed that the gene expression of nuclear factor κ light chain enhancer of activated B cells (NF-kB), Interleukin (IL-1β), C-C motif chemokine ligand 2 (CCL2), C-C motif chemokine ligand 7 (CCL7), and CD14 was significantly upregulated in the human pRBC group compared with that in the naive, whereas the rat pRBC and Oxyglobin groups were not different from that of naive. Flow cytometry demonstrated that the cell surface expression of the immune co-stimulatory protein, CD86, was significantly higher on liver-resident macrophages and plasmacytoid dendritic cells perfused with human pRBC compared to Oxyglobin. Mixed lymphocyte reactions revealed increased allogeneic T-cell proliferation in the human and rat pRBC groups compared to that in the Oxyglobin group.

Conclusions

Liver-resident immune cells are important mediators of rejection after transplantation. In this study, we show that the oxygen carrier used in NEVLP solutions can affect the phenotype of these liver-resident immune cells. The synthetic hemoglobin-based oxygen carrier, Oxyglobin, showed the least amount of liver-resident immune cell activation and the least amount of allogeneic proliferation when compared to human or rat pRBCs. To mitigate liver-resident immune cell activation during NEVLP (and subsequent transplantation), Oxyglobin may be an optimal oxygen carrier.

Effect of the COVID-19 pandemic on blood donations and transfusions in Nigeria - A multi-facility study of 34 tertiary hospitals

Background

The coronavirus disease 2019 (COVID-19) pandemic affected blood supplies globally. Mobile blood drive campaigns halted, and voluntary blood donations reduced, challenging available blood supplies. Furthermore, fears of virus transmission led to deferrals of elective surgeries and non-urgent clinical procedures with noticeable declines in blood donations and transfusions.

Aims

We aimed to assess the effect of the COVID-19 pandemic on the number of blood donations and transfusions across the country by blood product type across various hospital departments.

Materials and Methods

A retrospective descriptive study was conducted to determine the impact of the COVID-19 pandemic on blood services in 34 tertiary hospitals in Nigeria, comparing January to July 2019 (pre-COVID-19) to January to July 2020 (peri-COVID-19). Data were collected from the country's web-based software District Health Information System, Version 2 (DHIS2).

Results

A 17.1% decline in numbers of blood donations was observed over the study period, especially in April 2020 (44.3%), a 21.7% decline in numbers of blood transfusions, especially in April 2020 (44.3%). The largest declines in transfusion were noted in surgery department for fresh frozen plasma (80.1%) [p = 0.012] and accident and emergency department transfusion of platelets (78.3%) [p = 0.005]. The least decline of statistical significance was observed in internal medicine transfusions of whole blood (19.6%) [p = 0.011].

Conclusions

The COVID-19 pandemic significantly affected the numbers of blood donations and transfusions in Nigeria. Strengthening blood services to provide various blood components and secure safe blood supplies during public health emergencies is therefore critical.

Plasma procurement and plasma product safety in light of the COVID-19 pandemic from the perspective of the plasma industry

This review, written from the perspective of the plasma industry, discusses plasma procurement and plasma product safety in light of the COVID‐19 pandemic. The COVID‐19 pandemic impacted the whole world and, therefore, not unexpectedly, the pharmaceutical industry too. In spite of this, the plasma protein industry has continued to provide life saving therapies to critically ill patients. Moreover, companies have collected COVID convalescent plasma (CP) to support development of investigational therapies, for example, hyperimmune globulins to potentially treat SARS‐CoV‐2 infection, and collaborated with those collecting COVID CP for direct transfusion, which has been made available under emergency use in the United States. For plasma that is fractionated to become a therapy, general knowledge of coronaviruses and numerous new studies on the structure and function of SARS‐CoV‐2 provide reassurance that existing industry precautions, including donor selection, as well as virus inactivation and removal steps during the manufacturing process are sufficient to maintain the high standards of virus safety of plasma products. The pandemic also revealed the vulnerability and inadequacy of the current plasma ecosystem. There is a need for more plasma to be collected around the world to meet the growing need for safe and efficacious plasma‐derived therapies. This requires outdated regulatory and policy restrictions to be realigned with current scientific evidence. More countries around the world should be in a position to contribute to global supply of plasma so that patients with life‐threatening conditions ‐ and often no alternative therapeutic solutions ‐ have better access to care.

A Global Definition of Patient Blood Management

While patient blood management (PBM) initiatives are increasingly adopted across the globe as part of standard of care, there is need for a clear and widely accepted definition of PBM. To address this, an expert group representing PBM organizations, from the International Foundation for Patient Blood Management (IFPBM), the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), the Society for the Advancement of Patient Blood Management (SABM), the Western Australia Patient Blood Management (WAPBM) Group, and OnTrac (Ontario Nurse Transfusion Coordinators) convened and developed this definition: "Patient blood management is a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood, while promoting patient safety and empowerment." The definition emphasizes the critical role of informed choice. PBM involves the timely, multidisciplinary application of evidence-based medical and surgical concepts aimed at screening for, diagnosing and appropriately treating anemia, minimizing surgical, procedural, and iatrogenic blood losses, managing coagulopathic bleeding throughout the care and supporting the patient while appropriate treatment is initiated. We believe that having a common definition for PBM will assist all those involved including PBM organizations, hospital administrators, individual clinicians and policy makers to focus on the appropriate issues when discussing and implementing PBM. The proposed definition is expected to continue to evolve, making this endeavor a work in progress.

The Missing Pieces to the Cold-Stored Platelet Puzzle

Cold-stored platelets are making a comeback. They were abandoned in the late 1960s in favor of room-temperature stored platelets due to the need for longer post-transfusion platelet recoverability and survivability in patients with chronic thrombocytopenia. However, the current needs for platelet transfusions are rapidly changing. Today, more platelets are given to patients who are actively bleeding, such as ones receiving cardiac surgeries. It has been established that cold-stored platelets are more hemostatically effective, have reduced bacterial growth, and have longer potential shelf lives. These compelling characteristics led to the recent interest in bringing back cold-stored platelets to the blood systems. However, before reinstating cold-stored platelets in the clinics again, a thorough investigation of in vitro storage characteristics and in vivo transfusion effects is required. This review aims to provide an update on the recent research efforts into the storage characteristics and functions of cold-stored platelets using modern investigative tools. We will also discuss efforts made to improve cold-stored platelets to be a better and safer product. Finally, we will finish off with discussing the relevance of in vitro data to in vivo transfusion results and provide insights and directions for future investigations of cold-stored platelets.

Patient Blood Management in intensive care patients

PURPOSE OF REVIEW

Patients admitted to ICUs are a heterogeneous group, displaying multiple anaemia risk factors and comorbidities. Clinicians should therefore take all possible measures to identify modifiable risks. Patient Blood Management (PBM) is an approach promoting the timely application of evidence-based interventions designed to maintain patients own blood mass.

RECENT FINDINGS

Within ICU-patients, anaemia is highly prevalent. Generally, anaemia is associated with impaired outcome and need of blood transfusion. Currently, with ICUs working at full capacity and the global blood reserves exhausted, the SARS-CoV-2 pandemic reinforces the need for PBM implementation. For instance, implementation of a comprehensive coagulation management and measures to avoid iatrogenic blood loss may prevent bleeding-associated complications and adherence to blood transfusion guidelines may reduce adverse events associated with transfusion.

SUMMARY

Critically ill patients display various morbidities often requiring individualized treatment. PBM offers patient-centred measures to improve outcome any time during hospital stay.

Implementation of a Comprehensive Patient Blood Management Program for Hospitalized Patients at a Large United States Medical Center

OBJECTIVE

To assess changes in inpatient transfusion utilization and patient outcomes with implementation of a comprehensive patient blood management (PBM) program at a large US medical center.

PATIENTS AND METHODS

This is an observational study of graduated PBM implementation for hospitalized adults (age ≥18 years) from January 1, 2010, through December 31, 2017, at two integrated hospital campuses at a major academic US medical center. Allogeneic transfusion utilization and clinical outcomes were assessed over time through segmented regression with multivariable adjustment comparing observed outcomes against projected outcomes in the absence of PBM activities.

RESULTS

In total, 400,998 admissions were included. Total allogeneic transfusions per 1000 admissions decreased from 607 to 405 over the study time frame, corresponding to an absolute risk reduction for transfusion of 6.0% (95% confidence interval [CI]: 3.6%, 8.3%; P<.001) and a 22% (95% CI: 6%, 37%; P=.006) decrease in the rate of transfusions over projected. The risk of transfusion decreased for all blood components except cryoprecipitate. Transfusion reductions were experienced for all major surgery types except liver transplantation, which remained stable over time. Hospital length of stay (multiplicative increase in geometric mean 0.85 [95% CI: 0.81, 0.89]; P<.001) and incident in-hospital adverse events (absolute risk reduction: 1.5% [95% CI: 0.1%, 3.0%]; P=.04) were lower than projected at the end of the study time frame.

CONCLUSION

Patient blood management implementation for hospitalized patients in a large academic center was associated with substantial reductions in transfusion utilization and improved clinical outcomes. Broad-scale implementation of PBM in US hospitals is feasible without signal for patient harm.

Reduction in perioperative blood loss using ultrasound-activated scissors during tumour surgery

The aim of this study was to compare the effectiveness of Harmonic Focus+ scissors with the conventional surgical method regarding surgical blood loss and transfusion of blood products in the surgical treatment of head and neck tumours. In a retrospective study, the intraoperative blood loss, number of units of transfusion products given, operating time, and inpatient length of stay of 74 patients with squamous cell carcinoma were compared. Patients who underwent classic tumour surgery were compared with a group treated with Harmonic Focus+ scissors. A significantly lower intraoperative blood loss (496.15 ml vs 1096.0 ml, respectively; P = 0.002) and shorter operation time (436.89 minutes vs 493.13 minutes, respectively; P = 0.030) were achieved using the Harmonic Focus+ scissors when compared to the classic tumour surgery. Additionally, fewer units of blood products needed to be transfused (administration of red cell concentrates, P < 0.001) and the length of stay in the intensive care unit was shorter for patients treated with the Harmonic Focus+ scissors (P = 0.009). The study results indicate that the use of Harmonic Focus+ scissors during surgery for cancer of the oral cavity and pharynx is a safe and cost-effective method. This is of paramount importance during a pandemic when medical resources are scarce, including access to blood reserves.

The Impact of COVID-19 on Blood Transfusion Services: A Systematic Review and Meta-Analysis

Introduction

While SARS-CoV-2's main transmission route is through respiratory droplets, research has found that viral RNA could be detected in blood samples, causing concerns over the safety of blood donations and blood products. This paper therefore aims to systematically search for studies that have addressed their country's lack of donations and analyse the risk of blood transfusion-transmission. As such, it will answer the question "should blood services focus more on donation vigilance or worry more about the risks of transmission through blood products?"

Methods

38 articles were identified through a systematic review adopting the PRISMA and STROBE guidelines. Meta-analysis was conducted using OpenMeta software.

Results

The average decrease in blood donations was found to be 38%, with some regions showing up to 67% decrease. To assess the risk of actual blood transfusion-transmission, three datasets were analysed. Firstly, the viral load in COVID-19 patients was studied and found to have less than 1% detection rate (ARD = -0.831, 95% -0.963, -0.699). Secondly, the prevalence of finding viral RNA in a pool of donations was nearly -1.503 (ARD = -1.538, -1.468). Lastly, recipients who were given blood products of positive donors were found to be -0.911 (ARD 95% = -1.247, -0.575).

Discussion/Conclusion

Blood centres should focus more on launching initiatives and policies that would increase their countries' blood supply as the virus has no direct threat to blood safety.

Choice architecture for young adult blood donor recruitment - a feasibility study

Blood shortages remain an ongoing challenge, ameliorable by increasing blood donations. Choice architecture is an emerging concept in psychology dealing with the targeted presentation of options to encourage a desired decision. A pilot study was designed to test the feasibility of implementing six choice architecture strategies on a Midwest high-school blood drive. These include framing, conformity, mere measurement, availability heuristic, loss aversion and status quo bias. A pre-post interrupted time-series evaluation was performed to evaluate for an immediate impact on blood donations. All six of the intended choice architecture strategies were successfully implemented. The pre-intervention 5-year average number of blood donations per blood drive was 15 (4.3% of age eligible donors) whereas post intervention, the number of blood donors rose to 25 (7.1% of age eligible donors; p-value = .0013). The application of choice architecture to blood donor recruitment strategies is feasible and has the potential to reduce the burden of blood shortages.

Blood shortages and changes to massive transfusion protocols: Survey of hospital practices during the COVID-19 pandemic

Introduction

The COVID-19 pandemic has resulted in severe ongoing blood shortages across the US, despite employment of numerous blood-conservation measures. Massive transfusion protocols (MTP) are one resource-intensive practice that utilize significant amounts of blood products. Alterations to the composition of MTP parameters to conserve scarce biologic resources have hitherto not been examined during the pandemic.

Methods

An anonymous 18-question survey was administered to 115 hospitals with valid email contact information. Survey questions addressed whether institutions have altered their MTPs due to the COVID-19 pandemic and blood shortages, and if so, what adjustments they have made. Additional details concerning potential differences in the number and cycles of MTPs and blood product wastage during the COVID-19 pandemic compared to the year prior were assessed.

Results

50 responses were received (43 % response rate). 10 % (5/50) of institutions altered their MTPs utilizing a variety of approaches in attempt to conserve blood during the COVID-19 pandemic. Four additional institutions intend to alter them if it becomes necessary. Following onset of the COVID-19 pandemic, 24 % of institutions (12/50) reported an increase in monthly MTP activations, while 16 % (8/50) reported decreased activations compared to prior to the pandemic. 22 % (11/50) of institutions experienced increased blood wastage, whereas 16 % (8/50) reported decreased waste compared to pre-pandemic.

Discussion

The results of this survey highlight a variety of mechanisms by which institutions have attempted to conserve blood via altering MTPs. Whether an institution adjusted their MTP does not correlate with changes in blood product wastage compared to pre-pandemic.

Philadelphia-Negative Chronic Myeloproliferative Neoplasms during the COVID-19 Pandemic: Challenges and Future Scenarios

An outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) started in December 2019 in China and then become pandemic in February 2020. Several publications investigated the possible increased rate of COVID-19 infection in hematological malignancies. Based on the published data, strategies for the management of chronic Philadelphia-negative chronic myeloproliferative neoplasms (MPNs) are provided. The risk of severe COVID-19 seems high in MPN, particularly in patients with essential thrombocythemia, but not negligible in myelofibrosis. MPN patients are at high risk of both thrombotic and hemorrhagic complications and this must be accounted in the case of COVID-19 deciding on a case-by-case basis. There are currently no data to suggest that hydroxyurea or interferon may influence the risk or severity of COVID-19 infection. Conversely, while the immunosuppressive activity of ruxolitinib might pose increased risk of infection, its abrupt discontinuation during COVID-19 syndrome is associated with worse outcome. All MPN patients should receive vaccine against COVID-19; reassuring data are available on efficacy of mRNA vaccines in MPNs.