Recommendations for the transfusion of plasma and platelets

The foundation for investigating factor XI as a target for inhibition in human cardiovascular disease

Anticoagulant therapy is a mainstay in the management of patients with cardiovascular disease and related conditions characterized by a heightened risk for thrombosis. Acute coronary syndrome, chronic coronary syndrome, ischemic stroke, and atrial fibrillation are the most common. In addition to their proclivity for thrombosis, each of these four conditions is also characterized by local and systemic inflammation, endothelial/endocardial injury and dysfunction, oxidative stress, impaired tissue-level reparative capabilities, and immune dysregulation that plays a critical role in linking molecular events, environmental triggers, and phenotypic expressions. Knowing that cardiovascular disease and thrombosis are complex and dynamic, can the scientific community identify a common pathway or specific point of interface susceptible to pharmacological inhibition or alteration that is likely to be safe and effective? The contact factors of coagulation may represent the proverbial "sweet spot" and are worthy of investigation. The following review provides a summary of the fundamental biochemistry of factor XI, its biological activity in thrombosis, inflammation, and angiogenesis, new targeting drugs, and a pragmatic approach to managing hemostatic requirements in clinical trials and possibly day-to-day patient care in the future.

Effect of decreased platelets on postoperative recurrence of chronic subdural hematoma

Introduction

Chronic subdural hematoma (CSDH) is commonly treated using simple burr hole surgery. However, postoperative recurrence occurs at a relatively high rate of 10-20%. A decrease in platelet count (PC) may be associated with recurrence via a hemostasis disorder; however, this association has not been well-studied. Therefore, this study aimed to investigate the association between PC and postoperative CSDH recurrence.

Methods

We retrospectively reviewed the data for CSDHs in 488 cerebral hemispheres of 431 patients who underwent burr hole surgery at our institution between January 2013 and December 2022. The association between preoperative PC and postoperative CSDH recurrence was investigated. We used the first quartile of PC, PC < 170 × 103/μL to define a threshold for decreased PC.

Results

In total, 459 cerebral hemispheres with CSDHs in 405 patients were followed up postoperatively for at least 3 months or until CSDH disappeared. CSDH recurred in 39 (8.5%) cerebral hemispheres. The recurrence rate was gradually increased in parallel with a decreasing PC. Among 109 CSDHs with a decreased PC (<170 × 103/μL), 15 (13.8%) recurred, whereas only 24 (6.9%) of 350 CSDHs without a decreased PC recurred (p = 0.03). In univariable logistic analysis, eosinophil-rich blood (≥100/μL eosinophils in peripheral blood) and a decreased PC were significant risk factors. Multivariable analysis showed that eosinophil-rich blood (adjusted odds ratio, 2.51; 95% confidence interval, 1.26-4.99; p = 0.009) and a decreased PC (adjusted odds ratio, 2.15; 95% confidence interval, 1.07-4.35; p = 0.03) were independent risk factors for recurrence.

Conclusion

Our study showed that a decrease in PC was associated with postoperative CSDH recurrence. Patients with CSDH and a decreased PC require careful postoperative follow-up.

Cryopreservation affects platelet macromolecular composition over time after thawing and differently impacts on cancer cells behavior in vitro

Cryopreservation affects platelets' function, questioning their use for cancer patients. We aimed to investigate the biochemical events that occur over time after thawing to optimize transfusion timing and evaluate the effect of platelet supernatants on tumor cell behavior in vitro. We compared fresh (Fresh-PLT) with Cryopreserved platelets (Cryo-PLT) at 1 h, 3 h and 6 h after thawing. MCF-7 and HL-60 cells were cultured with Fresh- or 1 h Cryo-PLT supernatants to investigate cell proliferation, migration, and PLT-cell adhesion. We noticed a significant impairment of hemostatic activity accompanied by a post-thaw decrease of CD42b+ , which identifies the CD62P--population. FTIR spectroscopy revealed a decrease in the total protein content together with changes in their conformational structure, which identified two sub-groups: 1) Fresh and 1 h Cryo-PLT; 2) 3 h and 6 h cryo-PLT. Extracellular vesicle shedding and phosphatidylserine externalization (PS) increased after thawing. Cryo-PLT supernatants inhibited cell proliferation, impaired MCF-7 cell migration, and reduced ability to adhere to tumor cells. Within the first 3 hours after thawing, irreversible alterations of biomolecular structure occur in Cryo-PLT. Nevertheless, Cryo-PLT should be considered safe for the transfusion of cancer patients because of their insufficient capability to promote cancer cell proliferation, adhesion, or migration.

Spinal Cord Stimulation in Special Populations: Best Practices from the American Society of Pain and Neuroscience to Improve Safety and Efficacy

Chronic bleeding disorders, allergy to implants, and chronic infections are all complicating factors when considering neuromodulation therapies. The American Society of Pain and Neuroscience (ASPN) determined a need for clinical guidance in these special patient populations that have increased risk of complications, in order to ensure patient safety and optimal outcomes with device implantation. The purpose of this publication was to review the published literature and explore the unique clinical challenges encountered among several special patient populations with relation to spinal cord stimulation. The executive board of the ASPN appointed a diverse group of well-established physicians to develop best practice guidelines regarding spinal cord stimulation implantation in these special populations. The physicians used the United States Preventive Services Task Force (USPSTF) structured guidelines for grading and level of certainty to make evidence-based recommendations about clinical practice. Where sufficient evidence was lacking to justify a USPSTF ranking, the physicians queried experts in neuromodulation and achieved consensus. These best practices and interventional guideline found the evidence for the use of neuromodulation in specialized patient populations to be relatively modest.

Cost Analysis of Platelet Transfusion in Italy for Patients with Chronic Liver Disease and Associated Thrombocytopenia Undergoing Elective Procedures

Purpose

Platelet transfusions (PT) are commonly used as prophylaxis in patients with chronic liver disease (CLD) and severe thrombocytopenia (TCP) before invasive procedures, in order to reduce risk of bleeding. The aim of this cost analysis was to generate a comprehensive estimate of costs of platelet transfusions in Italy, focusing on patients with severe TCP due to CLD undergoing an elective procedure.

Methods

The research was conducted in different phases: 1) assessment of a pre-specified framework for the identification of processes related to PT; 2) estimation of resource consumption through Delphi technique and collection of unit costs through literature; 3) development of a cost analysis to estimate the overall average costs per PT, focusing on a representative patient with CLD and severe TCP. Robustness of results was tested in a sensitivity analysis.

Results

Despite the lack of some cost components estimation and uncertainty related to event probability, the analysis showed a total cost of 5297 € for each PT in patients with CLD and severe TCP. The total cost was largely driven by direct costs (4863 €) associated with platelet collection, transfusion, and management of refractoriness, which accounted for 92% of total.

Conclusion

In an environment of limited resources, it is crucial for the healthcare service to have accurate and inclusive information on transfusion costs, incorporating not only the cost of blood products but also those related to collection and management. The analysis showed that platelet collection and administration costs add substantially to the cost of platelet products themselves. As expected, the highest cost was the transfusion process itself (44% of total), followed by refractoriness (43% of total). Since limited literature exists concerning these cost estimates, this analysis represents a step forward in understanding the economic burden of patients with CLD and severe TCP scheduled to undergo an invasive procedure.

Plasma and Platelet Transfusion Strategies in Critically Ill Children With Malignancy, Acute Liver Failure and/or Liver Transplantation, or Sepsis: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding

OBJECTIVES

To present the consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding.

DESIGN

Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.

SETTING

Not applicable.

PATIENTS

Critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of 13 experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 12 expert consensus statements.

CONCLUSIONS

In the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program, the current absence of evidence for use of plasma and/or platelet transfusion in critically ill children with malignancy, acute liver disease and/or following liver transplantation, and sepsis means that only expert consensus statements are possible for these areas of practice.

Early Fresh Frozen Plasma Transfusion: Is It Associated With Improved Outcomes of Patients With Sepsis?

Background: So far, no study has investigated the effects of plasma transfusion in the patients with sepsis, especially in the terms of prognosis. Therefore, we aimed to explore the association of early fresh frozen plasma (FFP) transfusion with the outcomes of patients with sepsis.

Methods: We performed a cohort study using data extracted from the Medical Information Mart for Intensive Care III database (v1.4). External validation was obtained from the First Affiliated Hospital of Wenzhou Medical University, China. We adopted the Sepsis-3 criteria to extract the patients with sepsis and septic shock. The occurrence of transfusion during the first 3-days of intensive care unit (ICU) stay was regarded as early FFP transfusion. The primary outcome was 28-day mortality. We assessed the association of early FFP transfusion with the patient outcomes using a Cox regression analysis. Furthermore, we performed the sensitivity analysis, subset analysis, and external validation to verify the true strength of the results.

Results: After adjusting for the covariates in the three models, respectively, the significantly higher risk of death in the FFP transfusion group at 28-days [e.g., Model 2: hazard ratio (HR) = 1.361, P = 0.018, 95% CI = 1.054–1.756] and 90-days (e.g., Model 2: HR = 1.368, P = 0.005, 95% CI = 1.099–1.704) remained distinct. Contrarily, the mortality increased significantly with the increase of FFP transfusion volume. The outcomes of the patients with sepsis with hypocoagulable state after early FFP transfusion were not significantly improved. Similar results can also be found in the subset analysis of the septic shock cohort. The results of external validation exhibited good consistency.

Conclusions: Our study provides a new understanding of the rationale and effectiveness of FFP transfusion for the patients with sepsis. After recognizing the evidence of risk-benefit and cost-benefit, it is important to reduce the inappropriate use of FFP and avoid unnecessary adverse transfusion reactions.

Outcomes of Patients Who Undergo Transfusion of Fresh Frozen Plasma: A Prospective, Observational, Multicentre Cohort Study in Hiroshima, Japan

Purpose

Given the chronic shortage of blood for transfusion in Japan, promotion of appropriate use of fresh frozen plasma (FFP) urgently needs to be addressed by the national blood project in Japan. Whether FFP transfusions are administered appropriately in Japan is currently unclear. In this study, we aimed to investigate the outcomes of patients who undergo FFP transfusion and the appropriateness of use of FFP.

Patients and Methods

This multicentre, prospective, observational cohort study was conducted from September 2017 to April 2019 at the 15 medical institutions in Hiroshima Prefecture that are the top providers of FFP. All patients who underwent FFP transfusion during the study period were included, relevant data being extracted from the medical records. The indications for FFP transfusion were classified in accordance with the Guidelines of the Ministry of Health, Labour and Welfare of Japan. Factors associated with patient outcomes at day 28 after FFP transfusion were subjected to multivariable logistic regression analysis.

Results

In total, data of 1299 patients were eligible for analysis. At least 63.8% of indications for FFP were in accordance with the guideline for FFP transfusions. The mortality rate at day 28 after FFP transfusion was 16.2%. Older age (65–74 years: adjusted odds ratio [AOR]=4.3, ≥75 years: AOR=4.1), non-perioperative use (AOR=4.5), coagulopathy associated with liver damage (AOR=2.7), large volume of FFP transfused (AOR=2.5), and lack of improvement in blood coagulation following FFP transfusion were independently and significantly associated with death within 28 days after FFP transfusion.

Conclusion

Our findings do not support the simple conclusion that FFP transfusions contribute to prognosis. However, given that coagulopathy in patients with end-stage liver disease is infrequently improved by FFP transfusion, “inappropriate” use of FFP should be avoided. It is important to promote appropriate use of FFP so as not to waste blood resources.

Effect of Intra- and Post-Operative Fluid and Blood Volume on Postoperative Pulmonary Edema in Patients with Intraoperative Massive Bleeding

In patients with intraoperative massive bleeding, the effects of fluid and blood volume on postoperative pulmonary edema are uncertain. Patients with intraoperative massive bleeding who had undergone a non-cardiac surgery in five hospitals were enrolled in this study. We evaluated the association of postoperative pulmonary edema risk and intra- and post-operatively administered fluid and blood volumes in patients with intraoperative massive bleeding. In total, 2090 patients were included in the postoperative pulmonary edema analysis, and 300 patients developed pulmonary edema within 72 h of the surgery. The postoperative pulmonary edema with hypoxemia analysis included 1660 patients, and the condition occurred in 161 patients. An increase in the amount of red blood cells transfused per hour after surgery increased the risk of pulmonary edema (hazard ratio: 1.03; 95% confidence interval: 1.01–1.05; p = 0.013) and the risk of pulmonary edema with hypoxemia (hazard ratio: 1.04; 95% confidence interval: 1.01–1.07; p = 0.024). An increase in the red blood cells transfused per hour after surgery increased the risk of developing pulmonary edema. This increase can be considered as a risk factor for pulmonary edema.

Leg Compartment Syndrome Complicating Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: A Case Report

Patient: Male, 15-year-old

Final Diagnosis: Compartment syndrome

Symptoms: Pain

Medication: —

Clinical Procedure: —

Specialty: Orthopedics and Traumatology

A modified microchip-based flow chamber system for evaluating thrombogenicity in patients with thrombocytopenia

BACKGROUND

In the intensive care unit (ICU), patients with thrombocytopenia are at high risk for bleeding and should be assessed for their thrombogenic potential. However, the analytical conditions of conventional hemostatic tests are unsuitable for the evaluation of low-platelet samples. Here we aimed to establish suitable analytical conditions with the Total Thrombus-formation Analysis System (T-TAS) for quantitative assessment of thrombogenic potential in patients with thrombocytopenia and to investigate how T-TAS values relate to bleeding symptoms and the effects of platelet transfusion.

METHODS

Modified chips with a different chamber depth were developed for the analysis of low-platelet samples in the T-TAS. We included 10 adult patients admitted to the ICU of Kagoshima University Hospital who required platelet transfusion. Patients were divided into major and minor bleeding groups according to their bleeding scale before platelet transfusion. The thrombogenic potential of these patients before and after platelet transfusion was assessed with hemostatic function tests, including rotational thromboelastometry, multiplate aggregometry, and the T-TAS.

RESULTS

Analysis of low-platelet samples revealed that, compared with the conventional chip (80-μm-deep chamber), the modified chip (50-μm-deep chamber) achieved higher sensitivity in detecting elevation of flow pressure caused by growth of an occlusive thrombus in the T-TAS analytical chamber. All patients in the minor bleeding group retained thrombogenic potential that occluded the modified chip (occlusion time 16.3 ± 3.3 min), whereas most patients in the major bleeding group were unable to occlude the modified chip during the 30-min measurement (P <  0.01). The recovery of thrombogenic potential after platelet transfusion was confirmed with the T-TAS and correlated with the function, rather than the count, of transfused platelets. Among all evaluated parameters in hemostatic function tests, only the T-TAS showed significant differences in occlusion time and area under the curve both between the minor and major bleeding groups and between pre- and post-platelet transfusion.

CONCLUSIONS

We developed a modified microchip-based flow chamber system that reflects the hemostatic function of patients with thrombocytopenia.

Blood Supply and Demand in Korea: What is in Store for the Future?

PURPOSE

Presently, Korea is facing new challenges associated with an imbalance in blood supply and demand. The purpose of this study was to examine trends in blood supply and demand in Korea over the past 10 years through 2018 and to propose what to prepare in the future.

MATERIALS AND METHODS

Age demographics in Korea were analyzed using data from the Statistics Korea. Blood donation and blood supply data were analyzed using Blood Services Statistics 2018 by the Korean Red Cross. Blood transfusion data from hospitals in 2018 were obtained from the Health Insurance Review and Assessment Service.

RESULTS

In 2018, 2883270 whole blood and apheresis units were collected in Korea. The Korean Red Cross supplied 4277762 blood components to 2491 hospitals. The overall blood donation rate was 5.6%, and the most frequent donors were young male donors. Leukoreduced red blood cells (RBCs) constituted 25% of all RBCs used, and 40% of all platelets were supplied by single-donor platelets. The self-sufficiency rate of domestic plasma with which to produce plasma-derived medicinal products was 68.7% in 2018. Blood use was the most frequent among patients aged 70-79 years.

CONCLUSION

Blood management in Korea is changing rapidly due to a low birth rate, rapid aging, and an increase in severely ill patients who require most of the blood supply. Therefore, future plans to promote donation at a national level and optimal use of blood in hospitals is necessary.

Preterm neonates benefit from low prophylactic platelet transfusion threshold despite varying risk of bleeding or death

The Platelets for Neonatal Thrombocytopenia (PlaNeT-2) trial reported an unexpected overall benefit of a prophylactic platelet transfusion threshold of 25 × 109/L compared with 50 × 109/L for major bleeding and/or mortality in preterm neonates (7% absolute-risk reduction). However, some neonates in the trial may have experienced little benefit or even harm from the 25 × 109/L threshold. We wanted to assess this heterogeneity of treatment effect in the PlaNet-2 trial, to investigate whether all preterm neonates benefit from the low threshold. We developed a multivariate logistic regression model in the PlaNet-2 data to predict baseline risk of major bleeding and/or mortality for all 653 neonates. We then ranked the neonates based on their predicted baseline risk and categorized them into 4 risk quartiles. Within these quartiles, we assessed absolute-risk difference between the 50 × 109/L- and 25 × 109/L-threshold groups. A total of 146 neonates died or developed major bleeding. The internally validated C-statistic of the model was 0.63 (95% confidence interval, 0.58-0.68). The 25 × 109/L threshold was associated with absolute-risk reduction in all risk groups, varying from 4.9% in the lowest risk group to 12.3% in the highest risk group. These results suggest that a 25 × 109/L prophylactic platelet count threshold can be adopted in all preterm neonates, irrespective of predicted baseline outcome risk. Future studies are needed to improve the predictive accuracy of the baseline risk model. This trial was registered at www.isrctn.com as #ISRCTN87736839.

Platelet Transfusion: And Update on Challenges and Outcomes

Platelet transfusion is a common practice in onco-hematologic patients for preventing or treating hemorrhages. Platelet concentrates can be transfused with therapeutic or prophylactic purposes. With the aim to help clinicians to take the decisions on platelet transfusion, some guidelines have been developed based on the current scientific evidence. However, there are some controversial issues and available scientific evidence is not enough to solve them. There is little information about what is the best platelet product to be transfused: random platelets or single donor apheresis platelets, and plasma-suspended or additive solution suspended platelets. Platelets are often transfused without respecting the ABO compatibility, but influence of this practice on platelet transfusion outcome is not well established. In the prophylactic platelet transfusion set there are some questions unsolved as the platelet threshold to transfuse prior to specific procedures or surgery, and even if platelet transfusion is necessary for some specific procedures as autologous hematopoietic stem cell transplantation. A challenging complication raised from multiple platelet transfusions is the platelet transfusion refractoriness. The study and management of this complication is often disappointing. In summary, although it is a widespread practice, platelet transfusion has still many controversial and unknown issues. The objective of this article is to review the current evidence on platelet transfusion practices, focusing on the controversial issues and challenges.

Prophylactic plasma transfusion for patients without inherited bleeding disorders or anticoagulant use undergoing non-cardiac surgery or invasive procedures

BACKGROUND

In the absence of bleeding, plasma is commonly transfused to people prophylactically to prevent bleeding. In this context, it is transfused before operative or invasive procedures (such as liver biopsy or chest drainage tube insertion) in those considered at increased risk of bleeding, typically defined by abnormalities of laboratory tests of coagulation. As plasma contains procoagulant factors, plasma transfusion may reduce perioperative bleeding risk. This outcome has clinical importance given that perioperative bleeding and blood transfusion have been associated with increased morbidity and mortality. Plasma is expensive, and some countries have experienced issues with blood product shortages, donor pool reliability, and incomplete screening for transmissible infections. Thus, although the benefit of prophylactic plasma transfusion has not been well established, plasma transfusion does carry potentially life-threatening risks.

OBJECTIVES

To determine the clinical effectiveness and safety of prophylactic plasma transfusion for people with coagulation test abnormalities (in the absence of inherited bleeding disorders or use of anticoagulant medication) requiring non-cardiac surgery or invasive procedures.

SEARCH METHODS

We searched for randomised controlled trials (RCTs), without language or publication status restrictions in: Cochrane Central Register of Controlled Trials (CENTRAL; 2017 Issue 7); Ovid MEDLINE (from 1946); Ovid Embase (from 1974); Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCOHost) (from 1937); PubMed (e-publications and in-process citations ahead of print only); Transfusion Evidence Library (from 1950); Latin American Caribbean Health Sciences Literature (LILACS) (from 1982); Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (Thomson Reuters, from 1990); ClinicalTrials.gov; and World Health Organization (WHO) International Clinical Trials Registry Search Platform (ICTRP) to 28 January 2019.

SELECTION CRITERIA

We included RCTs comparing: prophylactic plasma transfusion to placebo, intravenous fluid, or no intervention; prophylactic plasma transfusion to alternative pro-haemostatic agents; or different haemostatic thresholds for prophylactic plasma transfusion. We included participants of any age, and we excluded trials incorporating individuals with previous active bleeding, with inherited bleeding disorders, or taking anticoagulant medication before enrolment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included five trials in this review, all were conducted in high-income countries. Three additional trials are ongoing. One trial compared fresh frozen plasma (FFP) transfusion with no transfusion given. One trial compared FFP or platelet transfusion or both with neither FFP nor platelet transfusion given. One trial compared FFP transfusion with administration of alternative pro-haemostatic agents (factors II, IX, and X followed by VII). One trial compared the use of different transfusion triggers using the international normalised ratio measurement. One trial compared the use of a thromboelastographic-guided transfusion trigger using standard laboratory measurements of coagulation. Four trials enrolled only adults, whereas the fifth trial did not specify participant age. Four trials included only minor procedures that could be performed by the bedside. Only one trial included some participants undergoing major surgical operations. Two trials included only participants in intensive care. Two trials included only participants with liver disease. Three trials did not recruit sufficient participants to meet their pre-calculated sample size. Overall, the quality of evidence was low to very low across different outcomes according to GRADE methodology, due to risk of bias, indirectness, and imprecision. One trial was stopped after recruiting two participants, therefore this review's findings are based on the remaining four trials (234 participants). When plasma transfusion was compared with no transfusion given, we are very uncertain whether there was a difference in 30-day mortality (1 trial comparing FFP or platelet transfusion or both with neither FFP nor platelet transfusion, 72 participants; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.13 to 1.10; very low-quality evidence). We are very uncertain whether there was a difference in major bleeding within 24 hours (1 trial comparing FFP transfusion vs no transfusion, 76 participants; RR 0.33, 95% CI 0.01 to 7.93; very low-quality evidence; 1 trial comparing FFP or platelet transfusion or both with neither FFP nor platelet transfusion, 72 participants; RR 1.59, 95% CI 0.28 to 8.93; very low-quality evidence). We are very uncertain whether there was a difference in the number of blood product transfusions per person (1 trial, 76 participants; study authors reported no difference; very low-quality evidence) or in the number of people requiring transfusion (1 trial comparing FFP or platelet transfusion or both with neither FFP nor platelet transfusion, 72 participants; study authors reported no blood transfusion given; very low-quality evidence) or in the risk of transfusion-related adverse events (acute lung injury) (1 trial, 76 participants; study authors reported no difference; very low-quality evidence). When plasma transfusion was compared with other pro-haemostatic agents, we are very uncertain whether there was a difference in major bleeding (1 trial; 21 participants; no events; very low-quality evidence) or in transfusion-related adverse events (febrile or allergic reactions) (1 trial, 21 participants; RR 9.82, 95% CI 0.59 to 162.24; very low-quality evidence). When different triggers for FFP transfusion were compared, the number of people requiring transfusion may have been reduced (for overall blood products) when a thromboelastographic-guided transfusion trigger was compared with standard laboratory tests (1 trial, 60 participants; RR 0.18, 95% CI 0.08 to 0.39; low-quality evidence). We are very uncertain whether there was a difference in major bleeding (1 trial, 60 participants; RR 0.33, 95% CI 0.01 to 7.87; very low-quality evidence) or in transfusion-related adverse events (allergic reactions) (1 trial; 60 participants; RR 0.33, 95% CI 0.01 to 7.87; very low-quality evidence). Only one trial reported 30-day mortality. No trials reported procedure-related harmful events (excluding bleeding) or quality of life.

AUTHORS' CONCLUSIONS

Review findings show uncertainty for the utility and safety of prophylactic FFP use. This is due to predominantly very low-quality evidence that is available for its use over a range of clinically important outcomes, together with lack of confidence in the wider applicability of study findings, given the paucity or absence of study data in settings such as major body cavity surgery, extensive soft tissue surgery, orthopaedic surgery, or neurosurgery. Therefore, from the limited RCT evidence, we can neither support nor oppose the use of prophylactic FFP in clinical practice.

Human Leucocyte Antigen Sensitisation and Its Impact on Transfusion Practice

Human leucocyte antigen (HLA) sensitisation, including the formation of antibodies against HLA, can cause serious effects in patients receiving blood. Under certain circumstances, donor HLA antibodies in the blood product can trigger the patient's granulocytes to release mediators that cause transfusion-associated lung injury (TRALI), a serious complication of transfusion. The HLA systems of both donor and patient are involved in transfusion-associated graft-versus-host disease, which is a rare disease with a high mortality. Patient HLA antibodies can destroy incompatible platelets and may cause refractoriness to platelet transfusion. Identification of a patient's HLA antibody specificities is necessary for issuing compatible platelets to overcome refractoriness. Many techniques for the detection and identification of HLA antibodies have been developed, including complement-dependent cytotoxicity assay, bead-based assays, the platelet adhesion immunofluorescence test, and the monoclonal antibody-specific immobilisation of platelet antigens assay. Different strategies for the selection of HLA-compatible platelets are applied. These strategies depend on the breadth of antibody reactivity and range from avoiding single HLA antigens in the platelet concentrates issued to apheresis of platelets from HLA-identical donors. The mechanisms of HLA sensitisation and the efforts made to provide compatible blood products to sensitised patients are reviewed in this article from the perspective of clinical transfusion medicine.

Prothrombin Complex Concentrates for Coagulopathy in Liver Disease: Single-Center, Clinical Experience in 105 Patients

Patients with liver disease frequently develop coagulopathy, and fresh frozen plasma is traditionally used for correction of coagulopathy to manage and prevent bleeding. Prothrombin complex concentrates (PCCs) offer an attractive alternative because they are more readily available and avoid large-volume transfusion. This retrospective, single-center study reviewed clinical use of PCC in patients with acute/chronic liver disease. A total of 105 patients with 194 episodes of PCC administration were reviewed. Data pertaining to indication, dosing, effectiveness, and safety were collected. The effect of PCC on coagulation was analyzed in patients for whom coagulation results were available 7 hours before and after PCC. Data on thromboembolic events and mortality within 4 weeks of PCC administration were captured. Most patients (77%) had chronic liver disease; the remainder had acute liver failure. Indications for PCC were preprocedure prophylaxis and treatment for active/recent bleeding in 48% and 52% of 194 treatment episodes, respectively. The median dose of PCC administered was 22 IU/kg (interquartile range, 16-29 IU/kg). Before PCC administration, 45% of patients had an international normalized ratio (INR) greater than 2.0, and 36% had fibrinogen levels of at least 1.5 g/L. PCC produced statistically significant reductions in prothrombin time and INR (coadministration with fibrinogen or cryoprecipitate: 3.1 versus 1.9; P < 0.001; no coadministration: 2.3 versus 1.8; P < 0.001). Three patients with multiple risk factors developed thrombotic events (hepatic artery thrombosis, incidental bilateral pulmonary embolism, nonocclusive portal vein thrombosis); there were no cardiovascular or cerebrovascular adverse events. Overall, 46 patients died of causes unrelated to PCC treatment. Conclusion: In patients with liver disease, PCC therapy was effective in improving coagulation test results without an excess of thrombotic events. Further assessment of PCC as hemostatic therapy in this setting is required.

Therapeutic Plasma Exchange in Renal Disorders

Nephrologists use hemodialysis and hemofiltration to remove low molecular weight toxic constituents, and increasingly deploy therapeutic plasma exchange (TPE)/plasmapheresis to eliminate higher molecular weight substances such as immunoglobulins or immune complexes from plasma. This review discusses different modalities of TPE, their application in renal disorders, its rationale and complications. TPE is recommended based on evidence, in alloantibody-mediated diseases such as humoral antibody mediated renal transplant rejection, autoantibody mediated glomerulonephritis (GN) disorders for example, anti-glomerular basement membrane GN, as well as in antineutrophil cytoplasmic antibody mediated GN and antibody mediated thrombotic thrombocytopenic purpura. In many other renal illnesses, the rational use of TPE is gaining currency. Double membrane filtration, immune adsorption and cryofiltration are important modifications in TPE

Immune Thrombocytopenia is Still the Commonest Diagnosis on Consultative Hematology

Thrombocytopenia is often a source of concern for physicians and patients alike and is one of the commonest reasons for a hematology consultation. Through this study, we wish to ascertain the different etiologies which should be kept in mind by a hematologist when a consultation for thrombocytopenia is sought. We assessed the etiology & clinical features of thrombocytopenia seen on consultative hematology calls for patients admitted in the general ward of a tertiary care hospital. 88/277 hematology consultations taken over a course of 2 months were for thrombocytopenia. The median age of these patients was 30 years, 62.5% were female, and median platelet of 40,500/µL (1000-112000). Mild, moderate & severe thrombocytopenia was seen in 6.8%, 27.3% and 65.9% respectively. 50% of patients had a primary hematological diagnosis. Immune thrombocytopenia (ITP) was the commonest diagnosis (38.6%). Bleeding manifestations were present in 48.9% patients with 20.5% having a major bleed. One third of hematology consultations in the general ward and emergency of a tertiary care hospital are for thrombocytopenia. Almost in half, the etiology of thrombocytopenia is related to a primary hematological disorder. This information should help in decision making of use of appropriate resources.

Comparison of a therapeutic-only versus prophylactic platelet transfusion policy for people with congenital or acquired bone marrow failure disorders

BACKGROUND

Bone marrow disorders encompass a group of diseases characterised by reduced production of red cells, white cells, and platelets, or defects in their function, or both. The most common bone marrow disorder is myelodysplastic syndrome. Thrombocytopenia, a low platelet count, commonly occurs in people with bone marrow failure. Platetet transfusions are routinely used in people with thrombocytopenia secondary to bone marrow failure disorders to treat or prevent bleeding. Myelodysplastic syndrome is currently the most common reason for receiving a platelet transfusion in some Western countries.

OBJECTIVES

To determine whether a therapeutic-only platelet transfusion policy (transfusion given when patient is bleeding) is as effective and safe as a prophylactic platelet transfusion policy (transfusion given to prevent bleeding according to a prespecified platelet threshold) in people with congenital or acquired bone marrow failure disorders.

SEARCH METHODS

We searched for randomised controlled trials (RCTs), non-RCTs, and controlled before-after studies (CBAs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2017, Issue 9), Ovid MEDLINE (from 1946), Ovid Embase (from 1974), PubMed (e-publications only), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 12 October 2017.

SELECTION CRITERIA

We included RCTs, non-RCTs, and CBAs that involved the transfusion of platelet concentrates (prepared either from individual units of whole blood or by apheresis any dose, frequency, or transfusion trigger) and given to treat or prevent bleeding among people with congenital or acquired bone marrow failure disorders.We excluded uncontrolled studies, cross-sectional studies, and case-control studies. We excluded cluster-RCTs, non-randomised cluster trials, and CBAs with fewer than two intervention sites and two control sites due to the risk of confounding. We included all people with long-term bone marrow failure disorders that require platelet transfusions, including neonates. We excluded studies of alternatives to platelet transfusion, or studies of people receiving intensive chemotherapy or a stem cell transplant.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures outlined by Cochrane. Due to the absence of evidence we were unable to report on any of the review outcomes.

MAIN RESULTS

We identified one RCT that met the inclusion criteria for this review. The study enrolled only nine adults with MDS over a three-year study duration period. The trial was terminated due to poor recruitment rate (planned recruitment 60 participants over two years). Assessment of the risk of bias was not possible for all domains. The trial was a single-centre, single-blind trial. The clinical and demographic characteristics of the participants were never disclosed. The trial outcomes relevant to this review were bleeding assessments, mortality, quality of life, and length of hospital stay, but no data were available to report on any of these outcomes.We identified no completed non-RCTs or CBAs.We identified no ongoing RCTs, non-RCTs, or CBAs.

AUTHORS' CONCLUSIONS

We found no evidence to determine the safety and efficacy of therapeutic platelet transfusion compared with prophylactic platelet transfusion for people with long-term bone marrow failure disorders. This review underscores the urgency of prioritising research in this area. People with bone marrow failure depend on long-term platelet transfusion support, but the only trial that assessed a therapeutic strategy was halted. There is a need for good-quality studies comparing a therapeutic platelet transfusion strategy with a prophylactic platelet transfusion strategy; such trials should include outcomes that are important to patients, such as quality of life, length of hospital admission, and risk of bleeding.

Anti-D Alloimmunization after RhD-Positive Platelet Transfusion in RhD-Negative Women under 55 Years Diagnosed with Acute Leukemia: Results of a Retrospective Study

Background

Anti-D alloimmunization can occur when platelets from RhD-positive donors are transfused to RhD-negative patients, due to red blood cell residues in the platelet concentrates.

Methods

Our objective was to analyze the anti-D alloimmunization rate in a selected group of women under 55 years of age diagnosed with acute leukemia over an 18-year period. We focused the analysis on RhD-negative patients who received RhD-positive platelet transfusions.

Results

From January 1998 to October 2016, 382 women under 55 years were diagnosed with acute leukemia. A total of 56 patients were RhD-negative, and 48 (85.7%) received RhD-positive platelets. The median number of platelet concentrates transfused per patient was 23, and 48% of all platelet transfusions were RhD-positive. The 48 RhD-negative patients received a total of 949 RhD-positive platelet concentrates. Two patients developed anti-D: a 36-year-old woman with M3 acute myeloblastic leukemia and a 52-year-old patient with a secondary acute myeloblastic leukemia.

Conclusion

We conclude that there is a need for agreement in the transfusion guidelines on the recommendation of anti-D alloimmunization prophylaxis. We suggest a possible benefit in favor of anti-D prophylaxis in childbearing women with acute leukemia.

The role of thromboelastography in predicting hemorrhage risk in patients with leukemia

This study aimed to compare the efficacy of thromboelastography (TEG) and conventional coagulation methods in predicting hemorrhage risk in patients with leukemia.A total of 226 patients diagnosed with leukemia were included and divided into bleeding and nonbleeding groups. All patients had their blood samples taken for TEG test to measure the reaction time (R time), alpha (α angle), and maximum amplitude (MA) as well as measure platelet count (PLT), prothrombin time, and activated partial thromboplastin time. Patients were followed up for bleeding episodes.The multivariate analysis showed that PLT [odds ratio (OR) = 0.993] and MA (OR = 0.921) have better association with bleeding risk. Receiver operating characteristic (ROC) analysis showed that the combination of PLT and MA (AUC = 0.824) was better for hemorrhage risk prediction than PLT [area under the curve (AUC) = 0.730] and MA (AUC = 0.819) alone.The combination of TEG and conventional coagulation methods could help in assessing the risk of hemorrhage in patients with leukemia.

Biomaterials and Advanced Technologies for Hemostatic Management of Bleeding

Bleeding complications arising from trauma, surgery, and as congenital, disease-associated, or drug-induced blood disorders can cause significant morbidities and mortalities in civilian and military populations. Therefore, stoppage of bleeding (hemostasis) is of paramount clinical significance in prophylactic, surgical, and emergency scenarios. For externally accessible injuries, a variety of natural and synthetic biomaterials have undergone robust research, leading to hemostatic technologies including glues, bandages, tamponades, tourniquets, dressings, and procoagulant powders. In contrast, treatment of internal noncompressible hemorrhage still heavily depends on transfusion of whole blood or blood's hemostatic components (platelets, fibrinogen, and coagulation factors). Transfusion of platelets poses significant challenges of limited availability, high cost, contamination risks, short shelf-life, low portability, performance variability, and immunological side effects, while use of fibrinogen or coagulation factors provides only partial mechanisms for hemostasis. With such considerations, significant interdisciplinary research endeavors have been focused on developing materials and technologies that can be manufactured conveniently, sterilized to minimize contamination and enhance shelf-life, and administered intravenously to mimic, leverage, and amplify physiological hemostatic mechanisms. Here, a comprehensive review regarding the various topical, intracavitary, and intravenous hemostatic technologies in terms of materials, mechanisms, and state-of-art is provided, and challenges and opportunities to help advancement of the field are discussed.

Two cases of liver cirrhosis treated with lusutrombopag before partial splenic embolization

Lusutrombopag, a small molecule thrombopoietin receptor agonist, has been approved for the treatment of chronic liver disease-associated thrombocytopenia due to hypersplenism in patients scheduled to undergo elective invasive procedures in Japan. We performed partial splenic embolization (PSE) after administration of lusutrombopag in two patients with thrombocytopenia due to cirrhosis.　Case 1 involved a 50-year-old man who developed cirrhosis due to hepatitis B virus (HBV) infection and alcohol consumption. Case 2 involved a 30-year-old woman who developed cirrhosis due to HBV infection only. Lusutrombopag administration led to an increase in platelet count in both patients, and PSE was performed safely. However, in Case 2, the patient developed disseminated intravascular coagulation. Further study with a larger population is required to investigate the indications for and risks of the use of lusutrombopag.

"Low platelet usage" haematology laboratories: To store or not to store?

In the UK, hospitals with annual platelet use of less than 500 pools, like our institution, usually do not store platelets on-site and these are only ordered from the national blood service (NBS) when a transfusion is required. In 2016, we piloted routine on-site storage of one pool of A RhD negative PLT. Data were collected retrospectively on units of PLTs ordered from NBS, units transfused to patients, wastage, requirements for emergency deliveries from NBS and overall cost. These were compared to corresponding data from the four preceding years (2012-2015). There was a 39% reduction in the PLT ordered from NBS in 2016 compared to previous years and a 50% reduction in transfused PLT. Annual wastage for 2016 increased by 23% even though the absolute number of wasted PLT did not alter significantly. Annual cost reduced by 36% in 2016 resulting from reduction in the total amount of PLTs ordered as well as reduction in emergency deliveries.

Bio-inspired nanomedicine strategies for artificial blood components

Blood is a fluid connective tissue where living cells are suspended in noncellular liquid matrix. The cellular components of blood render gas exchange (RBCs), immune surveillance (WBCs) and hemostatic responses (platelets), and the noncellular components (salts, proteins, etc.) provide nutrition to various tissues in the body. Dysfunction and deficiencies in these blood components can lead to significant tissue morbidity and mortality. Consequently, transfusion of whole blood or its components is a clinical mainstay in the management of trauma, surgery, myelosuppression, and congenital blood disorders. However, donor-derived blood products suffer from issues of shortage in supply, need for type matching, high risks of pathogenic contamination, limited portability and shelf-life, and a variety of side-effects. While robust research is being directed to resolve these issues, a parallel clinical interest has developed toward bioengineering of synthetic blood substitutes that can provide blood's functions while circumventing the above problems. Nanotechnology has provided exciting approaches to achieve this, using materials engineering strategies to create synthetic and semi-synthetic RBC substitutes for enabling oxygen transport, platelet substitutes for enabling hemostasis, and WBC substitutes for enabling cell-specific immune response. Some of these approaches have further extended the application of blood cell-inspired synthetic and semi-synthetic constructs for targeted drug delivery and nanomedicine. The current study provides a comprehensive review of the various nanotechnology approaches to design synthetic blood cells, along with a critical discussion of successes and challenges of the current state-of-art in this field. WIREs Nanomed Nanobiotechnol 2017, 9:e1464. doi: 10.1002/wnan.1464 For further resources related to this article, please visit the WIREs website.

Platelet Transfusion Thresholds Among Children Admitted to a Pediatric Intensive Care Unit

Objective To evaluate the threshold for platelet transfusion in children admitted to a pediatric intensive care unit (PICU). This is a retrospective chart review study, conducted at our tertiary level PICU and is related to critically ill pediatric patients who required platelet transfusion. Methods We retrieved the target patient population data from our blood bank database. The patients were subdivided into four subgroups: hematologic (hematologic malignancies, bone marrow suppression, hemolytic anemia, and sickle cell disease), surgical (post-surgical, trauma and acute bleeding), the unstable fraction of inspired oxygen (FiO₂ > 0.6 and/or inotropic support), and the stable patients. Critically ill children between one month and 21 years of age were enrolled. We excluded patients who underwent extracorporeal membrane oxygenation (ECMO). Results A total of 197 transfusion episodes in 64 patients were analyzed. The distribution of transfusions episodes included hematologic 82% (n=161), surgical 7% (n=13), unstable 8% (n=16), stable 3% (n=7). The mean standard deviation (SD) of pre-transfusion platelet count (x1000) in all the patients and children in hematologic, surgical, unstable and stable groups were 29 (22), 29 (19), 47 (46), 28 (19), and 24 (14), respectively. The platelet count threshold for transfusion among the surgical group was higher compared to hematologic and unstable groups (p <0.001; analysis of variance (ANOVA) with multiple comparison tests). The mean platelet count during all episodes increased from 29 (22) to 71 (57) (p <0.05; paired t-test). The post-transfusion increase in platelet count was significantly higher among surgical and unstable patients compared to hematologic patients (p <0.001; ANOVA with multiple comparison tests). Conclusion The most common indication for platelet transfusion in the pediatric intensive care unit (PICU) is the underlying hematologic condition. The platelet count threshold for transfusion varied with the clinical condition and is higher among the surgical patients. The rise of platelet count after transfusion was higher among the surgical and unstable patients.

Prophylactic plasma transfusion for patients undergoing non-cardiac surgery

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To determine the clinical effectiveness and safety of prophylactic plasma transfusion for people with confirmed or presumed coagulopathy requiring non-cardiac surgery.

Investigation of the status quo of massive blood transfusion in China and a synopsis of the proposed guidelines for massive blood transfusion

The aim of this study was to provide an overview of massive transfusion in Chinese hospitals, identify the important indications for massive transfusion and corrective therapies based on clinical evidence and supporting experimental studies, and propose guidelines for the management of massive transfusion. This multiregion, multicenter retrospective study involved a Massive Blood Transfusion Coordination Group composed of 50 clinical experts specializing in blood transfusion, cardiac surgery, anesthesiology, obstetrics, general surgery, and medical statistics from 20 tertiary general hospitals across 5 regions in China. Data were collected for all patients who received ≥10 U red blood cell transfusion within 24 hours in the participating hospitals from January 1 2009 to December 31 2010, including patient demographics, pre-, peri-, and post-operative clinical characteristics, laboratory test results before, during, and after transfusion, and patient mortality at post-transfusion and discharge. We also designed an in vitro hemodilution model to investigate the changes of blood coagulation indices during massive transfusion and the correction of coagulopathy through supplement blood components under different hemodilutions. The experimental data in combination with the clinical evidence were used to determine the optimal proportion and timing for blood component supplementation during massive transfusion. Based on the findings from the present study, together with an extensive review of domestic and international transfusion-related literature and consensus feedback from the 50 experts, we drafted the guidelines on massive blood transfusion that will help Chinese hospitals to develop standardized protocols for massive blood transfusion.

Quality Assessment of Established and Emerging Blood Components for Transfusion

Blood is donated either as whole blood, with subsequent component processing, or through the use of apheresis devices that extract one or more components and return the rest of the donation to the donor. Blood component therapy supplanted whole blood transfusion in industrialized countries in the middle of the twentieth century and remains the standard of care for the majority of patients receiving a transfusion. Traditionally, blood has been processed into three main blood products: red blood cell concentrates; platelet concentrates; and transfusable plasma. Ensuring that these products are of high quality and that they deliver their intended benefits to patients throughout their shelf-life is a complex task. Further complexity has been added with the development of products stored under nonstandard conditions or subjected to additional manufacturing steps (e.g., cryopreserved platelets, irradiated red cells, and lyophilized plasma). Here we review established and emerging methodologies for assessing blood product quality and address controversies and uncertainties in this thriving and active field of investigation.

Making the Switch: Alternatives to Fetal Bovine Serum for Adipose-Derived Stromal Cell Expansion

Adipose-derived stromal cells (ASCs) are being used extensively in clinical trials. These trials require that ASCs are prepared using good manufacturing practices (GMPs) and are safe for use in humans. The majority of clinical trials in which ASCs are expanded make use of fetal bovine serum (FBS). While FBS is used traditionally in the research setting for in vitro expansion, it does carry the risk of xenoimmunization and zoonotic transmission when used for expanding cells destined for therapeutic purposes. In order to ensure a GMP quality product for cellular therapy, in vitro expansion of ASCs has been undertaken using xeno-free (XF), chemically-defined, and human blood-derived alternatives. These investigations usually include the criteria proposed by the International Society of Cellular Therapy (ISCT) and International Fat Applied Technology Society (IFATS). The majority of studies use these criteria to compare plastic-adherence, morphology, the immunophenotype and the trilineage differentiation of ASCs under the different medium supplemented conditions. Based on these studies, all of the alternatives to FBS seem to be suitable replacements; however, each has its own advantages and drawbacks. Very few studies have investigated the effects of the supplements on the immunomodulation of ASCs; the transcriptome, proteome and secretome; and the ultimate effects in appropriate animal models. The selection of medium supplementation will depend on the downstream application of the ASCs and their efficacy and safety in preclinical studies.

How we treat bleeding associated with direct oral anticoagulants

Direct oral anticoagulants are at least as effective as vitamin K antagonists for the prevention and treatment of thromboembolism. Unfortunately, differently from vitamin K antagonists, they have the great drawback of lacking specific antidotes in the case of bleeding or emergency situations such as trauma, stroke requiring thrombolysis, and urgent surgery. The progressive development of antidotes for these new drugs, which, it is hoped, will become available in the near future, will allow better and safer management of the rapid reversal of their anticoagulant effect.

Comparison of a therapeutic-only versus prophylactic platelet transfusion policy for people with congenital or acquired bone marrow failure disorders

This is the protocol for a review and there is no abstract. The objectives are as follows: To compare a therapeutic-only versus prophylactic platelet transfusion policy for people with myelodysplasia, inherited or acquired aplastic anaemia, and other congenital bone marrow failure disorders.

Health Technology Assessment of pathogen reduction technologies applied to plasma for clinical use

Although existing clinical evidence shows that the transfusion of blood components is becoming increasingly safe, the risk of transmission of known and unknown pathogens, new pathogens or re-emerging pathogens still persists. Pathogen reduction technologies may offer a new approach to increase blood safety. The study is the output of collaboration between the Italian National Blood Centre and the Post-Graduate School of Health Economics and Management, Catholic University of the Sacred Heart, Rome, Italy. A large, multidisciplinary team was created and divided into six groups, each of which addressed one or more HTA domains.Plasma treated with amotosalen + UV light, riboflavin + UV light, methylene blue or a solvent/detergent process was compared to fresh-frozen plasma with regards to current use, technical features, effectiveness, safety, economic and organisational impact, and ethical, social and legal implications. The available evidence is not sufficient to state which of the techniques compared is superior in terms of efficacy, safety and cost-effectiveness. Evidence on efficacy is only available for the solvent/detergent method, which proved to be non-inferior to untreated fresh-frozen plasma in the treatment of a wide range of congenital and acquired bleeding disorders. With regards to safety, the solvent/detergent technique apparently has the most favourable risk-benefit profile. Further research is needed to provide a comprehensive overview of the cost-effectiveness profile of the different pathogen-reduction techniques. The wide heterogeneity of results and the lack of comparative evidence are reasons why more comparative studies need to be performed.

Italian daily platelet transfusion practice for haematological patients undergoing high dose chemotherapy with or without stem cell transplantation: a survey by the GIMEMA Haemostasis and Thrombosis Working Party

BACKGROUND

Following high-dose chemotherapy/bone marrow transplantation, patients are routinely, prophylactically transfused with platelet concentrates (PC) if they have a platelet count ≤10×10⁹/L or higher in the presence of risk factors for bleeding. However, whether such transfusions are necessary in clinically stable patients with no bleeding, or whether a therapeutic transfusion strategy could be sufficient and safe, is still debated.

MATERIALS AND METHODS

The GIMEMA Haemostasis and Thrombosis Working Party sent a questionnaire to Italian haematology departments to survey several aspects of daily platelet transfusion practice, such as the cut-off platelet count for transfusion, the evaluation of refractoriness and the type of PC administered.

RESULTS

The questionnaire was answered by 18 out of 31 centres (58%). A total of 23,162 PC were transfused in 2,396 patients in 2013. The vast majority of centres (95%) transfused PC according to Italian and international guidelines; only a few transfused always at platelet counts ≤20×10⁹/L. The broad agreement on platelet count cut-off for transfusion (≤10×10⁹/L) was not confirmed when the World Health Organization (WHO) bleeding score was considered: only a third of centres (33%) used transfusions as recommended when the bleeding grade was ≥2. Platelet refractoriness was poorly monitored and most centres (89%) evaluated, mostly empirically (67%), response to transfusion only 24 hours later. Thirty percent of centres transfused platelets in asymptomatic refractory patients.

DISCUSSION

Although most Italian haematology departments transfuse PC according to Italian and international guidelines, our survey shows that in routine daily practice physicians do not comply closely with the WHO recommendations on platelet transfusions and monitoring platelet refractoriness. This causes excessive platelet transfusions, with a resulting increase of costs and waste of public health resources.

Is solvent/detergent plasma better than standard fresh-frozen plasma? A systematic review and an expert consensus document

BACKGROUND

Only a few studies have compared solvent/detergent plasma (SD-plasma) to standard fresh-frozen plasma (FFP) in terms of efficacy and safety.

MATERIALS AND METHODS

A systematic review was performed in order to develop a consensus document on the use of SD-plasma. Moreover, a pharmacoeconomic study was performed in order to assess whether the use of SD-plasma can be cost-effective with respect to the use of FFP. A multidisciplinary panel used the systematic review and the GRADE methodology to develop evidence-based recommendations on this topic.

RESULTS

Based on moderate to very low quality evidence, the panel developed the following consensus statements: (i) the panel suggested that SD-plasma is safer than FFP; (ii) the panel could not express for or against a greater efficacy of SD-plasma as compared to FFP; (iii) the panel suggested that in patients undergoing liver transplantation SD-plasma can be preferred over FFP; (iv) the panel suggested that SD-plasma can be preferred over FFP in patients with thrombotic thrombocytopenic purpura undergoing plasma-exchange procedures; (v) the panel could not recommend for or against preferring SD-plasma over FFP in critical care patients; and (vi) the panel suggested that the use of SD-plasma can be cost-effective with respect to the use of FFP.

DISCUSSION

Data from additional randomised studies are needed to establish more definitive guidelines on the use of SD-plasma.

Plasma for fractionation in a public setting: cost analysis from the perspective of the third-party payer

BACKGROUND

In Italy, within the legal mandate to pursue national self-sufficiency of plasma-derived medical products, the Regions are starting to organise trade to offset imbalances between need and availability. It is, therefore, necessary to determine the full cost to the Regions of plasma collection and handling. Here we report an analysis of plasma production costs in the Department of Transfusion Medicine of Verona Province, Veneto Region.

MATERIALS AND METHODS

Plasma is obtained from voluntary, non-remunerated donors from either whole blood or apheresis donation, and in Verona it is collected, validated and distributed only in Regional Health Service facilities, and then delivered to industry for processing. The amounts and costs of materials and activities needed to collect, produce, validate and distribute plasma were obtained from the Department of Transfusion Medicine. Attributable overhead expenses were assumed at 15% of direct costs. When plasma was collected as part of whole blood or from multi-component apheresis, joint costs (the costs of the common manufacturing process before the separation) were allocated to the plasma based on the tariff for single components, taken as proxy of the willingness to pay for them. In an alternative scenario plasma recovered from whole blood donations was considered a by-product.

RESULTS

The estimated full cost of each valid unit of plasma derived from whole blood, multi-component apheresis, and plasma-apheresis was about € 30, € 73 and € 170, respectively. The estimated total cost per litre of plasma was € 113 for collection from whole blood and € 276 for collection from apheresis. When plasma recovered from whole blood donations was considered a by-product, its cost per litre was estimated to be € 26.

DISCUSSION

Our results suggest that the Italian donor-based system, in addition to its ethical and social values, can supply plasma at an affordable cost, comparable (albeit slightly higher) with costs in other recent analyses.

Coagulation defects associated with massive blood transfusion: A large multicenter study

The variations in the coagulation indices of patients receiving massive blood transfusion were investigated across 20 large-scale general hospitals in China. The data of 1,601 surgical inpatients receiving massive transfusion were retrospectively collected and the trends in the platelet counts and coagulation indices prior to and at 16 different time points during packed red blood cell (pRBC; after 2–40 units of pRBC) transfusion were evaluated by linear regression analysis. Temporal variations in the means of prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (APTT) and fibrinogen (FIB) concentration were also assessed and the theoretical estimates and actual measurements of the platelet count were compared. The results demonstrated that the platelet count decreased linearly with an increase in the number of pRBC units transfused (Y=150.460−3.041X; R² linear=0.775). Following transfusion of 18 units of pRBC (0.3 units of pRBC transfused per kilogram of body weight), the average platelet count decreased to 71×10⁹/l (<75×10⁹/l). Furthermore, variations in the means of PT, INR, APTT and FIB did not demonstrate any pronounced trends and actual platelet counts were markedly higher than the theoretical estimates. In conclusion, no variations in the means of traditional coagulation indices were identified, however, the platelet count demonstrated a significant linear decrease with an increase in the number of pRBC units transfused. Furthermore, actual platelet counts were higher than theoretical estimates, indicating the requirement for close monitoring of actual platelet counts during massive pRBC transfusion.

Investigation of the current situation of massive blood transfusion in different surgical departments: a large multicenter study in China

OBJECTIVE

This study aims to learn about the current situation of surgical massive blood transfusion of different surgical departments in China's Tertiary hospitals, which could provide the basis for the formulation of guidelines on massive blood transfusion.

METHOD

A multicenter retrospective research on the application status of blood constituents during massive blood transfusion was conducted and a comparative analyses of survival and length of hospitalization in patients from different departments (trauma, cardiac surgery, obstetric conditions, or other common surgeries), were performed.

RESULT

In China, during massive blood transfusion the ratio of the dosage of fresh frozen plasma to the dosage of red blood cell suspension reached 1:1-2, while the dosage of platelet and cryoprecipitate appeared to be very small. The risk of in-hospital death were associated with the primary disease in patients receiving massive blood transfusion (Log-Rank P = 0.000), cardiac surgery and trauma patients who received massive blood transfusion have a higher risk of death rate.

CONCLUSIONS

Patients undergoing massive blood transfusion among different surgical departments have a certain difference in use of blood transfusion, mortality rate and the time of death. Our findings suggested that we should set up an independent transfusion program in cardiac surgery and trauma patients of massive blood transfusion.

Tracheostomy in intensive care unit patients can be performed without bleeding complications in case of normal thromboelastometry results (EXTEM CT) despite increased PT-INR: a prospective pilot study

Background

Coagulopathy is often accompanied by prolongation of prothrombin time (PT) in septic and nonseptic patients in intensive care unit (ICU). The conventional way to correct the coagulopathy is to administer fresh frozen plasma (FFP) before invasive procedures to minimise the risk of bleeding. However, prolonged PT can be present even in hypercoagulation status, resulting in unnecessary administration of FFP. In the present study, we have assessed the reliability of thromboelastometry in case of prolonged PT and the relationship to bleeding complications during surgical tracheostomy.

Methods

The study was conducted during the period between April 2013 and April 2014 in patients undergoing surgical tracheostomy. Coagulation status was assessed using PT, and the status was reassessed by thromboelastometry for prolonged PT. Tracheostomy was performed in patients with normal thromboelastometry results without administering FFP.

Results

Tracheostomy was performed in total 119 patients. Normal value of PT as measured by international normalized ratio (INR) ≤ 1.2 was found in 64 (54 %) patients, while prolonged INR > 1.2 was found in 55 (46 %) patients. Patients with INR ≥ 1.3 (with INR min- 1.3, max- 1.84, and median- 1.48) were further analysed by thromboelastometry. Despite prolonged INR, thromboelastometry results were in normal ranges in all cases except one. With normal thromboelastometry, tracheostomy was performed safely without any bleeding complication.

Conclusions

Surgical tracheostomy in septic and nonseptic patients can be performed without bleeding complications in case of normal thromboelastometry results (EXTEM CT) despite increased PT-INR. This method can help physicians to reduce unnecessary administration of FFP in patients.

Namibia's transition from whole blood-derived pooled platelets to single-donor apheresis platelet collections

BACKGROUND

Few African countries separate blood donations into components; however, demand for platelets (PLTs) is increasing as regional capacity to treat causes of thrombocytopenia, including chemotherapy, increases. Namibia introduced single-donor apheresis PLT collections in 2007 to increase PLT availability while reducing exposure to multiple donors via pooling. This study describes the impact this transition had on PLT availability and safety in Namibia.

STUDY DESIGN AND METHODS

Annual national blood collections and PLT units issued data were extracted from a database maintained by the Blood Transfusion Service of Namibia (NAMBTS). Production costs and unit prices were analyzed.

RESULTS

In 2006, NAMBTS issued 771 single and pooled PLT doses from 3054 whole blood (WB) donations (drawn from 18,422 WB donations). In 2007, NAMBTS issued 486 single and pooled PLT doses from 1477 WB donations (drawn from 18,309 WB donations) and 131 single-donor PLT doses. By 2011, NAMBTS issued 837 single-donor PLT doses per year, 99.1% of all PLT units. Of 5761 WB donations from which PLTs were made in 2006 to 2011, a total of 20 (0.35%) were from donors with confirmed test results for human immunodeficiency virus or other transfusion-transmissible infections (TTIs). Of 2315 single-donor apheresis donations between 2007 and 2011, none of the 663 donors had a confirmed positive result for any pathogen. As apheresis replaced WB-derived PLTs, apheresis production costs dropped by a mean of 8.2% per year, while pooled PLT costs increased by an annual mean of 21.5%. Unit prices paid for apheresis- and WB-derived PLTs increased by 9 and 7.4% per year on average, respectively.

CONCLUSION

Namibia's PLT transition shows that collections from repeat apheresis donors can reduce TTI risk and production costs.

Perioperative neonatal and paediatric blood transfusion

Paediatric patients undergoing surgical procedures commonly require some volume of blood or blood component replacement in the perioperative period. Paediatric patients undergoing major surgery associated with substantial blood loss should be evaluated pre-operatively. Pre-operative correction of anaemia may be done considering the age, plasma volume status, clinical status and comorbidities. Maximum allowable blood loss (MABL) for surgery must be calculated, and appropriate quantity of blood and blood components should be arranged. Intraoperative monitoring of blood loss should be done, and volume of transfusion should be calculated in a protocol based manner considering the volemia and the trigger threshold for transfusion for the patient and the MABL. Early haemostasis should be achieved by judicious administration of red blood cells, blood components and pharmacological agents.

Cochlear implantation is safe and effective in patients with MYH9-related disease

BACKGROUND

MYH9-related disease (MYH9-RD) is a rare syndromic disorder deriving from mutations in MYH9, the gene for the heavy chain of non-muscle myosin IIA. Patients present with congenital thrombocytopenia and giant platelets and have a variable risk of developing sensorineural deafness, kidney damage, presenile cataract, and liver abnormalities. Almost all MYH9-RD patients develop the hearing defect, which, in many individuals, progresses to severe to profound deafness with high impact on quality of life. These patients are potential candidates for cochlear implantation (CI), however, no consistent data are available about the risk to benefit ratio of CI in MYH9-RD. The only reported patient who received CI experienced perisurgery complications that have been attributed to concurrent platelet defects and/or MYH9 protein dysfunction.

METHODS

By international co-operative study, we report the clinical outcome of 10 patients with MYH9-RD and severe to profound deafness who received a CI at 8 institutions.

RESULTS

Nine patients benefited from CI: in particular, eight of them obtained excellent performances with restoration of a practically normal hearing function and verbal communication abilities. One patient had a slightly worse performance that could be explained by the very long duration of severe deafness before CI. Finally, one patient did not significantly benefit from CI. No adverse events attributable to MYH9-RD syndrome were observed, in particular no perisurgery bleeding complications due to the platelet defects were seen. Patients' perioperative management is described and discussed.

CONCLUSIONS

CI is safe and effective in most patients with MYH9-RD and severe to profound deafness and should be offered to these subjects, possibly as soon as they develop the criteria for candidacy.

The challenge in management of hemorrhagic shock in trauma

Transfusion and resuscitation practices in trauma have undergone a sea change over the past decade. New understanding of transfusion physiology and experiences in military trauma over the last decade has identified key factors taken as challenges in trauma. The most important challenge remains acute traumatic coagulopathy (ATC) which sets in early after a trauma and spirals the patient into shock and continued bleeding. World wide trauma is the leading cause of mortality. More than 6 million deaths occur due to trauma out of which 20% are due to uncontrollable bleeding. Out of the hospital admissions in trauma 20% develop coagulopathy. Mortality is three to four times higher in a patient with coagulopathy and thus prevention and correction of coagulopathy is the central goal of the management of hemorrhagic shock in trauma. Damage control resuscitation (DCR), a strategy combining the techniques of permissive hypotension, hemostatic resuscitation and damage control surgery has been widely adopted as the preferred method of resuscitation in patients with haemorrhagic shock. The over-riding goals of DCR are to mitigate metabolic acidosis, hypothermia and coagulopathy, This article looks at the importance of acute traumatic coagulopathy, its etiology, diagnosis, effects and resuscitation strategies to prevent it and to see the background behind this shift.

Point of care perioperative coagulation management in liver transplantation and complete portal vein thrombosis

Liver transplantation (LT) is a serious hemostatic challenge in patients with portal vein thrombosis (PVT). Advances in monitoring systems have improved surgery in this setting. We report the successful application of a point-of-care (POC) rotational viscoelastic thromboelastometry-guided (TEM) testing system (ROTEM) which allowed management of coagulation during LT in a 64-year-old cirrhotic patient with a model for end-stage liver disease (MELD) score of 16. Perioperatively, the patient showed complete PVT, hepatomegaly, splenomegaly, recanalization of the umbilical vein, and portosystemic shunt. Macroscopic liver and spleen adherences with collateral circulation were evident. Coagulation factors and fibrinolysis were assessed preoperatively and at graft reperfusion to evaluate the need of hemostatic therapy. Based on ROTEM findings, the patient received 16 g of human fibrinogen concentrate, half preoperatively (with prothrombin complex concentrate 2000 IU, tranexamic acid 1 g, and platelets 2 IU), and two doses of 4 g before and after graft reperfusion; we achieved normalization of all monitored parameters. No ischemia-reperfusion syndrome was present. Postoperatively portal vein flux at Color-Doppler ultrasonography was normal. After a 3-day ICU stay, the patient was moved to the Department of Surgery and discharged on day 14. The postoperative course was uneventful and did not require any further haemostatic therapy.

Severe sepsis and septic shock: management and performance improvement

Morbidity and mortality from sepsis remains unacceptably high. Large variability in clinical practice, plus the increasing awareness that certain processes of care associated with improved critical care outcomes, has led to the development of clinical practice guidelines in a variety of areas related to infection and sepsis. The Surviving Sepsis Guidelines for Management of Severe Sepsis and Septic Shock were first published in 2004, revised in 2008, and recently revised again and published in 2013. The first part of this manuscript is a summary of the 2013 guidelines with some editorial comment. The second part of the manuscript characterizes hospital based sepsis performance improvement programs and highlights the sepsis bundles from the Surviving Sepsis Campaign as a key component of such a program.

Plasma in the PICU: why and when should we transfuse?

Whereas red blood cell transfusions have been used since the 19th century, plasma has only been available since 1941. It was originally mainly used as volume replacement, mostly during World War II and the Korean War. Over the years, its indication has shifted to correct coagulation factors deficiencies or to prevent bleeding. Currently, it remains a frequent treatment in the intensive care unit, both for critically ill adults and children. However, observational studies have shown that plasma transfusion fail to correct mildly abnormal coagulation tests. Furthermore, recent epidemiological studies have shown that plasma transfusions are associated with an increased morbidity and mortality in critically ill patients. Therefore, plasma, as any other treatment, has to be used when the benefits outweigh the risks. Based on observational data, most experts suggest limiting its use either to massively bleeding patients or bleeding patients who have documented abnormal coagulation tests, and refraining for transfusing plasma to nonbleeding patients whatever their coagulation tests. In this paper, we will review current evidence on plasma transfusions and discuss its indications.

Approach to a child with bleeding in the emergency room

A bleeding child is a cause of great concern and often, panic, for parents and pediatricians alike. Causes of bleeding could be trivial or secondary to an underlying bleeding disorder or a potentially serious systemic illness. Based on etiology, they can be categorized into disorders affecting platelets or the coagulation cascade and can be inherited or acquired. A systematic approach with relevant clinical history and examination along with appropriate laboratory investigations aid in reaching the diagnosis promptly. Indication and administration of blood products including fresh frozen plasma, cryoprecipitate, random donor and single donor apheresis platelets is elaborated. Management of hemophilia, Von Willebrand disease, disseminated intravascular coagulation and bleeding in cyanotic congenital heart disease, among other causes is outlined. Role of antifibrinolytic therapy, desmopressin and recombinant factor VIIa is briefly described. The review outlines the approach to a bleeding child in the emergency room. Practical points in history, examination, investigations and management are discussed. Management in resource constraint setting of developing countries is addressed.