The Effect of Albumin Administration in Critically Ill Patients: A Retrospective Single-Center Analysis

OBJECTIVES

The aim of this study was to analyze the development of albumin administration in patients admitted to the adult ICU. In addition, we assessed the impact of albumin administration on serum hemoglobin concentration.

DESIGN

We conducted a retrospective single-center study including all patients who were admitted to the ICU from January 2013 to December 2021 and stayed at least 24 hours.

SETTING

The study was conducted in an academic hospital (University Hospital Basel, Switzerland).

PATIENTS

A total of 20,927 admissions were included, of which 3748 received albumin at least once during their ICU stay. To analyze volume expansion, 2006 admissions met the inclusion criteria, namely at least two hemoglobin measurements within 12 hours, one albumin delivery, and experienced no bleeding, dialysis, or transfusions during this period.

INTERVENTIONS

None.

MEASUREMENTS

We examined the hemoglobin levels before and after albumin administration and compared them with a matched control group to assess the amount and duration of volume expansion.

MAIN RESULTS

From 2013 to 2021 the proportion of critically ill patients treated with albumin rose from 5.0% to 32.5%. An overproportioned increase in albumin use could be seen in surgical patients (4.7-47.2%) and in those receiving RBC transfusion (13.7-72.6%). In those patients receiving albumin, a significant drop in hemoglobin of around 5 g/L on average could be observed following treatment with albumin.

CONCLUSION

Hemodilution was observable for at least 12 hours after albumin administration and may have caused a decrease in hemoglobin concentration of greater than 8 g/L when isooncotic albumin solution (5%, 25 g in 500 mL) was administered. This makes albumin, especially in its isooncotic form, an ideal colloid to achieve long-lasting volume expansion. However, RBC transfusions may increase under albumin therapy, as transfusion thresholds may be undershot after albumin administration.

Modified one-step conservative uterine surgery (MOSCUS) versus cesarean hysterectomy in the management of placenta accreta spectrum: A single-center retrospective analysis based on 619 Vietnamese pregnant women

OBJECTIVES

To compare maternal outcome measures in surgical management of placenta accreta spectrum (PAS)-the modified one-step conservative uterine surgery (MOSCUS), a new approach at Tu Du Hospital in Vietnam, versus cesarean hysterectomy, and to identify factors that appear to contribute to the successful outcome of the MOSCUS.

METHODS

This retrospective study was conducted at Tu Du Hospital in southern Vietnam between January 2019 and December 2020. The study enrolled all pregnant women at more than 28 weeks of pregnancy with a diagnosis of PAS who underwent either a cesarean hysterectomy or a uterus-preserving approach using the MOSCUS method.

RESULTS

The prevalence of PAS at our single tertiary referral hospital was 0.4% (619 PAS cases/132 518 births) in 2 years. Among 296 patients, the surgical time duration, estimated blood loss, and red blood cell transfusion in the MOSCUS group (n = 217) were all significantly less than in the cesarean hysterectomy group (n = 79) (152.72 ± 42.23 vs 185.13 ± 58.22 min, 1000 vs 1500 mL, and 500 vs 710 mL, respectively). Intraoperatively, the rate of visceral injuries in the hysterectomy group was higher than that in the MOSCUS group (P < 0.001). However, the rate of postoperative infection was higher in the MOSCUS group than in the cesarean hysterectomy group (P = 0.012). Of a total of 217 cases managed using the MOSCUS management, 24 required a secondary hysterectomy; the success rate was 88.9% (95% confidence interval [CI] 84.3%-93.1%). Some of the primary factors associated with the success of MOSCUS included maternal age less than 35 years, planned surgery, severity of PAS, and estimated blood loss during surgery (odds ratio [OR] 5.16, 95% CI 1.96-13.59; OR 3.05, 95% CI 1.08-8.62; OR 3.62, 95% CI 1.19-10.98; and OR 49.66, 95% CI 11.16-221.02, respectively; P < 0.05).

CONCLUSION

MOSCUS is an acceptable alternative to cesarean hysterectomy in many patients diagnosed with PAS. This new surgical management of PAS resulted in the preservation of the uterus, and a favorable outcome in nearly 9 out of 10 pregnant women. We believe that MOSCUS can be safely offered for the management of PAS in referral hospital settings.

Postoperative long‑term outcomes of acute normovolemic hemodilution in pancreatic cancer: A propensity score matching analysis

Acute normovolemic hemodilution (ANH) is a useful intraoperative blood conservation technique. However, the impact on long-term outcomes in pancreatic ductal adenocarcinoma (PDAC) remains unclear. The present study investigated the impact of ANH on long-term outcomes in patients with PDAC undergoing radical surgery. Data from 155 resectable PDAC cases were collected. Patients were categorized according to whether or not they had received intraoperative allogeneic blood transfusion (ABT) or ANH. Postoperative complications, recurrence-free survival (RFS) and disease-specific survival (DSS), before and after propensity score matching (PSM), were compared among patients who did and did not receive ANH. A total of 44 patients (28.4%) were included in the ANH group and 30 patients (19.4%) were included in the ABT group; 81 (52.3%) patients, comprising the standard management (STD) group, received neither ANH nor ABT. The ABT group had the worst prognosis among them. Before PSM, ANH was significantly associated with decreased RFS (P=0.043) and DSS (P=0.029) compared with the STD group before applying Bonferroni correction; however, no significant difference was observed after applying Bonferroni correction. Cox regression analysis identified ANH as an independent prognostic factor for RFS [relative risk (RR), 1.696; P=0.019] and DSS (RR, 1.876; P=0.009). After PSM, the ANH group exhibited less favorable RFS [median survival time (MST), 12.1 vs. 18.1 months; P=0.097] and DSS (MST, 32.1 vs. 50.5 months; P=0.097) compared with the STD group; however, these differences were not statistically significant. In conclusion, while ANH was not as harmful as ABT, it exhibited potentially more negative effects on long-term postoperative outcomes in PDAC than STD.

Absence of evidence of transfusion transmission risk of Creutzfeldt-Jakob disease in the United States: Results froma 28-year lookback study

BACKGROUND

For many years, there has been concern about the risk of transmission of classic forms of Creutzfeldt-Jakob disease (CJD) by blood transfusion, particularly after the recognition of such transmission of variant CJD (vCJD). We report on a 28-year lookback study of recipients of blood from donors who subsequently developed CJD.

METHODS

Patients with diagnosed CJD and a history of blood donation were identified. Blood centers were asked to provide information about the distribution of the donations and consignees were requested to provide information about the recipients of the donations. Vital status of each available recipient was determined and, if deceased, the reported cause(s) of death were obtained primarily from the National Death Index. All recipients included in the study database contributed person-time up to the last recorded review of vital status.

RESULTS

There were 84 eligible donors who gave 3284 transfusable components, and it was possible to evaluate 1245 recipients, totaling 6495 person-years of observation. The mean observation period per recipient was 5.5 years with a maximum of 51 years. No case of CJD or prion disease was reported among the recipient population.

DISCUSSION

The study suggests that CJD may not be transfusion-transmissible, a position in agreement with similar findings from two similar European reports amounting to an overall observation period of 15,500 person-years. These studies have supported the conclusion that the risk, if any, of transmission of CJD by blood products is extremely small and remains theoretical.

Surgical patients' perception about risks related to blood transfusion: A cross-sectional survey

OBJECTIVE

To determine the perception of surgical patients at Aga Khan University Hospital (AKUH) about the risks related to blood transfusion. The ultimate aim was to influence patients' acceptability of blood transfusion by reducing their fears through effective counselling.

BACKGROUND

AKUH has a hospital-based blood bank with more than 90% family replacement donation. Many patients perceive blood transfusion as a risky procedure. This survey will help healthcare practitioners in addressing patients' concerns more effectively while counselling them about blood transfusion.

METHODS/MATERIALS

It was a cross-sectional survey of patients attending anaesthesia clinic at AKUH during the study period. It assessed patients' perception about adverse effects associated with blood transfusion.

RESULTS

A total of 363 patients were included. Among the participants, 18% considered blood transfusion to be very often or always risky. Blood transfusion related infections were considered most frequently occurring adverse events. Female patients were more concerned about the risks (p = 0.046).

CONCLUSION

Many patients consider blood transfusion as a high-risk procedure. Healthcare professionals need to understand patient's perceptions and conduct patient counselling accordingly. This will help physicians in addressing patient-specific concerns related to blood transfusion. Improved knowledge is hoped to translate into improvement in transfusion practices at the national level.

Perioperative Transfusion and Mortality for Cardiovascular Surgery: A Cohort Study Based on Population in Republic of Korea

Objective:This study aimed to evaluate the rate of transfusion for cardiovascular surgeries between 2010 and 2019 in Republic of Korea and the association between blood transfusion and postoperative mortality. Methods: Data were extracted from the National Health Insurance Service database in Republic of Korea. This study includes adult patients who underwent cardiovascular surgery between 1 January 2010 and 31 December 2019. The endpoints were in-hospital mortality and the 1-year all-cause mortality. Results: The analysis included 62,794 cases, with transfusions used in 88.8% of cases. Multivariable logistic regression revealed that older age, comorbidities, hospital admission through the emergency room, aortic procedures (versus coronary artery bypass grafting), cardiopulmonary bypass, repeat procedures, and supportive therapies during the intensive care (extracorporeal membrane oxygenation and mechanical ventilation) were risk factors for blood transfusion. Female sex was associated with a lower risk of transfusion. Perioperative blood transfusion was associated with a 6.87-fold increased risk of in-hospital mortality (odds ratio [OR]: 6.87, 95% confidence interval [CI]: 3.95, 11.93; p < 0.001) and a 3.20-fold increased risk of 1-year all-cause mortality (OR: 3.35, 95% CI: 2.75, 3.93; p < 0.001). Conclusions: Blood transfusion is used at a high rate in cardiovascular surgeries, and it was associated with increases in the risk of in-hospital and 1-year all-cause mortality. However, these correlations should be viewed with caution as emergent phenomena rather than causative. Understanding factors associated with the need for blood transfusion can assist surgeons in predicting the outcomes of cardiovascular surgery and in tailoring procedures as needed to optimize outcomes.

Prognostic Role of Initial Thromboelastography in Emergency Department Patients with Primary Postpartum Hemorrhage: Association with Massive Transfusion

BACKGROUND

The early prediction of the need for massive transfusions (MTs) and the preparation of blood products are essential for managing patients with primary postpartum hemorrhage (PPH). Thromboelastography (TEG) enables a thorough evaluation of coagulation status and is useful for guiding the treatment of hemorrhagic events in various diseases. We investigated the role of TEG in predicting the need for MT in patients with primary PPH.

METHODS

A retrospective observational study was conducted in the emergency department (ED) of a university-affiliated, tertiary referral center between November 2015 and August 2023. TEG was performed upon admission. We defined MT as the requirement for transfusion of more than 10 units of packed red blood cells within the first 24 h. The primary outcome was the need for MT.

RESULTS

Among the 184 patients with initial TEG, 34 (18.5%) required MT. Except for lysis after 30 min, the MT and non-MT groups had significantly different TEG values. Based on multivariate analysis, an angle < 60 was an independent predictor of MT (odds ratio (OR) 7.769; 95% confidence interval (CI), 2.736-22.062), along with lactate (OR, 1.674; 95% CI, 1.218-2.300) and shock index > 0.9 (OR, 4.638; 95% CI, 1.784-12.056). Alpha angle < 60 degrees indicated the need for MT with 73.5% sensitivity, 72.0% specificity, and 92.3% negative predictive value.

CONCLUSIONS

Point-of-care testing of TEG has the potential to be a useful tool in accurately predicting the necessity for MT in ED patients with primary PPH at an early stage.

Intraosseous access in the resuscitation of patients with trauma: the good, the bad, the future

The timely restoration of lost blood in hemorrhaging patients with trauma, especially those who are hemodynamically unstable, is of utmost importance. While intravenous access has traditionally been considered the primary method for vascular access, intraosseous (IO) access is gaining popularity as an alternative for patients with unsuccessful attempts. Previous studies have highlighted the higher success rate and easier training process associated with IO access compared with peripheral intravenous (PIV) and central intravenous access. However, the effectiveness of IO access in the early aggressive resuscitation of patients remains unclear. This review article aims to comprehensively discuss various aspects of IO access, including its advantages and disadvantages, and explore the existing literature on the clinical outcomes of patients with trauma undergoing resuscitation with IO versus intravenous access.

Crystalloid resuscitation is associated with decreased treatment delays and improved systolic blood pressures in a blood-constrained setting

Objectives

We analyzed resuscitation practices in Cameroonian patients with trauma as a first step toward developing a context-appropriate resuscitation protocol. We hypothesized that more patients would receive crystalloid-based (CB) resuscitation with a faster time to administration than blood product (BL) resuscitation.

Methods

We included patients enrolled between 2017 and 2019 in the Cameroon Trauma Registry (CTR). Patients presenting with hemorrhagic shock (systolic blood pressure (SBP) <100 mm Hg and active bleeding) were categorized as receiving CB, BL, or no resuscitation (NR). We evaluated differences between cohorts with the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. We compared time to treatment with the Wilcoxon rank sum test.

Results

Of 9635 patients, 403 (4%) presented with hemorrhagic shock. Of these, 278 (69%) patients received CB, 39 (10%) received BL, and 86 (21%) received NR. BL patients presented with greater injury severity (Highest Estimated Abbreviated Injury Scale (HEAIS) 4 BL vs 3 CB vs 1 NR, p<0.001), and lower median hemoglobin (8.0 g/dL BL, 11.4 g/dL CB, 10.6 g/dL NR, p<0.001). CB showed greater initial improvement in SBP (12 mm Hg CB vs 9 mm Hg BL vs 0 NR mm Hg, p=0.04) compared with BL or no resuscitation, respectively. Median time to treatment was lower for CB than BL (12 vs 131 min, p<0.01). Multivariate logistic regression adjusted for injury severity found no association between resuscitation type and mortality (CB adjusted OR (aOR) 1.28, p=0.82; BL aOR 1.05, p=0.97).

Conclusions

CB was associated with faster treatment, greater SBP elevation, and similar survival compared with BL in Cameroonian patients with trauma with hemorrhagic shock. In blood-constrained settings, treatment delays associated with blood product transfusion may offset the physiologic benefits of an early BL strategy. CB prior to definitive hemorrhage control in this resource-limited setting may be a necessary strategy to optimize perfusion pressure.

Level of evidence and study type

III, retrospective study.

Conclusive demonstration of iatrogenic Alzheimer's disease transmission in a model of stem cell transplantation

The risk of iatrogenic disease is often underestimated as a concern in contemporary medical procedures, encompassing tissue and organ transplantation, stem cell therapies, blood transfusions, and the administration of blood-derived products. In this context, despite the prevailing belief that Alzheimer's disease (AD) manifests primarily in familial and sporadic forms, our investigation reveals an unexpected transplantable variant of AD in a preclinical context, potentially indicating iatrogenic transmission in AD patients. Through adoptive transplantation of donor bone marrow stem cells carrying a mutant human amyloid precursor protein (APP) transgene into either APP-deficient knockout or normal recipient animals, we observed rapid development of AD pathological hallmarks. These pathological features were significantly accelerated and emerged within 6-9 months post transplantation and included compromised blood-brain barrier integrity, heightened cerebral vascular neoangiogenesis, elevated brain-associated β-amyloid levels, and cognitive impairment. Furthermore, our findings underscore the contribution of β-amyloid burden originating outside of the central nervous system to AD pathogenesis within the brain. We conclude that stem cell transplantation from donors harboring a pathogenic mutant allele can effectively transfer central nervous system diseases to healthy recipients, mirroring the pathogenesis observed in the donor. Consequently, our observations advocate for genomic sequencing of donor specimens prior to tissue, organ, or stem cell transplantation therapies, as well as blood transfusions and blood-derived product administration, to mitigate the risk of iatrogenic diseases.

Impact of Blood Products Transfusion on Patients in the Immediate Post-Lung Transplant Period: A Cohort Study

BACKGROUND Anemia is common in post-transplant patients. Blood product transfusion is associated with mortality and rejection in solid organ transplants. In lung transplant recipients, transfusion predisposes to primary graft dysfunction (PGD). The adverse effects and associated mortality of perioperative transfusions in lung transplant recipients have not been evaluated. This study examined the effects of perioperative blood transfusions in lung transplant recipients. MATERIAL AND METHODS We conducted a retrospective study of the effects of blood product transfusions in patients who received single- or double-lung transplantation at Houston Methodist Hospital between August 2017 and September 2019. Univariable and multiple logistic regression modeling were used to determine the characteristics associated with single events as well as a composite outcome within 30 days (including mortality, acute myocardial infarction, acute stroke, lower respiratory tract infection, urinary tract infection, surgical site infections, or PGD). RESULTS A total of 232 patients received lung transplants between December 2015 and September 2019 at our center. Univariable analysis revealed an increased risk of PGD (P<0.001), more mechanical ventilation days (P<0.001), more ICU days post-transplant (P<0.001), and greater need for ECMO support (P=0.001) in patients who received blood product transfusions. In univariate analysis, the composite outcome was also more common (P=0.01) in patients who received any transfusion perioperatively. A total of 7 patients died within 30 days from transplant, and they were all in the transfused group. CONCLUSIONS Among lung transplant recipients, PGD, ICU days, need for mechanical ventilation and ECMO support, and total composite events were significantly greater in patients who received blood transfusion perioperatively.

In vitro evaluation of a new viscoelastometry-based point-of-care analyzer

INTRODUCTION

The VCM is a point-of-care analyzer using a new viscoelastometry technique for rapid assessment of hemostasis on fresh whole blood. Its characteristics would make it suitable for use in austere environments. The purpose of this study was to evaluate the VCM in terms of repeatability, reproducibility and interanalyzer correlation, reference values in our population, correlation with standard coagulation assays and platelet count, correlation with the TEG5000 analyzer and resistance to stress conditions mimicking an austere environment.

METHODS

Repeatability, reproducibility, and interanalyzer correlation were performed on quality control samples (n = 10). Reference values were determined from blood donor samples (n = 60). Correlations with standard biological assays were assessed from ICU patients (n = 30) and blood donors (n = 60) samples. Correlation with the TEG5000 was assessed from blood donor samples. Evaluation of vibration resistance was performed on blood donor (n = 5) and quality control (n = 5) samples.

RESULTS

The CVs for repeatability and reproducibility ranged from 0% to 11%. Interanalyzer correlation found correlation coefficients (r2) ranging from 0.927 to 0.997. Our reference values were consistent with those provided by the manufacturer. No robust correlation was found with conventional coagulation tests. The correlation with the TEG5000 was excellent with r2 ranging from 0.75 to 0.92. Resistance to stress conditions was excellent.

CONCLUSION

The VCM analyzer is a reliable, easy-to-use instrument that correlates well with the TEG5000. Despite some logistical constraints, the results suggest that it can be used in austere environments. Further studies are required before its implementation.

A case of transfusion-transmission Anaplasma phagocytophilum from leukoreduced red blood cells

BACKGROUND

Anaplasma phagocytophilum is a tick-borne bacterium and the cause of human granulocytic anaplasmosis (HGA). Here, we report a case of transfusion-transmitted (TT)-HGA involving a leukoreduced (LR) red blood cell (RBC) unit.

CASE REPORT

A 64-year-old woman with gastric adenocarcinoma and multiple myeloma who received weekly blood transfusions developed persistent fevers, hypotension, and shortness of breath 1 week after receiving an RBC transfusion. Persistent fevers, new thrombocytopenia, and transaminitis suggested a tick-borne infection.

RESULTS

The absence of blood parasites on thick and thin blood smears suggested that malaria and Babesia infection were not present, and the recipient tested negative for antibodies to Borrelia burgdorferi. Blood testing by polymerase chain reaction (PCR) for Ehrlichia and Anaplasma species identified A. phagocytophilum. Treatment with doxycycline resolved the infection; however, the recipient expired due to complications of her known malignancies. The recipient lived in a nursing home and did not have pets or spend time outdoors. The donor was a female in her 70s from Maine who was diagnosed with HGA 3 weeks after donating blood and whose LR-RBCs from the donation were transfused to the recipient 9 days following collection.

CONCLUSION

This is a confirmed case of TT-HGA. Although rare, TT-HGA has been reported with LR-RBCs and platelets. In endemic areas, testing for tick-borne associated infections should be considered when investigating post-transfusion complications.

Changes in coagulation factor XIII activity during resuscitation for hemorrhagic shock

Objective

Little is known about the coagulation activity of factor XIII (FXIII) during resuscitation for hemorrhagic shock and the effects of plasma transfusions. We performed a single-center observational study to evaluate the changes in FXIII activity during resuscitation for hemorrhagic shock.

Patient and Methods

Twenty-three adult patients with hemorrhagic shock were enrolled in this study. Blood samples were drawn upon arrival (T1), at the time of hemostasis completion (T2), and on day 2 (T3). Baseline and changes in FXIII activity and the proportion of patients with adequate levels of FXIII activity (FXIII activity >70%) were evaluated. The effects of plasma transfusion on these parameters were also investigated.

Results

At T1, the median (interquartile range) FXIII activity was 53% (47-85%), which did not increase (T1 vs. T3: 53% [47-85%] vs. 63% [52-70%], P=0.8766). The proportion of patients with adequate FXIII activity decreased throughout the resuscitation period (T1, T2, and T3: 30, 34, and 21%, respectively). Plasma transfusion did not affect FXIII activity (T1 vs. T2, 66.4% [23.4] vs. 70.0% [16.2%], P=0.3956; T2 vs. T3, 72.0% [19.5] vs. 63.5% [8.6%], P=0.1161) or the proportion of adequate levels of FXIII activity at 44% at T2 and 27% at T3.

Conclusion

FXIII activity is low during the early phase of a hemorrhagic shock. Even with plasma transfusion, FXIII levels were not adequately maintained throughout resuscitation.

Gender is Independently Associated With Red Blood Cell and Platelet Transfusion in Patients Undergoing Coronary Artery Bypass Grafting: Data From the Netherlands Heart Registration

OBJECTIVES

The aim of this study was to evaluate the incidence of transfusions, including red blood cells (RBC), platelets, and fresh frozen plasma (FFP) during and after coronary artery bypass grafting (CABG) in the Netherlands. Furthermore, the authors aimed to identify the impact of sex on blood product transfusion.

DESIGN

A retrospective multicenter cohort study. Data were collected from January 2013 to December 2021 from the Netherlands Heart Registration (NHR) database.

SETTING

The NHR receives its data from 16 heart centers in the Netherlands.

PARTICIPANTS

Patients older than 18 years who underwent CABG in the Netherlands.

INTERVENTIONS

Coronary artery bypass grafting with extracorporeal circulation or off-pump coronary artery bypass grafting.

MEASUREMENTS AND MAIN RESULTS

The incidence of blood transfusion, defined as transfusions intraoperatively and during the length of the hospital admission after CABG. In addition, a differentiation was made according to the type of transfusion (packed RBC, platelets, and FFP). In the overall cohort (N = 42,388), the number of patients who received a transfusion of any type was 27.0% (n = 11,428). Women received more often RBC transfusions compared with men (45.4% v 15.6%, respectively, p < 0.001). There was a significant difference between the 2 sexes regarding platelet transfusion (women 10.0% v men 11.1%, p = 0.005) but not in FFP transfusion. Female sex was independently associated with RBC transfusion, using the multivariate logistic regression analysis.

CONCLUSIONS

The incidence of any blood transfusion was 27.0%, and was higher in women than in men. The female sex was independently associated with receiving RBC during and after CABG.

Preoperative aspirin and anticoagulants do not affect partial nephrectomy bleeding

INTRODUCTION

Studies have reached mixed conclusions on the role of antiplatelet and anticoagulant agents on postoperative complications of partial nephrectomies. This study examines whether preoperative anticoagulation use affected the risk of hemorrhagic complications after partial nephrectomy.

MATERIALS AND METHODS

This is a retrospective chart review of all partial nephrectomies performed between 2017 and 2022 at a single institution. For each operation, preoperative data was gathered on whether the patient was on anticoagulation, the type and dose of anticoagulation, and how many days the anticoagulation was held preoperatively. Bivariate analyses for continuous measures were performed using Student's t-tests when there were two comparison groups and ANOVA models when there were more than two comparison groups and Chi-Square tests were used for categorical variables, with Fisher's Exact being used when expected cell counts were small.

RESULTS

In this study, warfarin was held for an average of 5.43 days, clopidogrel was held for an average of 6.60 days, aspirin was held for an average of 7.65 days, and direct oral anticoagulants (DOACs) were held for an average of 4.00 days. There was no significant difference in hemoglobin (Hb) change, rate of intraoperative transfusion, postoperative transfusion, bleeding complication, pseudoaneurysm rate, or additional bleeding processes between patients on prior anticoagulation therapy and those not on therapy. There was no significant difference in intraoperative or postoperative outcomes based on history of aspirin use and continuation of aspirin through the surgery. While estimated blood loss appeared statistically significant initially, this difference was accounted for by the covariates of comorbidities, RENAL score, surgical approach, and type of renorrhaphy. Overall, there was no difference in complication rate based solely on aspirin use or continuation of aspirin through surgery.

CONCLUSIONS

No difference in complication rate of partial nephrectomy was determined to be solely due to prior use of anticoagulation or aspirin use alone with appropriate cessation of anticoagulation preoperatively. Overall, patients on anticoagulation are not at a higher risk of intraoperative or postoperative bleeding complications when undergoing partial nephrectomy.

Multimodal blood loss prevention bundle for endoscopic resection of juvenile nasopharyngeal angiofibroma: A case series

Surgery for excision of juvenile nasopharyngeal angiofibroma (JNA) carries the possibility of massive life-threatening haemorrhage. Anaesthetic management aims to maintain haemodynamic stability and reduce blood loss. This case series describes the application of the bundled approach as a multimodal blood loss prevention bundle (MBLPB). Twenty patients underwent 23 surgeries with MBLPB. The blood loss and the number of units of blood transfused were recorded. The surgeon satisfaction score was assessed. The median [interquartile range (IQR)] estimated blood loss was 1300 (650-2350) ml. Patients with tumours in stages I and II had a median (IQR) blood loss of 550 (270-750) ml compared to patients with higher grades of tumours (stages III, IV) with a median (IQR) blood loss of 2100 (1300-2500) ml. Median (IQR) units of packed red cells transfused was 1 (0-3). The surgeon's satisfaction score was high when MBLPB was applied for JNA. However, it does not appear to reduce blood loss markedly.

Past meets present: Reviving 80-year-old Canadian dried serum from World War II and its significance in advancing modern freeze-dried plasma for prehospital management of haemorrhage

During World War II, Charles H. Best utilized Charles R. Drew's plasma isolation and drying technique to lead Canada's initiative to provide dried serum as a means of primary resuscitation for British casualties on the frontlines. Serum was likely utilized over plasma for its volume expansion properties without the risk of clotting during prolonged storage. We reconstituted dried serum from 1943 and discovered intact albumin, as well as anti-thrombin, plasminogen, protein C and protein S activity. Proteomic analysis identified 71 proteins, most prominent being albumin, and positive for hepatitis B by serological testing. Transmission of blood-borne diseases ended the programme, until modern advances in testing and pathogen reduction revived this technology. We tested the latest iteration of Canadian freeze-dried plasma (FDP), which was stored for 4 years, and demonstrated that its clotting capacity remained equivalent to fresh frozen plasma. We recommend that FDP is a strong alternative to contemporary prehospital resuscitation fluids (e.g. normal saline/lactated Ringer's) in managing prehospital haemorrhage where whole blood is unavailable.

Blood Transfusion for Major Trauma in Emergency Department

Severe bleeding is the leading cause of death in patients with major trauma admitted to the emergency department. It is estimated that about 50% of deaths happen within a few minutes of the traumatic event due to massive hemorrhage; 30% of deaths are related to neurological dysfunction and typically happen within two days of trauma; and approximately 20% of patients died of multiorgan failure and sepsis within days to weeks of the traumatic event. Over the past ten years, there has been an increased understanding of the underlying mechanisms and pathophysiology associated with traumatic bleeding leading to improved management measures. Traumatic events cause significant tissue damage, with the potential for severe blood loss and the release of cytokines and hormones. They are responsible for systemic inflammation, activation of fibrinolysis pathways, and consumption of coagulation factors. As the final results of this (more complex in real life) cascade, patients can develop tissue hypoxia, acidosis, hypothermia, and severe coagulopathy, resulting in a rapid deterioration of general conditions with a high risk of mortality. Prompt and appropriate management of massive bleeding and coagulopathy in patients with trauma remains a significant challenge for emergency physicians in their daily clinical practice. Our review aims to explore literature studies providing evidence on the treatment of hemorrhage with blood support in patients with trauma admitted to the Emergency Department with a high risk of death. Advances in blood transfusion protocols, along with improvements in other resuscitation strategies, have become one of the most important issues to face and a key topic of recent clinical research in this field.

Association between Initial Fibrinogen Levels and the Need for Massive Transfusion in Emergency Department Patients with Primary Postpartum Hemorrhage: A Retrospective Study from a Single Center in Korea

BACKGROUND

This study aimed to evaluate the association between initial fibrinogen levels and massive transfusion (MT) in emergency department (ED) patients with primary postpartum hemorrhage (PPH).

METHODS

This retrospective study was conducted in the ED of a university-affiliated, tertiary referral center from January 2004 to August 2023. Patients were divided into two groups: the MT group, which included those who received a transfusion of 10 or more units of packed red blood cells within the first 24 h, and the Non-MT group.

RESULTS

Out of the 364 patients included in the study, 97 (26.6%) required MT. Fibrinogen, shock index, and lactate were independently associated with MT (odds ratio [OR] 0.987; 95% confidence interval [CI] 0.983-0.991; p < 0.001, OR 7.277; 95% CI 1.856-28.535; p = 0.004, and OR 1.261; 95% CI 1.021-1.557; p = 0.031, respectively). The area under the receiver operating characteristic curve for fibrinogen, shock index, and lactate in predicting MT was 0.871 (95% CI 0.832-0.904; p < 0.001), 0.821 (95% CI 0.778-0.859; p < 0.001), and 0.784 (95% CI 0.738-0.825; p < 0.001), respectively. When the cutoff value of fibrinogen was 400 mg/dL, both the sensitivity and negative predictive values for predicting MT were 100.0%. When the cutoff value of fibrinogen was 100 mg/dL, the specificity and positive predictive values were 91.8% and 70.7%, respectively.

CONCLUSION

The initial fibrinogen levels were independently associated with the need for MT in ED patients with primary PPH.

Transcatheter arterial embolization outperforms surgery in reducing blood transfusions for postpartum vulvovaginal hematoma

BACKGROUND

Postpartum vulvovaginal hematoma is a complication of vaginal delivery that may progress to life-threatening conditions. However, the management of hematomas, including conservative therapy, surgery, and arterial embolization, is yet to be standardized.

OBJECTIVE

This study aimed to: (1) evaluate hematoma features that can be treated conservatively, and (2) determine whether surgery or transcatheter arterial embolization is superior in reducing blood transfusion.

STUDY DESIGN

This cross-sectional study included postpartum women transferred to Tohoku University Hospital, Japan, between January 2016 and September 2023 for postpartum vulvovaginal hematomas. Notably, all patients except 1 underwent contrast-enhanced computed tomography. The patients were classified into the following groups: (1) the conservative group who received neither surgery nor transcatheter arterial embolization and (2) the therapeutic intervention group who received surgery or transcatheter arterial embolization. The primary analysis included all patients. Variables for the choice of therapeutic intervention, including the shock index, hemoglobin concentration at arrival, hematoma size, and presence of extravasation, were assessed using a modified Poisson regression model. The secondary analysis included patients who received therapeutic intervention (ie, surgery or transcatheter arterial embolization). Variables for estimating the total amount of blood transfusion, including shock index, hemoglobin concentration at arrival, hematoma size, type of intervention, and presence of extravasation, were analyzed using multiple linear regression.

RESULTS

Fifty-seven cases were included in this study. Patients underwent conservative treatment (n=19), surgery (n=11), or transcatheter arterial embolization (n=27). In primary analysis, only the presence of extravasation was significantly associated with the choice of therapeutic intervention (adjusted risk ratio [95% confidence interval], 5.30 [1.53-18.37]). In the secondary analysis, the choice of surgery as a therapeutic option (unstandardized coefficient [95% confidence interval], 4.64 [1.15-8.13]; reference: transcatheter arterial embolization), lower hemoglobin concentration at arrival (-2.84 [-4.71 to -0.97]; 1 g/dL increment), and larger hematoma size (3.38 [1.23-5.53]; 100 cm3 increments) were significantly associated with increased blood transfusion.

CONCLUSION

When a vulvovaginal hematoma does not exhibit extravasation, it can be treated conservatively regardless of size. When a therapeutic intervention is selected, transcatheter arterial embolization reduces the total amount of blood transfusion compared with surgery.

The Montana Interfacility Blood Network: A Novel Lifesaving "Hand-off" for the Optimal Care of Rural Patients

Purpose

The state of Montana encompasses and defines rural health care as it is known in the United States (US) today. This vast area is punctuated by pockets of health care availability with varying access to blood products for transfusion. Furthermore, timely transport is frequently challenged by weather that may limit air transportation options, resulting in multiple hours in ground transport to definitive care.

Patients and Methods

The Montana State Trauma Care Committee (MT-STCC) developed the Montana Interfacility Blood Network (MT-IBN) to ensure blood availability in geographically distanced cases where patients may otherwise not survive. The index case that led to the formal development of the MT-IBN is described, followed by a second case illustrating the IBN process.

Results

This process and development manuscript details the innovative efforts of MT-STCC to develop this fledgling idea unique to rural US health care. We review guidelines that have been developed to define broad aspects of the MT-IBN including the reason to share resources, proper packaging, paperwork necessary for transfer, and how to provide resources directly to the patient. Finally, we describe implementation within the state.

Conclusion

The MT-IBN was developed by MT-STCC to facilitate the hand-off of lifesaving blood to patients being transported by ground to definitive care in Montana without having to stop at an intermediary facility. This has already led to lives saved in areas that are limited in blood availability due to rurality.

Cerebral amyloid angiopathy decades after red blood cell transfusions: a report of two cases from a prospective cohort

BACKGROUND AND PURPOSE

Patients who underwent red blood cell (RBC) transfusion from donors who later developed multiple spontaneous intracerebral hemorrhages (ICHs) have recently been identified to have increased risk of ICH themselves. This increased risk of ICH was hypothesized to be related to iatrogenic cerebral amyloid angiopathy (iCAA) transmission. Two cases are presented who had RBC transfusion as an infant and presented with CAA at a relatively young age decades later.

METHOD

Cases were identified by prospectively asking all patients at our CAA outpatient clinic (November 2023 to January 2024) about a medical history with RBC transfusion or history with a high likelihood for RBC transfusion (e.g., hemolytic disease, trauma with massive hemorrhage). Eligible patients were all diagnosed with CAA, CAA with concomitant hypertensive arteriopathy or iCAA, and without hereditary CAA.

RESULTS

Between November 2023 and January 2024, 2/35 (6%, 95% confidence interval 2%-19%) outpatient clinic patients had a history of RBC transfusion and none had a high likelihood medical history. The cases presented at age 47 and 57 and had already developed severe CAA.

CONCLUSIONS

Red blood cell transfusion might be a possible mechanism for iCAA; however, further prospective data collection and experimental evidence concerning blood transmission of amyloid-β are needed.

Does Patient Blood Management Affect Outcomes in Metastatic Spine Tumour Surgery? A Review of Current Concepts

STUDY DESIGN

Narrative review.

OBJECTIVE

The spine is the most common site of metastases, associated with decreased quality of life. Increase in metastatic spine tumour surgery (MSTS) has caused us to focus on the management of blood, as blood loss is a significant morbidity in these patients. However, blood transfusion is also not without its own risks, and hence this led to blood conservation strategies and implementation of a concept of patient blood management (PBM) in clinical practise focusing on these patients.

METHODS

A narrative review was conducted and all studies that were related to blood management in metastatic spine disease as well as PBM surrounding this condition were included.

RESULTS

A total of 64 studies were included in this review. We discussed a new concept of patient blood management in patients undergoing MSTS, with stratification to pre-operative and intra-operative factors, as well as anaesthesia and surgical considerations. The studies show that PBM and reduction in blood transfusion allows for reduced readmission rates, lower risks associated with blood transfusion, and lower morbidity for patients undergoing MSTS.

CONCLUSION

Through this review, we highlight various pre-operative and intra-operative methods in the surgical and anaesthesia domains that can help with PBM. It is an important concept with the significant amount of blood loss expected from MSTS.

LEVEL OF EVIDENCE

Not applicable.

Comparison of Modified Shock Index and Shock Index for Predicting Massive Transfusion in Women with Primary Postpartum Hemorrhage: A Retrospective Study

BACKGROUND The modified shock index (MSI) is calculated as the ratio of heart rate (HR) to mean arterial pressure (MAP) and has been used to predict the need for massive transfusion (MT) in trauma patients. This retrospective study from a single center aimed to compare the MSI with the traditional shock index (SI) to predict the need for MT in 612 women diagnosed with primary postpartum hemorrhage (PPH) at the Emergency Department (ED) between January 2004 and August 2023. MATERIAL AND METHODS The patients were divided into the MT group and the non-MT group. The predictive power of MSI and SI was compared using the areas under the receiver operating characteristic curve (AUC). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value were calculated. RESULTS Out of 612 patients, 105 (17.2%) required MT. The MT group had higher median values than the non-MT group for MSI (1.58 vs 1.07, P<0.001) and SI (1.22 vs 0.80, P<0.001). The AUC for MSI, with a value of 0.811 (95% confidence interval [CI], 0.778-0.841), did not demonstrate a significant difference compared to the AUC for SI, which was 0.829 (95% CI, 0.797-0.858) (P=0.066). The optimal cutoff values for MSI and SI were 1.34 and 1.07, respectively. The specificity and PPV for MT were 77.1% and 40.2% for MSI, and 83.2% and 45.9% for SI. CONCLUSIONS Both MSI and SI were effective in predicting MT in patients with primary PPH. However, MSI did not demonstrate superior performance to SI.

Postoperative Interventions in Pediatric Digital Replantation: A Tertiary Referral Center Case Review

PURPOSE

Although a few case series have been published describing the excellent outcomes of replantation and revascularization operations in children, there has been limited study of the hospital course that these patients experience and the number of potentially harmful interventions and treatments that occur. The purpose of this study was to detail the results of various postoperative interventions, including anticoagulation, transfusion, leeching, sedation, and additional anesthetic exposures.

METHODS

Twenty-nine patients aged less than 18 years had 34 digital revascularizations or replantations performed between January 2000 and May 2020. The details of each patient's presentation, surgery, and postoperative care were analyzed.

RESULTS

Nine of 29 children underwent repeat anesthetics, including 6 revision amputations. No demographic, surgical, or postoperative variables consistently preceded revision amputation or additional anesthetic procedures. Only 5 patients had >1 hemoglobin (Hb) measurement. Two patients received blood transfusions; the average drop in Hb was 3.5 g/dL from before surgery to the lowest after surgery. Four patients underwent leech therapy. Only patients receiving leech therapy required postoperative transfusions. Anticoagulation regimens were prescribed on the basis of demographic and surgical factors, although no medication or regimen seemed to affect outcomes.

CONCLUSIONS

Although the experience of digital replantation is essentially the same in pediatric patients as adults, there may be different ramifications for children. Specifically, postoperative management of pediatric digital replantation or revascularization can involve multiple interventions that carry their risks. Parents should be counseled about the risks of anticoagulants, transfusions, and repeat anesthetics, and clinicians should monitor Hb closely when using leech therapy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A new technique to preserve the uterus in patients with placenta accreta spectrum disorders

BACKGROUND

Placenta accreta spectrum disorders are associated with substantial maternal morbidity and mortality. Despite a preoperative diagnosis, the rate of complications remains high, and the condition is generally associated with the need for a hysterectomy.

OBJECTIVE

This study aimed to evaluate the outcomes of a new uterine-preserving technique (called the combined approach, including surgical hemostasis, bilateral ligation of the descending branches of the uterine arteries, and hemostatic external supraplacental stitch with the use of the Zhukovsky double-balloon tamponade in patients with placenta accreta spectrum disorders) during cesarean delivery in women with placenta accreta spectrum disorders vs the surgical technique used until 2014.

STUDY DESIGN

This retrospective cohort study included 147 patients with placenta accreta spectrum disorders who were divided into 2 groups: the study group (n=95) is to undergo cesarean delivery using the combined approach, and the control group (n=52) is to undergo the surgical technique used until 2014, which included bilateral uterine artery ligation, which is the transfusion of plasma, red blood cells, platelets, and protease inhibitors.

RESULTS

The volume of blood loss was 1.5-fold lower (P=.0010), the number of blood transfusions was 5.1-fold lower (P=.026), and the rate of bladder injuries was 19-fold lower (P=.012) in the study group than that in the control group. The duration of hospital stay after delivery was 4 days lesser (P=.001) and the number of hysterectomies was 4.5-fold lower in the study group than in the control group (P=.023). The study groups did not differ in terms of placenta accreta spectrum type.

CONCLUSION

The combined approach during cesarean delivery proved to be more effective than the surgical technique used until 2014 in reducing the number of hysterectomies, blood loss volume, number of blood transfusions, and duration of hospital stay in patients with placenta accreta spectrum disorders.

Evaluation of post-transfusion RBC alloimmunization in dogs using a gel-column crossmatch with and without anti-canine globulin enhancement

A blood crossmatch is essential to ensure RBC compatibility for previously transfused dogs. There is no gold standard crossmatch method for dogs, although the standards used most commonly by academic institutions and reference laboratories are the tube and gel-column crossmatches. Addition of anti-canine globulin (ACG) has been suggested to increase detection of RBC incompatibilities. Our objective was to determine if there is a correlation between results of a standard and an ACG-enhanced gel-column crossmatch in detecting post-transfusion RBC alloimmunization. Pre- and post-transfusion serum or plasma samples were obtained from 33 dogs for major crossmatches to 1-6 (median: 3) blood donors. Crossmatches were performed with (n = 202) and without (n = 202) ACG, with results scored by 4 observers, 3 of whom were anonymized. Ten of 33 (30%) dogs had major crossmatch incompatibilities post-transfusion. RBC incompatibilities (2-4+ agglutination) were detected only with ACG in 4 dogs, only without ACG in 3 dogs, and with both methods in 3 dogs. There was fair correlation between crossmatch methods for determination of compatibility (ρ = 0.34; p < 0.001) and incompatibility (ρ = 0.35; p < 0.001) scores. Among 4 observers, there was near-perfect agreement in determining compatibility (κ = 0.97; p < 0.001) and substantial agreement in overall scoring of incompatibility (κ = 0.77; p < 0.001). Our results suggest that detection of RBC incompatibilities in dogs can be maximized by performing a gel-column crossmatch both with and without ACG enhancement.

Effect of leukoreduction on the metabolism of equine packed red blood cells during refrigerated storage

BACKGROUND

Understanding of the biochemical and morphological lesions associated with storage of equine blood is limited.

OBJECTIVE

To demonstrate the temporal sequences of lipid and metabolic profiles of equine fresh and stored (up to 42 days) and leukoreduced packed red blood cells (LR-pRBC) and non-leukoreduced packed RBC (nLR-pRBC).

ANIMALS

Packed RBC units were obtained from 6 healthy blood donor horses enrolled in 2 blood banks.

METHODS

Observational study. Whole blood was collected from each donor using transfusion bags with a LR filter. Leukoreduction pRBC and nLR-pRBC units were obtained and stored at 4°C for up 42 days. Sterile weekly sampling was performed from each unit for analyses.

RESULTS

Red blood cells and supernatants progressively accumulated lactate products while high-energy phosphate compounds (adenosine triphosphate and 2,3-Diphosphoglycerate) declined. Hypoxanthine, xanthine, and free fatty acids accumulated in stored RBC and supernatants. These lesions were exacerbated in non-LR-pRBC.

CONCLUSION AND CLINICAL IMPORTANCE

Leukoreduction has a beneficial effect on RBC energy and redox metabolism of equine pRBC and the onset and severity of the metabolic storage lesions RBC.

Major crossmatch compatibility of rabbit blood with rabbit, canine, and feline blood

OBJECTIVE

To evaluate the major crossmatch compatibility between rabbit recipients, rabbit donors, and the major canine and feline blood types.

DESIGN

Prospective in vitro study in December 2021.

SETTING

Academic veterinary teaching hospital.

ANIMALS

Whole blood samples were collected from 11 healthy New Zealand White rabbits (Oryctolagus cuniculus) with no previous transfusion history. Three pigtail segments were acquired from dog erythrocyte antigen (DEA)-1-positive, DEA-1-negative, and feline type A blood units. Whole blood was collected from a healthy type B blood donor cat.

INTERVENTIONS

Blood from each rabbit recipient underwent a major crossmatch using standard tube crossmatch methodology with itself and the following donor blood types: rabbit, DEA-1-positive, DEA-1-negative, feline type A, and feline type B.

MEASUREMENTS AND MAIN RESULTS

Self-crossmatches and crossmatches between rabbit recipients and conspecific donors were negative for hemolysis and agglutination. Crossmatches between rabbit recipients and canine and feline donors yielded no hemolysis but produced varying degrees of macroscopic and microscopic agglutination. Rabbit recipients had 1.4 (95% confidence interval: 1.1-1.8) times the risk of macroscopic agglutination when major crossmatched with canine blood compared to feline blood. No significant difference in agglutination was found between DEA-1-positive and DEA-1-negative or feline type A and type B donors.

CONCLUSIONS

These findings support allogeneic blood transfusions between rabbits being highly compatible and suggest rabbits have naturally occurring alloantibodies against both canine and feline red blood cells. However, feline red blood cells had a lower rate of in vitro incompatibility on major crossmatch, suggesting potentially higher in vivo compatibility if an emergency xenotransfusion is needed. Further prospective research is needed to determine if xenotransfusion is associated with a higher incidence of acute and delayed transfusion reactions in rabbits than allogeneic transfusions.

The role of viscoelastic hemostatic assays for postpartum hemorrhage management and bedside intrapartum care

Viscoelastic hemostatic assays are point-of-care devices that assess coagulation and fibrinolysis in whole blood samples. These technologies provide numeric and visual information of clot initiation, clot strength, and clot lysis under low-shear conditions, and have been used in a variety of clinical settings and subpopulations, including trauma, cardiac surgery, and obstetrics. Emerging data indicate that these devices are useful for detecting important coagulation defects during major postpartum hemorrhage (especially low plasma fibrinogen concentration [hypofibrinogenemia]) and informing clinical decision-making for blood product use. Data from observational studies suggest that, compared with traditional formulaic approaches to transfusion management, targeted or goal-directed transfusion approaches using data from viscoelastic hemostatic assays are associated with reduced hemorrhage-related morbidity and lower blood product requirement. Viscoelastic hemostatic assays can also be used to identify and treat coagulation defects in patients with inherited or acquired coagulation disorders, such as factor XI deficiency or immune-mediated thrombocytopenia, and to assess hemostatic profiles of patients prescribed anticoagulant medications to mitigate the risk of epidural hematoma after neuraxial anesthesia and postpartum hemorrhage after delivery.

Impact of fresh frozen plasma transfusion on mortality in extracorporeal membrane oxygenation

BACKGROUND

Patients who receive extracorporeal membrane oxygenation (ECMO) support require substantial transfusions. Red blood cell (RBC) and platelet (PLT) transfusions have been reported to be associated with adverse outcomes in ECMO patients. However, little is known about whether the transfusion of fresh frozen plasma (FFP) is associated with mortality and morbidity among patients receiving ECMO. The aim of this study was to examine the relationship between FFP transfusion and mortality in ECMO patients and assess risk factors for the transfusion of FFP.

METHODS

The clinical parameters of 116 ECMO patients were collected. The machine learning approach of the Boruta algorithm was employed to select the variables associated with ECMO patients' in-hospital mortality. Univariate and multivariate logistic regression analyses were applied to identify the association between the selected variables and in-hospital mortality. Spearman correlation and backwards stepwise multiple linear regression analyses were used to examine parameters contributing to FFP transfusion.

RESULTS

Among the 116 patients who received ECMO support, the in-hospital mortality was 32.8%. The median FFP (mL/kg/d) transfusion was higher in dead patients (5.07, IQR 1.78-8.90) when compared to alive patients (2.16, IQR 0.79-4.66) (p = 0.007). After adjustment for confounders, FFP transfusion (mL/kg/d) was associated with in-hospital mortality (OR 1.09, 95% CI, 1.01-1.18; p = 0.035). Further analysis found that higher activated partial thromboplastin time (APTT), higher levels of uric acid (UA) and lower PLT counts were significant risk factors for FFP transfusion, with estimated values of 0.06 (95% CI, 0.02-0.11; p = 0.009), 0.01 (95% CI, 0.00-0.02; p = 0.003) and -0.03 (95% CI, -0.05--0.01; p = 0.007), respectively.

CONCLUSION

FFP transfusion is markedly associated with in-hospital mortality among patients receiving ECMO, and higher APTT, higher levels of UA and lower PLT counts are risk factors for FFP transfusion. This suggests that better management of patients' coagulation system and kidney function may reduce the utilization of FFP, thus improving ECMO patient outcomes.

Incorporation of Blood and Fluid Management Within an Enhanced Recovery after Surgery Protocol in Complex Spine Surgery

STUDY DESIGN

retrospective review.

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) is a multidisciplinary set of evidence-based interventions to reduce morbidity and accelerate postoperative recovery. Complex spine surgery carries high risks of perioperative blood loss, blood transfusion, and suboptimal fluid states. This study evaluates the efficacy of a perioperative fluid and blood management component comprised of a restrictive transfusion policy, goal directed fluid management, number of tranexamic acid (TXA) utilization, and autologous blood transfusion within our ERAS protocol for complex spine surgery.

METHODS

A retrospective review compared patients undergoing elective complex spine surgery prior to and following implementation of an ERAS protocol with intraoperative blood and fluid management. Outcomes included incidence of blood transfusion, estimated blood loss, intraoperative crystalloids administered, frequency of intraoperative TXA utilized, incidence of patients extubated within the operating room (OR), intensive care unit (ICU) admission, and hospital length of stay.

RESULTS

Following implementation, the rate of blood transfusion decreased by 11.7%(P = .017) and average crystalloid infusion was reduced 680 mL per case(P < .001). Intraoperative blood loss decreased on average 342 mL per case(P = .001) and TXA use increased significantly by 25%(P < .001). Postoperative ICU admissions declined by 8.5%(P = .071); extubation within the OR increased by 13.3%(P = .005).

CONCLUSIONS

This protocol presents a unique perspective with the inclusion of an interdisciplinary and comprehensive blood and fluid management protocol as an integral part of our ERAS pathway for complex spine surgery. These results indicate that a standardized approach is associated with reduced rates of blood transfusion and optimized fluid states which was correlated with decreased postoperative ICU admissions.

Missingness matters: a secondary analysis of thromboelastography measurements from a recent prehospital randomized tranexamic acid clinical trial

Background

Tranexamic acid (TXA) has been hypothesized to mitigate coagulopathy in patients after traumatic injury. Despite previous prehospital clinical trials demonstrating a TXA survival benefit, none have demonstrated correlated changes in thromboelastography (TEG) parameters. We sought to analyze if missing TEG data contributed to this paucity of findings.

Methods

We performed a secondary analysis of the Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport Trial. We compared patients that received TEG (YES-TEG) and patients unable to be sampled (NO-TEG) to analyze subgroups in which to investigate TEG differences. TEG parameter differences across TXA intervention arms were assessed within subgroups disproportionately present in the NO-TEG relative to the YES-TEG cohort. Generalized linear models controlling for potential confounders were applied to findings with p<0.10 on univariate analysis.

Results

NO-TEG patients had lower prehospital systolic blood pressure (SBP) (100 (78, 140) vs 125 (88, 147), p<0.01), lower prehospital Glascow Coma Score (14 (3, 15) vs 15 (12, 15), p<0.01), greater rates of prehospital intubation (39.4% vs 24.4%, p<0.01) and greater mortality at 30 days (36.4% vs 6.8%, p<0.01). NO-TEG patients had a greater international normalized ratio relative to the YES-TEG subgroup (1.2 (1.1, 1.5) vs 1.1 (1.0, 1.2), p=0.04). Within a severe prehospital shock cohort (SBP<70), TXA was associated with a significant decrease in clot lysis at 30 min on multivariate analysis (β=-27.6, 95% CI (-51.3 to -3.9), p=0.02).

Conclusions

Missing data, due to the logistical challenges of sampling certain severely injured patients, may be associated with a lack of TEG parameter changes on TXA administration in the primary analysis. Previous demonstration of TXA's survival benefit in patients with severe prehospital shock in tandem with the current findings supports the notion that TXA acts at least partially by improving clot integrity.

Level of evidence

Level II.

Blood lactate after pre-hospital blood transfusion for major trauma by helicopter emergency medical services

BACKGROUND AND OBJECTIVES

The appropriate use of blood components is essential for ethical use of a precious, donated product. The aim of this study was to report in-hospital red blood cell (RBC) transfusion after pre-hospital transfusion by helicopter emergency medical service paramedics. A secondary aim was to assess the potential for venous blood lactate to predict ongoing transfusion.

MATERIALS AND METHODS

All patients who received RBC in air ambulance were transported to a single adult major trauma centre, had venous blood lactate measured on arrival and did not die before ability to transfuse RBC were included. The association of venous blood lactate with ongoing RBC transfusion was assessed using multi-variable logistic regression analysis and reported using adjusted odds ratios (aOR). The discriminative ability of venous blood lactate was assessed using area under receiver operating characteristics curve (AUROC).

RESULTS

From 1 January 2016 to 15 May 2019, there were 165 eligible patients, and 128 patients were included. In-hospital transfusion occurred in 97 (75.8%) of patients. Blood lactate was associated with ongoing RBC transfusion (aOR: 2.00; 95% confidence interval [CI]: 1.36-2.94). Blood lactate provided acceptable discriminative ability for ongoing transfusion (AUROC: 0.78; 95% CI: 0.70-0.86).

CONCLUSIONS

After excluding patients with early deaths, a quarter of those who had prehospital RBC transfusion had no further transfusion in hospital. Venous blood lactate appears to provide value in identifying such patients. Lactate levels after pre-hospital transfusion could be used as a biomarker for transfusion requirement after trauma.

Management and Outcome of Women with Placenta Accreta Spectrum and Treatment with Uterine Artery Embolization

BACKGROUND

Placenta accreta spectrum (PAS) disorders are a continuum of placental pathologies with increased risk for hemorrhage, blood transfusion and maternal morbidity. Uterine artery embolization (UAE) is a safe approach to the standardization of complex PAS cases. The aim of this study is to analyze anemia and transfusion rate, outcome and anesthesiological management of women who underwent caesarean delivery with subsequent UAE for the management of PAS.

MATERIAL AND METHODS

This retrospective observational study included all pregnant women admitted to the University Hospital Frankfurt between January 2012 and September 2023, with a diagnosis of PAS who underwent a two-step surgical approach for delivery and placenta removal. Primary procedure included cesarean delivery with subsequent UAE, secondary procedure included placenta removal after a minim of five weeks via curettage or HE. Maternal characteristics, anesthesiological management, complications, anemia rate, blood loss and administration of blood products were analyzed.

RESULTS

In total, 17 women with PAS were included in this study. Of these, 5.9% had placenta increta and 94.1% had placenta percreta. Median blood loss was 300 (200-600) mL during primary procedure and 3600 (450-5500) mL during secondary procedure. In total, 11.8% and 62.5% of women received red blood cell transfusion during the primary and secondary procedures, respectively. After primary procedure, postpartum anemia rate was 76.5%. The HE rate was 64.7%. Regional anesthesia was used in 88.2% during primary procedure.

CONCLUSION

The embolization of the uterine artery for women diagnosed with PAS is safe. Anemia management and the implementation of blood conservation strategies are crucial in women undergoing UAE for the management of PAS.

Impact of anticoagulation intensity on blood transfusion for venoarterial extracorporeal membrane oxygenation during lung transplantation

Venoarterial extracorporeal membrane oxygenation is increasingly used for mechanical circulatory support during lung transplant. Optimal intensity of intraoperative anticoagulation would be expected to mitigate thromboembolism without increasing bleeding and blood product transfusions. Yet, the optimal intensity of intraoperative anticoagulation is unknown. We performed a retrospective cohort study of 163 patients who received a bilateral lung transplant at a single center. We categorized the intensity of anticoagulation into 4 groups (very low to high) based on the bolus dose of unfractionated heparin given during lung transplant and compared the rates of intraoperative blood transfusions and the occurrence of thromboembolism between groups. When compared to the very low-intensity group, each higher intensity group was associated with higher red blood cell, fresh frozen plasma, and platelet transfusions. The occurrence of thromboembolism was similar across groups. These preliminary data suggest that lower intensity anticoagulation may reduce the rate of intraoperative blood transfusions, although further study is needed.

Haemovigilance survey and screening strategy for arthropod-borne viruses in blood donors from Argentina

Arthropod-borne viruses (arboviruses) count among emerging infections, which represent a major challenge for transfusion safety worldwide. To assess the risk of arboviruses-transmission by transfusion (ATT), we performed a survey to evaluate the potential threat for transfusion safety. Samples were retrospectively and randomly collected from donors who donated during the peak of dengue incidence in Cordoba (years: 2016 and 2019-2022). A cost-efficient strategy for molecular screening was implemented with a nucleic acid test (NAT) configured with Flavivirus and Alphavirus-universal degenerated primers targeting conserved gene regions. Besides, we evaluated the neutralizing antibody (NAb) prevalence by plaque reduction neutralization test (PRNT). A total of 1438 samples were collected. Among the NAT-screened samples, one resulted positive for Flavivirus detection. Subsequent sequencing of the PCR product revealed Saint Louis Encephalitis Virus (SLEV) infection (GeneBank accession number OR236721). NAb prevalence was 2.95% for anti-Dengue, 9.94% anti-SLEV, 1.09% anti-West Nile Virus, and 0% anti-Chikungunya. One of the NAb-positive samples also resulted positive for IgM against SLEV but negative by ARN detection. This is the first haemovigilance study developed in Argentina that evaluates the potential risk of ATT and the first research to determine the prevalence of NAb against Flavivirus through PNRT to avoid possible cross-reactions between Ab against Flavivirus. Herein, the finding of one SLEV-viremic donor and the detection of anti-SLEV IgM in a different donor demonstrated a potential threat for transfusion safety and emphasized the need for increased vigilance and proactive measures to ensure the safety of blood supplies.

Strategies to Obtain and Deliver Blood Products Into Critically Injured Children: A Survey of Pediatric Trauma Society Members

OBJECTIVES

Timely transfusion is associated with improved survival and a reduction in in-hospital morbidity. The benefits of early hemorrhagic shock recognition may be limited by barriers to accessing blood products and their timely administration. We examined how pediatric trauma programs obtain blood products, the types of rapid infusion models used, and the metrics tracked to improve transfusion process efficiency in their emergency department (ED).

METHODS

We developed and distributed a self-report survey to members of the Pediatric Trauma Society. The survey consisted of 6 initial questions, including the respondent's role and institution, whether a blood storage refrigerator was present in their ED, the rapid infuser model used to transfuse critically injured children in their ED, if their program tracked 4 transfusion process metrics, and if a video recording system was present in the trauma bay. Based on these responses, additional questions were prompted with an option for a free-text response.

RESULTS

We received 137 responses from 77 institutions. Most pediatric trauma programs have a blood storage refrigerator in the ED (n = 46, 59.7%) and use a Belmont rapid infuser to transfuse critically injured children (n = 45, 58.4%). The American College of Surgeons Level 1 designated trauma programs, or state-based equivalents, and "pediatric" trauma programs were more likely to have video recording systems for performance improvement review compared with lower designated trauma programs and "combined pediatric and adult" trauma programs, respectively.

CONCLUSIONS

Strategies to improve the timely acquisition and infusion of blood products to critically injured children are underreported. This study examined the current practices that pediatric trauma programs use to transfuse critically injured children and may provide a resource for trauma programs to cite for transfusion-related quality improvement.

Postpartum acute adrenal insufficiency of early-onset Sheehan syndrome: A case series study in a single center

AIM

To identify the symptoms and relevant factors associated with acute adrenal insufficiency of early-onset Sheehan syndrome.

METHODS

We retrospectively reviewed the charts of 125 women admitted to our intensive care unit because of postpartum hemorrhage between January 2011 and December 2021. Three women developed acute adrenal insufficiency. We investigated the total blood loss, shock status, consciousness level upon arrival, and intensive care provided to the women. We also analyzed the symptoms and laboratory data that led to the diagnosis of acute adrenal insufficiency. Continuous variables were presented by median (minimum-maximum).

RESULTS

The medians and ranges of age, total blood loss, and shock index [heart rate/systolic blood pressure] on admission were 33.1 (17.2-45.3) years, 3351 (595-20 260) g, and 0.94 (0.55-2.94), respectively. Seven women were older than 40 years, 28 experienced >5000 g blood loss, 17 had shock index >1.5, 27 had impaired consciousness upon arrival, and 15 underwent hysterectomy. Women who developed acute adrenal insufficiency were <40 years old and had a bleeding volume of over 5000 g, impaired consciousness upon arrival, and had undergone hysterectomy. They had experienced lactation failure, presented with hyponatremia-related symptoms on postpartum days 8-9, experienced general malaise, headache, and impaired consciousness, and showed severe hyponatremia.

CONCLUSIONS

Massive postpartum hemorrhage over 5000 g, impaired consciousness upon arrival, and hysterectomy as a hemostatic measure were relevant factors associated with acute adrenal insufficiency of early-onset Sheehan syndrome. Hyponatremia-related symptoms occurring after lactation failure are indicative of the onset of acute adrenal insufficiency.

The fatigue after infusion or transfusion pilot trial and feasibility study: A three-armed randomized pilot trial of intravenous iron and blood transfusion for the treatment of postpartum anemia

BACKGROUND

Evidence for the management of moderate-to-severe postpartum anemia is limited. A randomized trial is needed; recruitment may be challenging.

STUDY DESIGN AND METHODS

Randomized pilot trial with feasibility surveys.

INCLUSION

hemoglobin 65-79 g/L, ≤7 days of birth, hemodynamically stable.

EXCLUSION

ongoing heavy bleeding; already received, or contraindication to intravenous (IV)-iron or red blood cell transfusion (RBC-T). Intervention/control: IV-iron; RBC-T; or IV-iron and RBC-T.

PRIMARY OUTCOME

number of recruits; proportion of those approached; proportion considered potentially eligible.

SECONDARY OUTCOMES

fatigue, depression, baby-feeding, and hemoglobin at 1, 6 and 12 weeks; ferritin at 6 and 12 weeks. Surveys explored attitudes to trial participation.

RESULTS

Over 16 weeks and three sites, 26/34 (76%) women approached consented to trial participation, including eight (31%) Māori women. Of those potentially eligible, 26/167 (15.6%) consented to participate. Key participation enablers were altruism and study relevance. For clinicians and stakeholders the availability of research assistance was the key barrier/enabler. Between-group rates of fatigue and depression were similar. Although underpowered to address secondary outcomes, IV-iron and RBC-T compared with RBC-T were associated with higher hemoglobin concentrations at 6 (mean difference [MD] 11.7 g/L, 95% confidence interval [CI] 2.7-20.7) and 12 (MD 12.8 g/L, 95% CI 1.5-24.2) weeks, and higher ferritin concentrations at 6 weeks (MD 136.8 mcg/L, 95% CI 76.6-196.9).

DISCUSSION

Willingness to participate supports feasibility for a future trial assessing the effectiveness of IV-iron and RBC-T for postpartum anemia. Dedicated research assistance will be critical to the success of an appropriately powered trial including women-centered outcomes.

Clinical Prediction of Retained Products of Conception: Combining Obstetric History and Ultrasound for Improved Accuracy in Severe Postpartum Hemorrhage

Background The current challenge is how to improve the management of postpartum hemorrhage (PPH) to reduce the maternal mortality rate further. This study aimed to investigate whether a combined specific obstetric history and ultrasonographic findings can improve the predictive accuracy of retained products of conception (RPOC) with severe PPH. Methods This retrospective study included 56 patients who were diagnosed with RPOC. We extracted the following clinical data: obstetric history of second-trimester miscarriage, the time at which there was clinical suspicion of RPOC after the previous pregnancy (TIME), grayscale ultrasonographic finding (RPOC long-axis length [SIZE]), and color Doppler ultrasonographic finding based on the Gutenberg classification (RPOC hypervascularity). In this study, we defined cases requiring blood transfusion therapy or transcatheter arterial embolization as severe PPH. The patients were divided into two groups according to the presence or absence of severe PPH. The predictors of severe PPH were evaluated using logistic regression models. Model A comprised a combination of second-trimester miscarriage and TIME, Model B comprised a combination of Model A and long-axis SIZE, and Model C comprised a combination of Model B and RPOC hypervascularity. Results The multivariable analysis showed that long-axis SIZE was the only significant predictor of severe PPH (odds ratio [OR], 10.38; 95% confidence interval [CI], 2.06-63.86) independent of second-trimester miscarriage, TIME, and RPOC hypervascularity. The c-statistic was higher in Model C (OR, 0.863; 95% CI, 0.731-0.936) than in Model A (OR, 0.723; 95% CI, 0.551-0.847) and Model B (OR, 0.834; 95% CI, 0.677-0.923). Conclusion Combining a specific obstetric history (second-trimester miscarriage and TIME) and ultrasonographic findings (long-axis SIZE and RPOC hypervascularity) improves the predictive accuracy of RPOC with severe PPH. This prediction model may be a useful clinical screening tool for RPOC with severe PPH.

Impact of low-volume blood withdrawal on hematological biomarkers for the athlete biological passport

This study investigated the impact of low-volume blood withdrawal on the hematological biomarkers currently considered for anti-doping purposes. After baseline measurement (D - 7), a 140 mL blood withdrawal was completed (D + 0) on 12 healthy volunteers, followed by weekly monitoring for 21 days (D + 7 - 21). Each visit consisted of a full blood count (Sysmex XN-1000) and duplicate blood volume measurements by CO-rebreathing. A significant decrease in total hemoglobin mass (Hbmass) (-2.3%, p = 0.007) and red blood cell volume (RBCV) (-2.8%, p = 0.028) was reported at D + 7. Despite no atypical passport finding (ATPF) when considering the athlete biological passport adaptive longitudinal model, hemoglobin concentration ([Hb]) increased significantly at D + 21 (+3.8%, p = 0.031). Besides, ferritin (FERR) was significantly downregulated at all points following blood withdrawal, with the largest decrease occurring at D + 7 (-26.6%, p < 0.001). Regardless of the presumable effect of blood reinfusion on ABP biomarkers, these results illustrate the challenge of monitoring hematological variables for the detection of low-volume blood withdrawal. Finally, this study outlines the sensitivity of FERR to altered erythropoiesis to support the implementation of iron markers as complementary variables for the longitudinal monitoring of blood doping, despite the potential influence of confounding factors (e.g., iron supplementations).

The effect of transfusion on survival in head and neck cancer after free tissue reconstruction

Objective

To examine if perioperative blood transfusion affects overall survival (OS) and recurrence-free survival (RFS) in head and neck cancer patients who undergo free tissue reconstruction.

Design

Retrospective cohort study.

Methods

The medical records of free tissue flaps between 2007 and 2010 were reviewed. Differences in demographics and clinical factors based on the level of transfused packed red blood cells (PRBC) were examined using chi-squared tests, Kruskal-Wallis tests, and/or ANOVA tests. Survival time was compared using a Cox proportional hazard model.

Results

Data were available for 183 patients. Patients who had PRBC transfusion significantly differed from the non-transfused group by flap type, flap with bone, Charlson Comorbidity Index (CCI), and hemoglobin and hematocrit. When stratified into three groups based on units of PRBC; flap type, flap with bone, CCI, preoperative hemoglobin, and hematocrit were found to differ significantly. The 2-year Kaplan-Meier plot demonstrated improved OS for those who did not receive any PRBC transfusion. The use of more than 3 units of blood decreased 2-year OS significantly when compared to the non-transfused group. Finally, after adjusting for CCI using a Cox proportional hazard model, survival was significantly affected by CCI.

Conclusion

After controlling for patient age, oncologic stage, cancer subsite, histology, type of free flap, vascularized bone-containing flap, recurrence type, CCI, and preoperative hemoglobin and hematocrit, patients who received 3 or more units of PRBC in the perioperative period had significantly decreased OS. RFS did not differ between the transfused versus non-transfused groups.

Level of Evidence

Level 4.

Informing the State of Process Modeling and Automation of Blood Banking and Transfusion Services Through a Systematic Mapping Study

Purpose

The current state of the art in process modeling of blood banking and transfusion services is not well grounded; methodological reviews are lacking to bridge the gap between such blood banking and transfusion processes (and their models) and their automation. This research aims to fill this gap with a methodological review.

Methods

A systematic mapping study was adopted, driven by five key research questions. Identified research studies were accepted based on fulfilling the following inclusion criteria: 1) research studies should focus on blood banking and transfusion process modeling since the late 1970s; and 2) research studies should focus on process automation in relation to workflow-based systems, with papers classified into categories in line with the analysis undertaken to answer each of the research questions.

Results

The search identified 22 papers related to modeling and automation of blood banking and transfusion, published in the period 1979-2022. The findings revealed that only four process modeling languages were reported to visualize process workflows. The preparation of blood components, serologic testing, blood distribution, apheresis, preparation for emergencies, maintaining blood banking and transfusion safety, and documentation have not been reported to have been modeled in the literature. This review revealed the lack of use of Business Process Modeling Notation (BPMN) as the industry standard process modeling language in the domain. The review also indicated a deficiency in modeling specialized processes in blood banking and transfusion, with the majority of reported processes being described as high level, but lacking elaboration. Automation was reported to improve transfusion safety, and to reduce cost, time cycle, and human errors.

Conclusion

The work highlights the non-existence of a developed process architectural framework for blood banking and transfusion processes, which is needed to lay the groundwork for identifying and modeling strategic, managerial, and operational processes to bridge the gap with their enactment in healthcare systems. This paves the way for the development of a data-harvesting platform for blood banking and transfusion services.

How to Detect Antibodies Against Babesia divergens in Human Blood Samples

Background

Today only indirect fluorescent antibody assays (IFAs) are commercially available to detect antibodies against Babesia divergens in humans. IFA is subjective and requires highly experienced staff. We have therefore developed an enzyme-linked immunosorbent assay (ELISA)-based method for measuring anti-B. divergens immunoglobulin G antibodies in human blood samples.

Methods

Crude merozoite extract from in vitro cultures of a new B. divergens isolate was used in ELISA to detect antibodies in different sets of samples: Borrelia burgdorferi-positive samples, healthy individuals, tick-bitten individuals including follow-up samples 3 months later, positive control samples from patients with an active Babesia infection, and samples from malaria-endemic regions. As a reference, IFA was used to detect antibodies in the tick-bitten samples. Western blot was used to evaluate reactions against specific bands in extracts with/without parasites.

Results

Using IFA as the reference method, the sensitivity and specificity of the ELISA were 86% (12/14) and 100% (52/52). There was a very high correlation (r = -0.84; P = .0004) between IFA dilution factors and ELISA absorbances among the samples classified as positive. Five percent of the B. burgdorferi-positive samples were judged as weakly positive and 5% as strongly positive in our ELISA. Western blot showed that the immunodominant antigens (∼120 kDa) were from merozoites and not from erythrocytes.

Conclusions

This ELISA can detect antibodies directed against B. divergens, and it can be a useful and easy assay to handle compared with IFA. The ELISA can also measure high and low levels of antibodies, which could give insight into the recency of a B. divergens infection.

Hemostatic effect of fibrinogen concentrate on traumatic massive hemorrhage: a propensity score matching study

Background

Fibrinogen concentrate (FC) can be administered during massive transfusions to manage trauma-induced coagulopathy. However, its effectiveness in survival remains inconclusive due to scarce high-level evidence. This study aimed to investigate the hemostatic effects of FC regarding mortality in massive hemorrhage caused by trauma.

Methods

This retrospective study analyzed 839 patients who received massive transfusions (red blood cells (RBCs) ≥5 units in 4 hours or ≥10 units in 24 hours) at a level I trauma center between 2015 and 2022. Patients who were transferred to other hospitals or were deceased upon arrival, suffered or died from severe brain injury, and were aged 15 years or less were excluded (n=334). 1:2 propensity score matching was performed to compare the 'FC (+)' group who had received FC in 24 hours (n=68) with those who had not ('FC (-)', n=437). The primary outcome was mortality, and the secondary outcomes included transfusion volume.

Results

The variables for matching included vital signs, injury characteristics, prehospital time, implementation of resuscitative endovascular balloon occlusion of the aorta, and blood gas analysis results. The administration of FC did not significantly reduce or predict mortality (in-hospital, 24 hours, 48 hours, or 7 days). The FC (-) group received more units of RBC (25.69 units vs. 16.71 units, p<0.001, standardized mean difference [SMD] 0.595), fresh frozen plasma (16.79 units vs. 12.91 units, p=0.023, SMD 0.321), and platelets (8.76 units vs. 5.46 units, p=0.002, SMD 0.446) than the FC (+) group.

Conclusion

The use of FC did not show survival benefits but reduced transfusion requirements in traumatic massive hemorrhages, highlighting a need for future investigations. In the future, individualized goal-directed transfusion with FC may play a significant role in treating massive bleeding.

Level of evidence

IV, retrospective study having more than one negative criterion.