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Li Y, Wang J, Li C, Wang L, Chen Y. Prognostic of red blood cell transfusion during extracorporeal membrane oxygenation therapy on mortality: A meta-analysis. Perfusion 2024; 39:713-721. [PMID: 36800909 DOI: 10.1177/02676591231157234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
BACKGROUND This meta-analysis aimed to explore the impact of red blood cell (RBC) transfusion on mortality during extracorporeal membrane oxygenation (ECMO). Previous studies investigated the prognostic impact of RBC transfusion during ECMO on the risk of mortality, but no meta-analysis has been published before. METHODS The PubMed, Embase, and the Cochrane library were systematically searched for papers published up to 13 December 2021, using the MeSH terms "ECMO", "'Erythrocytes", and "Mortality" to identify meta-analyses. Total or daily RBC transfusion during ECMO and mortality were examined. RESULTS The random-effect model was used. Eight studies (794 patients, including 354 dead) were included. The total volume of RBC was associated with higher mortality standardized weighted difference (SWD = -0.62, 95% CI: -1.06,-0.18, p = .006; I2 = 79.7%, Pheterogeneity = 0.001). The daily volume of RBC was associated with higher mortality (SWD = -0.77, 95% CI: -1.11,-0.42, p < .001; I2 = 65.7%, Pheterogeneity = 0.020). The total volume of RBC was associated with mortality for venovenous (VV) (SWD = -0.72, 95% CI: -1.23, -0.20, p = .006) but not venoarterial ECMO (p = .126) or when reported together (p = .089). The daily volume of RBC was associated with mortality for VV (SWD = -0.72, 95% CI: -1.18, -0.26, p = 0.002; I2 = 0.0%, Pheterogeneity = 0.642) and venoarterial (SWD = -0.95, 95% CI: -1.32, -0.57, p < .001) ECMO, but not when reported together (p = .067). The sensitivity analysis suggested the robustness of the results. CONCLUSION When considering the total and daily volumes of RBC transfusion during ECMO, the patients who survived received smaller total and daily volumes of RBC transfusion. This meta-analysis suggests that RBC transfusion might be associated with a higher risk of mortality during ECMO.
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Affiliation(s)
- Yuan Li
- Department of Critical Care Medicine, Qilu Hospital of Shandong University, Shandong University, Jinan, China
| | - Jing Wang
- Department of Critical Care Medicine, Qilu Hospital of Shandong University, Shandong University, Jinan, China
| | - Chaoyang Li
- Department of Hematology, Qilu Hospital of Shandong University, Shandong University, Jinan, China
| | - Lin Wang
- Department of Hematology, Qilu Hospital of Shandong University, Shandong University, Jinan, China
| | - Yuguo Chen
- Department of Emergency, Qilu Hospital of Shandong University, Shandong University, Jinan, China
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Xu X, Zhang Y, Gan J, Ye X, Yu X, Huang Y. Association between perioperative allogeneic red blood cell transfusion and infection after clean-contaminated surgery: a retrospective cohort study. Br J Anaesth 2021; 127:405-414. [PMID: 34229832 DOI: 10.1016/j.bja.2021.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/08/2021] [Accepted: 05/08/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Allogeneic red blood cell (RBC) transfusion can induce immunosuppression, which can then increase the susceptibility to postoperative infection. However, studies in different types of surgery show conflicting results regarding this effect. METHODS In this retrospective cohort study conducted in a tertiary referral centre, we included adult patients undergoing clean-contaminated surgery from 2014 to 2018. Patients who received allogeneic RBC transfusion from preoperative Day 30 to postoperative Day 30 were included into the transfusion group. The control group was matched for the type of surgery in a 1:1 ratio. The primary outcome was infection within 30 days after surgery, which was defined by healthcare-associated infection, and identified mainly based on antibiotic regimens, microbiology tests, and medical notes. RESULTS Among the 8098 included patients, 1525 (18.8%) developed 1904 episodes of postoperative infection. Perioperative RBC transfusion was associated with an increased risk of postoperative infection after controlling for 27 confounders by multivariable regression analysis (odds ratio [OR]: 1.60; 95% confidence interval [CI]: 1.39-1.84; P<0.001) and propensity score weighing (OR: 1.64; 95% CI: 1.45-1.85; P<0.001) and matching (OR: 1.70; 95% CI: 1.43-2.01; P<0.001), and a dose-response relationship was observed. The transfusion group also showed higher risks of surgical site infection, pneumonia, bloodstream infection, multiple infections, intensive care admission, unplanned reoperation, prolonged postoperative length of hospital stay, and all-cause death. CONCLUSIONS Perioperative allogeneic RBC transfusion is associated with an increased risk of infection after clean-contaminated surgery in a dose-response manner. Close monitoring of infections and enhanced prophylactic strategies should be considered after transfusion.
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Affiliation(s)
- Xiaohan Xu
- Department of Anaesthesiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuelun Zhang
- Medical Research Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jia Gan
- Department of Blood Transfusion, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiangyang Ye
- Department of Information Management, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuerong Yu
- Department of Anaesthesiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
| | - Yuguang Huang
- Department of Anaesthesiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
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Wang P, Wang X, Deng H, Li L, Chong W, Hai Y, Zhang Y. Restrictive versus liberal transfusion thresholds in very low birth weight infants: A systematic review with meta-analysis. PLoS One 2021; 16:e0256810. [PMID: 34460843 PMCID: PMC8405031 DOI: 10.1371/journal.pone.0256810] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/17/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To assess the efficacy and safety of restrictive versus liberal red blood cell transfusion thresholds in very low birth weight infants. METHODS We searched MEDLINE, EMBASE, and Cochrane database without any language restrictions. The last search was conducted in August 15, 2020. All randomized controlled trials comparing the use of restrictive versus liberal red blood cell transfusion thresholds in very low birth weight (VLBW) infants were selected. Pooled risk ratio (RR) for dichotomous variable with 95% confidence intervals were assessed by a random-effects model. The primary outcome was all-cause mortality. RESULTS Overall, this meta-analysis included 6 randomized controlled trials comprising 3,483 participants. Restrictive transfusion does not increase the risk of all-cause mortality (RR, 0.99; 95% CI, 0.84 to 1.17; I2 = 0%; high-quality evidence), and does not increase the composite outcome of death or neurodevelopmental impairment (RR, 1.01, 95% CI, 0.93-1.09; I2 = 7%; high-quality evidence) or other serious adverse events. Results were similar in subgroup analyses of all-cause mortality by weight of infants, gestational age, male infants, and transfusion volume. CONCLUSIONS In very low birth weight infants, a restrictive threshold for red blood cell transfusion was not associated with increased risk of all-cause mortality, in either short term or long term.
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Affiliation(s)
- Peng Wang
- Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
| | - Xing Wang
- Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
| | - Haidong Deng
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Linjie Li
- Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
| | - Weelic Chong
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Yang Hai
- Zucker School of Medicine at Hofstra/Northwell, New York, New York, United States of America
| | - Yu Zhang
- Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
- * E-mail:
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4
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Ma HP, Zhang L, Chen CL, Li J, Ma ZT, Jiang QQ, Liang YY, Li SS, Long F, Zheng H. Evaluation of a novel Cardiac Peri-Operative Transfusion Trigger Scoring system in patients with coronary artery disease. BMC Cardiovasc Disord 2021; 21:40. [PMID: 33468068 PMCID: PMC7814977 DOI: 10.1186/s12872-021-01854-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/05/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND A simple and accurate scoring system to guide perioperative blood transfusion in patients with coronary artery disease (CAD) undergoing cardiac surgery is lacking. The trigger point for blood transfusions for these patients may be different from existing transfusion guidelines. This study aimed to evaluate the safety and efficacy of a new scoring strategy for use in guiding transfusion decisions in patients with CAD. METHODS A multicenter randomized controlled trial was conducted at three third-level grade-A hospitals from January 2015 to May 2018. Data of 254 patients in a Cardiac Peri-Operative Transfusion Trigger Score (cPOTTS) group and 246 patients in a group receiving conventional evaluation of the need for transfusion (conventional group) were analysed. The requirements for transfusion and the per capita consumption of red blood cells (RBCs) were compared between groups. RESULTS Baseline characteristics of the two groups were comparable. Logistic regression analyses revealed no significant differences between the two groups in primary outcomes (1-year mortality and perioperative ischemic cardiac events), secondary outcomes (shock, infections, and renal impairment), ICU admission, and ICU stay duration. However, patients in the cPOTTS group had significantly shorter hospital stays, lower hospital costs, lower utilization rate and lower per capita consumption of transfused RBCs than controls. Stratified analyses revealed no significant differences between groups in associations between baseline characteristics and perioperative ischemic cardiac events, except for hemofiltration or dialysis and NYHA class in I. CONCLUSIONS This novel scoring system offered a practical and straightforward guideline of perioperative blood transfusion in patients with CAD. Trial registration chiCTR1800016561(2017/7/19).
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Affiliation(s)
- Hai-Ping Ma
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Lei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Chun-Ling Chen
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Jin Li
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Zhi Tong Ma
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Qiao Qiao Jiang
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Yuan Yuan Liang
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Shan Shan Li
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Fei Long
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Hong Zheng
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China.
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Toriyama E, Hata T, Yokota K, Chiwata M, Kamijo R, Hashimoto M, Taguchi M, Horai M, Matsuo M, Matsuo E, Takasaki Y, Kawaguchi Y, Itonaga H, Sato S, Ando K, Sawayama Y, Taguchi J, Imaizumi Y, Tsushima H, Jo T, Yoshida S, Moriuchi Y, Miyazaki Y. No clear survival benefit of azacitidine for lower-risk myelodysplastic syndromes: A retrospective study of Nagasaki. Cancer Sci 2020; 111:4490-4499. [PMID: 32939867 PMCID: PMC7734160 DOI: 10.1111/cas.14653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/13/2020] [Accepted: 09/05/2020] [Indexed: 12/11/2022] Open
Abstract
The efficacy of azacitidine (AZA) on survival of lower risk (LR) - myelodysplastic syndromes (MDS) is controversial. To address this issue, we retrospectively evaluated the long-term survival benefit of AZA for patients with LR-MDS defined by International Prognostic Scoring System (IPSS). Using data from 489 patients with LR-MDS in Nagasaki, hematologic responses according to International Working Group 2006 and overall survival (OS) were compared among patients that received best supportive care (BSC), immunosuppressive therapy (IST), erythropoiesis-stimulating agents (ESA), and AZA. Patients treated with AZA showed complete remission (CR) rate at 11.3%, marrow CR at 1.9%, and any hematologic improvement at 34.0%, with transfusion independence (TI) of red blood cells in 27.3% of patients. and platelet in 20% of patients, respectively. Median OS for patients received IST, ESA, BSC, and AZA (not reached, 91 months, 58 months, and 29 months, respectively) differed significantly (P < .001). Infection-related severe adverse events were observed in more than 20% of patients treated with AZA. Multivariate analysis showed age, sex, IPSS score at diagnosis, and transfusion dependence were significant for OS, but AZA treatment was not, which maintained even response to AZA, and IPSS risk status at AZA administration was added as factors. We could not find significant survival benefit of AZA treatment for LR-MDS patients.
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Affiliation(s)
- Eo Toriyama
- Department of HematologyAtomic Bomb Disease and Hibakusha Medicine UnitAtomic Bomb Disease InstituteNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Tomoko Hata
- Department of HematologyAtomic Bomb Disease and Hibakusha Medicine UnitAtomic Bomb Disease InstituteNagasaki UniversityNagasakiJapan
| | - Ken‐ichi Yokota
- Biostatistics SectionDivision of Scientific Data RegistryAtomic Bomb Disease InstituteNagasaki UniversityNagasakiJapan
| | - Masahiko Chiwata
- Department of HematologyNational Hospital Organization Nagasaki Medical CenterOhmuraJapan
| | - Rena Kamijo
- Department of HematologySasebo City General Medical CenterSaseboJapan
| | - Miki Hashimoto
- Department of HematologyAtomic Bomb Disease and Hibakusha Medicine UnitAtomic Bomb Disease InstituteNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Masataka Taguchi
- Department of HematologyNagasaki University HospitalNagasakiJapan
| | - Makiko Horai
- Department of HematologyNagasaki University HospitalNagasakiJapan
| | - Masatoshi Matsuo
- Department of HematologyNagasaki Harbor Medical CenterNagasakiJapan
| | - Emi Matsuo
- Department of HematologyJapan Community Health Care Organization Isahaya General HospitalIsahayaJapan
| | - Yumi Takasaki
- Department of Internal MedicineSaint Francis HospitalNagasakiJapan
| | - Yasuhisa Kawaguchi
- Department of Internal MedicineNational Hospital Organization Nagasaki HospitalNagasakiJapan
| | - Hidehiro Itonaga
- Department of HematologyNagasaki University HospitalNagasakiJapan
| | - Shinya Sato
- Department of HematologyNagasaki University HospitalNagasakiJapan
| | - Koji Ando
- Department of HematologyAtomic Bomb Disease and Hibakusha Medicine UnitAtomic Bomb Disease InstituteNagasaki UniversityNagasakiJapan
| | - Yasushi Sawayama
- Department of HematologyNagasaki University HospitalNagasakiJapan
| | - Jun Taguchi
- Department of HematologyJapanese Red Cross Nagasaki Genbaku HospitalNagasakiJapan
| | | | - Hideki Tsushima
- Department of HematologyNagasaki Harbor Medical CenterNagasakiJapan
| | - Tatsuro Jo
- Department of HematologyJapanese Red Cross Nagasaki Genbaku HospitalNagasakiJapan
| | - Shinichiro Yoshida
- Department of HematologyNational Hospital Organization Nagasaki Medical CenterOhmuraJapan
| | | | - Yasushi Miyazaki
- Department of HematologyAtomic Bomb Disease and Hibakusha Medicine UnitAtomic Bomb Disease InstituteNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
- Department of HematologyAtomic Bomb Disease and Hibakusha Medicine UnitAtomic Bomb Disease InstituteNagasaki UniversityNagasakiJapan
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Franz AR, Engel C, Bassler D, Rüdiger M, Thome UH, Maier RF, Krägeloh-Mann I, Kron M, Essers J, Bührer C, Rellensmann G, Rossi R, Bittrich HJ, Roll C, Höhn T, Ehrhardt H, Avenarius S, Körner HT, Stein A, Buxmann H, Vochem M, Poets CF. Effects of Liberal vs Restrictive Transfusion Thresholds on Survival and Neurocognitive Outcomes in Extremely Low-Birth-Weight Infants: The ETTNO Randomized Clinical Trial. JAMA 2020; 324:560-570. [PMID: 32780138 PMCID: PMC7420159 DOI: 10.1001/jama.2020.10690] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Red blood cell transfusions are commonly administered to infants weighing less than 1000 g at birth. Evidence-based transfusion thresholds have not been established. Previous studies have suggested higher rates of cognitive impairment with restrictive transfusion thresholds. OBJECTIVE To compare the effect of liberal vs restrictive red blood cell transfusion strategies on death or disability. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted in 36 level III/IV neonatal intensive care units in Europe among 1013 infants with birth weights of 400 g to 999 g at less than 72 hours after birth; enrollment took place between July 14, 2011, and November 14, 2014, and follow-up was completed by January 15, 2018. INTERVENTIONS Infants were randomly assigned to liberal (n = 492) or restrictive (n = 521) red blood cell transfusion thresholds based on infants' postnatal age and current health state. MAIN OUTCOME AND MEASURES The primary outcome, measured at 24 months of corrected age, was death or disability, defined as any of cognitive deficit, cerebral palsy, or severe visual or hearing impairment. Secondary outcome measures included individual components of the primary outcome, complications of prematurity, and growth. RESULTS Among 1013 patients randomized (median gestational age at birth, 26.3 [interquartile range {IQR}, 24.9-27.6] weeks; 509 [50.2%] females), 928 (91.6%) completed the trial. Among infants in the liberal vs restrictive transfusion thresholds groups, respectively, incidence of any transfusion was 400/492 (81.3%) vs 315/521 (60.5%); median volume transfused was 40 mL (IQR, 16-73 mL) vs 19 mL (IQR, 0-46 mL); and weekly mean hematocrit was 3 percentage points higher with liberal thresholds. Among infants in the liberal vs restrictive thresholds groups, the primary outcome occurred in 200/450 (44.4%) vs 205/478 (42.9%), respectively, for a difference of 1.6% (95% CI, -4.8% to 7.9%; P = .72). Death by 24 months occurred in 38/460 (8.3%) vs 44/491 (9.0%), for a difference of -0.7% (95% CI, -4.3% to 2.9%; P = .70), cognitive deficit was observed in 154/410 (37.6%) vs 148/430 (34.4%), for a difference of 3.2% (95% CI, -3.3% to 9.6%; P = .47), and cerebral palsy occurred in 18/419 (4.3%) vs 25/443 (5.6%), for a difference of -1.3% (95% CI, -4.2% to 1.5%; P = .37), in the liberal vs the restrictive thresholds groups, respectively. In the liberal vs restrictive thresholds groups, necrotizing enterocolitis requiring surgical intervention occurred in 20/492 (4.1%) vs 28/518 (5.4%); bronchopulmonary dysplasia occurred in 130/458 (28.4%) vs 126/485 (26.0%); and treatment for retinopathy of prematurity was required in 41/472 (8.7%) vs 38/492 (7.7%). Growth at follow-up was also not significantly different between groups. CONCLUSIONS AND RELEVANCE Among infants with birth weights of less than 1000 g, a strategy of liberal blood transfusions compared with restrictive transfusions did not reduce the likelihood of death or disability at 24 months of corrected age. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01393496.
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Affiliation(s)
- Axel R. Franz
- Center for Pediatric Clinical Studies, University Children’s Hospital Tübingen, Tübingen, Germany
- Neonatology, University Children’s Hospital Tübingen, Tübingen, Germany
| | - Corinna Engel
- Center for Pediatric Clinical Studies, University Children’s Hospital Tübingen, Tübingen, Germany
| | - Dirk Bassler
- University Hospital Zurich, Department of Neonatology, University of Zurich, Zurich, Switzerland
| | - Mario Rüdiger
- Clinic for Pediatrics, Department for Neonatology and Pediatric Intensive Care Medicine, Medical Faculty, TU Dresden, Dresden, Germany
| | - Ulrich H. Thome
- Children’s Hospital, Division of Neonatology, Department of Women and Children’s Health, University of Leipzig, Leipzig, Germany
| | - Rolf F. Maier
- Children’s Hospital, University Hospital, Philipps University Marburg, Marburg, Germany
| | - Ingeborg Krägeloh-Mann
- Department of Paediatric Neurology and Developmental Medicine, University Children’s Hospital Tübingen, Tübingen, Germany
| | - Martina Kron
- Institute for Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | | | | | | | | | | | - Claudia Roll
- Vestische Kinder-und Jugendklinik Datteln, Universität Witten/Herdecke, Datteln, Germany
| | - Thomas Höhn
- Neonatology and Pediatric Intensive Care, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Harald Ehrhardt
- Department of General Pediatrics and Neonatology, Justus-Liebig-University Giessen, Giessen, Germany
| | | | | | - Anja Stein
- Department of Paediatrics I, University Duisburg-Essen, Essen, Germany
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7
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Trentino KM, Farmer SL, Leahy MF, Sanfilippo FM, Isbister JP, Mayberry R, Hofmann A, Shander A, French C, Murray K. Systematic reviews and meta-analyses comparing mortality in restrictive and liberal haemoglobin thresholds for red cell transfusion: an overview of systematic reviews. BMC Med 2020; 18:154. [PMID: 32576194 PMCID: PMC7313211 DOI: 10.1186/s12916-020-01614-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/30/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND There are no overviews of systematic reviews investigating haemoglobin thresholds for transfusion. This is important as the literature on transfusion thresholds has grown considerably in recent years. Our aim was to synthesise evidence from systematic reviews and meta-analyses of the effects of restrictive and liberal transfusion strategies on mortality. METHODS This was a systematic review of systematic reviews (overview). We searched MEDLINE, Embase, Web of Science Core Collection, PubMed, Google Scholar, and the Joanna Briggs Institute EBP Database, from 2008 to 2018. We included systematic reviews and meta-analyses of randomised controlled trials comparing mortality in patients assigned to red cell transfusion strategies based on haemoglobin thresholds. Two independent reviewers extracted data and assessed methodological quality. We assessed the methodological quality of included reviews using AMSTAR 2 and the quality of evidence pooled using an algorithm to assign GRADE levels. RESULTS We included 19 systematic reviews reporting 33 meta-analyses of mortality outcomes from 53 unique randomised controlled trials. Of the 33 meta-analyses, one was graded as high quality, 15 were moderate, and 17 were low. Of the meta-analyses presenting high- to moderate-quality evidence, 12 (75.0%) reported no statistically significant difference in mortality between restrictive and liberal transfusion groups and four (25.0%) reported significantly lower mortality for patients assigned to a restrictive transfusion strategy. We found few systematic reviews addressed clinical differences between included studies: variation was observed in haemoglobin threshold concentrations, the absolute between group difference in haemoglobin threshold concentration, time to randomisation (resulting in transfusions administered prior to randomisation), and transfusion dosing regimens. CONCLUSIONS Meta-analyses graded as high to moderate quality indicate that in most patient populations no difference in mortality exists between patients assigned to a restrictive or liberal transfusion strategy. TRIAL REGISTRATION PROSPERO CRD42019120503.
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Affiliation(s)
- Kevin M. Trentino
- School of Population and Global Health, The University of Western Australia, Perth, Australia
- Data and Digital Innovation, East Metropolitan Health Service, Perth, Australia
| | - Shannon L. Farmer
- Medical School and Division of Surgery, The University of Western Australia, Perth, Australia
- School of Health Sciences and Graduate Studies, Curtin University, Bentley, Australia
- Department of Haematology, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, Australia
| | - Michael F. Leahy
- Department of Haematology, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, Australia
- Medical School, The University of Western Australia, Perth, Australia
| | - Frank M. Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, Australia
| | | | - Rhonda Mayberry
- Library and Information Service, South Metropolitan Health Service, Murdoch, Australia
| | - Axel Hofmann
- School of Health Sciences and Graduate Studies, Curtin University, Bentley, Australia
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Aryeh Shander
- Department of Anesthesiology, Englewood Hospital and Medical Center, TeamHealth Research Institute New Jersey, Englewood, USA
| | - Craig French
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Kevin Murray
- School of Population and Global Health, The University of Western Australia, Perth, Australia
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8
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Mille FK, Badheka A, Yu P, Zhang X, Friedman DF, Kheir J, van den Bosch S, Cabrera AG, Lasa JJ, Katcoff H, Hu P, Borasino S, Hock K, Huskey J, Weller J, Kothari H, Blinder J. Red Blood Cell Transfusion After Stage I Palliation Is Associated With Worse Clinical Outcomes. J Am Heart Assoc 2020; 9:e015304. [PMID: 32390527 PMCID: PMC7660859 DOI: 10.1161/jaha.119.015304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/27/2020] [Indexed: 12/13/2022]
Abstract
Background Packed red blood cell transfusion may improve oxygen content in single-ventricle neonates, but its effect on clinical outcomes after Stage 1 palliation is unknown. Methods and Results Retrospective multicenter analysis of packed red blood cell transfusion exposures in neonates after Stage 1 palliation, excluding those with intraoperative mortality or need for extracorporeal membrane oxygenation. Transfusion practice variability was assessed, and multivariable regression used to identify transfusion risk factors. After propensity score adjustment for severity of illness, clinical outcomes were compared between transfused and nontransfused subjects. Of 396 subjects, 323 (82%) received 930 postoperative red blood cell transfusions. Packed red blood cell volume (median 9-42 mL/kg [P<0.0001]), donor exposures (1-2 [P<0.0001]), transfusion number (1-3 [P<0.0001]), and pretransfusion hemoglobin (12.1-13 g/dL, P=0.0049) varied between sites. Cyanosis (P=0.02), chest tube output (P=0.0003), and delayed sternal closure (P=0.0033) increased transfusion risk. Transfusion was associated with prolonged mechanical ventilation (6 [interquartile range 4, 12] versus 3 [1, 5] days, P=0.02) and intensive care unit stay (19 [12, 33] versus 9 [6, 19] days, P=0.016). When stratified by number of transfusions (0, 1, or >1), duration of mechanical ventilation (3 [1, 5] versus 4 [3, 6] versus 9 [5, 16] days [P<0.0001]) and intensive care unit stay (9 [6, 19] versus 13 [8, 25] versus 21 [13, 38] days [P<0.0001]) increased for those transfused more than once. Most subjects who died were transfused, though the association with mortality was not significant. Conclusions Packed red blood cell transfusion after Stage 1 palliation is common, and transfusion practice is variable. Transfusion is a significant predictor of longer intensive care unit stay and mechanical ventilation. Further studies to define evidence-based transfusion thresholds are warranted.
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Affiliation(s)
| | - Aditya Badheka
- University of Iowa Stead Family Children’s HospitalIowa CityIA
| | - Priscilla Yu
- University of Texas Southwestern Medical CenterDallasTX
| | - Xuemei Zhang
- The Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | | | | | | | | | | | | | - Paula Hu
- The Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | | | | | | | - Jamie Weller
- University of Texas Southwestern Medical CenterDallasTX
| | - Harsh Kothari
- University of Iowa Stead Family Children’s HospitalIowa CityIA
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9
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Callcut RA, Simpson KN, Baraniuk S, Fox EE, Tilley BC, Holcomb JB. Cost-effectiveness evaluation of the PROPPR trial transfusion protocols. Transfusion 2020; 60:922-931. [PMID: 32358836 PMCID: PMC7567498 DOI: 10.1111/trf.15784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period. STUDY DESIGN AND METHODS International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments. RESULTS The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained. CONCLUSION The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.
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Affiliation(s)
- Rachael A. Callcut
- Division of General Surgery, Department of Surgery, School of Medicine, University of California San Francisco, San Francisco, California
| | - Kit N. Simpson
- Department of Healthcare Leadership & Management, Medical University of South Carolina, Charleston, South Carolina
| | - Sarah Baraniuk
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - Erin E. Fox
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Barbara C. Tilley
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - John B. Holcomb
- Division of Acute Care Surgery, Department of Surgery, Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
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10
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Ming Y, Liu J, Zhang F, Chen C, Zhou L, Du L, Yan M. Transfusion of Red Blood Cells, Fresh Frozen Plasma, or Platelets Is Associated With Mortality and Infection After Cardiac Surgery in a Dose-Dependent Manner. Anesth Analg 2020; 130:e32. [PMID: 31702696 DOI: 10.1213/ane.0000000000004528] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND It is unclear whether transfusion of platelets or fresh frozen plasma, in addition to red blood cells, is associated with an increased risk of mortality and infection after cardiac surgery. METHODS Patients who underwent valve surgery and/or coronary artery bypass grafting from January 1, 2011 to June 30, 2017 and September 1, 2013 to June 30, 2017 at 2 centers performing cardiac surgery were included in this retrospective study. After stratifying patients based on propensity score matching, we compared rates of mortality and infection between patients who transfused red blood cells, fresh frozen plasma, or platelets with those who did not receive such transfusions. We also compared outcomes between patients who received any of the 3 blood products and patients who received no transfusions at all. Multivariable logistic regression was used to assess associations between transfusion and outcomes. RESULTS Of 8238 patients in this study, 109 (1.3%) died, 812 (9.9%) experienced infection, and 4937 (59.9%) received at least 1 type of blood product. Transfusion of any blood type was associated with higher rates of mortality (2.0% vs 0.18%; P < .01) and infection (13.3% vs 4.8%; P < .01). Each of the 3 blood products was independently associated with an increase in mortality per unit transfused (red blood cells, odds ratio 1.18, 95% confidence interval [CI], 1.14-1.22; fresh frozen plasma, odds ratio 1.24, 95% CI, 1.18-1.30; platelets, odds ratio 1.12, 95% CI, 1.07-1.18). Transfusing 3 units of any of the 3 blood products was associated with a dose-dependent increase in the incidence of mortality (odds ratio 1.88, 95% CI, 1.70-2.08) and infection (odds ratio 1.50, 95% CI, 1.43-1.57). CONCLUSIONS Transfusion of red blood cells, fresh frozen plasma, or platelets is an independent risk factor of mortality and infection, and combination of the 3 blood products is associated with adverse outcomes after cardiac surgery in a dose-dependent manner.
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Affiliation(s)
- Yue Ming
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jing Liu
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fengjiang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Changwei Chen
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Zhou
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lei Du
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
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11
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Contrella BN, Park AW, Wilkins LR, Sheeran D, Hassinger TE, Angle JF. Spontaneous Rectus Sheath Hematoma: Factors Predictive of Conservative Management Failure. J Vasc Interv Radiol 2020; 31:323-330. [PMID: 31734076 DOI: 10.1016/j.jvir.2019.06.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 06/03/2019] [Accepted: 06/10/2019] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To evaluate radiographic, laboratory, and clinical factors associated with conservative management (CM) failure in spontaneous rectus sheath hematoma (RSH). MATERIALS AND METHODS Retrospective review of 72 patients with spontaneous RSH between 2006 and 2017 was performed. Patients were initially managed conservatively and then divided into 2 groups based on decision to embolize. No differences were found between embolization (n = 32) and CM (n = 40) groups in age (67.5 vs 69.5 y; P = .79), sex (31% vs 38% male; P = .58), body mass index (27.7 vs 25.7 kg/m2; P = .20), or medical comorbidities. Univariate analyses compared initial hemoglobin level, change in hemoglobin level, coagulation parameters, transfusion requirements, hematoma volume, and active extravasation on computed tomographic (CT) angiography between groups. Multivariable logistic regression identified factors predictive of CM failure. A scoring system was then created to predict CM failure. RESULTS CM failed in 32 of 72 patients. Multivariable regression identified active extravasation on CT angiography (P = .02), hematoma volume (P = .01), and packed red blood cell (pRBC) transfusion of ≥ 4 U (P = .03) as predictors of embolization. A scoring system using these factors along with maximum rate of hemoglobin decrease yielded a sensitivity of 100% and specificity of 98% in determining need for embolization. CONCLUSIONS CM for RSH was more likely to fail in patients with active extravasation on CT angiography, larger hematoma volume, pRBC transfusion of ≥ 4 U, and higher rate of hemoglobin decrease. Using these parameters, a scoring system was created that achieved high sensitivity and specificity in identifying patients who would require embolization.
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Affiliation(s)
- Benjamin N Contrella
- Department of Radiology, University of Virginia, 1215 Lee Street, Charlottesville, VA 22908.
| | - Auh Whan Park
- Department of Radiology, University of Virginia, 1215 Lee Street, Charlottesville, VA 22908
| | - Luke R Wilkins
- Department of Radiology, University of Virginia, 1215 Lee Street, Charlottesville, VA 22908
| | - Daniel Sheeran
- Department of Radiology, University of Virginia, 1215 Lee Street, Charlottesville, VA 22908
| | - Taryn E Hassinger
- Department of Medical Imaging and Surgery, University of Virginia, 1215 Lee Street, Charlottesville, VA 22908
| | - J Fritz Angle
- Department of Radiology, University of Virginia, 1215 Lee Street, Charlottesville, VA 22908
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12
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Heafner T, Bews K, Kalra M, Oderich G, Colglazier J, Shuja F, Bower T, DeMartino R. Transfusion Timing and Postoperative Myocardial Infarction and Death in Patients Undergoing Common Vascular Procedures. Ann Vasc Surg 2019; 63:53-62. [PMID: 31626929 DOI: 10.1016/j.avsg.2019.08.090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/06/2019] [Accepted: 08/14/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Perioperative allogenic blood transfusions, specifically packed red bloods cells (pRBC), after vascular surgery procedures are modifiable risk factors that are associated with increased cardiovascular events and 30-day mortality. The aim of this study is to evaluate the effect of transfusion timing (intraoperative vs. postoperative) on the rate of postoperative myocardial infarction (POMI) and death. METHODS Six surgical and endovascular modules within the Vascular Quality Initiative (VQI) from 2013 to 2017 were reviewed at a single institution. Transfusion data on elective and urgent cases were abstracted and all patients who underwent inpatient procedures had routine postoperative troponin/ECG testing. The primary endpoint was POMI utilizing the American Heart Association's third universal definition for myocardial infarction. These criteria include the detection of a rise/and or fall of cTnT with at least one value above the 99th percentile and with at least one of the following 1) symptoms of acute myocardial ischemia, 2) new ischemic ECG changes, 3) development of pathological Q waves, 4) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with ischemic etiology. The secondary endpoint was 30-day all-cause mortality. Multivariable logistic regression analysis was utilized to evaluate the risk of transfusions on POMI and death. RESULTS We identified 1,154 cases for analysis (299 abdominal aortic aneurysm [EVAR], 117 infrainguinal bypasses, 127 open abdominal aortic aneurysm [AAA], 41 suprainguinal bypasses, 168 thoracic endovascular aortic repair [TEVAR], and 402 peripheral vascular interventions). Overall, the POMI rate was 2% and mortality 1%. Rates of POMI differed by procedure type (P = 0.04), where infrainguinal bypass had the highest rate of POMI at 4%. Death rates did not vary by type of procedure (P = 0.89). Mean number of intraoperative pRBC and postoperative pRBC transfusion was higher for patients with POMI (intraop: 1.3 vs. 0.3, postop: 1.8 vs. 0.4, both P < 0.01) and death (intraop: 1.4 vs. 0.3, postop: 2.5 vs. 0.4, both P < 0.01). In addition, older age and coronary artery disease (CAD) were associated with POMI on univariate analysis. On multivariable analysis for POMI, CAD (odds ratio [OR] = 5.15, 95% confidence interval [CI] [2.00-13.24], P < 0.001), receiving both an intraoperative and postoperative transfusion (OR = 6.20, 95% CI [1.78-21.55], P < 0.01) as well as a postoperative transfusion only (OR = 5.70, 95% CI [1.81-17.94], P < 0.01) compared to no transfusion were associated with higher odds of POMI; however intraoperative transfusion only was not (OR = 3.42, 95% CI [0.88-13.31], P = 0.08). On multivariable analysis, increasing age of the patient was associated with higher odds of death (OR = 1.08, 95% CI [1.01-1.15], P = 0.02) and statin use was highly protective (OR = 0.27, 95% CI [0.10-0.74], P = 0.01), but any intraoperative or postoperative transfusion compared to no transfusion was not associated with death after adjustment. CONCLUSIONS In our series with routine postoperative troponin screening in the inpatient setting, the use of an isolated postoperative transfusion as well as cases requiring both an intraoperative and postoperative transfusion was associated with POMI. However, isolated intraoperative transfusion was not associated with POMI, and we did not identify an association of transfusion with 30-day mortality. These data suggest that the perioperative setting of transfusions is important in its impact on postoperative outcomes and needs to be accounted for when evaluating transfusion outcomes and indications.
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Affiliation(s)
- Thomas Heafner
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
| | | | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Gustavo Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Thomas Bower
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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13
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Trentino KM, Farmer SL, Sanfilippo FM, Leahy MF, Isbister J, Mayberry R, Hofmann A, Murray K. Systematic reviews and meta-analyses comparing mortality in restrictive and liberal haemoglobin thresholds for red cell transfusion: protocol for an overview of systematic reviews. BMJ Open 2019; 9:e029828. [PMID: 31446415 PMCID: PMC6719757 DOI: 10.1136/bmjopen-2019-029828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION There has been a significant increase in the number of systematic reviews and meta-analyses of randomised controlled trials investigating thresholds for red blood cell transfusion. To systematically collate, appraise and synthesise the results of these systematic reviews and meta-analyses, we will conduct an overview of systematic reviews. METHODS AND ANALYSIS This is a protocol for an overview of systematic reviews. We will search five databases: MEDLINE, Embase, Web of Science Core Collection, PubMed (for prepublication, in process and non-Medline records) and Google Scholar. We will consider systematic reviews and meta-analyses of randomised controlled trials evaluating the effect of haemoglobin thresholds for red blood cell transfusion on mortality. Two authors will independently screen titles and abstracts retrieved in the literature search and select studies meeting the eligibility criteria for full-text review. We will extract data onto a predefined form designed to summarise the key characteristics of each review. We will assess the methodological quality of included reviews and the quality of evidence in included reviews. ETHICS AND DISSEMINATION Formal ethics approval is not required for this overview as we will only analyse published literature. The findings of this study will be presented at relevant conferences and submitted for peer-review publication. The results are likely to be used by clinicians, policy makers and developers of clinical guidelines and will inform suggestions for future systematic reviews and randomised controlled trials. PROSPERO REGISTRATION NUMBER CRD42019120503.
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Affiliation(s)
- Kevin M Trentino
- School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
- Data and Digital Innovation, East Metropolitan Health Service, Perth, Western Australia, Australia
| | - Shannon L Farmer
- Medical School and Division of Surgery, The University of Western Australia, Crawley, Western Australia, Australia
- School of Health Sciences and Graduate Studies, Curtin University, Curtin, Western Australia, Australia
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Michael F Leahy
- Department of Haematology, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- School of Medicine and Pharmacology, The University of Western Australia, Crawley, Western Australia, Australia
| | - James Isbister
- Northern Clinical School, Sydney Medical School, St Leonards, New South Wales, Australia
| | - Rhonda Mayberry
- Library and Information Service, South Metropolitan Health Service, Murdoch, Western Australia, Australia
| | - Axel Hofmann
- Medical School and Division of Surgery, The University of Western Australia, Crawley, Western Australia, Australia
- School of Health Sciences and Graduate Studies, Curtin University, Curtin, Western Australia, Australia
- Institute of Anesthesiology, Universitat Zurich, Zurich, Switzerland
| | - Kevin Murray
- School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
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14
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Wedel C, Møller CM, Budtz-Lilly J, Eldrup N. Red blood cell transfusion associated with increased morbidity and mortality in patients undergoing elective open abdominal aortic aneurysm repair. PLoS One 2019; 14:e0219263. [PMID: 31295273 PMCID: PMC6623955 DOI: 10.1371/journal.pone.0219263] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 06/19/2019] [Indexed: 01/28/2023] Open
Abstract
Background Red blood cell (RBC) transfusions are associated with increased mortality and morbidity. The aim of this analysis was to examine the association between RBC transfusions and long-term survival for patients undergoing elective open infrarenal abdominal aortic aneurysm (AAA) repair with up to 15 years of follow-up. Methods Prospective cohort study using data from The Danish Vascular Registry from 2000–2015. Primary endpoint was all-cause mortality. Secondary endpoints were in-hospital complications. Transfused patients were divided into subgroups based on received RBC transfusions (1, 2–3, 4–5 or > 5). Using Cox regression multi-adjusted analysis, non-transfused patients were compared to transfused patients (1, 2–3, 4–5, >5 transfusions) for both primary and secondary endpoints. Results There were 3 876 patients included with a mean survival of 9.1 years. There were 801 patients who did not receive transfusions. Overall 30-day mortality was 3.1% (121 patients) and 3.6% (112) for all transfused patients. For the five subgroups 30-day mortality was: No transfusions 1.1% (9 patients), 1 RBC 1.2% (4 patients), 2–3 RBC 2.2% (26 patients), 4–5 RBC 1.9% (14 patients) and > 5 RBC 7.9% (68 patients). After receiving RBCs, the hazard ratio for death was 1.54 (95% CI 1.27–1.85) compared to non-transfused patients. There was a significant increase in mortality when receiving 2–3 RBC: HR 1.32 (95% CI 1.07–1.62), 4–5 RBC: 1.64 (1.32–2.03) and >5 RBC: 1.96 (1.27–1.85) in a multi-adjusted model. Conclusion There is a dose-dependent association between RBC transfusions received during elective AAA repair and an increase in short- and long-term mortality. Approximately 25% of included patients had preoperative anemia. These findings should raise awareness regarding potentially unnecessary and harmful RBC transfusions.
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Affiliation(s)
- Charlotte Wedel
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- * E-mail:
| | - Cecilie M. Møller
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jacob Budtz-Lilly
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Nikolaj Eldrup
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Danish Vascular Registry, Aarhus University Hospital, Aarhus, Denmark
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15
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Edgren G, Murphy EL, Brambilla DJ, Westlake M, Rostgaard K, Lee C, Cable RG, Triulzi D, Bruhn R, St. Lezin EM, Erikstrup C, Ullum H, Glynn SA, Kleinman S, Hjalgrim H, Roubinian NH. Association of Blood Donor Sex and Prior Pregnancy With Mortality Among Red Blood Cell Transfusion Recipients. JAMA 2019; 321:2183-2192. [PMID: 31184739 PMCID: PMC6563535 DOI: 10.1001/jama.2019.7084] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Evidence regarding associations of blood donor sex with mortality among red blood cell transfusion recipients is conflicting. OBJECTIVE To study associations of donor sex and prior pregnancy with mortality of transfusion recipients. DESIGN, SETTING, AND PARTICIPANTS Data from 3 retrospective cohorts of transfusion recipients (the Kaiser Permanente Northern California [KPNC] and Recipient Epidemiology and Donor Evaluation Study-III [REDS-III] databases of data from January 2013 to December 2016 and the Scandinavian Donations and Transfusions [SCANDAT] database with data from January 2003 to December 2012) were analyzed. Final dates of follow-up were December 31, 2016, for the KPNC and REDS-III cohorts and December 31, 2012, for the SCANDAT cohort. Stratified Cox regression models were used to estimate associations between donor exposure groups with risk of mortality, adjusting for the number of red blood cell unit transfusions. EXPOSURES The number of transfused red blood cell units from female donors, previously pregnant donors, and sex-discordant donors (male donor and female recipient or female donor and male recipient). MAIN OUTCOMES AND MEASURES In-hospital mortality. RESULTS The study population included 34 662 patients (mean age, 69 years; 18 652 [54%] women) from the KPNC cohort, 93 724 patients (mean age, 61 years; 48 348 [52%] women) from the REDS-III cohort, and 918 996 patients (mean age, 72 years; 522 239 [57%] women) from the SCANDAT cohort. The median number of red blood cell transfusions per patient was 3 in the KPNC cohort, 2 in the REDS-III cohort, and 3 in the SCANDAT cohort. The percentage of transfusions from previously pregnant or parous donors was 9% in the KPNC cohort, 18% in the REDS-III cohort, and 25% in the SCANDAT cohort. The percentage of transfusions in the 3 cohorts from female donors ranged from 39% to 43%, from previously pregnant or parous donors ranged from 9% to 25%, and from sex-discordant donors ranged from 44% to 50%. There were 3217 in-hospital deaths in the KPNC cohort, 8519 in the REDS-III cohort, and 198 537 in the SCANDAT cohort. There were no statistically significant associations between any of the 3 donor exposures and in-hospital mortality in the 3 cohorts. Hazard ratios for in-hospital mortality per transfused unit from female donors were 0.99 (95% CI, 0.96-1.03) for the KPNC cohort, 1.00 (95% CI, 0.99-1.01) for the REDS-III cohort, and 1.00 (95% CI, 0.99-1.00) for the SCANDAT cohort. For units from previously pregnant or parous female donors, hazard ratios were 1.00 (95% CI, 1.00-1.01) for the KPNC cohort, 1.01 (95% CI, 0.98-1.03) for the REDS-III cohort, and 1.00 (95% CI, 1.00-1.01) for the SCANDAT cohort. For units from sex-discordant transfusions, hazard ratios were 1.02 (95% CI, 0.99-1.05) for the KPNC cohort, 0.99 (95% CI, 0.98-1.00) for the REDS-III cohort, and 1.00 (95% CI, 0.99-1.00) for the SCANDAT cohort. CONCLUSIONS AND RELEVANCE Among red blood cell transfusion recipients, transfusions from female, previously pregnant, or sex-discordant donors were not significantly associated with increased mortality.
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Affiliation(s)
- Gustaf Edgren
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Edward L. Murphy
- Vitalant Research Institute, San Francisco, California
- Department of Laboratory Medicine, University of California San Francisco
| | | | | | - Klaus Rostgaard
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Catherine Lee
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Darrell Triulzi
- Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
| | - Roberta Bruhn
- Vitalant Research Institute, San Francisco, California
| | - Elizabeth M. St. Lezin
- Department of Laboratory Medicine, University of California San Francisco
- Veterans Affairs Healthcare System, San Francisco, California
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Ullum
- Department of Clinical Immunology, the Blood Bank, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Simone A. Glynn
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Henrik Hjalgrim
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nareg H. Roubinian
- Vitalant Research Institute, San Francisco, California
- Department of Laboratory Medicine, University of California San Francisco
- Division of Research, Kaiser Permanente Northern California, Oakland
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16
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Shah A, Brunskill SJ, Desborough MJR, Doree C, Trivella M, Stanworth SJ. Transfusion of red blood cells stored for shorter versus longer duration for all conditions. Cochrane Database Syst Rev 2018; 12:CD010801. [PMID: 30578732 PMCID: PMC6516801 DOI: 10.1002/14651858.cd010801.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Red blood cell (RBC) transfusion is a common treatment for anaemia in many conditions. The safety and efficacy of transfusing RBC units that have been stored for different durations before a transfusion is a current concern. The duration of storage for a RBC unit can be up to 42 days. If evidence from randomised controlled trials (RCT) were to indicate that clinical outcomes are affected by storage duration, the implications for inventory management and clinical practice would be significant. OBJECTIVES To assess the effects of using red blood cells (RBCs) stored for a shorter versus a longer duration, or versus RBCs stored for standard practice duration, in people requiring a RBC transfusion. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PubMed (for epublications), LILACS, Transfusion Evidence Library, Web of Science CPCI-S and four international clinical trial registries on 20 November 2017. SELECTION CRITERIA We included RCTs that compared transfusion of RBCs of shorter versus longer storage duration, or versus standard practice storage duration. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. MAIN RESULTS We included 22 trials (42,835 participants) in this review.The GRADE quality of evidence ranged from very low to moderate for our primary outcome of in-hospital and short-term mortality reported at different time points.Transfusion of RBCs of shorter versus longer storage duration Eleven trials (2249 participants) compared transfusion of RBCs of shorter versus longer storage duration. Two trials enrolled low birth weight neonates, two enrolled children with severe anaemia secondary to malaria or sickle cell disease, and eight enrolled adults across a range of clinical settings (intensive care, cardiac surgery, major elective surgery, hospitalised in-patients, haematology outpatients). We judged only two trials to be at low risk of bias across all domains; most trials had an unclear risk for multiple domains.Transfusion of RBCs of shorter versus longer storage duration probably leads to little or no difference in mortality at seven-day follow-up (risk ratio (RR) 1.42, 95% confidence interval (CI) 0.66 to 3.06; 1 trial, 3098 participants; moderate quality evidence) or 30-day follow-up (RR 0.85, 95%CI 0.50 to 1.45; 2 trials, 1121 participants; moderate quality evidence) in adults undergoing major elective cardiac or non-cardiac surgery.For neonates, no studies reported on the primary outcome of in-hospital or short-term mortality. At 40 weeks gestational age, the effect of RBCs of shorter versus longer storage duration on the risk of death was uncertain, as the quality of evidence is very low (RR 0.90, 95% CI 0.41 to 1.85; 1 trial, 52 participants).The effect of RBCs of shorter versus longer storage duration on the risk of death in children with severe anaemia was also uncertain within 24 hours of transfusion (RR 1.50, 95% CI 0.43 to 5.25; 2 trials, 364 participants; very low quality evidence), or at 30-day follow-up (RR 1.40, 95% CI 0.45 to 4.31; 1 trial, 290 participants; low quality evidence).Only one trial, in children with severe anaemia (290 participants), reported adverse transfusion reactions. Only one child in each arm experienced an adverse reaction within 24 hours of transfusion.Transfusion of RBCs of shorter versus standard practice storage duration Eleven trials (40,588 participants) compared transfusion of RBCs of shorter versus standard practice storage duration. Three trials enrolled critically ill term neonates; two of these enrolled very low birth weight neonates. There were no trials in children. Eight trials enrolled critically ill and non-critically ill adults, with most being hospitalised. We judged four trials to be at low risk of bias across all domains with the others having an unclear risk of bias across multiple domains.Transfusion of RBCs of shorter versus standard practice storage duration probably leads to little or no difference in adult in-hospital mortality (RR 1.05, 95% CI 0.97 to 1.14; 4 trials, 25,704 participants; moderate quality evidence), ICU mortality (RR 1.06, 95% CI 0.98 to 1.15; 3 trials, 13,066 participants; moderate quality evidence), or 30-day mortality (RR 1.04, 95% CI 0.96 to 1.13; 4 trials, 7510 participants;moderate quality evidence).Two of the three trials that enrolled neonates reported that there were no adverse transfusion reactions. One trial reported an isolated case of cytomegalovirus infection in participants assigned to the standard practice storage duration group. Two trials in critically ill adults reported data on transfusion reactions: one observed no difference in acute transfusion reactions between arms (RR 0.67, 95% CI 0.19 to 2.36, 2413 participants), but the other observed more febrile nonhaemolytic reactions in the shorter storage duration arm (RR 1.48, 95% CI 1.13 to 1.95, 4919 participants).Trial sequential analysis showed that we may now have sufficient evidence to reject a 5% relative risk increase or decrease of death within 30 days when transfusing RBCs of shorter versus longer storage duration across all patient groups. AUTHORS' CONCLUSIONS The effect of storage duration on clinically important outcomes has now been investigated in large, high quality RCTs, predominantly in adults. There appears to be no evidence of an effect on mortality that is related to length of storage of transfused RBCs. However, the quality of evidence in neonates and children is low. The current practice in blood banks of using the oldest available RBCs can be continued safely. Additional RCTs are not required, but research using alternative study designs, should focus on particular subgroups (e.g. those requiring multiple RBC units) and on factors affecting RBC quality.
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Affiliation(s)
- Akshay Shah
- University of OxfordRadcliffe Department of MedicineOxfordUK
| | - Susan J Brunskill
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | | | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
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17
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Lu Q, Zhang J, Gao WM, Lv Y, Zhang XF, Liu XM. Intraoperative Blood Transfusion and Postoperative Morbidity Following Liver Resection. Med Sci Monit 2018; 24:8469-8480. [PMID: 30470732 PMCID: PMC6270889 DOI: 10.12659/msm.910978] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 07/24/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Blood transfusion is common during liver resection (LR). The objective of the present study was to investigate the effects of intraoperative transfusion of different blood components on post-LR morbidity. MATERIAL AND METHODS We included 610 patients undergoing LR and grouped them according to intraoperative transfusion of different blood components: packed red blood cells only (PRBC, n=81); frozen fresh plasma, platelets, and cryoprecipitate (FPC, n=38); transfusion only with PRBC + FPC transfusion (n=244); and no blood transfusion (n=247). Propensity score matching (PSM) analysis was used to mitigate selection bias in comparisons. RESULTS The overall blood transfusion rate was 59.5%. In comparison with the no blood transfusion group, PRBC-only and PRBC + FPC transfusion were more common in patients with lower preoperative hemoglobin, worse liver function, larger tumor size, and undergoing a major LR, and thus were associated with increased postoperative morbidity. In contrast, FPC-only transfusion was more frequent in patients with a liver function of Child-Pugh B and lower preoperative albumin vs. the no blood transfusion group. In the propensity model, transfusion of PRBC (PRBC-only and PRBC+FPC) and FPC (FPC-only and FPC+PRBC) were significantly associated with increased postoperative complications vs. the no blood transfusion group (OR and 95% CI, 1.9 [1.2-2.7], p=0.002; OR and 95% CI, 1.6 [1.0-2.4], p=0.029). In contrast, intraoperative PRBC-only or FPC-only transfusion showed no significant adverse effects on postoperative morbidity. CONCLUSIONS Allogenic transfusion of PRBC and FPC blood components was associated with increased postoperative morbidity after liver surgery. Different blood components should be used only when absolutely necessary.
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Affiliation(s)
- Qiang Lu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
- Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Jing Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
- Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Wei-Man Gao
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
- Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Yi Lv
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
- Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Xu-Feng Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
- Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Xue-Min Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
- Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
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18
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Yu AJ, Inaba K, Biswas S, de Leon LA, Wong M, Benjamin E, Lam L, Demetriades D. Supermassive Transfusion: A 15-Year Single Center Experience and Outcomes. Am Surg 2018; 84:1617-1621. [PMID: 30747681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The objective of this study was to determine the survival outcome associated with large-volume blood transfusion after trauma. This was a retrospective study at a Level I trauma center from January 2000 to December 2014 that included trauma patients who received ≥25 units packed red blood cell (pRBC) within the first 24 hours of hospital admission. Univariate and multivariable logistic regressions identified risk factors for mortality. Receiver operating characteristic curve analysis evaluated the ability of pRBC volume to predict mortality. Among 74,065 adults (≥18 years old), 178 patients (0.24%) received ≥25 units of pRBC in the first 24 hours, of which 142 (79.8%) received 25 to 49 units, 28 (15.7%) received 50 to 74 units, and 8 (4.5%) received ≥75 units. Overall, 92.2 per cent were male, mean age 33.9 (±14.0), mean Injury Severity Score 28.9 (±14.3), and median Glasgow Coma Scale score 12 (3-15). The overall mortality was 65.2 per cent and 64.1 per cent for those receiving 25 to 49 units, 64.3 per cent for 50 to 74 units, and 87.5 per cent for ≥75 units. In univariate analysis, female gender was associated with lower mortality [odds ratio (OR) 0.24, P = 0.025]. Decreasing Glasgow Coma Scale (OR 0.82, P < 0.001), increasing Injury Severity Score (OR 1.07, P < 0.001), and thoracotomy (OR 3.91, P < 0.001) were associated with higher mortality. There was no transfusion cutoff that was significantly associated with higher mortality.
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Affiliation(s)
- Alison J Yu
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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19
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Cooper DJ, McQuilten ZK, Nichol A, Ady B, Aubron C, Bailey M, Bellomo R, Gantner D, Irving DO, Kaukonen KM, McArthur C, Murray L, Pettilä V, French C. Age of Red Cells for Transfusion and Outcomes in Critically Ill Adults. N Engl J Med 2017; 377:1858-1867. [PMID: 28952891 DOI: 10.1056/nejmoa1707572] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is uncertain whether the duration of red-cell storage affects mortality after transfusion among critically ill adults. METHODS In an international, multicenter, randomized, double-blind trial, we assigned critically ill adults to receive either the freshest available, compatible, allogeneic red cells (short-term storage group) or standard-issue (oldest available), compatible, allogeneic red cells (long-term storage group). The primary outcome was 90-day mortality. RESULTS From November 2012 through December 2016, at 59 centers in five countries, 4994 patients underwent randomization and 4919 (98.5%) were included in the primary analysis. Among the 2457 patients in the short-term storage group, the mean storage duration was 11.8 days. Among the 2462 patients in the long-term storage group, the mean storage duration was 22.4 days. At 90 days, there were 610 deaths (24.8%) in the short-term storage group and 594 (24.1%) in the long-term storage group (absolute risk difference, 0.7 percentage points; 95% confidence interval [CI], -1.7 to 3.1; P=0.57). At 180 days, the absolute risk difference was 0.4 percentage points (95% CI, -2.1 to 3.0; P=0.75). Most of the prespecified secondary measures showed no significant between-group differences in outcome. CONCLUSIONS The age of transfused red cells did not affect 90-day mortality among critically ill adults. (Funded by the Australian National Health and Medical Research Council and others; TRANSFUSE Australian and New Zealand Clinical Trials Registry number, ACTRN12612000453886 ; ClinicalTrials.gov number, NCT01638416 .).
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Affiliation(s)
- D James Cooper
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Zoe K McQuilten
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Alistair Nichol
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Bridget Ady
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Cécile Aubron
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Michael Bailey
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Rinaldo Bellomo
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Dashiell Gantner
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - David O Irving
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Kirsi-Maija Kaukonen
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Colin McArthur
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Lynne Murray
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Ville Pettilä
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Craig French
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
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Caram-Deelder C, Kreuger AL, Evers D, de Vooght KMK, van de Kerkhof D, Visser O, Péquériaux NCV, Hudig F, Zwaginga JJ, van der Bom JG, Middelburg RA. Association of Blood Transfusion From Female Donors With and Without a History of Pregnancy With Mortality Among Male and Female Transfusion Recipients. JAMA 2017; 318:1471-1478. [PMID: 29049654 PMCID: PMC5817970 DOI: 10.1001/jama.2017.14825] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Transfusion of red blood cells from female donors has been associated with increased mortality in male recipients. OBJECTIVE To quantify the association between red blood cell transfusion from female donors with and without a history of pregnancy and mortality of red blood cell recipients. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of first-time transfusion recipients at 6 major Dutch hospitals enrolled from May 30, 2005, to September 1, 2015; the final follow-up date was September 1, 2015. The primary analysis was the no-donor-mixture cohort (ie, either all red blood cell transfusions exclusively from male donors, or all exclusively from female donors without a history of pregnancy, or all exclusively from female donors with a history of pregnancy). The association between mortality and exposure to transfusions from ever-pregnant or never-pregnant female donors was analyzed using life tables and time-varying Cox proportional hazards models. EXPOSURES Red blood cell transfusions from ever-pregnant or never-pregnant female donors, compared with red blood cell transfusions from male donors. MAIN OUTCOMES AND MEASURES All-cause mortality during follow-up. RESULTS The cohort for the primary analyses consisted of 31 118 patients (median age, 65 [interquartile range, 42-77] years; 52% female) who received 59 320 red blood cell transfusions exclusively from 1 of 3 types of donors (88% male; 6% ever-pregnant female; and 6% never-pregnant female). The number of deaths in this cohort was 3969 (13% mortality). For male recipients of red blood cell transfusions, all-cause mortality rates after a red blood cell transfusion from an ever-pregnant female donor vs male donor were 101 vs 80 deaths per 1000 person-years (time-dependent "per transfusion" hazard ratio [HR] for death, 1.13 [95% CI, 1.01-1.26]). For receipt of transfusion from a never-pregnant female donor vs male donor, mortality rates were 78 vs 80 deaths per 1000 person-years (HR, 0.93 [95% CI, 0.81-1.06]). Among female recipients of red blood cell transfusions, mortality rates for an ever-pregnant female donor vs male donor were 74 vs 62 per 1000 person-years (HR, 0.99 [95% CI, 0.87 to 1.13]); for a never-pregnant female donor vs male donor, mortality rates were 74 vs 62 per 1000 person-years (HR, 1.01 [95% CI, 0.88-1.15]). CONCLUSIONS AND RELEVANCE Among patients who received red blood cell transfusions, receipt of a transfusion from an ever-pregnant female donor, compared with a male donor, was associated with increased all-cause mortality among male recipients but not among female recipients. Transfusions from never-pregnant female donors were not associated with increased mortality among male or female recipients. Further research is needed to replicate these findings, determine their clinical significance, and identify the underlying mechanism.
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Affiliation(s)
- Camila Caram-Deelder
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Aukje L. Kreuger
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Dorothea Evers
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Centre, Leiden, the Netherlands
| | - Karen M. K. de Vooght
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daan van de Kerkhof
- Department of Clinical Chemistry and Haematology, Catharina Hospital, Eindhoven, the Netherlands
| | - Otto Visser
- Department of Haematology, VU Medical Center, Amsterdam, the Netherlands
| | - Nathalie C. V. Péquériaux
- Department of Clinical Chemistry and Haematology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, the Netherlands
| | | | - Jaap Jan Zwaginga
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Centre, Leiden, the Netherlands
| | - Johanna G. van der Bom
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rutger A. Middelburg
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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21
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Leahy MF, Trentino KM, May C, Swain SG, Chuah H, Farmer SL. Blood use in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation: the impact of a health system-wide patient blood management program. Transfusion 2017; 57:2189-2196. [PMID: 28671296 DOI: 10.1111/trf.14191] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 04/23/2017] [Accepted: 04/24/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Little is published on patient blood management (PBM) programs in hematology. In 2008 Western Australia announced a health system-wide PBM program with PBM staff appointments commencing in November 2009. Our aim was to assess the impact this program had on blood utilization and patient outcomes in intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation. STUDY DESIGN AND METHODS A retrospective study of 695 admissions at two tertiary hospitals receiving intensive chemotherapy for acute leukemia or undergoing hematopoietic stem cell transplantation between July 2010 and December 2014 was conducted. Main outcomes included pre-red blood cell (RBC) transfusion hemoglobin (Hb) levels, single-unit RBC transfusions, number of RBC and platelet (PLT) units transfused per admission, subsequent day case transfusions, length of stay, serious bleeding, and in-hospital mortality. RESULTS Over the study period, the mean RBC units transfused per admission decreased 39% from 6.1 to 3.7 (p < 0.001), and the mean PLT units transfused decreased 35% from 6.3 to 4.1 (p < 0.001), with mean RBC and PLT units transfused for follow-up day cases decreasing from 0.6 to 0.4 units (p < 0.001). Mean pre-RBC transfusion Hb level decreased from 8.0 to 6.8 g/dL (p < 0.001), and single-unit RBC transfusions increased 39% to 67% (p < 0.001). This reduction represents blood product cost savings of AU$694,886 (US$654,007). There were no significant changes in unadjusted or adjusted length of stay, serious bleeding events, or in-hospital mortality over the study. CONCLUSION The health system-wide PBM program had a significant impact, reducing blood product use and costs without increased morbidity or mortality in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation.
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Affiliation(s)
- Michael F Leahy
- School of Medicine and Pharmacology
- Department of Haematology
- PathWest Laboratory Medicine, Royal Perth Hospital
| | | | | | - Stuart G Swain
- Business Intelligence Unit, South Metropolitan Health Service
| | | | - Shannon L Farmer
- School of Surgery, Faculty of Medicine Dentistry and Health Sciences, The University of Western Australia
- Centre for Population Health Research, Faculty of Health, Sciences, Curtin University, Perth, Western Australia, Australia
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22
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Bennett S, Baker LK, Martel G, Shorr R, Pawlik TM, Tinmouth A, McIsaac DI, Hébert PC, Karanicolas PJ, McIntyre L, Turgeon AF, Barkun J, Fergusson D. The impact of perioperative red blood cell transfusions in patients undergoing liver resection: a systematic review. HPB (Oxford) 2017; 19:321-330. [PMID: 28161216 DOI: 10.1016/j.hpb.2016.12.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/16/2016] [Accepted: 12/30/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver resection is associated with a high proportion of red blood cell transfusions. There is a proposed association between perioperative transfusions and increased risk of complications and tumor recurrence. This study reviews the evidence of this association in the literature. METHODS The Medline, EMBASE, and Cochrane databases were searched for clinical trials or observational studies of patients undergoing liver resection that compared patients who did and did not receive a perioperative red blood cell transfusion. Outcomes were mortality, complications, and cancer survival. RESULTS Twenty-two studies involving 6832 patients were included. All studies were retrospective, with no clinical trials. No studies were scored as low risk of bias. The overall proportion of patients transfused was 38.3%. After multivariate analysis, 1 of 5 studies demonstrated an association between transfusion and increased mortality; 5 of 6 demonstrated an association between transfusion and increased complications; and 10 of 18 demonstrated an association between transfusion and decreased cancer survival. CONCLUSION This review supports the evidence linking perioperative blood transfusions to negative outcomes. The most convincing association was with post-operative complications, some association with long-term cancer outcomes, and no convincing association with mortality. These findings support the initiation, and further study, of restrictive transfusion protocols.
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Affiliation(s)
- Sean Bennett
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Laura K Baker
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital, Ottawa, ON, Canada
| | - Guillaume Martel
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Alan Tinmouth
- The Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Daniel I McIsaac
- The Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Anesthesiology, University of Ottawa, Ottawa, ON, Canada
| | - Paul C Hébert
- Department of Medicine, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | | | - Lauralyn McIntyre
- The Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology, Université Laval, Québec, QC, Canada
| | - Jeffrey Barkun
- Department of Surgery, McGill University, Montréal, QC, Canada
| | - Dean Fergusson
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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23
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Pieri M, Nardelli P, De Luca M, Landoni G, Frassoni S, Melissano G, Zangrillo A, Chiesa R, Monaco F. Predicting the Need for Intra-operative Large Volume Blood Transfusions During Thoraco-abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2017; 53:347-353. [PMID: 28089084 DOI: 10.1016/j.ejvs.2016.12.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 12/05/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Thoraco-abdominal aortic aneurysm (TAAA) repair is a complex procedure performed in patients at high cardiovascular risk. High volume intra-operative bleeding is often recorded, and the amount of intra-operative blood product transfusion is associated with relevant morbidity and mortality. The aim of the study was to identify pre-operative predictors of intra-operative large volume blood transfusions (LVBT) to stratify patients pre-operatively. METHODS This was a retrospective analysis of prospectively collected data of all patients who underwent open TAAA surgery at San Raffaele Scientific Institute from January 2009 to December 2015. Intra-operative red blood cell (RBC) transfusions were administered to maintain a hematocrit of at least 30%. A LVBT was defined as a transfusion of at least four RBC units, corresponding to 1000 mL. RESULTS The study population included 428 patients: 260 (61%) received fewer than 4 RBC units, and 168 (39%) were transfused with at least 4 RBC units. In patients who underwent LVBT, higher mortality was observed after surgery (p=.003), longer intensive care unit admission (p=.004), and longer mechanical ventilation compared with less transfused patients (p=.0002). The patients who received fewer units were administered a higher dose of heparin during the surgical operation compared with patients of the LVBT group: 3400±1100 vs. 2900±1300 IU (international units) (p=.0004). Pre-operative chronic renal failure (OR 1.8), the pre-operative haemoglobin value (OR 0.8), and the need for urgent or emergent surgery (OR 3.15) were independent predictors of LVBT on multivariate analysis. CONCLUSIONS The identification of patients at risk of intra-operative LVBT during TAAA surgery is critical as these patients experience a worse outcome. Nevertheless, only few independent predictors are available for clinical practice.
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Affiliation(s)
- M Pieri
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - P Nardelli
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - M De Luca
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - G Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - S Frassoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - G Melissano
- Department of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - A Zangrillo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - R Chiesa
- Department of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - F Monaco
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Wu HP, Lin CL, Chang YC, Wu KH, Lei RL, Peng CT, Weng T, Tai YM, Chao YH. Survival and complication rates in patients with thalassemia major in Taiwan. Pediatr Blood Cancer 2017; 64:135-138. [PMID: 27571924 DOI: 10.1002/pbc.26181] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/08/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND While transfusion and iron chelation therapy for thalassemia major (TM) has improved dramatically in recent years, the consequences of this improvement (current rates of survival and TM-related complications) remain unknown. METHODS This nationwide population-based cohort study analyzed 2007-2011 data obtained from the Taiwanese National Health Insurance Research Database. RESULTS After excluding those patients receiving hematopoietic stem cell transplantation, we enrolled 454 patients with TM who received transfusion and chelation therapy (median age, 17.2 years). Among these patients, the mortality rate was 2.9% in 2007, 2.3% in 2008, 2.9% in 2009, 2.6% in 2010, and 0.7% in 2011. Heart was the most common target organ of TM-related complications. There were 80 patients (17.6%) with arrhythmia and 86 patients (18.9%) with congestive heart failure. Dysfunction of endocrine organs was common, and the most common endocrinopathy was hypogonadism (23.1%), followed by diabetes (21.2%). There were 75 patients (16.5%) with liver cirrhosis and 79 patients (17.4%) with osteoporosis. CONCLUSIONS Adequate red blood cell transfusion and iron chelation is available to all patients with TM in Taiwan under the universal health insurance system, and has resulted in reduction of TM-related mortality to very low levels. As these patients get older, early detection of complications and adequate intervention are important to quality-of-life improvement.
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Affiliation(s)
- Han-Ping Wu
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Yin-Chen Chang
- Division of Pediatric Hematology-Oncology, Children's Hospital, China Medical University, Taichung, Taiwan
| | - Kang-Hsi Wu
- Division of Pediatric Hematology-Oncology, Children's Hospital, China Medical University, Taichung, Taiwan
- School of Post-Baccalaureate Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Rouh-Lih Lei
- Department of Nursing, College of Medicine and Nursing, Hungkuang University, Taichung, Taiwan
| | - Ching-Tien Peng
- Division of Pediatric Hematology-Oncology, Children's Hospital, China Medical University, Taichung, Taiwan
- Department of Biotechnology and Bioinformatics, Asia University, Taichung, Taiwan
| | - Tefu Weng
- Division of Pediatric Hematology-Oncology, Children's Hospital, China Medical University, Taichung, Taiwan
| | - Yu-Man Tai
- Division of Pediatric Hematology-Oncology, Children's Hospital, China Medical University, Taichung, Taiwan
| | - Yu-Hua Chao
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
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25
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English SW, Fergusson D, Chassé M, Turgeon AF, Lauzier F, Griesdale D, Algird A, Kramer A, Tinmouth A, Lum C, Sinclair J, Marshall S, Dowlatshahi D, Boutin A, Pagliarello G, McIntyre LA. Aneurysmal SubArachnoid Hemorrhage-Red Blood Cell Transfusion And Outcome (SAHaRA): a pilot randomised controlled trial protocol. BMJ Open 2016; 6:e012623. [PMID: 27927658 PMCID: PMC5168610 DOI: 10.1136/bmjopen-2016-012623] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Anaemia is common in aneurysmal subarachnoid haemorrhage (aSAH) and is a potential critical modifiable factor affecting secondary injury. Despite physiological evidence and management guidelines that support maintaining a higher haemoglobin level in patients with aSAH, current practice is one of a more restrictive approach to transfusion. The goal of this multicentre pilot trial is to determine the feasibility of successfully conducting a red blood cell (RBC) transfusion trial in adult patients with acute aSAH and anaemia (Hb ≤100 g/L), comparing a liberal transfusion strategy (Hb ≤100 g/L) with a restrictive strategy (Hb ≤80 g/L) on the combined rate of death and severe disability at 12 months. METHODS Design This is a multicentre open-label randomised controlled pilot trial at 5 academic tertiary care centres. Population We are targeting adult aSAH patients within 14 days of their initial bleed and with anaemia (Hb ≤110 g/L). Randomisation Central computer-generated randomisation, stratified by centre, will be undertaken from the host centre. Randomisation into 1 of the 2 treatment arms will occur when the haemoglobin levels of eligible patients fall to ≤100 g/L. Intervention Patients will be randomly assigned to either a liberal (threshold: Hb ≤100 g/L) or a restrictive transfusion strategy (threshold: Hb ≤80 g/L). Outcome Primary: Centre randomisation rate over the study period. Secondary: (1) transfusion threshold adherence; (2) study RBC transfusion protocol adherence; and (3) outcome assessment including vital status at hospital discharge, modified Rankin Score at 6 and 12 months and Functional Independence Measure and EuroQOL Quality of Life Scale scores at 12 months. Outcome measures will be reported in aggregate. ETHICS AND DISSEMINATION The study protocol has been approved by the host centre (OHSN-REB 20150433-01H). This study will determine the feasibility of conducting the large pragmatic RCT comparing 2 RBC transfusion strategies examining the effect of a liberal strategy on 12-month outcome following aSAH. TRIAL REGISTRATION NUMBER NCT02483351; Pre-results.
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Affiliation(s)
- Shane W English
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - D Fergusson
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - M Chassé
- Centre Hospitalier de l'Université de Montréal (CHUM) Research Center, Evaluation, Care Systems and Services Theme, Montréal, Québec, Canada
- Department of Medicine (Critical Care), Université de Montréal, Montréal, Québec, Canada
| | - A F Turgeon
- Department of Anesthesiology and Critical Care, Division of Critical Care Medicine, Université Laval, Québec City, Quebec, Canada
- Population Health and Optimal Health Practices Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Center, Québec City, Quebec, Canada
| | - F Lauzier
- Department of Anesthesiology and Critical Care, Division of Critical Care Medicine, Université Laval, Québec City, Quebec, Canada
- Population Health and Optimal Health Practices Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Center, Québec City, Quebec, Canada
- Department of Medicine, Université Laval, Québec City, Quebec, Canada
| | - D Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - A Algird
- Department of Surgery (Neurosurgery), McMaster University, Hamilton, Ontario, Canada
| | - A Kramer
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, The Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - A Tinmouth
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - C Lum
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - J Sinclair
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - S Marshall
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - D Dowlatshahi
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - A Boutin
- Population Health and Optimal Health Practices Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Center, Québec City, Quebec, Canada
| | - G Pagliarello
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - L A McIntyre
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Carson JL, Stanworth SJ, Roubinian N, Fergusson DA, Triulzi D, Doree C, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2016; 10:CD002042. [PMID: 27731885 PMCID: PMC6457993 DOI: 10.1002/14651858.cd002042.pub4] [Citation(s) in RCA: 153] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND There is considerable uncertainty regarding the optimal haemoglobin threshold for the use of red blood cell (RBC) transfusions in anaemic patients. Blood is a scarce resource, and in some countries, transfusions are less safe than others because of a lack of testing for viral pathogens. Therefore, reducing the number and volume of transfusions would benefit patients. OBJECTIVES The aim of this review was to compare 30-day mortality and other clinical outcomes in participants randomized to restrictive versus liberal red blood cell (RBC) transfusion thresholds (triggers) for all conditions. The restrictive transfusion threshold uses a lower haemoglobin level to trigger transfusion (most commonly 7 g/dL or 8 g/dL), and the liberal transfusion threshold uses a higher haemoglobin level to trigger transfusion (most commonly 9 g/dL to 10 g/dL). SEARCH METHODS We identified trials by searching CENTRAL (2016, Issue 4), MEDLINE (1946 to May 2016), Embase (1974 to May 2016), the Transfusion Evidence Library (1950 to May 2016), the Web of Science Conference Proceedings Citation Index (1990 to May 2016), and ongoing trial registries (27 May 2016). We also checked reference lists of other published reviews and relevant papers to identify any additional trials. SELECTION CRITERIA We included randomized trials where intervention groups were assigned on the basis of a clear transfusion 'trigger', described as a haemoglobin (Hb) or haematocrit (Hct) level below which a red blood cell (RBC) transfusion was to be administered. DATA COLLECTION AND ANALYSIS We pooled risk ratios of clinical outcomes across trials using a random-effects model. Two people extracted the data and assessed the risk of bias. We conducted predefined analyses by clinical subgroups. We defined participants randomly allocated to the lower transfusion threshold as 'restrictive transfusion' and to the higher transfusion threshold as 'liberal transfusion'. MAIN RESULTS A total of 31 trials, involving 12,587 participants, across a range of clinical specialities (e.g. surgery, critical care) met the eligibility criteria. The trial interventions were split fairly equally with regard to the haemoglobin concentration used to define the restrictive transfusion group. About half of them used a 7 g/dL threshold, and the other half used a restrictive transfusion threshold of 8 g/dL to 9 g/dL. The trials were generally at low risk of bias .Some items of methodological quality were unclear, including definitions and blinding for secondary outcomes.Restrictive transfusion strategies reduced the risk of receiving a RBC transfusion by 43% across a broad range of clinical specialties (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.49 to 0.65; 12,587 participants, 31 trials; high-quality evidence), with a large amount of heterogeneity between trials (I² = 97%). Overall, restrictive transfusion strategies did not increase or decrease the risk of 30-day mortality compared with liberal transfusion strategies (RR 0.97, 95% CI 0.81 to 1.16, I² = 37%; N = 10,537; 23 trials; moderate-quality evidence) or any of the other outcomes assessed (i.e. cardiac events (low-quality evidence), myocardial infarction, stroke, thromboembolism (high-quality evidence)). Liberal transfusion did not affect the risk of infection (pneumonia, wound, or bacteraemia). AUTHORS' CONCLUSIONS Transfusing at a restrictive haemoglobin concentration of between 7 g/dL to 8 g/dL decreased the proportion of participants exposed to RBC transfusion by 43% across a broad range of clinical specialities. There was no evidence that a restrictive transfusion strategy impacts 30-day mortality or morbidity (i.e. mortality at other points, cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism, infection) compared with a liberal transfusion strategy. There were insufficient data to inform the safety of transfusion policies in certain clinical subgroups, including acute coronary syndrome, myocardial infarction, neurological injury/traumatic brain injury, acute neurological disorders, stroke, thrombocytopenia, cancer, haematological malignancies, and bone marrow failure. The findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds above 7 g/dL to 8 g/dL.
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Affiliation(s)
- Jeffrey L Carson
- Rutgers Robert Wood Johnson Medical SchoolDivision of General Internal Medicine125 Paterson StreetNew BrunswickNew JerseyUSA08903
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
| | - Nareg Roubinian
- Ottawa Hospital Research Institute725 Parkdale Ave.OttawaONCanadaK1Y 4E9
| | - Dean A Fergusson
- Ottawa Hospital Research InstituteClinical Epidemiology Program501 Smyth RoadOttawaONCanadaK1H 8L6
| | - Darrell Triulzi
- University of PittsburghThe Institute for Transfusion MedicineFive Parkway Center875 Greentree RoadPittsburghPAUSA15220
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Paul C Hebert
- University of Montreal Hospital Research CentreCentre for Research900 rue St‐Denis, local R04‐402 Tour VigerMontrealQCCanadaH2X 0A9
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Piriyapatsom A, Pisitsak C, Chittawatanarat K, Chaiwat O, Kongsayreepong S. The Association between Red Blood Cell Transfusion and Hospital Mortality in Critically Ill Surgical Patients: The Multi-center Thai University-Based Surgical Intensive Care Units Study (THAI-SICU Study). J Med Assoc Thai 2016; 99 Suppl 6:S100-S111. [PMID: 29906364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Red blood cell transfusion (RBCT) is commonly prescribed to critically ill patients with anemia. Nevertheless, the benefits of RBCT in these patients, particularly critically ill surgical patients, are still controversial. The aim of this study is to explore the association between RBCT and hospital mortality in Thai critically ill surgical patients. MATERIAL AND METHOD This study was a part of the multi-center, prospective, observational study, which included adult patients admitted to the SICUs after surgery. Patients were categorized into transfusion and no transfusion groups according to whether they received RBCT during SICU stay or not. The multiple logistic regression analysis was performed to determine whether RBCT was an independent risk factor for hospital mortality. The patients were also matched between two groups based on the propensity score for RBCT requirement and were then compared. RESULTS There were 2,531 patients included in this study. The incidence of RBCT in SICU was 40.3%. Overall, there was no association between RBCT in SICU and hospital mortality (adjusted OR 1.33, 95% CI 0.83-2.11) except in the subgroup of patients with age of <65 years old (adjusted OR 1.99, 95% CI 1.03-3.84). However, when the amount of RBCT was more than 1,200 mL, it was independently associated with increased hospital mortality (adjusted OR 2.55, 95% CI 1.35-4.81). In the propensity-score matching cohort, there was no association between RBCT in SICU and hospital mortality (adjusted OR 1.56, 95% CI 0.88-2.77) except when the amount of RBCT was more than 600 mL (601-1,200 mL, adjusted OR 3.14, 95% CI 1.47-6.72 and >1,200 mL, adjusted OR 3.58, 95% CI 1.36-9.48). CONCLUSION RBCT should be considered as a life-saving intervention but with potential risks of adverse events. Identifying patients who will likely gain benefit from RBCT and implementing the restrictive transfusion strategy may be the keys to improve outcomes.
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Elmi M, Mahar A, Kagedan D, Law CH, Karanicolas PJ, Lin Y, Callum J, Coburn NG, Hallet J. The impact of blood transfusion on perioperative outcomes following gastric cancer resection: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Can J Surg 2016; 59:322-9. [PMID: 27668330 PMCID: PMC5042719 DOI: 10.1503/cjs.004016] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Red blood cell transfusions (RBCT) carry risk of transfusion-related immunodulation that may impact postoperative recovery. This study examined the association between perioperative RBCT and short-term postoperative outcomes following gastrectomy for gastric cancer. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database, we compared outcomes of patients (transfused v. nontransfused) undergoing elective gastrectomy for gastric cancer (2007-2012). Outcomes were 30-day major morbidity, mortality and length of stay. The association between perioperative RBCT and outcomes was estimated using modified Poisson, logistic, or negative binomial regression. RESULTS Of the 3243 patients in the entire cohort, we included 2884 patients with nonmissing data, of whom 535 (18.6%) received RBCT. Overall 30-day major morbidity and mortality were 20% and 3.5%, respectively. After adjustment for baseline and clinical characteristics, RBCT was independently associated with increased 30-day mortality (relative risk [RR] 3.1, 95% confidence interval [CI] 1.9-5.0), major morbidity (RR 1.4, 95% CI 1.2-1.8), length of stay (RR 1.2, 95% CI 1.1-1.2), infections (RR 1.4, 95% CI 1.1-1.6), cardiac complications (RR 1.8, 95% CI 1.0-3.2) and respiratory failure (RR 2.3, 95% CI 1.6-3.3). CONCLUSION Red blood cell transfusions are associated with worse postoperative short-term outcomes in patients with gastric cancer. Blood management strategies are needed to reduce the use of RBCT after gastrectomy for gastric cancer.
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Affiliation(s)
- Maryam Elmi
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Alyson Mahar
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Daniel Kagedan
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Calvin H.L. Law
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Paul J. Karanicolas
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Yulia Lin
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Jeannie Callum
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Natalie G. Coburn
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Julie Hallet
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
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Blake BS, Aniskevich S, Thomas CS, Ladlie BL. Preoperative Clinical Characteristics That Identify Potential Low-Volume Transfusion Candidates Among Orthotopic Liver Transplant Patients. EXP CLIN TRANSPLANT 2016; 14:405-411. [PMID: 27506259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES The primary aim of this study was to determine whether specific preoperative clinical characteristics were associated with low-volume transfusion in liver transplant recipients. Low-volume transfusion was defined as transfusion of < 2100 mL of packed red blood cells intraoperatively during liver transplant. The ability to accurately predict low-volume transfusion could increase patient safety, decrease complications associated with transfusion, improve blood management, and decrease transplant case cost. MATERIALS AND METHODS Data were retrieved by retrospective chart review of 266 patients who received a liver transplant at the Mayo Clinic (Jacksonville, FL, USA). The primary outcome was low-volume transfusion. Associations of preoperative information with low-volume transfusion were explored using single-variable and multivariable logistic regression models; missing data were imputed with the sample median for continuous data and the most frequent category for categorical variables. RESULTS Low-volume transfusion occurred in 23% of first-time liver transplant recipients (62/266 patients; 95% confidence interval, 18%-29%). History of hepatitis C virus infection (P = .048), history of hepatocellular carcinoma (P = .050), short cold ischemia time (P = .006), and low international normalized ratio (P = .002) were independently associated with low-volume transfusion during liver transplant in a multivariable logistic regression model. CONCLUSIONS Multiple studies have shown increased morbidity and mortality after orthotopic liver transplant when more than 6 U of packed red blood cells are administered within 24 hours of surgical incision. A method to identify low-volume transfusion candidates could help predict patient outcomes, decrease blood handling, and reduce costs. If patients with low-volume transfusion could be identified, fewer blood products would need to be prepared in advance. Although elevated preoperative coagulation parameters decrease the probability of low-volume transfusion, a definitive profile of a low-volume transfusion liver transplant recipient was not established.
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Affiliation(s)
- Brittany S Blake
- From the Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA
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Keir AK, Wilkinson D, Andersen C, Stark MJ. Washed versus unwashed red blood cells for transfusion for the prevention of morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2016; 2016:CD011484. [PMID: 26788664 PMCID: PMC8733671 DOI: 10.1002/14651858.cd011484.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Infants born very preterm often receive multiple red blood cell (RBC) transfusions during their initial hospitalisation. However, there is an increasing awareness of potential adverse effects of RBC transfusions in this vulnerable patient population. Modification of RBCs prior to transfusion, through washing with 0.9% saline, may reduce these adverse effects and reduce the rate of significant morbidity and mortality for preterm infants and improve outcomes for this high-risk group. OBJECTIVES To determine whether pre-transfusion washing of RBCs prevents morbidity and mortality in preterm infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 7), MEDLINE via PubMed (31 July 2015), EMBASE (31 July 2015), and CINAHL (31 July 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised, cluster randomised, and quasi-randomised controlled trials including preterm infants (less than 32 weeks gestation) or very low birth weight infants (less than 1500 g), or both, who received one or more washed packed RBC transfusions. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of the trials. We identified four studies from the initial search. After further review of the full-text studies, we found one study meeting the selection criteria. MAIN RESULTS We included a single study enrolling a total of 21 infants for analysis in this review and reported on all-cause mortality during hospital stay, length of initial neonatal intensive care unit (NICU) stay (days), and duration of mechanical ventilation (days). There was no significant difference in mortality between the washed versus the unwashed RBCs for transfusion groups (risk ratio 1.63, 95% confidence interval (CI) 0.28 to 9.36; risk difference 0.10, 95% CI -0.26 to 0.45). There was no significant difference in the length of initial NICU stay between the washed versus the unwashed RBCs for transfusion groups (mean difference (MD) 25 days, 95% CI -21.15 to 71.15) or the duration of mechanical ventilation between the washed versus the unwashed RBCs for transfusion groups (MD 9.60 days, 95% CI -1.90 to 21.10). AUTHORS' CONCLUSIONS We identified a single small study. The results from this study show a high level of uncertainty, as the confidence intervals are consistent with both a large improvement or a serious harm caused by the intervention. Consequently, there is insufficient evidence to support or refute the use of washed RBCs to prevent the development of significant neonatal morbidities or mortality. Further clinical trials are required to assess the potential effects of pre-transfusion washing of RBCs for preterm or very low birth weight infants, or both, on short- and long-term outcomes.
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Affiliation(s)
- Amy K Keir
- University of AdelaideRobinson Research Institute72 King William RoadAdelaideAustralia
- Women's and Children's HospitalDepartment of Neonatal Medicine72 King William RoadNorth AdelaideAustralia
| | - Dominic Wilkinson
- University of AdelaideRobinson Research Institute72 King William RoadAdelaideAustralia
- University of OxfordOxford Uehiro Centre for Practical EthicsOxfordUK
| | - Chad Andersen
- University of AdelaideRobinson Research Institute72 King William RoadAdelaideAustralia
- Women's and Children's HospitalDepartment of Neonatal Medicine72 King William RoadNorth AdelaideAustralia
| | - Michael J Stark
- University of AdelaideRobinson Research Institute72 King William RoadAdelaideAustralia
- Women's and Children's HospitalDepartment of Neonatal Medicine72 King William RoadNorth AdelaideAustralia
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Dhabangi A, Ainomugisha B, Cserti-Gazdewich C, Ddungu H, Kyeyune D, Musisi E, Opoka R, Stowell CP, Dzik WH. Effect of Transfusion of Red Blood Cells With Longer vs Shorter Storage Duration on Elevated Blood Lactate Levels in Children With Severe Anemia: The TOTAL Randomized Clinical Trial. JAMA 2015; 314:2514-23. [PMID: 26637812 DOI: 10.1001/jama.2015.13977] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Although millions of transfusions are given annually worldwide, the effect of red blood cell (RBC) unit storage duration on oxygen delivery is uncertain. OBJECTIVE To determine if longer-storage RBC units are not inferior to shorter-storage RBC units for tissue oxygenation as measured by reduction in blood lactate levels and improvement in cerebral tissue oxygen saturation among children with severe anemia. DESIGN, SETTING, AND PARTICIPANTS Randomized noninferiority trial of 290 children (aged 6-60 months), most with malaria or sickle cell disease, presenting February 2013 through May 2015 to a university-affiliated national referral hospital in Kampala, Uganda, with a hemoglobin level of 5 g/dL or lower and a lactate level of 5 mmol/L or higher. INTERVENTIONS Patients were randomly assigned to receive RBC units stored 25 to 35 days (longer-storage group; n = 145) vs 1 to 10 days (shorter-storage group; n = 145). All units were leukoreduced prior to storage. All patients received 10 mL/kg of RBCs during hours 0 through 2 and, if indicated per protocol, an additional 10 mL/kg during hours 4 through 6. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients with a lactate level of 3 mmol/L or lower at 8 hours using a margin of noninferiority equal to an absolute difference of 25%. Secondary measures included noninvasive cerebral tissue oxygen saturation during the first transfusion, clinical and laboratory changes up to 24 hours, and survival and health at 30 days after transfusion. Adverse events were monitored up to 24 hours. RESULTS In the total population of 290 children, the mean (SD) presenting hemoglobin level was 3.7 g/dL (1.3) and mean lactate level was 9.3 mmol/L (3.4). Median (interquartile range) RBC unit storage was 8 days (7-9) for shorter storage vs 32 days (30-34) for longer storage without overlap. The proportion achieving the primary end point was 0.61 (95% CI, 0.52 to 0.69) in the longer-storage group vs 0.58 (95% CI, 0.49 to 0.66) in the shorter-storage group (between-group difference, 0.03 [95% CI, -0.07 to ∞], P < .001), meeting the prespecified margin of noninferiority. Mean lactate levels were not statistically different between the 2 groups at 0, 2, 4, 6, 8, or 24 hours. Kaplan-Meier analysis and global nonlinear regression revealed no statistical difference in lactate reduction between the 2 groups. Clinical assessment, cerebral oxygen saturation, electrolyte abnormalities, adverse events, survival, and 30-day recovery were also not significantly different between the groups. CONCLUSIONS AND RELEVANCE Among children with lactic acidosis due to severe anemia, transfusion of longer-storage compared with shorter-storage RBC units did not result in inferior reduction of elevated blood lactate levels. These findings have relevance regarding the efficacy of stored RBC transfusion for patients with critical tissue hypoxia and lactic acidosis due to anemia. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01586923.
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Affiliation(s)
- Aggrey Dhabangi
- Child Health and Development Centre, Makerere University, Kampala, Uganda
| | | | | | - Henry Ddungu
- Uganda Cancer Institute, Makerere University, Kampala, Uganda
| | | | - Ezra Musisi
- Uganda National Blood Transfusion Service, Kampala, Uganda
| | - Robert Opoka
- Mulago Hospital Department of Paediatrics, Makerere University, Kampala, Uganda
| | - Christopher P Stowell
- Blood Transfusion Service, Harvard Medical School, Massachusetts General Hospital, Boston
| | - Walter H Dzik
- Blood Transfusion Service, Harvard Medical School, Massachusetts General Hospital, Boston
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Abstract
BACKGROUND A blood transfusion is an acute intervention, used to address life- and health-threatening conditions on a short-term basis. Packed red blood cells are most often used for blood transfusion. Sometimes blood is transfused after prolonged storage but there is continuing debate as to whether transfusion of 'older' blood is as beneficial as transfusion of 'fresher' blood. OBJECTIVES To assess the clinical benefits and harms of prolonged storage of packed red blood cells, in comparison with fresh, on recipients of blood transfusion. SEARCH METHODS We ran the search on 1st May 2014. We searched the Cochrane Injuries Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), Embase (OvidSP), CINAHL (EBSCO Host) and two other databases. We also searched clinical trials registers and screened reference lists of the retrieved publications and reviews. We updated this search in June 2015 but these results have not yet been incorporated. SELECTION CRITERIA Randomised clinical trials including participants assessed as requiring red blood cell transfusion were eligible for inclusion. Prolonged storage was defined as red blood cells stored for ≥ 21 days in a blood bank. We did not apply limits regarding the duration of follow-up, or country where the study took place. We excluded trials where patients received a combination of short- and long-stored blood products, and also trials without a clear definition of prolonged storage. DATA COLLECTION AND ANALYSIS We independently performed study selection, risk of bias assessment and data extraction by at least two review authors. The major outcomes were death from any cause, transfusion-related acute lung injury, and adverse events. We estimated relative risk for dichotomous outcomes. We measured statistical heterogeneity using I(2). We used a random-effects model to synthesise the findings. MAIN RESULTS We identified three randomised clinical trials, involving a total of 120 participants, comparing packed red blood cells with ≥ 21 days storage ('prolonged' or 'older') versus packed red blood cells with < 21 days storage ('fresh'). We pooled data to assess the effect of prolonged storage on death from any cause. The confidence in the results from these trials was very low, due to the bias in their design and their limited sample sizes.The estimated effect of packed red blood cells with ≥ 21 days storage versus packed red blood cells with < 21 days storage for the outcome death from any cause was imprecise (5/45 [11.11%] versus 2/46 [4.34%]; RR 2.36; 95% CI 0.65 to 8.52; I(2): 0%, P = 0.26, very low quality of evidence). Trial sequential analysis, with only two trials, shows that we do not yet have convincing evidence that older packed red blood cells induce a 20% relative risk reduction of death from any cause compared with fresher packed red blood cells. No trial included other outcomes of interest specified in this review, namely transfusion-related acute lung injury, postoperative infections, and adverse events. The safety profile is unknown. AUTHORS' CONCLUSIONS Recognising the limitations of the review, relating to the size and nature of the included trials, this Cochrane Review provides no evidence to support or reject the use of packed red blood cells for blood transfusion which have been stored for ≥ 21 days ('prolonged' or 'older') compared with those stored for < 21 days ('fresh'). These results are based on three small single centre trials with high risks of bias. There is insufficient evidence to determine the effects of fresh or older packed red blood cells for blood transfusion. Therefore, we urge readers to interpret the trial results with caution. The results from four large ongoing trials will help to inform future updates of this review.
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Affiliation(s)
| | - Daniel Simancas‐Racines
- Universidad Tecnológica EquinoccialFacultad de Ciencias de la Salud Eugenio EspejoAvenida República de El Salvador 733 y PortugalEdificio Gabriela 3. Of. 403Quito (Pichincha)PichinchaEcuadorCasilla Postal 17‐17‐525
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Abstract
BACKGROUND Red blood cell transfusion is a common treatment for anaemia in many clinical conditions. One current concern is uncertainty as to the clinical consequences (notably efficacy and safety) of transfusing red blood cell units that have been stored for different durations of time before a transfusion. If evidence from randomised controlled trials were to indicate that clinical outcomes are affected by storage age, the implications for inventory management and clinical practice would be significant. OBJECTIVES To assess the effects of using fresher versus older red blood cells in people requiring a red blood cell transfusion. SEARCH METHODS We ran the search on 29th September 2014. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), Embase (OvidSP), CINAHL (EBSCO), PubMed (for e-publications), three other databases and trial registers. SELECTION CRITERIA We included randomised controlled trials comparing fresher red blood cell transfusion versus active transfusion of older red blood cells, and comparing fresher red blood cell transfusion versus current standard practice. All definitions of 'fresher' and 'older'/'standard practice' red blood cells were included. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted from the trial report data on adverse red blood cell transfusion reactions, when reported. MAIN RESULTS We included 16 trials (1864 participants) in the review. Eight trials (279 participants) compared transfusion of fresher red blood cells versus transfusion of older stored red blood cells ('fresher' vs 'older'). Eight trials (1585 participants) compared the transfusion of fresher red blood cells versus current standard practice ('fresher' vs 'standard practice'). Five trials enrolled neonates, one trial enrolled children and 12 trials enrolled adults. Overall sample sizes were small: only two trials randomly assigned more than 100 participants.We performed no meta-analyses for a variety of reasons: no uniform definition of 'fresher' or 'older' red blood cell storage; overlap in the distribution of the age of red blood cells; and heterogeneity in measurements and reporting of outcomes of interest to this review. We tabulated and reported results by individual trial. Overall risk of bias was low or unclear, with four incidences of high risk of bias: in allocation concealment (three trials) and in incomplete outcome data (one trial).No trial measured all of the outcomes of interest in this review. Four trials comparing 'fresher' with 'older' red blood cells reported the primary outcome: mortality within seven days (one study; 74 participants) and at 30 days (three trials; 62 participants). Six trials comparing 'fresher' with 'standard practice' red blood cells reported the primary outcome: mortality within seven days (three studies; 159 participants) and at 30 days (three trials; 1018 participants). All 10 trials reported no clear differences in mortality at either time point between intervention arms.Three trials comparing 'fresher' with 'standard practice' red blood cells reported red blood cell transfusion-associated adverse events. No adverse reactions were reported in two trials, and one incidence of cytomegalovirus (CMV) infection was described in the 'standard practice' arm in one trial.Overall the trials reported no clear difference between either of the intervention comparisons in long-term mortality (three trials; 478 participants); clinically accepted measures of multiple organ dysfunction (two trials: 399 participants); incidence of in-hospital infection (two trials; 429 participants); duration of mechanical ventilation (three trials: 95 participants); and number of participants requiring respiratory organ support (five trials; 528 participants) or renal support (one trial; 57 participants). The outcome 'physiological markers of oxygen consumption or alterations in microcirculation' was reported by 11 studies, but the measures used were highly varied, and no formal statistical analysis was undertaken. AUTHORS' CONCLUSIONS Several factors precluded firm conclusions about the clinical outcomes of transfusing red blood cell units that have been stored for different periods of time before transfusion, including differences in clinical population and setting, diversity in the interventions used, methodological limitations and differences in how outcomes were measured and reported.No clear differences in the primary outcome - death - were noted between 'fresher' and 'older' or 'standard practice' red blood cells in trials that reported this outcome. Findings of a large number of ongoing trials will be incorporated into this review when they are published.Updates of this review will explore the degree of overlap in trials between 'fresher', 'older' and 'standard practice' storage ages of red blood cells and will consider whether the size of any observed effects is dependent on recipient factors such as clinical background, patient age or clinical presentation.
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Affiliation(s)
- Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Level 2, John Radcliffe Hospital, Headington, Oxford, Oxon, UK, OX3 9BQ
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Abstract
BACKGROUND The incidence of hip fracture is increasing and it is more common with increasing age. Surgery is used for almost all hip fractures. Blood loss occurs as a consequence of both the fracture and the surgery and thus red blood cell transfusion is frequently used. However, red blood cell transfusion is not without risks. Therefore, it is important to identify the evidence for the effective and safe use of red blood cell transfusion in people with hip fracture. OBJECTIVES To assess the effects (benefits and harms) of red blood cell transfusion in people undergoing surgery for hip fracture. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (31 October 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014, Issue 10), MEDLINE (January 1946 to 20 November 2014), EMBASE (January 1974 to 20 November 2014), CINAHL (January 1982 to 20 November 2014), British Nursing Index Database (January 1992 to 20 November 2014), the Systematic Review Initiative's Transfusion Evidence Library, PubMed for e-publications, various other databases and ongoing trial registers. SELECTION CRITERIA Randomised controlled trials comparing red blood cell transfusion versus no transfusion or an alternative to transfusion, different transfusion protocols or different transfusion thresholds in people undergoing surgery for hip fracture. DATA COLLECTION AND ANALYSIS Three review authors independently assessed each study's risk of bias and extracted data using a study-specific form. We pooled data where there was homogeneity in the trial comparisons and the timing of outcome measurement. We used GRADE criteria to assess the quality (low, moderate or high) of the evidence for each outcome. MAIN RESULTS We included six trials (2722 participants): all compared two thresholds for red blood cell transfusion: a 'liberal' strategy to maintain a haemoglobin concentration of usually 10 g/dL versus a more 'restrictive' strategy based on symptoms of anaemia or a lower haemoglobin concentration, usually 8 g/dL. The exact nature of the transfusion interventions, types of surgery and participants varied between trials. The mean age of participants ranged from 81 to 87 years and approximately 24% of participants were men. The largest trial enrolled 2016 participants, over 60% of whom had a history of cardiovascular disease. The percentage of participants receiving a red blood cell transfusion ranged from 74% to 100% in the liberal transfusion threshold group and from 11% to 45% in the restrictive transfusion threshold group. There were no results available for the smallest trial (18 participants). All studies were at some risk of bias, in particular performance bias relating to the absence of blinding of personnel. We judged the evidence for all outcomes, except myocardial infarction, was low quality reflecting risk of bias primarily from imbalances in protocol violations in the largest trial and imprecision, often because of insufficient events. Thus, further research is likely to have an important impact on these results.There was no evidence of a difference between a liberal versus restricted threshold transfusion in mortality, at 30 days post hip fracture surgery (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.67 to 1.26; five trials; 2683 participants; low quality evidence) or at 60 days post surgery (RR 1.08, 95% CI 0.80 to 1.44; three trials; 2283 participants; low quality evidence). Assuming an illustrative baseline risk of 50 deaths per 1000 participants in the restricted threshold group at 30 days, these data equate to four fewer (95% CI 17 fewer to 14 more) deaths per 1000 in the liberal threshold group at 30 days.There was no evidence of a difference between a liberal versus restricted threshold transfusion in functional recovery at 60 days, assessed in terms of the inability to walk 10 feet (3 m) without human assistance (RR 1.00, 95% CI 0.87 to 1.15; two trials; 2083 participants; low quality evidence).There was low quality evidence of no difference between the transfusion thresholds in postoperative morbidity for the following complications: thromboembolism (RR 1.15 favouring a restrictive threshold, 95% CI 0.56 to 2.37; four trials; 2416 participants), stroke (RR 2.40 favouring a restrictive threshold, 95% CI 0.85 to 6.79; four trials; 2416 participants), wound infection (RR 1.61 favouring a restrictive threshold, 95% CI 0.77 to 3.35; three trials; 2332 participants), respiratory infection (pneumonia) (RR 1.35 favouring a restrictive threshold, 95% CI 0.95 to 1.92; four trials; 2416 participants) and new diagnosis of congestive heart failure (RR 0.77 favouring a liberal threshold, 95% CI 0.48 to 1.23; three trials; 2332 participants). There was very low quality evidence of a lower risk of myocardial infarction in the liberal compared with the restrictive transfusion threshold group (RR 0.59, 95% CI 0.36 to 0.96; three trials; 2217 participants). Assuming an illustrative baseline risk of myocardial infarction of 24 per 1000 participants in the restricted threshold group, this result was compatible with between one and 15 fewer myocardial infarctions in the liberal threshold group. AUTHORS' CONCLUSIONS We found low quality evidence of no difference in mortality, functional recovery or postoperative morbidity between 'liberal' versus 'restrictive' thresholds for red blood cell transfusion in people undergoing surgery for hip fracture. Although further research may change the estimates of effect, the currently available evidence does not support the use of liberal red blood cell transfusion thresholds based on a 10 g/dL haemoglobin trigger in preference to more restrictive transfusion thresholds based on lower haemoglobin levels or symptoms of anaemia in these people. Future research needs to address the effectiveness of red blood cell transfusions at different time points in the surgical pathway, whether pre-operative, peri-operative or postoperative. In particular, such research would need to consider people who are symptomatic or haemodynamically unstable who were excluded from most of these trials.
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Affiliation(s)
- Susan J Brunskill
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Sarah L Millette
- John Radcliffe HospitalDepartment of Geriatric MedicineHeadley WayOxfordUKOX3 9DU
| | - Ali Shokoohi
- Welsh Blood ServiceEly Valley RoadPontyclunMid GlamorganUKCF72 9WB
| | - EC Pulford
- Oxford University HospitalsDepartment of Trauma and GeratologyLevel 4 Academic CorridorJohn Radcliffe HospitalOxfordUKOX3 9DU
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Michael F Murphy
- Oxford University Hospitals and the University of OxfordNHS Blood and Transplant; National Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe HospitalHeadingtonOxfordUK
- Oxford University Hospitals and the University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreOxfordUK
| | - Simon Stanworth
- Oxford University Hospitals and the University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreOxfordUK
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Holst LB, Petersen MW, Haase N, Perner A, Wetterslev J. Restrictive versus liberal transfusion strategy for red blood cell transfusion: systematic review of randomised trials with meta-analysis and trial sequential analysis. BMJ 2015; 350:h1354. [PMID: 25805204 PMCID: PMC4372223 DOI: 10.1136/bmj.h1354] [Citation(s) in RCA: 293] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To compare the benefit and harm of restrictive versus liberal transfusion strategies to guide red blood cell transfusions. DESIGN Systematic review with meta-analyses and trial sequential analyses of randomised clinical trials. DATA SOURCES Cochrane central register of controlled trials, SilverPlatter Medline (1950 to date), SilverPlatter Embase (1980 to date), and Science Citation Index Expanded (1900 to present). Reference lists of identified trials and other systematic reviews were assessed, and authors and experts in transfusion were contacted to identify additional trials. TRIAL SELECTION Published and unpublished randomised clinical trials that evaluated a restrictive compared with a liberal transfusion strategy in adults or children, irrespective of language, blinding procedure, publication status, or sample size. DATA EXTRACTION Two authors independently screened titles and abstracts of trials identified, and relevant trials were evaluated in full text for eligibility. Two reviewers then independently extracted data on methods, interventions, outcomes, and risk of bias from included trials. random effects models were used to estimate risk ratios and mean differences with 95% confidence intervals. RESULTS 31 trials totalling 9813 randomised patients were included. The proportion of patients receiving red blood cells (relative risk 0.54, 95% confidence interval 0.47 to 0.63, 8923 patients, 24 trials) and the number of red blood cell units transfused (mean difference -1.43, 95% confidence interval -2.01 to -0.86) were lower with the restrictive compared with liberal transfusion strategies. Restrictive compared with liberal transfusion strategies were not associated with risk of death (0.86, 0.74 to 1.01, 5707 patients, nine lower risk of bias trials), overall morbidity (0.98, 0.85 to 1.12, 4517 patients, six lower risk of bias trials), or fatal or non-fatal myocardial infarction (1.28, 0.66 to 2.49, 4730 patients, seven lower risk of bias trials). Results were not affected by the inclusion of trials with unclear or high risk of bias. Using trial sequential analyses on mortality and myocardial infarction, the required information size was not reached, but a 15% relative risk reduction or increase in overall morbidity with restrictive transfusion strategies could be excluded. CONCLUSIONS Compared with liberal strategies, restrictive transfusion strategies were associated with a reduction in the number of red blood cell units transfused and number of patients being transfused, but mortality, overall morbidity, and myocardial infarction seemed to be unaltered. Restrictive transfusion strategies are safe in most clinical settings. Liberal transfusion strategies have not been shown to convey any benefit to patients. TRIAL REGISTRATION PROSPERO CRD42013004272.
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Affiliation(s)
- Lars B Holst
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marie W Petersen
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Nicolai Haase
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research 7812, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Chassé M, McIntyre L, Tinmouth A, Acker J, English SW, Knoll G, Forster A, Shehata N, Wilson K, van Walraven C, Ducharme R, Fergusson DA. Clinical effects of blood donor characteristics in transfusion recipients: protocol of a framework to study the blood donor-recipient continuum. BMJ Open 2015; 5:e007412. [PMID: 25600255 PMCID: PMC4305074 DOI: 10.1136/bmjopen-2014-007412] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION When used appropriately, transfusion of red blood cells (RBCs) is a necessary life-saving therapy. However, RBC transfusions have been associated with negative outcomes such as infection and organ damage. Seeking explanations for the beneficial and deleterious effects of RBC transfusions is necessary to ensure the safe and optimal use of this precious resource. This study will create a framework to analyse the influence of blood donor characteristics on recipient outcomes. METHODS AND ANALYSIS We will conduct a multisite, longitudinal cohort study using blood donor data routinely collected by Canadian Blood Services, and recipient data from health administrative databases. Our project will include a thorough validation of primary data, the linkage of various databases into one large longitudinal database, an in-depth epidemiological analysis and a careful interpretation and dissemination of the results to assist the decision-making process of clinicians, researchers and policymakers in transfusion medicine. Our primary donor characteristic will be age of blood donors and our secondary donor characteristics will be donor-recipient blood group compatibility and blood donor sex. Our primary recipient outcome will be a statistically appropriate survival analysis post-RBC transfusion up to a maximum of 8 years. Our secondary recipient outcomes will include 1-year, 2-year and 5-year mortality; hospital and intensive care unit length of stay; rehospitalisation; new cancer and cancer recurrence rate; infection rate; new occurrence of myocardial infarctions and need for haemodialysis. ETHICS AND DISSEMINATION Our results will help determine whether we need to tailor transfusion based on donor characteristics, and perhaps this will improve patient outcome. Our results will be customised to target the different stakeholders involved with blood transfusions and will include presentations, peer-reviewed publications and the use of the dissemination network of blood supply organisations. We obtained approval from the Research Ethics boards and privacy offices of all involved institutions.
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Affiliation(s)
- Michaël Chassé
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lauralyn McIntyre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jason Acker
- Centre for Innovation, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Shane W English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada
| | - Greg Knoll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Nadine Shehata
- Department of Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Kumanan Wilson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada
| | - Carl van Walraven
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Robin Ducharme
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Spadaro S, Reverberi R, Fogagnolo A, Ragazzi R, Napoli N, Marangoni E, Bellini T, Volta CA. Transfusion of stored red blood cells in critically ill trauma patients: a retrospective study. Eur Rev Med Pharmacol Sci 2015; 19:2689-96. [PMID: 26221901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/16/2023]
Abstract
OBJECTIVE The many published studies on the effects of the transfusion of stored red blood cells on clinical outcomes yielded discordant results. Therefore, we chose to study patients with severe trauma. The clinical outcomes considered included in-hospital mortality, the occurrence of sepsis, length of stay in intensive care unit and in hospital, and days of mechanical ventilation. PATIENTS AND METHODS We selected all patients with traumatic injury, who received at least 2 red cell units in the first day of admission. Patients were divided into two groups: those who had received fresh red cells only (fresh group) and those who had received at least one "old" red cell unit (old group). The red cells were considered fresh if they had been stored <14 days. RESULTS The fresh and old groups included 376 and 321 patients, respectively. Baseline demographic and clinical characteristics were comparable between the groups. However, old group received more red cell and plasma units during whole hospital stay (red cells: 11 ± 7 vs 6 ± 4, p < 0.001; plasma: 7 [0-9] vs 3 [0-6]). Among outcomes, only length of stay in intensive care unit (old vs fresh: 18 ± 9 vs 12 ± 8 days, p < 0.001) and in hospital (77 ± 35 vs 45 ± 30 days, p < 0.001) differed significantly between groups. The association remained statistically significant in a multivariate analysis including known confounding factors. CONCLUSIONS Patients with major trauma transfused with old (≥14 days) red cells had a longer length of stay in intensive care unit and in hospital, without any difference in mortality, occurence of sepsis or days of mechanical ventilation.
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Affiliation(s)
- S Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Anesthesia and Intensive Care Unit, University of Ferrara, Ferrara, Italy.
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Zheng Y, Lu C, Wei S, Li Y, Long L, Yin P. Association of red blood cell transfusion and in-hospital mortality in patients admitted to the intensive care unit: a systematic review and meta-analysis. Crit Care 2014; 18:515. [PMID: 25394759 PMCID: PMC4256753 DOI: 10.1186/s13054-014-0515-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 08/28/2014] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Previous research has debated whether red blood cell (RBC) transfusion is associated with decreased or increased mortality in patients admitted to the intensive care unit (ICU). We conducted a systematic review and meta-analysis to assess the relationship of RBC transfusion with in-hospital mortality in ICU patients. METHODS We carried out a literature search on Medline (1950 through May 2013), Web of Science (1986 through May 2013) and Embase (1980 through May 2013). We included all prospective and retrospective studies on the association between RBC transfusion and in-hospital mortality in ICU patients. The relative risk for the overall pooled effects was estimated by random effects model. Sensitivity analyses were conducted to assess potential bias. RESULTS The meta-analysis included 28,797 participants from 18 studies. The pooled relative risk for transfused versus nontransfused ICU patients was 1.431 (95% CI, 1.105 to 1.854). In sensitivity analyses, the pooled relative risk was 1.211 (95% CI, 0.975 to 1.505) if excluding studies without adjustment for confounders, 1.178 (95% CI, 0.937 to 1.481) if excluding studies with relative high risk of bias, and 0.901 (95% CI, 0.622 to 1.305) if excluding studies without reporting hazard ratio (HR) or relative risk (RR) as an effect size measure. Subgroup analyses revealed increased risks in studies enrolling patients from all ICU admissions (RR 1.513, 95%CI 1.123 to 2.039), studies without reporting information on leukoreduction (RR 1.851, 95%CI 1.229 to 2.786), studies reporting unadjusted effect estimates (RR 3.933, 95%CI 2.107 to 7.343), and studies using odds ratio as an effect measure (RR 1.465, 95%CI 1.049 to 2.045). Meta-regression analyses showed that RBC transfusion could decrease risk of mortality in older patients (slope coefficient -0.0417, 95%CI -0.0680 to -0.0154). CONCLUSIONS There is lack of strong evidence to support the notion that ICU patients who receive RBC transfusion have an increased risk of in-hospital death. In studies adjusted for confounders, we found that RBC transfusion does not increase the risk of in-hospital mortality in ICU patients. Type of patient, information on leukoreduction, statistical method, mean age of patient enrolled and publication year of the article may account for the disagreement between previous studies.
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Affiliation(s)
- Yi Zheng
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Caihong Lu
- Department of ENT department, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Shiqing Wei
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Ye Li
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Lu Long
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Ping Yin
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
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Zatta AJ, McQuilten ZK, Mitra B, Roxby DJ, Sinha R, Whitehead S, Dunkley S, Kelleher S, Hurn C, Cameron PA, Isbister JP, Wood EM, Phillips LE. Elucidating the clinical characteristics of patients captured using different definitions of massive transfusion. Vox Sang 2014; 107:60-70. [PMID: 24697251 DOI: 10.1111/vox.12121] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 11/05/2013] [Accepted: 11/06/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The type and clinical characteristics of patients identified with commonly used definitions of massive transfusion (MT) are largely unknown. The objective of this study was to define the clinical characteristics of patients meeting different definitions of MT for the purpose of patient recruitment in observational studies. MATERIALS AND METHODS Data were extracted on all patients who received red blood cell (RBC) transfusions in 2010 at three tertiary Australian hospitals. MT patients were identified according to three definitions: ≥10 units RBC in 24 h (10/24 h), ≥6 units RBC in 6 h (6/6 h) and ≥5 units RBC in 4 h (5/4 h). Clinical coding data were used to assign bleeding context. Data on in-hospital mortality were also extracted. RESULTS Five hundred and forty-two patients met at least one MT definition, with 236 (44%) included by all definitions. The most inclusive definition was 5/4 h (508 patients, 94%) followed by 6/6 h (455 patients, 84%) and 10/24 h (251 patients, 46%). Importantly, 40-55% of most types of critical bleeding events and 82% of all obstetric haemorrhage cases were excluded by the 10/24 h definition. Patients who met both the 5/4 h and 10/24 h definitions were transfused more RBCs (19 vs. 8 median total RBC units; P < 0·001), had longer ventilation time (120 vs. 55 h; P < 0·001), median ICU (149 vs. 99 h; P < 0·001) and hospital length of stay (23 vs. 18 h; P = 0·006) and had a higher in-hospital mortality rate (23·3% vs. 16·4%; P = 0·050). CONCLUSION The 5/4 h MT definition was the most inclusive, but combination with the 10/24 h definition appeared to identify a clinically important patient cohort.
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Affiliation(s)
- A J Zatta
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic., Australia
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Perel P, Clayton T, Altman DG, Croft P, Douglas I, Hemingway H, Hingorani A, Morley KI, Riley R, Timmis A, Van der Windt D, Roberts I. Red blood cell transfusion and mortality in trauma patients: risk-stratified analysis of an observational study. PLoS Med 2014; 11:e1001664. [PMID: 24937305 PMCID: PMC4060995 DOI: 10.1371/journal.pmed.1001664] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 05/08/2014] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death. METHODS AND FINDINGS A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: <6%, 6%-20%, 21%-50%, and >50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction <0.0001). Transfusion was associated with an increase in all-cause mortality among patients with <6% and 6%-20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08-7.13, p<0.0001, and OR 2.31, 95% CI 1.96-2.73, p<0.0001, respectively), but with a decrease in all-cause mortality in patients with >50% predicted risk of death (OR 0.59, 95% CI 0.47-0.74, p<0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05-3.24, p<0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (<6%) predicted risk of death (p-value for interaction <0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar. CONCLUSIONS The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial. TRIAL REGISTRATION www.ClinicalTrials.gov NCT01746953.
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Affiliation(s)
- Pablo Perel
- Epidemiology & Population Health Faculty, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Tim Clayton
- Epidemiology & Population Health Faculty, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Doug G. Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Peter Croft
- Arthritis Research UK Primary Care Centre, Keele University, Staffordshire, United Kingdom
| | - Ian Douglas
- Epidemiology & Population Health Faculty, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Harry Hemingway
- Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Aroon Hingorani
- Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Katherine I. Morley
- Department of Epidemiology and Public Health, University College London, London, United Kingdom
- School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Richard Riley
- School of Health and Population Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Adam Timmis
- London Chest Hospital, London, United Kingdom
| | - Danielle Van der Windt
- Arthritis Research UK Primary Care Centre, Keele University, Staffordshire, United Kingdom
| | - Ian Roberts
- Epidemiology & Population Health Faculty, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Kalil AN, Laporte GA, Rodrigues A, Felipe RM, Torrez SL. Outcomes of Liver Resection in the Elderly: Is it safe? Hepatogastroenterology 2014; 61:732-740. [PMID: 26176066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND/AIMS There has been an increase in the incidence of neoplasms of the liver in recent years, although there is still a fear of performing aggressive surgical procedures in elderly patients, especially regarding hepatic surgery. The objective of this study was to analyse the influence of age on the morbidity and mortality of patients undergoing hepatic resection. METHODOLOGY This was a study of 414 patients who underwent 447 hepatic resections between November 1993 and December 2010. The patients were divided into two groups according to whether they were ≤ 65 or > 65 years of age. RESULTS The elderly group included 113 resections, while the young group was composed of 334 procedures. The elderly group had more malignant lesions and more comorbidities. With regard to the transoperative and post-operative data, the two groups displayed similar results. According to the multivariate analysis, cirrhosis and the use of transoperative pedicular clamping were independent predictors of morbidity. Cirrhosis was also an independent predictor of mortality. CONCLUSIONS The results indicate that age is not a predisposing factor for the worsening of results of hepatic resection in selected patients, especially with regard to cirrhosis. Moreover, surgeons must avoid the use of transoperative pedicular clamping.
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Pommergaard HC, Nørgaard A, Burcharth J, Stissing T, Rosenberg J. [Liberal red blood cell transfusion may increase mortality]. Ugeskr Laeger 2014; 176:V06130398. [PMID: 25096347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In addition to the known adverse effects of red blood cell transfusion, evidence suggests that transfusion with allogeneic red blood cells in itself may increase mortality, risk of infection and even cancer recurrence rates. Among possible mechanisms to explain this effect are transfusion-related immune modulation and storage lesions. However, anaemia may also increase mortality and the risk of anaemia should be balanced against the risks of transfusion. Further properly designed and powered studies are needed to clarify the beneficial and harmful effects of red blood cell transfusion in well-defined patient categories.
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Wilkinson KL, Brunskill SJ, Doree C, Trivella M, Gill R, Murphy MF. Red cell transfusion management for patients undergoing cardiac surgery for congenital heart disease. Cochrane Database Syst Rev 2014; 2014:CD009752. [PMID: 24510598 PMCID: PMC11066839 DOI: 10.1002/14651858.cd009752.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Congenital heart disease is the most commonly diagnosed neonatal congenital condition. Without surgery, only 30% to 40% of patients affected will survive to 10 years old. Mortality has fallen since the 1990s with 2006 to 2007 figures showing surgical survival at one year of 95%. Patients with congenital heart disease are potentially exposed to red cell transfusion at many points in the surgical pathway. There are a number of risks associated with red cell transfusion that may be translated into increased patient morbidity and mortality. OBJECTIVES To evaluate the effects of red cell transfusion on mortality and morbidity on patients with congenital heart disease at the time of cardiac surgery. SEARCH METHODS We searched 11 bibliographic databases and three ongoing trials databases including the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2013), MEDLINE (Ovid, 1950 to 11 June 2013), EMBASE (Ovid, 1980 to 11 June 2013), ClinicalTrials.gov, World Health Organization (WHO) ICTRP and the ISRCTN Register (to June 2013). We also searched references of all identified trials, relevant review articles and abstracts from between 2006 and 2010 of the most relevant conferences. We did not limit the searches by language of publication. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing red cell transfusion interventions in patients undergoing cardiac surgery for congenital heart disease. We included participants of any age (neonates, paediatrics and adults) and with any type of congenital heart disease (cyanotic or acyanotic). We excluded patients with congenital heart disease undergoing non-cardiac surgery. No co-morbidities were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. MAIN RESULTS We identified 11 trials (862 participants). All trials were in neonatal or paediatric populations. The trials covered only three areas of interest: restrictive versus liberal transfusion triggers (two trials), leukoreduction versus non-leukoreduction (two trials) and standard versus non-standard cardiopulmonary bypass (CPB) prime (seven trials). Owing to the clinical diversity in the participant groups (cyanotic (three trials), acyanotic (four trials) or mixed (four trials)) and the intervention groups, it was not appropriate to pool data in a meta-analysis. No study reported data for all the outcomes of interest to this review. Risk of bias was mixed across the included trials, with only attrition bias being low across all trials. Blinding of study personnel and participants was not always possible, depending on the intervention being used.Five trials (628 participants) reported the primary outcome: 30-day mortality. In three trials (a trial evaluating restrictive and liberal transfusion (125 participants), a trial of cell salvage during CPB (309 participants) and a trial of washed red blood cells during CPB (128 participants)), there was no clear difference in mortality at 30 days between the intervention arms. In two trials comparing standard and non-standard CPB prime, there were no deaths in either randomised group. Long-term mortality was similar between randomised groups in one trial each comparing restrictive and liberal transfusion or standard and non-standard CPB prime.Four trials explored a range of adverse effects following red cell transfusion. Kidney failure was the only adverse event that was significantly different: patients receiving cell salvaged red blood cells during CPB were less likely to have renal failure than patients not exposed to cell salvage (risk ratio (RR) 0.26, 95% confidence interval (CI) 0.09 to 0.79, 1 study, 309 participants). There was insufficient evidence to determine whether there was a difference between transfusion strategies for any other severe adverse events.The duration of mechanical ventilation was measured in seven trials (768 participants). Overall, there was no consistent difference in the duration of mechanical ventilation between the intervention and control arms.The duration of intensive care unit (ICU) stay was measured in six trials (459 participants). There was no clear difference in the duration of ICU stay between the intervention arms in the transfusion trigger and leukoreduction trials. In the standard versus non-standard CPB prime trials, one trial examining the impact of washing transfused bypass prime red blood cells showed no clear difference in duration of ICU stay between the intervention arms, while the trial assessing ultrafiltration of the priming blood showed a shorter duration of ICU stay in the ultrafiltration group. AUTHORS' CONCLUSIONS There are only a small number of small and heterogeneous trials so there is insufficient evidence to assess the impact of red cell transfusion on patients with congenital heart disease undergoing cardiac surgery accurately. It is possible that the presence or absence of cyanosis impacts on trial outcomes, which would necessitate different clinical management of two groups. Further adequately powered, specific, high-quality trials are warranted to assess this fully.
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Affiliation(s)
- Kirstin L Wilkinson
- Southampton University NHS HospitalPaediatric and Adult Cardiothoracic AnaesthesiaTremona RoadSouthamptonUKSO16 6YD
| | - Susan J Brunskill
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Ravi Gill
- Southampton University Hospital NHS TrustDepartment of AnaestheticsTremona RoadSouthamptonHampshireUKSO16 6YD
| | - Michael F Murphy
- John Radcliffe HospitalNHS Blood and TransplantHeadley WayHeadingtonOxfordUKOX3 9BQ
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Long K, Heaney JB, Simms ER, McSwain NE, Duchesne JC. When enough is enough: impact of packed red blood cells in massive transfusion outcomes. Am Surg 2013; 79:810-814. [PMID: 23896250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Massive transfusion protocol (MTP) with fresh-frozen plasma and packed red blood cells (PRBCs) in a 1:1 ratio is one of the most common resuscitative strategies used in patients with severe hemorrhage. There are no studies to date that examine the best postoperative hematocrit range as a marker for survival after MTP. We hypothesize a postoperative hematocrit dose-dependent survival benefit in patients receiving MTP. This was a 53-month retrospective analysis of patients with intra-abdominal injuries requiring surgery and transfusion of 10 units PRBCs or more at a single Level I trauma center. Groups were defined by postoperative hematocrit (less than 21, 21 to 29, 29.1 to 39, and 39 or more). Kaplan-Meier (KM) survival probability was calculated. One hundred fifty patients requiring operative abdominal explorations and 10 units PRBCs or more were identified. There were no significant differences in demographics between groups. When comparing postoperative hematocrit groups, relative to a hematocrit of less than 21 per cent in KM survival analysis, an overall survival advantage was only evident in patients transfused to hematocrits 29.1 to 39 per cent (P < 0.03; odds ratio [OR], 0.284; 95% confidence interval [CI], 0.089 to 0.914). This survival advantage was not seen in the other groups (21 to 29: OR, 0.352; 95% CI, 0.103 to 1.195 or 39% or greater: OR, 0.107; 95% CI, 0.010 to 1.121). This is the first study to examine the impact of postoperative hematocrit as an indicator of survival after MTP in the trauma patient. Transfusion to hematocrits between 29.1 and 39 per cent conveyed a survival benefit, whereas resuscitation to supraphysiologic hematocrits 39 per cent or greater conveyed no additional survival benefit. This study highlights the need for judicious PRBC administration during MTP and its potential impact on survival in patients with postoperative supraphysiologic hematocrits.
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Affiliation(s)
- Kira Long
- Department of Surgery, Tulane University, New Orleans, Louisiana 70112, USA.
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Mudumbai SC, Cronkite R, Hu KU, Heidenreich PA, Gonzalez C, Bertaccini E, Stafford RS, Cason BA, Mariano ER, Wagner T. Association of age and packed red blood cell transfusion to 1-year survival--an observational study of ICU patients. Transfus Med 2013; 23:231-7. [PMID: 23480030 PMCID: PMC4012294 DOI: 10.1111/tme.12010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 12/31/2012] [Accepted: 01/09/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the 1-year survival for different age strata of intensive care unit (ICU) patients after receipt of packed red blood cell (PRBC) transfusions. BACKGROUND Despite guidelines documenting risks of PRBC transfusion and data showing that increasing age is associated with ICU mortality, little data exist on whether age alters the transfusion-related risk of decreased survival. METHODS We retrospectively examined data on 2393 consecutive male ICU patients admitted to a tertiary-care hospital from 2003 to 2009 in age strata: 21-50, 51-60, 61-70, 71-80 and >80 years. We calculated Cox regression models to determine the modifying effect of age on the impact of PRBC transfusion on 1-year survival by using interaction terms between receipt of transfusion and age strata, controlling for type of admission and Charlson co-morbidity indices. We also examined the distribution of admission haematocrit and whether transfusion rates differed by age strata. RESULTS All age strata experienced statistically similar risks of decreased 1-year survival after receipt of PRBC transfusions. However, patients age >80 were more likely than younger cohorts to have haematocrits of 25-30% at admission and were transfused at approximately twice the rate of each of the younger age strata. DISCUSSION We found no significant interaction between receipt of red cell transfusion and age, as variables, and survival at 1 year as an outcome.
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Affiliation(s)
- S C Mudumbai
- Anesthesiology and Perioperative Care Service; Center for Health Care Evaluation, VA Palo Alto Health Care System, Palo Alto, CA 94304, USA.
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Giffhorn H. Impact on early and late mortality after blood transfusion in CABG surgery. Braz J Cardiovasc Surg 2013; 28:150-1. [PMID: 23739944 DOI: 10.5935/1678-9741.20130020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Recent progress has been made in the identification and implementation of best transfusion practices on the basis of evidence-based clinical trials, published clinical practice guidelines, and process improvements for blood use and clinical patient outcomes. However, substantial variability persists in transfusion outcomes for patients in some clinical settings--eg, patients undergoing cardiothoracic surgery. This variability could be the result of insufficient understanding of published guidelines; different recommendations of medical societies, including the specification of a haemoglobin concentration threshold to use as a transfusion trigger; the value of haemoglobin as a surrogate indicator for transfusion benefit, even though only changes in concentration and not absolute red cell mass of haemoglobin can be identified; and disagreement about the validity of the level 1 evidence for clinical practice guidelines. Nevertheless, institutional experience and national databases suggest that a restrictive blood transfusion approach is being increasingly implemented as best practice.
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Holst LB, Haase N, Wetterslev J, Wernerman J, Åneman A, Guttormsen AB, Johansson PI, Karlsson S, Klemenzson G, Winding R, Nebrich L, Albeck C, Vang ML, Bülow HH, Elkjær JM, Nielsen JS, Kirkegaard P, Nibro H, Lindhardt A, Strange D, Thormar K, Poulsen LM, Berezowicz P, Bådstøløkken PM, Strand K, Cronhjort M, Haunstrup E, Rian O, Oldner A, Bendtsen A, Iversen S, Langva JÅ, Johansen RB, Nielsen N, Pettilä V, Reinikainen M, Keld D, Leivdal S, Breider JM, Tjäder I, Reiter N, Gøttrup U, White J, Wiis J, Andersen LH, Steensen M, Perner A. Transfusion requirements in septic shock (TRISS) trial - comparing the effects and safety of liberal versus restrictive red blood cell transfusion in septic shock patients in the ICU: protocol for a randomised controlled trial. Trials 2013; 14:150. [PMID: 23702006 PMCID: PMC3679866 DOI: 10.1186/1745-6215-14-150] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 04/25/2013] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Transfusion of red blood cells (RBC) is recommended in septic shock and the majority of these patients receive RBC transfusion in the intensive care unit (ICU). However, benefit and harm of RBCs have not been established in this group of high-risk patients. METHODS/DESIGN The Transfusion Requirements in Septic Shock (TRISS) trial is a multicenter trial with assessor-blinded outcome assessment, randomising 1,000 patients with septic shock in 30 Scandinavian ICUs to receive transfusion with pre-storage leuko-depleted RBC suspended in saline-adenine-glucose and mannitol (SAGM) at haemoglobin level (Hb) of 7 g/dl or 9 g/dl, stratified by the presence of haematological malignancy and centre. The primary outcome measure is 90-day mortality. Secondary outcome measures are organ failure, ischaemic events, severe adverse reactions (SARs: anaphylactic reaction, acute haemolytic reaction and transfusion-related circulatory overload, and acute lung injury) and mortality at 28 days, 6 months and 1 year.The sample size will enable us to detect a 9% absolute difference in 90-day mortality assuming a 45% event rate with a type 1 error rate of 5% and power of 80%. An interim analysis will be performed after 500 patients, and the Data Monitoring and Safety Committee will recommend the trial be stopped if a group difference in 90-day mortality with P ≤0.001 is present at this point. DISCUSSION The TRISS trial may bridge the gap between clinical practice and the lack of efficacy and safety data on RBC transfusion in septic shock patients. The effect of restrictive versus liberal RBC transfusion strategy on mortality, organ failure, ischaemic events and SARs will be evaluated.
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Affiliation(s)
- Lars B Holst
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Nicolai Haase
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jan Wernerman
- Department of Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Anders Åneman
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
| | - Anne B Guttormsen
- Department of Intensive Care, Haukeland University Hospital and University of Bergen, Bergen, Norway
| | - Pär I Johansson
- Section for Transfusion Medicine, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Sari Karlsson
- Department of Intensive Care, Tampere University Hospital, Tampere, Finland
| | | | - Robert Winding
- Department of Intensive Care, Herning Hospital, Herning, Denmark
| | - Lars Nebrich
- Department of Intensive Care, Hvidovre Hospital, Hvidovre, Denmark
| | - Carsten Albeck
- Department of Intensive Care, Hvidovre Hospital, Hvidovre, Denmark
| | - Marianne L Vang
- Department of Intensive Care, Randers Hospital, Randers, Denmark
| | | | - Jeanie M Elkjær
- Department of Intensive Care, Holbæk Hospital, Holbæk, Denmark
| | - Jane S Nielsen
- Department of Intensive Care, Kolding Hospital, Kolding, Denmark
| | - Peter Kirkegaard
- Department of Intensive Care, Næstved Hospital, Næstved, Denmark
| | - Helle Nibro
- Department of Intensive Care, Århus University Hospital Nørreborgade, Århus, Denmark
| | - Anne Lindhardt
- Department of Intensive Care, Bispebjerg Hospital, Bispebjerg, Denmark
| | - Ditte Strange
- Department of Intensive Care, Bispebjerg Hospital, Bispebjerg, Denmark
| | - Katrin Thormar
- Department of Intensive Care, Bispebjerg Hospital, Bispebjerg, Denmark
| | - Lone M Poulsen
- Department of Intensive Care, Slagelse Hospital, Slagelse, Denmark
| | | | | | - Kristian Strand
- Department of Intensive Care, Stavanger Hospital, Stavanger, Norway
| | - Maria Cronhjort
- Department of Intensive Care, Södersjukhuset, Stockholm, Sweden
| | | | - Omar Rian
- Department of Intensive Care, Horsens Hospital, Horsens, Denmark
| | - Anders Oldner
- Department of Intensive Care, Karolinska University Hospital, Solna, Sweden
| | - Asger Bendtsen
- Department of Intensive Care, Glostrup Hospital, Glostrup, Denmark
| | - Susanne Iversen
- Department of Intensive Care, Slagelse Hospital, Slagelse, Denmark
| | - Jørn-Åge Langva
- Department of Intensive Care, Ålesund Hospital, Ålesund, Norway
| | | | - Niklas Nielsen
- Department of Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Ville Pettilä
- Department of Intensive Care, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matti Reinikainen
- Department Of Intensive Care, North Karelia Central Hospital, Joensuu, Finland
| | - Dorte Keld
- Department of Intensive Care, Århus University Hospital Skejby, Århus, Denmark
| | - Siv Leivdal
- Department of Intensive Care, Sønderborg Hospital, Sønderborg, Denmark
| | | | - Inga Tjäder
- Department of Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Nanna Reiter
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Ulf Gøttrup
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jonathan White
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jørgen Wiis
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Lasse Høgh Andersen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Morten Steensen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
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Santos AAD. Answer. Rev Bras Cir Cardiovasc 2013; 28:151-152. [PMID: 23885383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Restrictive approach to transfusion best in upper gastrointestinal bleeding. BMJ 2013; 346:f71. [PMID: 23303897 DOI: 10.1136/bmj.f71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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