Tag Archives: Erythrocyte Transfusion

Should All Massively Transfused Patients Be Treated Equally? An Analysis of Massive Transfusion Ratios in the Nontrauma Setting. (Chaudhary)

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Etchill EW, Myers SP, McDaniel LM, Rosengart MR, Raval JS, Triulzi DJ,
Peitzman AB, Sperry JL, Neal MD. Should All Massively Transfused Patients Be Treated Equally? An Analysis of Massive Transfusion Ratios in the Nontrauma Setting. Crit Care Med. 2017 Aug;45(8):1311-1316.

OBJECTIVES: Although balanced resuscitation has become integrated into massive transfusion practice, there is a paucity of evidence supporting the delivery of high ratios of plasma and platelet to RBCs in the nontrauma setting. This study investigated the administration of blood component ratios in the massively transfused nontrauma demographic.

DESIGN: Retrospective analysis of a prospective, observational cohort of massively bleeding patients.

SETTING: Surgical and critically ill patients at a tertiary medical center between 2011 and 2015.

PATIENTS: Massively transfused nontrauma patients.

INTERVENTIONS: Patients receiving plasma, platelet, and RBC transfusions were categorized into high and low ratio groups and analyzed for differences in characteristics and clinical outcomes.

MEASUREMENTS AND MAIN RESULTS: The primary outcome was 30-day mortality. Secondary outcomes included 48-hour mortality, hospital length of stay, ICU length of stay, and ventilator-free days. Among 601 massively transfused nontrauma patients, cardiothoracic surgery and gastrointestinal or hepato-pancreatico-biliary bleeds were the most common indications for massive transfusion. Higher fresh frozen plasma ratios (> 1:2) were not associated with increased 30-day mortality. A high platelets-to-packed RBCs ratio (> 1:2) was associated with decreased 48-hour mortality (10.5% vs 19.3%; p = 0.032), but not 30-day mortality. Fresh frozen plasma-to-packed RBCs and platelets-to-packed RBCs ratios were not associated with 30-day mortality hazard ratios after controlling for baseline characteristics and disease severity.

CONCLUSIONS: The benefits of higher ratios of fresh frozen plasma-to-packed RBCs and platelets-to-packed RBCs described in trials of trauma patients were not observed in this analysis of a nontrauma, massively transfused population. These data suggest that greater than 1:2 ratio transfusion in the setting of massive hemorrhage may not be appropriate for all patients, and that further research to guide appropriate resuscitation strategies in nontrauma patients is warranted

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. (Sirignano)

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Dhabangi A, et al. 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 Dec 15;314(23):2514-23.

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.

RBC Transfusion in Pediatric Patients Supported With Extracorporeal Membrane Oxygenation: Is There an Impact on Tissue Oxygenation? (Ruth)

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Fiser RT, Irby K, Ward RM, et al. RBC Transfusion in Pediatric Patients Supported With Extracorporeal Membrane Oxygenation: Is There an Impact on Tissue Oxygenation?*. Pediatr Crit Care Med. 2014 Nov;15(9):806-13.

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OBJECTIVE: To examine first the RBC transfusion practice in pediatric patients supported with extracorporeal membrane oxygenation and second the relationship between transfusion of RBCs and changes in mixed venous saturation (SvO2) and cerebral regional tissue oxygenation, as measured by near-infrared spectroscopy in patients supported with extracorporeal membrane oxygenation.

DESIGN: Retrospective observational study.

SETTING: Pediatric, cardiovascular, and neonatal ICUs of a tertiary care children’s hospital.

PATIENTS: All pediatric patients supported with extracorporeal membrane oxygenation between January 1, 2010, and December 31, 2010.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: There were 45 patients supported with extracorporeal membrane oxygenation. The median (interquartile range) phlebotomy during extracorporeal membrane oxygenation was 75 mL/kg (33, 149 mL/kg). A total of 617 transfusions were administered (median, 9 per patient; range = 1-57). RBC volumes transfused during extracorporeal membrane oxygenation support were 254 mL/kg (136, 557) and 267 mL/kg (187, 393; p = 0.82) for cardiac and noncardiac patients, respectively. Subtracting the volume of RBCs used for extracorporeal membrane oxygenation circuit priming, median RBC transfusion volumes were 131 and 80 mL/kg for cardiac and noncardiac patients, respectively (p = 0.26). The cardiac surgical patients received the most RBCs (529 vs 74 mL/kg for nonsurgical cardiac patients). The median hematocrit maintained during extracorporeal membrane oxygenation support was 37%, with no difference between cardiac and noncardiac patients. Patients supported with extracorporeal membrane oxygenation were exposed to a median of 10.9 (range, 3-43) individual donor RBC units. Most transfusions resulted in no significant change in either SvO2 or cerebral near-infrared spectroscopy. Only 5% of transfusions administered (31/617) resulted in an increase in SvO2 of more than 5%, whereas an increase in cerebral near-infrared spectroscopy of more than 5 was only observed in 9% of transfusions (53/617). Most transfusions (73%) were administered at a time when the pretransfusion SvO2 was more than 70%.

CONCLUSIONS: Patients supported with extracorporeal membrane oxygenation were exposed to large RBC transfusion volumes for treatment of mild anemia resulting from blood loss, particularly phlebotomy. In the majority of events, RBC transfusion did not significantly alter global tissue oxygenation, as assessed by changes in SvO2 and cerebral near-infrared spectroscopy. Most transfusions were administered at a time at which the patient did not appear to be oxygen delivery dependent according to global measures of tissue oxygenation.

Relationship between red cell storage duration and outcomes in adults receiving red cell transfusions: a systematic review. (Paden)

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Crit Care. 2013 Apr 8;17(2):R66. PMID: 23566599

INTRODUCTION: The duration of red blood cell (RBC) storage before transfusion may alter RBC function and supernatant and, therefore, influence the incidence of complications or even mortality.

METHODS: A MEDLINE search from 1983 to December 2012 was performed to identify studies reporting age of transfused RBCs and mortality or morbidity in adult patients.

RESULTS: Fifty-five studies were identified; most were single-center (93%) and retrospective (64%), with only a few, small randomized studies (8 studies, 14.5%). The numbers of patients included ranged from 8 to 364,037. Morbidity outcomes included hospital and intensive care unit (ICU) length of stay (LOS), infections, multiple organ failure, microcirculatory alterations, cancer recurrence, thrombosis, bleeding, vasospasm after subarachnoid hemorrhage, and cognitive dysfunction. Overall, half of the studies showed no deleterious effects of aged compared to fresh blood on any endpoint. Eleven of 22 (50%) studies reported no increased mortality, and three of 9 (33%) showed no increased LOS with older RBCs. Ten of 18 (55%) studies showed increased infections and 8 of 12 (66%) studies showed no increased risks of organ failure with transfusion of older RBCs. The considerable heterogeneity among studies and numerous methodological flaws precluded a formal meta-analysis.

CONCLUSIONS: In this systematic review, we could find no definitive argument to support the superiority of fresh over older RBCs for transfusion.

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