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1.
J Paediatr Child Health. 2019 Jan 19. doi: 10.1111/jpc.14377. [Epub ahead of print]

Mortality and hospital readmissions in the first year of life after intra-uterine and neonatal blood product transfusions: A population data linkage study.

Author information

1
The University of Sydney Northern Clinical School, Clinical and Population Perinatal Health Research, Sydney, New South Wales, Australia.
2
Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia.
3
Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia.
4
Research and Development, Australian Red Cross Blood Service, Sydney, New South Wales, Australia.
5
University of Technology, Sydney, New South Wales, Australia.

Abstract

AIM:

Blood product transfusions are a potentially life-saving therapy for fetal and neonatal anaemia, but there is limited population-based research on outcomes. We aimed to describe mortality, readmission and average hospital stay in the first year of life for infants with or without intra-uterine or neonatal blood product transfusions.

METHODS:

Linked birth, hospital and deaths data from New South Wales, Australia (January 2002-June 2014) were used to identify singleton infants (≥23 weeks' gestation, surviving to 29 days; n = 1 089 750) with intra-uterine or neonatal transfusion or no transfusion. Rates of mortality and readmission in the first year (29-365 days) and days in hospital were calculated.

RESULTS:

Overall, 68 (0.06/1000) infants had experienced intra-uterine transfusion and 4332 (3.98/1000) neonatal transfusion. Transfusion was more common among those born at earlier gestational ages requiring invasive ventilation. Mortality, readmissions and average days in hospital were higher among transfused than non-transfused infants. Over half of infants with intra-uterine and neonatal transfusion had ≥1 readmission in the first 29-365 days (55.9 and 51.8%, respectively), and around a quarter had ≥2 (20.6 and 28.5%, respectively) compared with 15.3% with ≥1 and 3.5% with ≥2 in the non-transfused group.

CONCLUSION:

Infants with a history of blood product transfusion, particularly those needing a neonatal transfusion, had higher mortality and more frequent contact with the hospital system in the first year of life than those infants with no history of transfusion.

KEYWORDS:

epidemiology; haematology; neonatology

PMID:
30659697
DOI:
10.1111/jpc.14377
Icon for Wiley Icon for South & East Metropolitan Health Service Library, Australia
2.
J Blood Med. 2019 Jan 3;10:37-46. doi: 10.2147/JBM.S166316. eCollection 2019.

Traditional and emerging technologies for washing and volume reducing blood products.

Author information

1
Department of Biomedical Engineering, University of Houston, Houston, TX 77204-5060, USA, sshevkoplyas@uh.edu.

Abstract

Millions of blood components including red blood cells, platelets, and granulocytes are transfused each year in the United States. The transfusion of these blood products may be associated with adverse clinical outcomes in some patients due to residual proteins and other contaminants that accumulate in blood units during processing and storage. Blood products are, therefore, often washed in normal saline or other media to remove the contaminants and improve the quality of blood cells before transfusion. While there are numerous methods for washing and volume reducing blood components, a vast majority utilize centrifugation-based processing, such as manual centrifugation, open and closed cell processing systems, and cell salvage/autotransfusion devices. Although these technologies are widely employed with a relatively low risk to the average patient, there is evidence that centrifugation-based processing may be inadequate when transfusing to immunocompromised patients, neonatal and infant patients, or patients susceptible to transfusion-related allergic reactions. Cell separation and volume reduction techniques that employ centrifugation have been shown to damage blood cells, contributing to these adverse outcomes. The limitations and disadvantages of centrifugation-based processing have spurred the development of novel centrifugation-free methods for washing and volume reducing blood components, thereby causing significantly less damage to the cells. Some of these emerging technologies are already transforming niche applications, poised to enter mainstream blood cell processing in the not too distant future.

KEYWORDS:

granulocytes; platelets; red blood cells; transfusion; volume reduction; washing

PMID:
30655711
PMCID:
PMC6322496
DOI:
10.2147/JBM.S166316
Icon for Dove Medical Press Icon for PubMed Central Icon for South & East Metropolitan Health Service Library, Australia

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Publication type

Publication type

3.
Paediatr Anaesth. 2019 Jan 4. doi: 10.1111/pan.13574. [Epub ahead of print]

Society for the Advancement of Blood Management Administrative and Clinical Standards for Patient Blood Management Programs. 4th Edition (Pediatric Version).

Author information

1
Department of Anaesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA.
2
Patient Blood Management Division, Washington State Hospital Association, Seattle, WA, USA.
3
Patient Blood Management Division, Accumen Inc at Eastern Maine Medical Center, Bangor, ME, USA.
4
Department of Anesthesiology and Bloodless Medicine, Englewood Hospital and Medical Center, NJ, USA.

Abstract

Patient Blood Management is the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss to improve patient outcomes. Conceptually similar to a "bundle" strategy, it is designed to improve clinical care by using comprehensive evidence-based treatment strategies to manage patients with potential or ongoing critical bleeding, bleeding diathesis, critical anemia and/ or a coagulopathy. Patient Blood Management includes multimodal strategies to screen, diagnose and properly treat anemia, coagulopathies and minimize bleeding, using goal-directed therapy and leverages a patient's physiologic ability to adapt to anemia while definitive treatment is undertaken. Allogeneic blood component transfusion is one traditional therapeutic modality out of many for managing blood loss and anemia and, while it may be the best choice in certain situations, other effective and more appropriate options are available and should be used in conjunction or alone. Therefore, comprehensive Patient Blood Management is the new standard of care to prevent and manage anemia and optimize hemostasis and has been recommended by the World Health Organization, the American Society of Anesthesiologists, the European Society of Anaesthesiology and the Australian National Blood Authority. While there is a plethora of expert consensus and good practice guidelines published for blood component transfusion from multiple professional organizations and societies, there remains a need for more comprehensive and broader standards of patient medical management to proactively reduce the risk of exposure to allogeneic transfusions. In 2010, the Society for Advancement of Blood Management published the first comprehensive standards to address the administrative and clinical components of an effective, patient-centered Patient Blood Management program. Recognizing the need to reduce inappropriate transfusions, some professional organizations have placed their emphasis on transfusion guidelines. In contrast, the focus of the Society for Advancement of Blood Management Standard is on the centrality of the patient and the full spectrum of therapeutic strategies needed to improve clinical outcomes in patients at risk for blood loss or anemia, thereby reducing avoidable transfusions as well. The Standards are meant not to replace, but to complement transfusion guidelines by more completely addressing the need for a multi-modal clinical approach with the goal to improve patient outcomes. Compared to adult programs, Pediatric Patient Blood Management programs are currently not commonly accepted as standard of care for pediatric patients. This is partly due the fact that, until recently, there was a paucity of robust evidence based literature and expert consensus guidelines on pediatric patient blood management. Managing pediatric bleeding and blood product transfusion presents a unique set of challenges. The main goal of transfusion is to correct or avoid imminent inadequate oxygen carrying capacity caused by inadequate red blood cell mass. Determining when, what and how much to transfuse can be difficult. Neonates, infants, children and adolescents each have specific considerations based on age, weight, physiology and pharmacology. In this edition of Pediatric Anaesthesia we provide, in abbreviated format, the 4th  edition of the Administrative and Clinical Standards for Patient Blood Management; Pediatric Version, first published in 2010 with the addition of a new Pediatric section in 2016. These Standards provide guidance for implementing a comprehensive Pediatric Patient Blood Management program at both pediatric and adult medical institutions. While every hospital may not be equipped to have a dedicated Pediatric Patient Blood Management program, this document highlights important universal clinical strategies that can be implemented to optimize pediatric bleeding management and minimize allogeneic blood product exposure through the use of multi-modal therapeutic strategies that have their central emphasis on the patient rather than the transfusion. Important strategies include: treatment of preoperative anemia, standardized transfusion algorithms, the use of restrictive transfusion thresholds, goal-directed therapy based on point of care and viscoelastic testing, antifibrinolytics, and avoidance of hemodilution and hypothermia as supported by evidence. For the full version, please go to https://www.sabm.org/publications. This article is protected by copyright. All rights reserved.

KEYWORDS:

PBM ; Patient Blood Management; anemia; guidelines; indicators; iron deficiency; preoperative assessment; standards; transfusion

PMID:
30609198
DOI:
10.1111/pan.13574
Icon for Wiley Icon for South & East Metropolitan Health Service Library, Australia
4.
Injury. 2018 Dec 12. pii: S0020-1383(18)30724-1. doi: 10.1016/j.injury.2018.11.049. [Epub ahead of print]

What is the impact of prehospital blood product administration for patients with catastrophic haemorrhage: an integrative review.

Author information

1
Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia; NSW Ambulance, Sydney Ambulance Centre, Eveleigh, NSW, Australia. Electronic address: Sophie.Shand@health.nsw.gov.au.
2
Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia; Illawarra Shoalhaven Local Health District, NSW, Australia.
3
Royal Prince Alfred Hospital, NSW, Australia; Institute of Trauma and Injury Management, NSW, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.
4
Greater Sydney Area HEMS, NSW Ambulance, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.

Abstract

INTRODUCTION:

Catastrophic haemorrhage is recognised as the leading cause of preventable death in trauma and is also prevalent in medical and other surgical aetiology. Prehospital blood product transfusion is increasingly available for both military and civilian emergency teams. Hospitals have well-established massive transfusion protocols for the resuscitation of this patient group, however the use and impact in the prehospital field is less understood.

AIM:

To identify and evaluate the current knowledge surrounding prehospital blood product administration for patients with catastrophic haemorrhage.

METHODS:

The integrative review method included systematic searching of online databases Medline, EMBASE, SCOPUS and CINAHL alongside hand-searching for primary research articles published prior to 19 November 2018. Papers were included if the population studied patients with catastrophic haemorrhage who received prehospital transfusion of blood products. The level of evidence and quality was evaluated using the NHMRC hierarchy of evidence. All identified full text articles were reviewed by all authors.

RESULTS:

Twenty-two papers were included in the final analysis, including both civilian (16) and military (6) practice. The earliest publication for prehospital transfusion was 1999, with increasing prevalence in recent years. Findings were extracted and into two main categories; (1) transfusion processes included team staffing, product selection, and criteria for transfusion and (2) transfusion outcomes; transfusion safety, haemoglobin, hospital intervention and mortality.

DISCUSSION:

The level of evidence specific to prehospital blood product transfusion is low, with predominantly retrospective methods and rarely sufficient sample sizes to reach statistical significance. Prehospital research is challenged by clinical and logistical variability preventing accurate cohort matching, sample sizes and inconsistent data collection. Evaluation of prehospital transfusion in isolation is also particularly problematic as multiple factors and developments in clinical practice affect patient outcomes and all samples were subject to survival bias. Conclusion The volume and strength of the available evidence prevents accurate evaluation of the intervention and definitive practice recommendations however prehospital transfusion is shown to be logistically achievable and without serious incident. The reviewed evidence broadly supports the translation of recent in-hospital studies, such as PROMTT and PROPPR. Further research specific to prehospital practice is required to guide the development of evidence-based protocols.

KEYWORDS:

Ambulance; Bleeding; Blood; Haemorrhage; Hypovolemia; Plasma; Prehospital; Retrieval; Shock; Transfusion; Trauma

Publication type

Publication type

5.
Medicine (Baltimore). 2018 Dec;97(50):e13643. doi: 10.1097/MD.0000000000013643.

The efficacy and safety of tranexamic acid in reducing perioperative blood loss in patients with multilevel thoracic spinal stenosis: A retrospective observational study.

Author information

1
Xi'an Medical University, No. 74 Hanguang Road.
2
Honghui Hospital, Xi'an Jiaotong University, No. 76 Nanguo Road, District Beilin, Xi'an, Shaanxi, China.

Abstract

STUDY DESIGN:

A retrospective study.

OBJECTIVE:

To investigate the effectiveness and safety of intravenous tranexamic acid for reducing perioperative blood loss in patients with multilevel thoracic spinal stenosis (TSS).

METHODS:

This is a retrospective observational study of 42 patients with multilevel TSS admitted from December 2016 to October 2017 to the spine department of Honghui Hospital who underwent posterolateral bone graft fusion with posterior laminectomy and decompression fixation. The patients were divided into 2 groups. All the surgeries were completed by the same surgeon. Group A received an intravenous infusion of 15 mg/kg 15 min prior to surgery. Continuous infuse on of tranexamic acid (TXA) at a dose of 1 mg/kg/h was provided throughout the operation until the skin was closed. Group B received no TXA as a blank control group. Group A comprised 10 males and 10 females with an average age of 53.41 ± 7.93 years; group B comprised 11 males and 11 females with an average age of 55.10 ± 8.43 years. The need for blood transfusion, volume of blood transfusion, blood coagulation function, extubation time, postoperative hospital stay and incidence of postoperative deep venous thrombosis (DVT) were recorded during and after the operation for the 2 groups.

RESULTS:

There was no significant difference between the 2 groups in general characteristics, such as age, sex and body mass index (BMI) (P > .05). There was no significant difference between the 2 groups in the levels are instrumented and the laminectomy levels in each group. The average postoperative blood loss, need for blood transfusion, time to postoperative extubation and length of postoperative hospital stay in group A were lower than those in group B, and there was a significant difference between the 2 groups (P < .05). The preoperative and postoperative coagulation, and postoperative DVT did not occur 48 h after operation.

CONCLUSION:

In the treatment of multilevel thoracic spinal canal stenosis using trabeculectomy with posterior laminectomy and posterolateral bone graft fusion, TXA can reduce the amount of blood transfused and the need for blood transfusion and can shorten the extubation time and the length of postoperative hospital stay without increasing the incidence of postoperative coagulation dysfunction or postoperative DVT.

LEVEL OF EVIDENCE:

4.

PMID:
30558058
DOI:
10.1097/MD.0000000000013643
[Indexed for MEDLINE]
Free full text
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6.
Medicine (Baltimore). 2018 Dec;97(50):e13626. doi: 10.1097/MD.0000000000013626.

Anemia secondary to the use of sodium valproate for preventing postoperative seizures in a 79-year-old man: A case report.

Author information

1
Department of Geriatrics.
2
Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.

Abstract

RATIONALE:

Sodium valproate is a widely used antiepileptic drug and also used to prevent postoperative seizures in neurosurgery. Anemia caused by sodium valproate is occasionally reported and most are from pediatric patients.

PATIENT CONCERNS:

We present the case of a 79-year-old man who developed anemia in the setting of a short-term sodium valproate therapy for the prevention of postoperative seizures.

DIAGNOSIS:

By testing complete blood count we found anemia and hepatic enzyme elevations arising after 3-week standard dose sodium valproate therapy for preventing postoperative seizures. Our investigations ruled out most of the known causes of anemia including infection, uncontrolled bleeding, underlying systemic disease, malnutrition, immune hemolytic anemia, and neoplasia. On the drug's discontinuation as diagnostic therapy the patient's hemoglobin began to rise spontaneously and liver function returned to normal. Thus anemia secondary to sodium valproate was considered as the most likely diagnosis.

INTERVENTIONS:

Sodium valproate was suspended and the patient was transfused with concentrated red blood cells.

OUTCOMES:

The hemoglobin recovered obviously on the drug's discontinuation.

LESSONS:

Hematologic toxicity of sodium valproate can occur quickly. Regular complete blood count test helps to make prompt diagnosis and drug discontinuation leads to the recovery.

PMID:
30558048
PMCID:
PMC6320182
DOI:
10.1097/MD.0000000000013626
[Indexed for MEDLINE]
Free PMC Article
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7.
Medicine (Baltimore). 2018 Dec;97(50):e13581. doi: 10.1097/MD.0000000000013581.

Bloodless living donor liver transplantation: Risk factors, outcomes, and diagnostic predictors.

Yoon JU1,2, Byeon GJ1,2, Park JY1,2, Yoon SH1,2, Ryu JH3,4, Ri HS1,2.

Author information

1
Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University.
2
Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital.
3
Department of Surgery, School of Medicine, Pusan National University.
4
Department of Surgery, Pusan National University Yangsan Hospital, Yangsan-si, Republic of Korea.

Abstract

Massive bleeding is often unavoidable during liver transplantation (LT). However, blood transfusions are associated with risks and should be avoided whenever possible. This study compares preoperative factors and outcomes between non-transfusion and transfusion groups to identify variables that could be used to predict bloodless surgery in living donor liver transplantation (LDLT) patients.We conducted a retrospective study of 87 LDLT patients. The group of patients who did not require packed red blood cell (PRBC) transfusion (non-PRBC group, n = 44) was compared with those who did (PRBC group, n = 43). We compared risk factors, fluid management, and outcomes between the groups and identified variables for prediction of transfusion during LDLT.Compared with the PRBC group, the non-PRBC group had a lower model for end-stage liver disease (MELD) score (8.1 ± 1.1 vs 18.2 ± 8.8), international normalized ratio (INR) (1.16 ± 0.1 vs 1.80 ± 0.94), and partial thromboplastin time (PTT) (37.1 ± 6.3 vs 54.1 ± 24.0), but higher hemoglobin (Hb) (13.6 ± 1.6 vs 11.5 ± 2.2) and hematocrit (HCT) (39.1 ± 4.4 vs 32.6 ± 6.0). The non-PRBC group were more likely to receive colloid and albumin but had shorter intensive care unit (ICU) and hospital length of stay. The area under the receiver operative characteristic (ROC) curve of the MELD score was the highest (91%) using a cutoff value of 10.5.Patients without PRBC transfusion during LDLT were in better condition preoperatively and had better outcomes. The MELD score is a significant predictor for PRBC transfusion.

PMID:
30558025
PMCID:
PMC6320073
DOI:
10.1097/MD.0000000000013581
[Indexed for MEDLINE]
Free PMC Article
Icon for Wolters Kluwer Icon for PubMed Central Icon for South & East Metropolitan Health Service Library, Australia
8.
Semin Perinatol. 2018 Nov 14. pii: S0146-0005(18)30128-9. doi: 10.1053/j.semperi.2018.11.008. [Epub ahead of print]

Postpartum hemorrhage: Blood product management and massive transfusion.

Author information

1
Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins Hospital, Johns Hopkins University Medical Center, Baltimore, MD, United States. Electronic address: Avaught2@jhmi.edu.
2
Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins Hospital, Johns Hopkins University Medical Center, Baltimore, MD, United States; Department of Surgery, Division of Surgical Critical Care, Johns Hopkins Hospital, Johns Hopkins University Medical Center, Baltimore, MD, United States.

Abstract

Blood product transfusion capabilities are crucial for appropriate response to postpartum hemorrhage. Novel treatments are continually being sought to improve maternal morbidity and mortality associated with massive hemorrhage.

KEYWORDS:

Adjuncts; Hemorrhage; Massive Transfusion

Publication type

Publication type

9.
J Surg Res. 2019 Feb;234:110-115. doi: 10.1016/j.jss.2018.09.018. Epub 2018 Oct 6.

Outcomes After Massive Transfusion in Trauma Patients: Variability Among Trauma Centers.

Author information

1
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona.
2
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona. Electronic address: bjoseph@surgery.arizona.edu.

Abstract

BACKGROUND:

Exsanguinating trauma patients often require massive blood transfusion (defined as transfusion of 10 or more pRBC units within first 24 h). The aim of our study is to assess the outcomes of trauma patients receiving massive transfusion at different levels of trauma centers.

METHODS:

Two-y (2013-2014) retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adult trauma patients who received massive transfusion (MT) of blood. Outcome measures were mortality, hospital length of stay, intensive care unit-free and ventilator-free days, blood products received, and complications.

RESULTS:

We analyzed a total of 416,957 patients, of which 2776 met the inclusion criteria and included in the study. Mean age was 40.6 ± 20 y, 78.3% were males and 33.1% of the injuries were penetrating. Median injury severity score [IQR] was 29 [18-40], median [IQR] Glasgow Coma Scale 10[4-15]. Mean packed red blood cells transfusion in the first 24 h was 20 ± 13 units and mean plasma transfusion was 13 ± 11 units. Overall in-hospital mortality was 43.5%. Receiving MT in level I trauma center was independently associated with lower rates of mortality (odds ratio [OR]: 0.75 [0.46-0.96], P < 0.001). Higher injury severity score (OR: 1.020 [1.010-1.030], P < 0.001) and increased units of packed red blood cells transfused (OR: 1.067 [1.041-1.093], P < 0.001) were independently associated with increased mortality. However, there was no association between teaching status, age, gender, emergency department vitals, and units of plasma transfused.

CONCLUSIONS:

Hemorrhage continues to remain one of the most common cause of death after trauma. Almost half of the patients who received massive transfusion died. Patients who receive massive blood transfusion in a level I trauma centers have improved survival compared with level II trauma centers.

10.
Int J Organ Transplant Med. 2018;9(3):105-111. Epub 2018 Aug 1.

Blood Product Transfusion in Liver Transplantation and its Impact on Short-term Survival.

Author information

1
Blood Transfusion Research Center, Higher Institute for Research and Education in Transfusion Medicine, Tehran, Iran.
2
Department of Hepatobiliary and Transplantation Surgery, Shiraz University of Medical Sciences, Shiraz Transplant Center, Shiraz, Iran.

Abstract

Background:

Estimation of the amount of blood products required during liver transplantation can help provision of adequate blood supply, minimize transfusion-associated complications, and plan for preventive measures in high risk patients.

Objective:

To investigate independent predictors of peri-operative blood product transfusion and its impact on short-term survival of liver transplant recipients.

Methods:

In a cross-sectional study, old charts of patients who underwent liver transplantation between March 2003 and March 2013 at Namazi Hospital, Shiraz, Iran, were reviewed. The mean amount of blood product utilized during surgery and hospital stay and the related factors, including demographic characteristics, pre-transplant laboratory data, pre-transplant clinical data, operation data, and post-transplantation data were recorded.

Results:

We studied 1198 patients who underwent liver transplantation. The mean±SD amounts of red blood cells, fresh frozen plasma, and platelet transfusion during surgery and hospital stay were 2.67±3.5, 2.06±3.8, and 1.6±3.8 units, respectively. The mortality rate was significantly higher in patients who received high amounts of blood products (p<0.001). The mean amount of blood products' utilized during operation was significantly (p<0.001) decreased from 2003 to 2013.The mean amount of packed cell usage during operation and hospital stay was significantly (p<0.001) correlated with age, technique of surgery, serum albumin level, cirrhosis, blood urea nitrogen, length of operation, and prothrombin time.

Conclusion:

Pre-operative factors may predict blood transfusion requirements in patients undergoing liver transplantation. Therefore, evaluation of patients before operation should be considered to provide adequate blood supply and minimize transfusion-associated complications. Understanding pre-operative factors associated with rate of transfusion may help us to best utilize the limited available blood resources.

KEYWORDS:

Blood loss; Blood product transfusion; Liver transplantation; Survival rate

11.
J Matern Fetal Neonatal Med. 2018 Nov 28:1-151. doi: 10.1080/14767058.2018.1554049. [Epub ahead of print]

The role of supracervical hysterectomy in reducing blood products requirement in the management of placenta accreta: A case control study.

Author information

1
a Department of Obstetrics and Gynecology , Hadassah , Hebrew University Medical Center , Jerusalem , Israel.

Abstract

OBJECTIVE:

While surgical management is the treatment of choice for abnormally invasive placenta, the role of supracervical hysterectomy in this setting is not well established. We aimed to compare supracervical versus total cesarean hysterectomy as a surgical option for abnormally invasive placenta.

METHODS:

We carried out a 8-year retrospective case-control study. Six cases of patient treated by total hysterectomy were matched and compared to 30 controls treated by supracervical hysterectomy. Matching of cases with controls was based on coexisting placenta previa, number of previous caesarean sections, and age, with five controls per case. Cases and controls were comparable in placental invasion topography. We compared the operative approach in all histologically identified cases of abnormally invasive placenta.

RESULTS:

Overall, 36 women with histologically proven abnormally invasive placenta were identified. Composite blood products morbidity was higher among total hysterectomy patients (p = 0.02). Fresh frozen plasma utilization was greater among total hysterectomy patients (p = 0.01). Median operative time (142 ± 48 versus 136 ± 58 minutes) and hospitalization time (8.9 ± 3.1 versus 7.3 ± 1.5 days) were comparable between those who underwent supracervical versus total hysterectomy (p > 0.05). No case of maternal or neonatal death was encountered.

CONCLUSION:

The favorable maternal and perinatal outcomes observed in our study, suggest that supracervical hysterectomy should be considered as the first-line approach in cases of abnormally invasive placenta managed operatively.

KEYWORDS:

Abnormally invasive placenta; cesarean hysterectomy; placenta accreta; supracervical hysterectomy

12.
Transfus Apher Sci. 2018 Nov 16. pii: S1473-0502(18)30315-X. doi: 10.1016/j.transci.2018.11.002. [Epub ahead of print]

Assessment of the knowledge of usage of blood and blood products amongst medical doctors in the Department of Medicine at the Faculty of Health Sciences, University of the Witwatersrand affiliated academic hospitals.

Author information

1
Clinical Haematology Unit, Department of Medicine and Faculty of Health Sciences, University of the Witwatersrand, South Africa. Electronic address: laherm2@gmail.com.
2
Clinical Haematology Unit, Department of Medicine and Faculty of Health Sciences, University of the Witwatersrand, South Africa.

Abstract

BACKGROUND:

Rational and appropriate use of blood and blood products is important in a resource limited setting like South Africa. Proper education is required in decision-making and management with regard to blood transfusion. Status of the current knowledge of blood transfusion practice is also necessary in order to identify target areas of teaching and patient management.

OBJECTIVE:

To assess the knowledge regarding blood and blood products among doctors of varying ranks at the University of the Witwatersrand affiliated academic hospitals.

RESEARCH DESIGN AND METHODS:

This is an observational, descriptive study using a self-administered questionnaire, comprising of 40 questions, equally divided into 6 sections covering different areas of transfusion medicine. Demographics of the participants and an opinion on how to impart further information was also included.

RESULTS:

A response rate of 33% was obtained from the distributed questionnaires. After grouping medical professionals together, an average score of 61% was obtained. As individual groups, the consultants achieved the highest score of 64%, while the interns, who averaged 56%, achieved the lowest score. The medical officers and registrars averaged 63%, while community service doctors averaged 58%. Participants scored the best in the section pertaining to 'consent' averaging 87%. This was followed by 64%, achieved for the section regarding 'adverse effects'. The section regarding 'red blood cell usage' and 'blood product ordering' was scored at 60%, while the section on 'platelet usage' attained a score of 44%. The lowest score was achieved in the section regarding 'plasma product usage', 30%. A statistically significant gap in knowledge (p = 0.0139) was noted from intern up to medical officer level, after which the increase in knowledge up to consultant level was not found to be statistically significantly different.

CONCLUSIONS:

The overall results obtained appear to be suboptimal and can be improved upon. Formalized and on-going teaching around blood and blood product usage is required at both undergraduate and postgraduate levels, to ensure that this scarce, but invaluable resource is used judiciously and appropriately.

KEYWORDS:

Blood transfusion; Doctors in internal medicine; Knowledge of blood product usage; Observational study; South Africa

13.
Afr J Emerg Med. 2018 Jun;8(2):69-74. doi: 10.1016/j.afjem.2018.01.004. Epub 2018 Mar 20.

Estimated injury-associated blood loss versus availability of emergency blood products at a district-level public hospital in Cape Town, South Africa.

Author information

1
Khayelitsha Hospital, Cape Town, South Africa.
2
Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa.
3
Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.

Abstract

Introduction:

International guidance suggests that injury-associated haemorrhagic shock should be resuscitated using blood products. However, in low- and middle-income countries resuscitation emphasises the use of crystalloids - mainly due to poor access to blood products. This study aimed to estimate the amount of blood loss from serious injury in relation to available emergency blood products at a secondary-level, public Cape Town hospital.

Methods:

This retrospective, cross-sectional study included all injured patients cared for in the resuscitation area of Khayelitsha Hospital's emergency centre over a fourteen-week period. Injuries were coded using the Abbreviated Injury Scale, which was then used to estimate blood loss for each patient using an algorithm from the Trauma Audit Research Network. Descriptive statistics were used to describe blood volume lost and blood units required to replace losses greater than 15% circulating blood volume. Four units of emergency blood are stored in a dedicated blood fridge in the emergency centre. Platelets and fresh plasma are not available.

Results:

A total of 389 injury events were enrolled of which 93 were excluded due to absent clinic data. The mean age was 29 (±10) years. We estimated a median of one unit of blood requirement per week or weekend, up to a maximum of eight or six units, respectively. Most patients (n = 275, 94%) did not have sufficient injury to warrant transfusion. Overall, one person would require a transfusion for every 15 persons with a moderate to serious injury.

Conclusion:

The volume of available emergency blood appears inadequate for injury care, and doesn't consider the need for other causes of acute haemorrhage (e.g. gastric, gynaecological, etc.). Furthermore, lack of other blood components (i.e. plasma and platelets) presents a challenge in this low-resourced setting. Further research is required to determine the appropriate management of injury-associated haemorrhage from a resource and budget perspective.

KEYWORDS:

Blood products; Injury; Low resource

14.
Medicine (Baltimore). 2018 Nov;97(46):e13215. doi: 10.1097/MD.0000000000013215.

Perioperative predictors of moderate and severe postoperative pain in idiopathic scoliosis patients following spinal correction and fusion operations.

Author information

1
Department of Medicine.
2
School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China.
3
Department of Anesthesiology.
4
Department of Scoliosis Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School.

Abstract

To investigate the predictive factors of pain intensity during the first 48 hours after spinal correction and fusion operations for idiopathic scoliosis patients.A total of 290 scoliosis patients who underwent posterior spinal instrumentation and fusion operations were enrolled in this study. A standard surgical and analgesic method was implemented for all participants and pain intensity was evaluated at fixed times within 48 hours after the operation. Variables including demographics (age, sex, body mass index [BMI], patient sources), surgical variables (procedure, duration of operation), intraoperative variables (total transfusion, autologous transfusion, heterogeneous transfusion, fluid intake, use of preventive analgesia) were investigated.On univariate analysis, BMI, transfusion type and not implementing preventive analgesia were associated with more serious pain after a scoliosis correction operation. Multivariate analysis indicated that receiving heterogeneous transfusion and not implementing preventive analgesia were significant predictive factors for moderate and severe pain after the spinal correction operation.Our research indicated that the type of transfusion and preventive analgesia were significantly associated with the severity of pain. Body mass and patient sources should be considered before surgery. For patients under high risk of moderate and severe pain, the type of transfusion must be taken into consideration. This study explored the influencing factors of postoperative pain from a novel perspective, but some limitations existed in this present study, and future studies are needed.

PMID:
30431597
PMCID:
PMC6257568
DOI:
10.1097/MD.0000000000013215
[Indexed for MEDLINE]
Free PMC Article
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15.
Air Med J. 2018 Nov - Dec;37(6):392-399. doi: 10.1016/j.amj.2018.08.003. Epub 2018 Sep 21.

Prehospital Blood Product Transfusion in Mountain Rescue Operations.

Author information

1
Department of Anaesthesiology and Pain Therapy, University Hospital of Bern, Bern, Switzerland; Air Zermatt, Emergency Medical Service, Zermatt, Switzerland. Electronic address: juergen.knapp@insel.ch.
2
Air Zermatt, Emergency Medical Service, Zermatt, Switzerland; Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St Gallen, St Gallen, Switzerland.
3
Air Zermatt, Emergency Medical Service, Zermatt, Switzerland.
4
Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm, Germany; Task Force "Tactical Medicine" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany.
5
Emergency Department, University Hospital of Düsseldorf, Düsseldorf, Germany; Task Force "Trauma and Resuscitation Room Management" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany.
6
Task Force "Tactical Medicine" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany; Department of Anaesthesiology and Postoperative Intensive Care Medicine, University of Cologne, Köln, Germany.

Abstract

Severely injured patients with hemorrhage present major challenges for emergency medical services, especially during mountain rescue missions in which harsh environmental conditions and long out-of-hospital times are frequent. Because uncontrolled hemorrhage is the leading cause of death within the first 48 hours after severe trauma, initiating damage control resuscitation (DCR) as early as possible after severe trauma and exporting the concept of DCR to the out-of-hospital arena is pivotal for patient survival. Appropriate bleeding control, management of coagulopathy, and transfusion of blood products are core aspects of DCR. This review summarizes the available evidence on out-of-hospital blood product transfusion and the management of coagulopathy with a special focus on mountain rescue missions. An overview of upcoming trials and possible future trends in the management of coagulopathy during rescue operations is provided.

16.
Air Med J. 2018 Nov - Dec;37(6):349-350. doi: 10.1016/j.amj.2018.09.002. Epub 2018 Oct 14.

Out-Of-Hospital Blood Product Administration Considerations.

[No authors listed]
17.
Ann Surg. 2018 Nov 9. doi: 10.1097/SLA.0000000000003095. [Epub ahead of print]

Multimodal Patient Blood Management Program Based on a Three-pillar Strategy: A Systematic Review and Meta-analysis.

Author information

1
Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany.
2
Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Frankfurt, Germany.
3
Data and Digital Innovation, East Metropolitan Health Service, Perth, Western Australia.
4
Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
5
St Michael's Hospital, University of Toronto, Toronto, Canada.
6
Department of Anesthesiology and Bioengineering, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA.
7
Medical School, CTEC and Division of Surgery, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.
8
Faculty of Health Sciences, Centre for Population Health Research, Curtin University, Perth, Western Australia, Australia.
9
Department of Hematology, School of Medicine and Pharmacology, PathWest Laboratory Medicine Royal Perth Hospital, The University of Western Australia, Perth, Western Australia.

Abstract

OBJECTIVES:

To determine whether a multidisciplinary, multimodal Patient Blood Management (PBM) program for patients undergoing surgery is effective in reducing perioperative complication rate, and thereby is effective in improving clinical outcome.

BACKGROUND:

PBM is a medical concept with the focus on a comprehensive anemia management, to minimize iatrogenic (unnecessary) blood loss, and to harness and optimize patient-specific physiological tolerance of anemia.

METHODS:

A systematic review and meta-analysis was performed. Eligible studies had to address each of the 3 PBM pillars with at least 1 measure per pillar, for example, preoperative anemia management plus cell salvage plus rational transfusion strategy. The study protocol has been registered with PROSPERO (CRD42017079217).

RESULTS:

Seventeen studies comprising 235,779 surgical patients were included in this meta-analysis (100,886 pre-PBM group and 134,893 PBM group). Implementation of PBM significantly reduced transfusion rates by 39% [risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55-0.68, P < 0.00001], 0.43 red blood cell units per patient (mean difference -0.43, 95% CI -0.54 to -0.31, P < 0.00001), hospital length of stay (mean difference -0.45, 95% CI -0.65 to -0.25, P < 0,00001), total number of complications (RR 0.80, 95% CI 0.74-0.88, P <0.00001), and mortality rate (RR 0.89, 95% CI 0.80-0.98, P = 0.02).

CONCLUSIONS:

Overall, a comprehensive PBM program addressing all 3 PBM pillars is associated with reduced transfusion need of red blood cell units, lower complication and mortality rate, and thereby improving clinical outcome. Thus, this first meta-analysis investigating a multimodal approach should motivate all executives and health care providers to support further PBM activities.This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0.

18.
Medicine (Baltimore). 2018 Oct;97(43):e12911. doi: 10.1097/MD.0000000000012911.

The impact of perioperative allogeneic blood transfusion on prognosis of hepatocellular carcinoma after radical hepatectomy: A systematic review and meta-analysis of cohort studies.

Xun Y1,2,3, Tian H4,5, Hu L6, Yan P5, Yang K2,3, Guo T5.

Author information

1
School of Public Health.
2
Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University.
3
Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China.
4
The First Clinical Medical College, Lanzhou University, Lanzhou.
5
Department of General Surgery, Gansu Provincial Hospital.
6
Medical College of Xiamen University, Xiamen.

Abstract

This meta-analysis aims to clarify the clinical impacts of allogeneic blood transfusion (ABT) on hepatectomy outcome in hepatocellular carcinoma (HCC) patients. A systematic literature search was performed for relevant articles in international and Chinese databases up to May 2018. Random- or fixed-effect meta-analysis was used to pool the effect estimates. Publication bias was assessed by Egger's and Peters's test. Heterogeneity was assessed using the I statistic. The strength of evidence was rated by the Grading of Recommendations Assessment, Development, and Evaluation system. A total of 29 studies met the eligibility criteria. Meta-analysis showed HCC patients in ABT group had lower survival rate at 1, 3, 5, and 10 years after radical hepatectomy than those in no blood transfusion (NBT) group (RR = 0.9, 95%CI: 0.87-0.93, P < .05; RR = 0.83, 95%CI: 0.77-0.89, P < .05; RR = 0.7, 95%CI: 0.65-0.74, P < .05; RR = 0.64, 95%CI: 0.54-0.75, P < .05). Similar results were observed in disease-free survival (DFS) (respectively: RR = 0.86, 95%CI: 0.82-0.91, P < .05; RR = 0.77, 95%CI: 0.67-0.79, P < .05; RR = 0.71, 95%CI: 0.64-0.79, P < .05; RR = 0.62, 95%CI: 0.48-0.8, P < .05). Cancer recurrence rate was higher for the patients in ABT group at 1 and 3 years (RR = 1.5, 95%CI: 1-2.24, P < .05; RR = 1.27, 95%CI: 1.09-1.49, P < .05, respectively), but not statistically significant at 5years (RR = 1.08, 95%CI: 0.98-1.19, P = .512). The HCC patients in ABT group increased postoperative complications occurrence compared with those in NBT group (RR = 1.87, 95%CI: 1.42-2.45, P < .05). This meta-analysis demonstrated that ABT was associated with adverse clinical outcomes for HCC patients undergoing radical hepatectomy, including poor survival, DFS, and complications. Surgeons should reduce blood loss during hepatectomy and avoid perioperative allogenic blood transfusion.

PMID:
30412094
PMCID:
PMC6221652
DOI:
10.1097/MD.0000000000012911
[Indexed for MEDLINE]
Free PMC Article
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19.
J Pediatr Surg. 2018 Oct 5. pii: S0022-3468(18)30658-4. doi: 10.1016/j.jpedsurg.2018.10.040. [Epub ahead of print]

Massive transfusion in pediatric trauma: An ATOMAC perspective.

Author information

1
Children's Medical Center, the flagship of Children's Health(SM), 1935 Medical District Dr, Dallas, TX, USA 75235.
2
Children's Medical Center, the flagship of Children's Health(SM), 1935 Medical District Dr, Dallas, TX, USA 75235. Electronic address: Cynthia.greenwell@childrens.com.
3
Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, USA 85016.
4
Dell Children's Medical Center, 4900 Mueller Blvd, Austin, TX, USA 78723.
5
Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR, USA 72202.
6
Le Bonheur Children's Hospital, 50 N Dunlap St, Memphis, TN, USA 38103.

Abstract

BACKGROUND/PURPOSE:

Massive transfusion protocols (MTPs) are considered valuable in pediatric trauma. Important questions regarding the survival benefit and optimal blood component ratio remain unknown.

METHODS:

The study time frame was January 2007 through December 2013 five Level I Pediatric Trauma Centers reviewed all trauma activations involving children ≤18 years of age. Included were patients who either had the institutional MTP or received >20 mL/kg or > 2 units packed red blood cells (PRBCs).

RESULTS:

110/202 qualified for inclusion. Median age was 5.9 years (3.0-11.4). 73% survived to discharge; median hospitalization was 10 (3.1-22.8) days. Survival did not vary by arrival hemoglobin (Hgb), gender or age. Partial prothrombin time (PTT), INR, GCS and injury severity score (ISS) significantly differed for nonsurvivors (all p < 0.05). Logistic regression found increased mortality (OR 3.08 (1.10-8.57), 95% CI; p = 0.031) per unit increase over a 1:1 ratio of pRBC:FFP.

CONCLUSION:

In pediatric trauma pRBC:FFP ratio of 1:1 was associated with the highest survival of severely injured children receiving massive transfusion. Ratios 2:1 or ≥3:1 were associated with significantly increased risk of death. These data support a higher proportion of plasma products for pediatric trauma patients requiring massive transfusion.

LEVEL OF EVIDENCE:

Level IV.

KEYWORDS:

Pediatric massive transfusion; Trauma resuscitation

20.
J Clin Apher. 2018 Dec;33(6):661-665. doi: 10.1002/jca.21662. Epub 2018 Nov 2.

Patient consultation about a trial of therapeutic plasma exchange for complex regional pain syndrome.

Author information

1
Department of Translational Medicine, Faculty of Health and Life Sciences, Pain Research Institute, University of Liverpool, Liverpool, United Kingdom.
2
Department of Pain Medicine, Walton Centre NHS Foundation Trust, Liverpool, United Kingdom.
3
NHS Blood and Transplant, Liverpool, United Kingdom.
4
Clinical Ethics, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom.

Abstract

BACKGROUND:

Complex regional pain syndrome (CRPS) is a severe post-traumatic chronic pain condition affecting distal limbs, for which few effective treatments exist. Complex regional pain syndrome is listed in the 2016 American Society for Apheresis guidelines as an indication for plasma exchange treatment, but patient perspectives are lacking.

STUDY DESIGN AND METHODS:

We convened a "patient and public consultation exercise." Supervised by a clinical ethicist, the case for using therapeutic plasma exchange (TPE) was presented by a researcher and two TPE experts to five patients with severe, long-standing CRPS and to one relative. Discussions were recorded and transcribed.

RESULTS:

Participants supported the technology's use but expressed concern that the small trauma of repeat cannulations of CRPS unaffected limbs might theoretically cause a spread of the condition, a risk which requires highlighting when taking consent. For a preliminary trial, the participants proposed to include no less than 10, preferably 20 participants. They suggested that the threshold for a decision to conduct a definite trial based on preliminary trial results should be set no higher than 1/5 patients achieving >30% pain reduction in the preliminary trial, with half of these responders achieving >50%. The use of sham-TPE and a long trial duration (1 year) of a definite, parallel trial was considered acceptable, provided patients would be offered voluntary swap to the other trial arm at the end of the main trial period.

CONCLUSION:

These results provide pertinent patient views about TPE treatment which can inform both clinical consultation and consent procedure and the design of future trials.

KEYWORDS:

CRPS; apheresis; chronic pain; complex regional pain syndrome; patient and public involvement exercise; therapeutic plasma exchange

PMID:
30387202
DOI:
10.1002/jca.21662
[Indexed for MEDLINE]
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