RESUMO
BACKGROUND: Randomized controlled trials relatively consistently show that restrictive red blood cell (RBC) transfusion strategies are safe and associated with similar outcomes compared to liberal transfusion strategies in critically ill patients. Based on these data, the general threshold for RBC transfusion was changed to 70 g/L at a 9-bed tertiary level intensive care unit in September 2020. Implementation measures included lectures, webinars and feedback during clinical practice. The aim of this study was to investigate how implementation of a restrictive transfusion strategy influenced RBC usage, haemoglobin trigger levels and adherence to prescribed trigger levels. METHODS: In this registry-based, observational study, critically ill adult patients without massive bleeding were included and divided into a pre-cohort, with admissions prior to the change of transfusion strategy, and a post-cohort, with admissions following the change of transfusion strategy. These cohorts were compared regarding key RBC transfusion-related variables. RESULTS: In total 5626 admissions were included in the analyses (pre-cohort n = 4373, post-cohort n = 1253). The median volume (interquartile range, IQR) of RBC transfusions per 100 admission days, in the pre-cohort was 6120 (4110-8110) mL versus 3010 (2890-4970) mL in the post-cohort (p < .001). This corresponds to an estimated median saving of 1128 per 100 admission days after a restrictive RBC transfusion strategy was implemented. In total, 26% of the admissions in the pre-cohort and 19% in the post-cohort (p < .001) received RBC transfusion(s) during days 0-10. Both median (IQR) prescribed trigger levels (determined by intensivist) and actual haemoglobin trigger levels (i.e., levels prior to actual administration of transfusion) were higher in the pre- versus post-cohort (90 [80-100] vs. 80 [72-90] g/L, p < .001 and 89 [82-96] g/L vs. 83 [79-94], p < .001, respectively). Percentage of days without compliance with the prescribed transfusion trigger was higher in the pre-cohort than in the post-cohort (23% vs. 14%, p < .001). Sensitivity analyses, excluding patients with traumatic brain injury, ischemic heart disease and COVID-19 demonstrated similar results. CONCLUSIONS: Implementation of a restrictive transfusion trigger in a critical care setting resulted in lasting decreased RBC transfusion use and costs, decreased prescribed and actual haemoglobin trigger levels and improved adherence to prescribed haemoglobin trigger levels.
Assuntos
Estado Terminal , Transfusão de Eritrócitos , Fidelidade a Diretrizes , Humanos , Transfusão de Eritrócitos/métodos , Estado Terminal/terapia , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Fidelidade a Diretrizes/estatística & dados numéricos , Estudos de Coortes , Hemoglobinas/análise , Sistema de Registros , Unidades de Terapia IntensivaRESUMO
INTRODUCTION: The current management of severely injured patients includes damage control resuscitation strategies that minimise the use of crystalloids and emphasise earlier transfusion of red blood cells (RBC) to prevent coagulopathy. In 2012, London's air ambulance (LAA) became the first UK civilian pre-hospital service to routinely carry RBC to the trauma scene. OBJECTIVE: To investigate the effect of pre-hospital RBC transfusion (phRTx) on overall blood product consumption. METHODS: A retrospective trauma database study compares before implementation with after implementation of phRTx in exsanguinating trauma patients transported directly to one major trauma centre. Pre-hospital deaths were excluded. Univariate and multivariate Poisson regression analyses on data subject to multiple imputation were conducted. RESULTS: We included 137 and 128 patients in the before and after the implementation of phRTx groups, respectively. LAA transfused 304 RBC units (median 2, inter quartile range 1-3). We found a significant reduction in total RBC usage and reduced early use of platelets and fresh-frozen plasma (FFP) after the implementation of phRTx in both univariate (P < 0·001) and multivariate analyses (P < 0·001). No immediate adverse transfusion reactions were identified. CONCLUSION: Pre-hospital trauma transfusion practice is feasible and associated with overall reduced RBC, platelets and FFP consumption.
Assuntos
Transtornos da Coagulação Sanguínea/terapia , Transfusão de Eritrócitos , Plasma , Transfusão de Plaquetas , Ferimentos e Lesões/terapia , Adulto , Transtornos da Coagulação Sanguínea/sangue , Feminino , Humanos , Londres , Masculino , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos e Lesões/sangueRESUMO
Recombinant human erythropoietin (rhEPO) treatment is an alternative to red blood cell (RBC) transfusions in neonates presenting anemia of prematurity (AOP). This study assesses the impact of early rhEPO administration on AOP (any stage) incidence, as well as the incidence of individual AOP stages and RBC transfusions. Out of 108 preterm neonates, 49 were administered rhEPO and compared to the remaining group using univariate and multivariate analyses. Univariately, gestational age (GA), birth weight (BW), hemoglobin (Hb), hematocrit (HCT), RBC levels, and iron administration were significantly associated with AOP (p < 0.05 each); however, only the latter remained significant following multivariate analysis (AOR: 2.75, 95% CI, 1.06-7.11). Multinomial analysis revealed rhEPO treatment was associated with a near three-fold reduction in moderate AOP incidence (OR: 0.36, 95% CI, 0.15-0.89). Furthermore, ANCOVA revealed positive correlations between rhEPO administration and 21-day Hb (p < 0.01), HCT (p < 0.05), and EPO (p < 0.001) levels. The results confirm previously reported benefits of rhEPO treatment, such as reduced moderate AOP incidence and increased Hb, HCT, and serum EPO levels.
RESUMO
OBJECTIVE: To identify to what extent distinguishing patient and procedural characteristics can explain center-level transfusion variation during coronary artery bypass grafting surgery. METHODS: Observational cohort study using the Perfusion Measures and Outcomes Registry from 43 adult cardiac surgical programs from July 1, 2011, to July 1, 2017. Iterative multilevel logistic regression models were constructed using patient demographic characteristics, preoperative risk factors, and intraoperative conservation strategies to progressively explain center-level transfusion variation. RESULTS: Of the 22,272 adult patients undergoing isolated coronary artery bypass surgery using cardiopulmonary bypass, 7241 (32.5%) received at least 1 U allogeneic red blood cells (range, 10.9%-59.9%). When compared with patients who were not transfused, patients who received at least 1 U red blood cells were older (68 vs 64 years; P < .001), were women (41.5% vs 15.9%; P < .001), and had a lower body surface area (1.93 m2 vs 2.07 m2; P < .001), respectively. Among the models explaining center-level transfusion variability, the intraclass correlation coefficients were 0.07 for model 1 (random intercepts), 0.12 for model 2 (patient factors), 0.14 for model 3 (intraoperative factors), and 0.11 for model 4 (combined). The coefficient of variation for center-level transfusion rates were 0.31, 0.29, 0.40, and 0.30 for models 1 through 4, respectively. The majority of center-level variation could not be explained through models containing both patient and intraoperative factors. CONCLUSIONS: The results suggest that variation in center-level red blood cells transfusion cannot be explained by patient and procedural factors alone. Investigating organizational culture and programmatic infrastructure may be necessary to better understand variation in transfusion practices.
Assuntos
Ponte de Artéria Coronária/tendências , Doença da Artéria Coronariana/cirurgia , Transfusão de Eritrócitos/tendências , Disparidades em Assistência à Saúde/tendências , Hospitais/tendências , Assistência Perioperatória/tendências , Padrões de Prática Médica/tendências , Idoso , Ponte de Artéria Coronária/efeitos adversos , Bases de Dados Factuais , Transfusão de Eritrócitos/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/efeitos adversos , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Objective: To evaluate the extent and plausible effects of blood transfusions given during cisplatin-based neoadjuvant chemotherapy (NAC) on overall survival in patients with muscle-invasive urothelial bladder cancer (MIBC) undergoing NAC and radical cystectomy (RC).Background: Several studies have demonstrated a decreased survival for MIBC patients receiving allogenic peri- and postoperative blood transfusions in conjunction with RC. No studies have previously investigated the effects of blood transfusions during NAC.Materials and methods: 120 patients with MIBC (cT2-T4aN0M0) undergoing NAC and RC between 2008 and 2014 at four Swedish cystectomy centers were retrospectively evaluated. Clinicopathological data were obtained, including data of allogenic blood administration. Survival data was analyzed by Kaplan-Meier plotting and Cox regression.Results: One third of the cohort received blood transfusions during the period of NAC. In univariate analysis, blood transfusions during NAC, nodal stage and advanced tumor stage (pT >2) were negative prognostic factors for survival. In multivariate analysis, only pNx and pT >2 remained significant negative prognostic factors. In a subgroup analysis consisting of patients with localized tumors without dissemination (n = 96), patients that received transfusions during NAC showed an 18.5% absolute risk increase of death at five years of observation, although without statistical significance (p = .197).Conclusions: This is the first time that the extent and plausible effects of allogenic blood transfusions during NAC is examined in MIBC. Data suggest that there may be an association between blood transfusion and poor pathological and oncological outcome. Firm conclusions are difficult to draw due to few study participants and the retrospective nature of the study.
Assuntos
Anemia/terapia , Antineoplásicos/uso terapêutico , Transfusão de Sangue/estatística & dados numéricos , Carcinoma de Células de Transição/tratamento farmacológico , Cistectomia , Terapia Neoadjuvante , Taxa de Sobrevida , Neoplasias da Bexiga Urinária/tratamento farmacológico , Idoso , Anemia/complicações , Carcinoma de Células de Transição/complicações , Carcinoma de Células de Transição/imunologia , Carcinoma de Células de Transição/patologia , Cisplatino/uso terapêutico , Feminino , Humanos , Imunomodulação/imunologia , Estimativa de Kaplan-Meier , Excisão de Linfonodo , Masculino , Músculo Liso/patologia , Invasividade Neoplásica , Estadiamento de Neoplasias , Assistência Perioperatória , Cuidados Pós-Operatórios , Modelos de Riscos Proporcionais , Neoplasias da Bexiga Urinária/complicações , Neoplasias da Bexiga Urinária/imunologia , Neoplasias da Bexiga Urinária/patologiaRESUMO
PURPOSE: We investigated the iron status of very low birth weight infants receiving multiple erythrocyte transfusions during hospitalization in the neonatal intensive care unit (NICU). METHODS: We enrolled 46 very low birth weight infants who were admitted to the Kyungpook National University Hospital between January 2012 and December 2013. Serum ferritin was measured on their first day of life and weekly thereafter. We collected individual data of the frequency and volume of erythrocyte transfusion and the amount of iron intake. RESULTS: A total of 38 (82.6%) of very low birth weight infants received a mean volume of 99.3±93.5 mL of erythrocyte transfusions in NICU. The minimum and maximum serum ferritin levels during hospitalization were 146.2±114.9 ng/mL and 456.7±361.9 ng/mL, respectively. The total volume of erythrocyte transfusion was not correlated to maximum serum ferritin concentrations after controlling for the amount of iron intake (r=0.012, p=0.945). Non-transfused infants took significantly higher iron intake compared to infants receiving ≥100 mL/kg erythrocyte transfusion (p<0.001). Minimum and maximum serum ferritin levels of non-transfused infants were higher than those of infants receiving <100 mL/kg erythrocyte transfusions (p=0.026 and p=0.022, respectively). Infants with morbidity including bronchopulmonary dysplasia or retinopathy of prematurity received a significantly higher volume of erythrocyte transfusions compared to infants without morbidity (p<0.001). CONCLUSION: Very low birth weight infants undergoing multiply erythrocyte transfusions had excessive iron stores and non-transfused infants also might had a risk of iron overload during hospitalization in the NICU.