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Hemoglobin-based red blood cell transfusion (RBC) triggers do not clearly identify which patients with moderate anemia (hemoglobin 7-10 g/dL) will benefit from RBC transfusion. The National Heart, Lung, and Blood Institute has recognized the need for bedside oxygenation measures to enhance transfusion decision-making. This narrative review uses four studies to explore the potential of the oxygen extraction ratio (O2ER)-the ratio of consumed oxygen to delivered oxygen in a critical tissue bed as a more physiologically relevant indicator for guiding RBC transfusions in patients with moderate anemia. The aim of this review is to present existing data on the relationship between O2ER and responsiveness to RBC transfusion, as well as the feasibility of O2ER as bedside measure of tissue oxygenation. This review presents a narrative appraisal of three critical papers that investigate the relationship between O2ER and transfusion outcomes, and one paper that demonstrates proof-of-concept for a noninvasive device to measure O2ER at the bedside. Despite limitations in the existing studies, including small sample sizes and observational designs, the evidence collectively suggests that O2ER has the potential to enhance transfusion decision accuracy. The development of noninvasive measurement devices could facilitate widespread implementation in many kinds of care settings.
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Anemia , Transfusão de Eritrócitos , Oxigênio , Humanos , Transfusão de Eritrócitos/métodos , Oxigênio/sangue , Anemia/terapia , Anemia/sangue , Consumo de Oxigênio/fisiologia , Hemoglobinas/análiseRESUMO
BACKGROUND: Administering platelets through a rapid infuser is proven to be safe. However, the clinical significance of infusing ABO-incompatible platelets with red blood cells (RBCs) in a rapid infuser remains unclear. There is a theoretical risk that isoagglutinin in the plasma of a platelet unit can interact with RBCs and induce hemolysis. MATERIALS AND METHODS: Seven in vitro studies were performed including five cases (type A RBCs and type O platelets) and two controls (type A RBCs and platelets). Anti-A titers were measured in platelet units. An RBC unit and a platelet unit were mixed in the rapid infuser reservoir and incubated for 30 min. The primary outcome was the presence of hemolysis based on the following parameters: free hemoglobin concentration, hemolysis check, direct antiglobulin test (DAT), and direct agglutination. RESULTS: The post-mix DAT was positive for IgG in all test samples (5/5), and weakly positive for complement in 3/5. The changes in free Hb in test cases between measured and calculated post-mix spanned -2.2 to +3.4 mg/dL. Post-mix hemolysis check was negative in 3/5 and slightly positive in 2/5 cases, with no significant differences compared to the control case. Anti-A titers ranged from 16 to 512 and were not associated with hemolysis. All samples were negative for direct agglutination. CONCLUSION: Our study suggested that mixing ABO-incompatible platelets with RBCs in a rapid infuser does not induce in vitro hemolysis. These findings support the use of rapid infusers regardless of platelet compatibility in support of hemostatic resuscitation.
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Sistema ABO de Grupos Sanguíneos , Hemólise , Humanos , Transfusão de Plaquetas/efeitos adversos , Incompatibilidade de Grupos Sanguíneos , Plaquetas , AnticorposRESUMO
INTRODUCTION: Artificial intelligence and large language models (LLMs) have emerged as potentially disruptive technologies in healthcare. In this study GPT-3.5, an accessible LLM, was assessed for its accuracy and reliability in performing guideline-based evaluation of neuraxial bleeding risk in hypothetical patients on anticoagulation medication. The study also explored the impact of structured prompt guidance on the LLM's performance. METHODS: A dataset of 10 hypothetical patient stems and 26 anticoagulation profiles (260 unique combinations) was developed based on American Society of Regional Anesthesia and Pain Medicine guidelines. Five prompts were created for the LLM, ranging from minimal guidance to explicit instructions. The model's responses were compared with a "truth table" based on the guidelines. Performance metrics, including accuracy and area under the receiver operating curve (AUC), were used. RESULTS: Baseline performance of GPT-3.5 was slightly above chance. With detailed prompts and explicit guidelines, performance improved significantly (AUC 0.70, 95% CI (0.64 to 0.77)). Performance varied among medication classes. DISCUSSION: LLMs show potential for assisting in clinical decision making but rely on accurate and relevant prompts. Integration of LLMs should consider safety and privacy concerns. Further research is needed to optimize LLM performance and address complex scenarios. The tested LLM demonstrates potential in assessing neuraxial bleeding risk but relies on precise prompts. LLM integration should be approached cautiously, considering limitations. Future research should focus on optimization and understanding LLM capabilities and limitations in healthcare.
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Importance: Red blood cell transfusion is a common medical intervention with benefits and harms. Objective: To provide recommendations for use of red blood cell transfusion in adults and children. Evidence Review: Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed. Findings: For adults, 45 randomized controlled trials with 20â¯599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence). Conclusions and Relevance: It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.
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Transfusão de Eritrócitos , Hemoglobinas , Adulto , Criança , Humanos , Doenças Cardiovasculares , Tomada de Decisões , Transfusão de Eritrócitos/normas , Cardiopatias Congênitas , Hemoglobinas/análise , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
We have previously published a novel transfusion medicine curriculum for first-year anesthesiology residents, making available open access learning materials. We now present a curriculum iteration, by incorporating resident feedback and developing an additional "capstone" session for use at the end of the rotation that integrates several learning points into a practical problem-based simulation. This iteration of the curriculum was piloted with the 2019-2020 PGY-1 anesthesiology residents of the University of Wisconsin Hospitals and Clinics. Pre-course and post-course surveys, which assessed trainee understanding of course topics, were used to subjectively evaluate the usefulness of the curriculum. Results of the surveys demonstrated post-test mean scores were significantly increased when compared with the equivalent pre-course questions. This suggests the piloted curriculum iteration serves as a useful tool for resident learning. As an adjunct to our previous existing materials, in the spirit of open-access education, we share this additional curriculum material, consisting of four patient cases with 16 questions that can be used immediately for teaching purposes.
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BACKGROUND: Large language models (LLMs) excel at answering knowledge-based questions. Many aspects of blood banking and transfusion medicine involve no direct patient care and require only knowledge and judgment. We hypothesized that public LLMs could perform such tasks with accuracy and precision. STUDY DESIGN AND METHODS: We presented three sets of tasks to three publicly-available LLMs (Bard, GPT-3.5, and GPT-4). The first was to review short case presentations and then decide if a red blood cell transfusion was indicated. The second task was to answer a set of consultation questions common in clinical transfusion practice. The third task was to take a multiple-choice test experimentally validated to assess internal medicine postgraduate knowledge of transfusion practice (the BEST-TEST). RESULTS: In the first task, the area under the receiver operating characteristic curve for correct transfusion decisions was 0.65, 0.90, and 0.92, respectively for Bard, GPT-3.5 and GPT-4. All three models had a modest rate of acceptable responses to the consultation questions. Average scores on the BEST-TEST were 55%, 40%, and 87%, respectively. CONCLUSION: When presented with transfusion medicine tasks in natural language, publicly available LLMs demonstrated a range of ability, but GPT-4 consistently scored very well in all tasks. Research is needed to assess the utility of LLMs in transfusion medicine practice. Transfusion Medicine physicians should consider their role alongside such technologies, and how they might be used for the benefit and safety of patients.
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Médicos , Medicina Transfusional , Humanos , Inteligência Artificial , Transfusão de Sangue , Transfusão de EritrócitosRESUMO
BACKGROUND: The Association for the Advancement of Blood and Biotherapies Clinical Transfusion Medicine Committee (CTMC) composes a summary of new and important advances in transfusion medicine (TM) on an annual basis. Since 2018, this has been assembled into a manuscript and published in Transfusion. STUDY DESIGN AND METHODS: CTMC members selected original manuscripts relevant to TM that were published electronically and/or in print during calendar year 2022. Papers were selected based on perceived importance and/or originality. References for selected papers were made available to CTMC members to provide feedback. Members were also encouraged to identify papers that may have been omitted initially. They then worked in groups of two to three to write a summary for each new publication within their broader topic. Each topic summary was then reviewed and edited by two separate committee members. The final manuscript was assembled by the first and senior authors. While this review is extensive, it is not a systematic review and some publications considered important by readers may have been excluded. RESULTS: For calendar year 2022, summaries of key publications were assembled for the following broader topics within TM: blood component therapy; infectious diseases, blood donor testing, and collections; patient blood management; immunohematology and genomics; hemostasis; hemoglobinopathies; apheresis and cell therapy; pediatrics; and health care disparities, diversity, equity, and inclusion. DISCUSSION: This Committee Report reviews and summarizes important publications and advances in TM published during calendar year 2022, and maybe a useful educational tool.
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BACKGROUND: Both Red Blood Cell (RBC) transfusion and anemia are thought to negatively impact cancer survival. These effects have been reported with mixed findings in cancer of the esophagus. The potential impact of the application of restrictive transfusion strategies on this patient population has not been defined. MATERIALS AND METHODS: We conducted a retrospective study of esophagectomies and studied cases based on whether they were anemic or were transfused peri-operatively. Clinical characteristics and known clinicopathologic prognosticators were compared between these groups. Survival was compared by Cox proportional hazard modeling. Post-operative transfusions were assessed for compliance with restrictive transfusion thresholds. RESULTS: Three-hundred ninety-nine esophagectomy cases were reviewed and after exclusions 348 cases were analyzed. The median length of follow-up was 33 months (range 1-152 months). Sixty-four percent of patients were anemic pre-operatively and 22% were transfused. Transfusion and anemia were closely related to each other. Microcytic anemia was uncommon but was evaluated and treated in only 50% of cases. Most anemic patients had normocytic RBC parameters. Transfusion but not anemia was associated with a protracted/prolonged post-operative stay. Transfusion and anemia were both associated with reduced survival however only anemia was associated with decreased survival in multi-variable modeling. Sixty-eight percent of patients were transfused post-operatively and 11% were compliant with the restrictive threshold of 7 g/dL. CONCLUSIONS: Pre-operative anemia and transfusion are closely associated, however only anemia was found to compromise survival in our esophageal cancer cohort, supporting the need for more aggressive evaluation and treatment of anemia. Adherence to restrictive transfusion guidelines offers an opportunity to reduce transfusion rates which may also improve short-term outcomes.
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Anemia , Neoplasias , Humanos , Estudos Retrospectivos , Anemia/etiologia , Anemia/terapia , Transfusão de Sangue , Neoplasias/complicações , EsôfagoRESUMO
BACKGROUND: The purpose of this study was to survey liver transplant centers in the United States to assess baseline practices in blood utilization and identify opportunities for standardization to optimize blood use in these complex cases. STUDY DESIGN AND METHODS: Two surveys, one for transfusion medicine physicians and the other for anesthesiologists, were distributed to high-volume liver transplant centers. RESULTS: The response rate was 52% for both surveys. The majority of respondents (90%) indicated they issue a standardized number of blood products to start surgeries. The most common number of products issued before the start of cases were 10 red blood cells (RBC) and 10 plasma units with no platelets or cryoprecipitate. On average, fewer RBC (7.5) and plasma (7) units were transfused than issued. Decisions to transfuse RhD+ RBCs to RhD- patients and use antigen untested units in alloimmunized patients were mainly handled on a case-by-case basis. Many centers reported utilizing viscoelastic testing (97%) and cell salvage (97%). Most centers reported standardized, laboratory-based intraoperative transfusion goals for RBCs (65%) and fibrinogen replacement (52%) but lacked a standardized approach for plasma (55%) and platelets (58%). DISCUSSION: More blood products are issued during surgery than are transfused. Responses from anesthesiology providers suggest a broad consensus on practice. Almost all respondents use viscoelastic testing in the management of intraoperative coagulopathy, either alone or in combination with classical coagulation tests. The majority of programs do not transfuse clotting factor concentrates, including fibrinogen concentrate, prothrombin complex concentrates, and recombinant activated FVII, and do not use antifibrinolytics prophylactically.
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Transtornos da Coagulação Sanguínea , Transplante de Fígado , Humanos , Transfusão de Sangue , Fibrinogênio/uso terapêutico , Testes de Coagulação SanguíneaRESUMO
BACKGROUND: At the start of the coronavirus disease 2019 (COVID-19) pandemic, widespread blood shortages were anticipated. We sought to determine how hospital blood supply and blood utilization were affected by the first wave of COVID-19. STUDY DESIGN AND METHODS: Weekly red blood cell (RBC) and platelet (PLT) inventory, transfusion, and outdate data were collected from 13 institutions in the United States, Brazil, Canada, and Denmark from March 1st to December 31st of 2020 and 2019. Data from the sites were aligned based on each site's local first peak of COVID-19 cases, and data from 2020 (pandemic year) were compared with data from the corresponding period in 2019 (pre-pandemic baseline). RESULTS: RBC inventories were 3% lower in 2020 than in 2019 (680 vs. 704, p < .001) and 5% fewer RBCs were transfused per week compared to 2019 (477 vs. 501, p < .001). However, during the first COVID-19 peak, RBC and PLT inventories were higher than normal, as reflected by deviation from par, days on hand, and percent outdated. At this time, 16% fewer inpatient beds were occupied, and 43% fewer surgeries were performed compared to 2019 (p < .001). In contrast to 2019 when there was no correlation, there was, in 2020, significant negative correlations between RBC and PLT days on hand and both percentage occupancy of inpatient beds and percentage of surgeries performed. CONCLUSION: During the COVID-19 pandemic in 2020, RBC and PLT inventories remained adequate. During the first wave of cases, significant decreases in patient care activities were associated with excess RBC and PLT supplies and increased product outdating.
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COVID-19 , Pandemias , COVID-19/epidemiologia , Transfusão de Eritrócitos , Eritrócitos , Hospitais , Humanos , Estados UnidosRESUMO
Patients with acute and chronic liver disease present with a wide range of disease states and severity that may require liver transplantation (LT). Physiologic alterations occur that are dynamic throughout all phases of perioperative care, creating complex management scenarios that necessitate multidisciplinary clinical care. Specifically, alterations in hemostasis in liver disease can be pronounced and evolve with disease progression over time. Recent studies and society guidance address this emerging paradigm and offer recommendations to assist with hemostatic management in patients with liver disease. However, patients undergoing LT are unique and diverse, often with unstable diseaseâ¯that requires specialized approaches. Our aim is to provide a focused review of hemostatic management of the LT patient, distinguish unique aspects of the three main phases of care (before LT, perioperative, and after LT), and identify knowledge gaps and critical areas of future research.
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Transtornos da Coagulação Sanguínea , Hemostáticos , Hepatopatias , Transplante de Fígado , Transtornos da Coagulação Sanguínea/diagnóstico , Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/terapia , Hemostasia/fisiologia , Humanos , Hepatopatias/complicações , Hepatopatias/cirurgia , Transplante de Fígado/efeitos adversosRESUMO
Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.
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Anestesiologia , Procedimentos Cirúrgicos Cardíacos , Humanos , Cuidados Críticos , Unidades de Terapia Intensiva , Assistência PerioperatóriaRESUMO
COVID-19 infection caused by the SARS-CoV-2 virus has been associated with cardiac abnormalities, including conduction abnormalities. Convalescent plasma is emerging as a potentially safe and effective treatment option for patients severely or critically ill with COVID-19. Here, we describe a case of a COVID-19 patient with new-onset cardiac ectopy who had near resolution of his cardiac sequelae following convalescent plasma transfusion.