Association of perioperative transfusion of fresh frozen plasma and outcomes after cardiac surgery.

BACKGROUND: Fresh frozen plasma (FFP) transfusion is used to manage coagulopathy and bleeding in cardiac surgery patients despite uncertainty about its safety and effectiveness. METHODS: We performed a propensity score matched analysis of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database including patients from 39 centres from 2005 to 2018. We investigated the association of perioperative FFP transfusion with mortality and other clinical outcomes. RESULTS: Of 119,138 eligible patients, we successfully matched 13,131 FFP recipients with 13,131 controls. FFP transfusion was associated with 30-day mortality (odds ratio (OR), 1.41; 99% CI, 1.17-1.71; p < .0001), but not with long-term mortality (hazard ratio (HR), 0.92; 99% CI, 0.85-1.00; p = .007, Holm-Bonferroni α = 0.0004). FFP was also associated with return to theatre for bleeding (OR, 1.97; 99% CI, 1.66-2.34; p < .0001), prolonged intubation (OR, 1.15; 99% CI, 1.05-1.26; p < .0001) and increased chest tube drainage (Mean difference (MD) in mL, 131; 99% CI, 120-141; p < .0001). It was also associated with reduced postoperative creatinine levels (MD in g/L, -6.33; 99% CI, -10.28 to -2.38; p < .0001). CONCLUSION: In a multicentre, propensity score matched analysis, perioperative FFP transfusion was associated with increased 30-day mortality and had variable associations with secondary clinical outcomes.

Infection Is Not Associated With Plasma or Cryoprecipitate Transfusion Volumes in Trauma: A Retrospective Study Using the National Trauma Data Bank.

Background: Packed red blood cell (PRBC) transfusion has been shown to increase nosocomial infection risk in the injured population; however, the post-traumatic infectious risk profiles of non-PRBC blood products are less clear. We hypothesized that plasma (fresh frozen plasma [FFP]), platelet (PLT), and cryoprecipitate administration would not be associated with increased rates of nosocomial infections. Patients and Methods: We performed a retrospective, matched, case-control study utilizing the American College of Surgeons National Trauma Data Bank data for 2019. We included all patients who received any volume of PRBC within four hours of presentation. Our outcome of interest was any infection. Controls were matched to cases using individual matching with a desired 1:3 case:control ratio. Bivariable analysis according to infection status, and multivariable logistic regression modeling the development of infection were then performed upon the matched data. Results: A total of 1,563 infectious cases were matched to 3,920 non-infectious controls. First four-hour transfusion volumes for FFP, PLT, and cryoprecipitate in the infection group exceeded those in the control group. The first four-hour FFP transfusion volume (per unit odds ratio [OR], 1.02; 95% confidence interval [CI], 0.99-1.04; p = 0.28) and cryoprecipitate transfusion volume (per unit OR, 1.01; 95% CI, 0.99-1.02; p = 0.43) were similar in cases and controls whereas PLT transfusion volume (per unit OR, 0.92; 95% CI, 0.86-0.98; p = 0.01) was lower in cases of infection than in controls. Conclusions: Fresh frozen plasma, PLT, and cryoprecipitate transfusion volumes were not independent risk factors for the development of nosocomial infection in a trauma population. PLT transfusion volume was associated with less infection.

Cost Savings of Whole Blood Versus Component Therapy at a Community Level 1 Trauma Center.

BACKGROUND: Blood product component-only resuscitation (CORe) has been the standard of practice in both military and civilian trauma care with a 1:1:1 ratio used in attempt to recreate whole blood (WB) until recent data demonstrated WB to confer a survival advantage, leading to the emergence of WB as the contemporary resuscitation strategy of choice. Little is known about the cost and waste reduction associated with WB vs CORe. METHODS: This study is a retrospective single-center review of adult trauma patients admitted to a community trauma center who received WB or CORe as part of their massive transfusion protocol (MTP) resuscitation from 2017 to 2021. The WB group received a minimum of one unit WB while CORe received no WB. Univariate and multivariate analyses were completed. Statistical analysis was conducted using a 95% confidence level. Non-normally distributed, continuous data were analyzed using the Wilcoxon rank sum test. RESULTS: 576 patients were included (201 in WB and 375 in CORe). Whole blood conveyed a survival benefit vs CORe (OR 1.49 P < .05, 1.02-2.17). Whole blood use resulted in an overall reduction in products prepared (25.8%), volumes transfused (16.5%), product waste (38.7%), and MTP activation (56.3%). Cost savings were $849 923 annually and $3 399 693 over the study period. DISCUSSION: Despite increased patient volumes over the study period (43.7%), the utilization of WB as compared to CORe resulted in an overall $3.39 million cost savings while improving mortality. As such, we propose WB should be utilized in all resuscitation strategies for the exsanguinating trauma patient.

Perfil tromboelastométrico y coagulopatía aguda del paciente politraumatizado: implicaciones clínicas y pronósticas / Thromboelastometric Profile and Acute Coagulopathy of the Polytraumatized Patient: Clinical and Prognostic Implications

Introducción: El 25-35% de los pacientes politraumatizados presentan profundas alteraciones de la coagulación a su llegada al hospital (coagulopatía aguda traumática [CAT]). Los test viscoelásticos (ROTEM®) valoran rápidamente la capacidad hemostática y detectan precozmente la CAT. Los objetivos de este estudio son describir el tromboelastograma inicial de estos enfermos y determinar la prevalencia de CAT según unos perfiles tromboelastográficos predefinidos. Métodos: Estudio unicéntrico, observacional y prospectivo en pacientes politraumatizados. Se realizó analítica, prueba tromboelastográfica (ROTEM®) y se registraron datos prehospitalarios y hospitalarios, transfusiones, intervenciones quirúrgicas/arteriografía iniciales, paradas cardiorrespiratorias y fallecimientos. Los pacientes fueron clasificados en grupos según su ROTEM® inicial: «normal», «hipercoagulabilidad», «hipocoagulabilidad», «hipocoagulabilidad + hiperfibrinólisis» e «hiperfibrinólisis aislada». Resultados: Se analizaron 123 pacientes. En 32 casos (26%) se objetivó CAT: 15 pacientes presentaron hipocoagulabilidad, 9 hiperfibrinólisis aislada y 8 hipocoagulabilidad +hiperfibrinólisis. El grupo con CAT, respecto al grupo «normal», presentó mayor ISS (23 vs. 16; p < 0,01), mayor transfusión de hemoderivados (2,5 vs. 0; p = 0,001), más episodios de PCR (19 vs. 1%, p < 0,01) y mayor mortalidad (34 vs. 5%, p < 0,01). El subgrupo con hipocoagulabilidad +hiperfibrinólisis, respecto a los grupos con hipocoagulabilidad o hiperfibrinólisis aislada, presentó mayor ISS (41 vs. 25 vs. 15, p < 0,01), mayor necesidad de arteriografía (62% vs. 13% vs. 0%, p < 0,01) y mortalidad superior (75% vs. 33% vs. 0%, p = 0,05). Conclusiones: El 26% de los enfermos politraumatizados presenta coagulopatía precoz evaluada mediante tromboelastografía, asociada a mayor consumo de hemoderivados y menor supervivencia. El perfil combinado de «hipocoagulabilidad +hiperfibrinólisis» se asocia a mayor gravedad y necesidades superiores de hemoderivados y arteriografía (AU)

Introduction: About 25-35% of polytraumatized patients have a profound alteration of hemostasis on arrival at the hospital (acute traumatic coagulopathy [CAT]). Viscoelastic tests (ROTEM®) measure the hemostatic capacity and provide an early detection of CAT. The objectives of this study are to describe the initial thromboelastogram of these patients and to determine the prevalence of CAT according to predefined thromboelastographic profiles. Methods: Single-center, observational, prospective study in polytraumatic patients. Initial blood nd thromboelastographic test (ROTEM®) were made, and pre-hospital, hospital, transfusion, initial surgical/angiographic interventions, cardiac arrest and mortality data were collected. ROTEM®-based, patients were classified as: normal, hypercoagulable, hypocoagulable, hipocoagulable + hyperfibrinolytic and isolated hyperfibrinolysis. Results: One hundred and twenty-three patients were analyzed. 32 cases (26%) with CAT: 15 patients with hypocoagulability, 9 with hyperfibrinolysis alone and 8 with hypocoagulability + hyperfibrinolysis. The CAT group, related to the normal group, presented higher ISS (23 vs. 16, P < .01), higher blood products transfusion (2.5 vs. 0; P = .001), more cardiac arrest (19 vs. 1%, P < .01), and higher mortality (34 vs. 5%, P < .01). The subgroup with hypocoagulability/hyperfibrinolysis, related to the groups with hypocoagulability or hyperfibrinolysis alone, presented a higher ISS (41 vs. 25 vs. 15, P < .01), higher angiographic procedures (62% vs. 13% vs. 0%, P < .01) and higher mortality (75% vs. 33% vs. 0%, P=.05). Conclusions: Twenty-six percent of the polytrauma patients presented early coagulopathy assessed by thromboelastography. It is associated with higher consumption of blood products and lower survival. The presence of hypocoagulability + hyperfibrinolysis is associated with greater severity and a higher requirement of blood products (AU)

Transfusión en Urgencias: algo más que una transfusión de sangre / Transfusions in the Emergency department: more than a blood transfusion

La elevación del nivel de hemoglobina y de hematocrito con transfusiones sanguíneas ha sido el estándar de oro para el tratamiento de la anemia grave. Sin embargo, la indicación para la transfusión de concentrado de hematíes se basa meramente en unos marcadores analíticos, como el nivel de hemoglobina o hematocritos, en lugar de basarse en la clínica (según las guías de práctica clínica), en la implementación de regulaciones legales o en los consensos alcanzados por los comités de transfusión de los hospitales. El objetivo de este estudio multicéntrico es reevaluar la idoneidad de la indicación de transfusión de concentrado de hematíes y los volúmenes transfundidos en los servicios de urgencias. Se plantea un diseño observacional multicéntrico y transversal en 2centros participantes: el Hospital Universitario de La Paz y el Hospital de Salamanca. En total se obtuvieron datos de 381 pacientes; 220 eran hombres (57,74%), con una edad promedio de 71,4±14,0 años y 161 eran mujeres (42,26%) con una edad promedio de 75,3±15,3 años (p < 0,001). Las enfermedades subyacentes más prevalentes en los pacientes que recibieron transfusión fueron las cardiológicas, que incluyeron hemorragia debido a la terapia antiagregante plaquetaria o anticoagulante (57,7%), las hematooncológicas (15,3%) y las neurológicas. Solo el 54,9% (209/381) de las prescripciones de transfusión se consideraron apropiadas, con diferencias significativas observadas según la indicación

Increasing haemoglobin and haematocrit levels with blood transfusions has been the gold standard for treating severe anaemia; however, the indication for transfusing concentrated red blood cells is based merely on a few laboratory markers, such as haemoglobin and haematocrit levels, rather than based on the symptoms according to clinical practice guidelines, the implementation of legal regulations and the consensus achieved by the hospitals' transfusion committees. The aim of this multicentre study was to reassess the suitability of the indication for transfusing concentrated red blood cells and the volumes transfused in emergency departments. We established an observational, multicentre, cross-sectional design with 2 participating centres: the La Paz University Hospital and the Hospital of Salamanca. In total, we obtained data from 381 patients, 220 (57.74%) of whom were men with an average age of 71.4±14.0 years and 161 (42.26%) of whom were women with an average age of 75.3±15.3 years (P<.001). The most prevalent underlying diseases in the patients who underwent transfusions were heart disease, which included haemorrhaging due to antiplatelet or anticoagulant therapy (57.7%), haemato-oncologic (15.3%) diseases and neurological disease. Only 54.9% (209/381) of the prescriptions for transfusion were considered appropriate, with significant differences according to the indication

Uso de hemocomponentes na emergência médica / Blood products use in medical emergency

Este trabalho tem por objetivo abordar de forma prática e objetiva as principais indicações, contraindicações e dose usual dos principais hemocomponentes, orientando dessa forma seu uso adequado.

The aim of this study is to approach in a practical and objective way the main indication, contraindication and usual dose of principal blood components in order to guide their appropriate use.

Resultados de una encuesta nacional sobre hábito transfusional en unidades de cuidados intensivos / Results of a national survey on transfusion habit in Intensive Care Units

Introducción. Los hemoderivados son productos clínicos de uso habitual que presentan unas características de escasez, relevancia clínica y de efectos secundarios concomitantes que obligan a conocer y evaluar su utilización con rigurosidad. Objetivo. Analizar actitudes, conocimientos y conductas sobre la política transfusional de las diferentes unidades de cuidados intensivos (UCI) españolas. Diseño. Encuesta mediante correo (electrónico y tradicional) en las unidades de cuidados intensivos. Periodo. Planificación durante 2004 y realización durante todo 2005. Ambito. UCI españolas. Pacientes y método. Cuestionario de 27 preguntas. Resultados. La mayoría son UCI de tamaño medio (10-20 camas), con actividad predominantemente médica. El adjunto, solo o con el residente, suele decidir la transfusión según su experiencia, aunque con tendencia a seguir las recomendaciones científicas. No suele haber comités transfusionales. Cuando se transfunden concentrados de hematíes, suelen ser entre 2 y 4 unidades. La cifra de hemoglobina es orientativa, aunque la decisión es clara si es < 7 g/dl (10 g/dl si hay cardiopatía). No se suele emplear alternativas farmacológicas a las transfusiones por motivos de escasa evidencia y precio. En el 50% de los casos se considera cierta la relación entre transfusión y aumento de mortalidad. Conclusiones. Debemos reflexionar sobre la transfusión y evitar la sobreutilización. Para ello se necesitan protocolos educacionales y conferencias de consensos que establezcan recomendaciones sobre el uso de los hemoderivados y sus alternativas farmacológicas

Introduction. Blood derivatives are clinical products that are currently used, for which their lack of availability, clinical relevance and presence of associated side effect that make it necessary to known and evaluate their utility rigorously are characteristic. Objective. To analyze knowledge of attitudes, knowledge and behavior on transfusional policy in the different Spanish Intensive Care Units (ICU). Design. A mail-based survey (electronic and conventional) in the ICUs. Duration. The study was planned in 2005 and conducted during the year 2006. Setting. Spanish ICUs. Patients and Method. A 27-question questionnaire. Results. Most are middle-sized ICUs (10-20 beds), with predominantly medical activities. The staff member, alone or with the resident, generally decides the transfusion based on his/her experience, although with a tendency to follow the scientific guidelines. Generally, there is no transfusional committee. When red blood packs are transfused, generally between 2 to 4 units are used. The hemoglobin value is orientative, although the decision is clear if < 7 g/dl (10 g/dl if there is heart disease). Drug alternatives to transfusion are not generally used due to lack of evidence and price. In 50% of cases, the association between transfusion and increase in mortality is considered to be certain. Conclusions: Strong consideration must be made about transfusion and its over use should be avoided. For this purpose, educational guidelines and consensus meetings are necessary to establish recommendations on the use of blood products and their pharmacological alternatives

Estratégias para redução do uso de hemoderivados em cirurgia cardiovascular / Strategies to reduce the use of blood components in cardiovascular surgery

OBJETIVO: O objetivo deste estudo é avaliar as estratégias adotadas por nossa equipe para reduzir o uso de hemoderivados em pacientes submetidos a cirurgia cardiovascular. MÉTODOS: Entre outubro de 2005 e janeiro de 2007, foram operados 101 pacientes. Destes, 51 (50,5 por cento) eram do sexo masculino e 50 (49,5 por cento) do feminino. A idade variou de 13 a 80 anos (média de 50,76 anos). A estratégia utilizada consiste em uso de antifibrinolíticos, hemodiluição normovolêmica e reposição total do perfusato. RESULTADOS: A média de utilização de hemoderivados por paciente foi de 1,45 UI de CH; 0,75 UI de PF; 0,89 UI de crioprecipitados e 1,43 UI de plaquetas. Em 59 (58,4 por cento) pacientes, não foram usados hemoderivados e somente 12 (11,9 por cento) pacientes necessitaram mais de quatro UI de CH. Dentre os 27 (26,7 por cento) pacientes cujo tempo de circulação extracorpórea (CEC) excedeu os 120 minutos, 17 (63 por cento) necessitaram de hemotransfusão. Apenas três (2,97 por cento) pacientes desenvolveram coagulopatia, sendo dois (1,98 por cento) reoperados por sangramento. Dos três pacientes que desenvolveram coagulopatia, dois pertenciam ao subgrupo de idosos. CONCLUSÃO: Na série apresentada, as medidas adotadas conseguiram reduzir a necessidade de hemotransfusão no pós-operatório de cirurgia cardíaca. Pacientes com tempo de CEC maior que 120 minutos tenderam a necessitar de hemotransfusão. A associação de cirurgia em pacientes idosos e tempo de CEC superior a 120 minutos resultou em maior utilização de sangue e hemoderivados no período pós-operatório.

OBJECTIVE: The aim of this study is to evaluate the strategies adopted by our team to reduce the use of bloods components in patients undergoing cardiovascular surgical procedures. METHODS: Between October 2005 and January 2007, 101 patients were operated. Fifty-one (50.5 percent) were male and 50 (49.5 percent) female. Patients' age ranged from 13 to 80 years (mean of 50.76 years). The strategy consisted in using antifibrinolytics and normovolemic hemodilution, and reinfusion of all the blood remaining in the CPB circuit. RESULTS: Mean use of blood components was 1.45 UI, red blood cells; 0.75 UI, fresh frozen plasma; 0.89 UI, cryoprecipitate, and 1.43 UI, platelet. Fifty-nine patients (58.4 percent) had not used blood components and 12 (11.9 percent) patients used more than 4 UI of red blood cells. In 27 patients (26.7 percent) whose CPB time was higher than 120 minutes, 17 (63 percent) needed hemotransfusion. However, 3 (2.97 percent) developed coagulopathy and 2 (1.98 percent) needed reoperation due to bleeding. Of the three patients who developed coagulopathy, two were in the elderly subgroup. CONCLUSION: In the presented series, the measures adopted succeeded in reducing the need of hemotransfusion in the postoperative period of thoracic surgery. Patients with CPB time higher than 120 minutes tended to need hemotransfusion. The association of surgery in elderly patients and CPB time over 120 minutes resulted in significantly greater use of blood components postoperatively.

Desarrollo de un sistema de hemovigilancia en el Hospital Iluminado Rodríguez, del Municipio Jagüey Grande, Matanzas / Development of a system of hemosurveillance in Iluminado Rodríguez Hospital of Jagüey Grande municipality, Matanzas

En la etapa comprendida entre enero de 2003 y diciembre de 2005, se desarrolló un sistema de hemovigilancia en nuestra provincia, con el objetivo de incrementar la seguridad transfusional mediante la reducción de los efectos adversos de la transfusión y el uso adecuado de la sangre y sus componentes. En el Hospital Municipal “Iluminado Rodríguez” de Jagüey Grande, se realizaron las siguientes acciones: reporte de las reacciones transfusionales, creación del Comité Hospitalario de Hemovigilancia (que permitió tener un control más eficiente del uso de sangre y componentes) y establecimiento de un sistema rápido de alerta que permite tomar decisiones acertadas en un mínimo de tiempo. Se implementó un programa de capacitación continua para profesionales y técnicos que estuvieran directamente relacionados con el Programa de Sangre, con el fin de elevar su nivel científico técnico y se desarrolló una campaña de reclutamiento y retención de donantes. Los resultados de estas acciones demuestran la eficiencia del sistema: incremento de la seguridad transfusional por la disminución de las reacciones transfusionales de 15 en el año 2002 a 6 en el 2005; ausencia de efectos adversos graves, erradicación del consumo de sangre total, disminución del uso de glóbulos y plasma, elevación del nivel de capacitación en el tema en profesionales y técnicos y aporte de sangre segura a la población

Resultados de la encuesta sobre práctica transfusional entre traumatólogos-ortopedas en España / Results of a survey on transfusion practices among orthopedic surgeons in Spain

Objetivo. Conocer la práctica sobre transfusiones de hematíes entre traumatólogos-ortopedas en España y la importancia dada al uso de las técnicas de hemoderivados. Material y método. Se remitieron 100 cartas a otros tantos servicios de Traumatología y Ortopedia de hospitales españoles con 5 encuestas en cada carta. Resultados. Respondieron 59 hospitales (240 encuestas).Los resultados se analizan globalmente y estratificando los hospitales. Se transfunde habitualmente cuando el hematocrito baja del 24 por ciento (49,37 por ciento) o del 27 por ciento (33,47 por ciento), o cuando la hemoglobina disminuye por debajo de 8 g/dl-1 (58,30 por ciento) o de 9 g/dl-1 (25,40 por ciento). Se considera que determinadas circunstancias clínicas pueden modificar las necesidades transfusionales: edad (84,20 por ciento), coexistencia de enfermedad cardíaca (75,40 por ciento), respiratoria (51,25 por ciento), renal (51,25 por ciento) o hepática (42,90 por ciento), concentración de hematocrito o hemoglobina previos (87,50 por ciento) y sangrado (85,80 por ciento). La técnica más valorada para el ahorro de transfusión de hemoderivados de origen homólogo es la predonación de sangre autóloga (autotransfusión), señalándose los problemas de organización y planificación quirúrgicas y la necesidad de una mayor colaboración con los servicios relacionados. Para indicar una transfusión se valoran fundamentalmente la necesidad de hemograma antes de transfundir (9,295 puntos sobre 10) y la importancia del juicio clínico (8,26/10). Entre los traumatólogos españoles se mantiene la idea de que "la transfusión mínima" debe ser de dos concentrados de hematíes (8,02/10). Conclusión. Los traumatólogos españoles han mostrado su inquietud por un mejor uso de los hemoderivados, y el conocimiento y potenciación de técnicas de ahorro de hemoderivados homólogos en aras de transfundir mejor. La cooperación con los Servicios de Anestesia y Hematología es imprescindible (AU)