Supplemental findings of the 2019 National Blood Collection and Utilization Survey.

INTRODUCTION: Supplemental data from the 2019 National Blood Collection and Utilization Survey (NBCUS) are presented and include findings on donor characteristics, autologous and directed donations and transfusions, platelets (PLTs), plasma and granulocyte transfusions, pediatric transfusions, transfusion-associated adverse events, cost of blood units, hospital policies and practices, and implementation of blood safety measures, including pathogen reduction technology (PRT). METHODS: National estimates were produced using weighting and imputation methods for a number of donors, donations, donor deferrals, autologous and directed donations and transfusions, PLT and plasma collections and transfusions, a number of crossmatch procedures, a number of units irradiated and leukoreduced, pediatric transfusions, and transfusion-associated adverse events. RESULTS: Between 2017 and 2019, there was a slight decrease in successful donations by 1.1%. Donations by persons aged 16-18 decreased by 10.1% while donations among donors >65 years increased by 10.5%. From 2017 to 2019, the median price paid for blood components by hospitals for leukoreduced red blood cell units, leukoreduced apheresis PLT units, and for fresh frozen plasma units continued to decrease. The rate of life-threatening transfusion-related adverse reactions continued to decrease. Most whole blood/red blood cell units (97%) and PLT units (97%) were leukoreduced. CONCLUSION: Blood donations decreased between 2017 and 2019. Donations from younger donors continued to decline while donations among older donors have steadily increased. Prices paid for blood products by hospitals decreased. Implementation of PRT among blood centers and hospitals is slowly expanding.

Strategies to reduce blood product utilization in obstetric practice.

PURPOSE OF REVIEW: Patient blood management (PBM) aims to improve patient outcome and safety by reducing the number of unnecessary RBC transfusions and vitalizing patient-specific anemia reserves. Although PBM is increasingly recognized as best clinical practice in elective surgery, implementation of PBM is restrained in the setting of obstetrics. This review summarizes recent findings to reduce blood product utilization in obstetric practice. RECENT FINDINGS: PBM-related evidence-based benefits should be urgently adopted in the field of obstetric medicine. Intravenous iron can be considered a safe, effective strategy to replenish iron stores and to correct both pregnancy-related and hemorrhage-related iron deficiency anemia. In addition to surgical techniques and the use of uterotonics, recent findings support early administration of tranexamic acid, fibrinogen and a coagulation factor concentrate-based, viscoelastically guided practice in case of peripartum hemorrhage to manage coagulopathy. In patients with cesarean section, autologous red cell blood salvage may reduce blood product utilization, although its use in this setting is controversial. SUMMARY: Implementation of PBM in obstetric practice offers large potential to reduce blood loss and transfusion requirements of allogeneic blood products, even though large clinical trials are lacking in this specific field. Intravenous iron supplementation may be suggested to increase peripartum hemoglobin levels. Additionally, tranexamic acid and point-of-care-guided supplementation of coagulation factors are potent methods to reduce unnecessary blood loss and blood transfusions in obstetrics.

[Patient blood management]. / Gestion du sang du patient et pour le patient.

OBJECTIVES: In a context of regular review of transfusion practice, the aim of this review is to present an update of the scientific basis of the so-called "patient blood management" (PBM), the state of its development in Europe, and possible ways to progress its development further in France. METHODS: Analysis and synthesis of the data from scientific literature on the scientific basis of PBM (methods, indications, efficacy, risks, efficiency). RESULTS: PBM appears as an evidence-based, patient centred, multidisciplinary approach, aiming to optimise the care of patients who might need transfusion and, consequently, the use of blood products. PBM is based on three pillars: optimise the patient's own blood supplies, minimise blood loss, optimise patient's tolerance of anaemia. Available scientific evidence can be considered as sufficient to consider PBM guidelines and practices as an indispensable complement to the transfusion medicine guidelines and practices. Several countries have launched PBM programmes (alternatives to allogeneic transfusion and optimisation of the use of blood components). Although current French national transfusion guidelines contain some PBM measures, PBM programmes should be further developed in France, primarily for medical reasons. CONCLUSIONS: Possible ways, using the existing basis having proved to be effective, are proposed to further develop PBM in France, as a complement to transfusion medicine, with the participation of involved stakeholders, including experts from relevant medical specialties, both at local and national levels.

Novel oral anticoagulants vs warfarin for the management of postoperative atrial fibrillation: clinical outcomes and cost analysis.

BACKGROUND: The novel oral anticoagulants (NOACs) apixaban, rivaroxaban, and dabigatran are indicated for the treatment of nonvalvular atrial fibrillation, but their use in patients with postoperative atrial fibrillation (POAF) is less well defined. METHODS: All patients undergoing isolated coronary artery bypass grafting from 2013 to 2015 (n = 598) were studied. Patients with POAF anticoagulated with either warfarin or NOACs were evaluated for differences in length of stay, blood product use, bleeding, and cost of therapy. RESULTS: There was no significant difference between the NOAC and warfarin group for any of the clinical outcomes evaluated. Time to therapeutic anticoagulation was significantly longer with warfarin. Neither group had a major bleeding event during the initial hospitalization, but 2 patients in the warfarin group had delayed major bleeding complications. Total costs were significantly reduced in patients treated with NOACs. CONCLUSIONS: Both NOACs and warfarin are safe and effective means of anticoagulation for POAF after coronary artery bypass grafting. Patients were therapeutic more rapidly and with less cost of treatment when NOACs were used.

[General anaesthesia and obstetric bleeding in caesarean section. One year's experience in a university hospital]. / Anestesia general y hemorragia obstétrica con transfusión en la cesárea. Experiencia durante un año en un hospital universitario.

INTRODUCTION: Obstetric haemorrhage is an important worldwide cause of morbidity and mortality. General anaesthesia for caesarean section is rarely used. Our goal is to analyse the incidence, causes and risk factors associated with general anaesthesia for caesarean section, and the prevalence of obstetric haemorrhage (HO), its risk factors and predictors of post-caesarean HO together with the use of blood in our hospital population. METHODS: A retrospective study was conducted on all caesarean section discharge reports from PACU in 2008. RESULTS: General anaesthesia was required in 12.4% of the patients. Epidural catheter failure as a cause of general anaesthesia was infrequent (2.8%) and within the recommended standards. CONCLUSIONS: The most frequent indications for caesarean section under general anaesthesia included mainly life-threatening emergencies, and the most important risk factors for general anaesthesia, including coagulation disorders, bleeding in the third trimester, foetal distress and severe pre-eclampsia. General anaesthesia is a risk factor for transfusion, as is abruptio placentae, placenta previa and pre-eclampsia.

The usage of blood components in obstetrics.

Major obstetric hemorrhage remains the leading cause of maternal morbidity and mortality worldwide. Even though blood transfusion may be a life-saving procedure, an inappropriate usage of blood products in obstetric emergencies especially in cases of massive bleeding is associated with increased morbidity and risk of death. Thorough knowledge of the etiology, pathophysiology, and optimal therapeutic options of major obstetric hemorrhage may help to avoid lethal outcomes. There are evidence-based data about some risks related with transfusion of blood components: acute or delayed hemolytic, febrile, allergic reactions, transfusion-related acute lung injury, negative immunomodulative effect, transmission of infectious diseases, dissemination of cancer. This is why the indications for allogeneic blood transfusion are restricted, and new safer methods are being discovered to decrease the requirement for it. Red cell alloimmunization may develop in pregnancy; therefore, all pregnant women should pass screening for irregular antibodies. Antierythrocytic irregular antibodies may occur due to previous pregnancies or allogeneic red blood cell transfusions, and it is important for blood cross-matching in the future. Under certain circumstances, such as complicated maternal history, severe coagulation abnormalities, severe anemia, the preparation of cross-matched blood is necessary. There is evidence of very significant variation in the use of blood products (red cells, platelets, fresh frozen plasma, or cryoprecipitate) among clinicians in various medical institutions, and sometimes indications for transfusion are not correctly motivated. The transfusion of each single blood product must be performed only in case of evaluation of expected effect. The need for blood products and for their combination is necessary to estimate for each patient individually in case of obstetric emergencies either. Indications for transfusion of blood components in obstetrics are presented in order to improve the skills of doctors and to optimize therapeutic options in obstetric emergencies.

Autologous blood transfusion during emergency trauma operations.

HYPOTHESIS: Intraoperative cell salvage (CS) of shed blood during emergency surgical procedures provides an effective and cost-efficient resuscitation alternative to allogeneic blood transfusion, which is associated with increased morbidity and mortality in trauma patients. DESIGN: Retrospective matched cohort study. SETTING: Level I trauma center. PATIENTS: All adult trauma patients who underwent an emergency operation and received CS as part of their intraoperative resuscitation. The CS group was matched to a no-CS group for age, sex, Injury Severity Score, mechanism of injury, and operation performed. MAIN OUTCOME MEASURES: Amount and cost of allogeneic transfusion of packed red blood cells and plasma. RESULTS: The 47 patients in the CS group were similar to the 47 in the no-CS group for all matched variables. Patients in the CS group received an average of 819 mL of autologous CS blood. The CS group received fewer intraoperative (2 vs 4 U; P = .002) and total (4 vs 8 U; P < .001) units of allogeneic packed red blood cells. The CS group also received fewer total units of plasma (3 vs 5 U; P = .03). The cost of blood product transfusion (including the total cost of CS) was less in the CS group ($1616 vs $2584 per patient; P = .004). CONCLUSION: Intraoperative CS provides an effective and cost-efficient resuscitation strategy as an alternative to allogeneic blood transfusion in trauma patients undergoing emergency operative procedures.

Four-year survival of transfusion recipients identified by hepatitis C lookback.

BACKGROUND: Information on the probability of survival of transfused patients is needed for policy making, but there is a paucity of empirical research into this question. A Swedish population-based study reported that the 40-month posttransfusion probability of survival was 51 percent in all patients and 41 percent in recipients of more than 10 units of blood and blood components. These figures were 20 percent lower than the figures reported previously from Olmsted County, Minnesota. STUDY DESIGN AND METHODS: Information was collected on the 4-year survival of 695 patients transfused at the New York University Medical Center between 1988 and 1996. These patients had been identified previously by hepatitis C lookback. RESULTS: Seventy-five percent of patients survived at 1 month after transfusion, 66 percent at 3 months, 60 percent at 6 months, 54 percent at 1 year, 50 percent at 2 years, 45 percent at 3 years, and 41 percent at 4 years. Seventy-eight percent of patients included in the study had received more than 10 units of blood and blood components. The 4-year survival of patients receiving 1 to 3, 4 to 10, or more than 10 units was 62 percent, 48 percent, and 38 percent, respectively (p < 0.0001). CONCLUSIONS: When transfusion dose is taken into account, the probability of survival of patients transfused at the New York University Medical Center in 1988 to 1996 and identified by lookback is similar to that reported for Swedish county residents transfused in 1993. Based on both the Swedish data and the information presented here and in the absence of any recent results from population-based studies, the survival of U.S. patients transfused in the 1990s appears to be 20 percent lower than that of Olmsted County residents transfused in 1981.

[The use of blood and blood products in total hip arthroplasty in 31 European hospitals, 1990/'91]. / Het gebruik van bloed en bloedproducten bij totale heupartroplastieken in 31 Europese ziekenhuizen, 1990/'91.

OBJECTIVE: To compare the use of blood products and artificial colloids during total hip arthroplasty in European hospitals. DESIGN: Descriptive. SETTING: Europe. METHODS: During the period October 1990-October 1991 transfusion data were obtained about patients who underwent a planned total hip replacement for the first time. The investigations were performed in 31 teaching hospitals in ten countries of the EC, as a part of the ¿Safe and good use of blood in surgery' (SANGUIS)-project. RESULTS: Red cells were ordered preoperatively in 97.4% of the 1647 cases and transfused in 81% (ranges among hospitals: 29-100). Hospitals in the Mediterranean area used more auto-transfusion than those in Central and Northern Europe. Plasma was transfused in 6% of the patients, predominantly in hospitals in southern European countries. Albumin was used especially in Central and Northern European countries. The reasons for red cell transfusion were stated in the medical records in 23% of the cases, for plasma transfusions in 7% and for albumin in 1%. Averaged transfusion-related costs were 192 ecu per patient (ranges per hospital: 60-383 ecu). CONCLUSION: Differences between European hospitals in the use of blood products for total hip arthroplasty are considerable.

[The organization of the donation of autologous blood and its components in cardiac surgery]. / Organizatsiia autodonorstva krovi i ee komponentov v kardiokhirurgii.

The article analyzes an experience with the organization of autodonation of blood and its components in surgical treatment of 305 patients with congenital and acquired defects and ischemic heart disease. Methods of plasmacytapheresis and cryopreservation used at the terms from 3 days to 12 months before operation allowed storage of the autologous components of blood in 41.2% of the patients having indications for autodonation. In 29.1% of the observations the autotransfusion media were reserved under the outpatient clinic conditions which resulted in shorter terms of treatment at the hospital. The number of unfavorable reactions during the donation in patients did not exceed analogous parameters in regular donors. Autohemotransfusions 3-5 times reduced the volume of transfusions of the allogenic blood components and they were completely avoided in 20.1% of the patients.

Autologous blood donation in support of cardiac surgery: a preliminary report on a hospital-based autologous donor programme.

The purpose of this study was to assess the success or otherwise of the introduction of an autologous blood programme in support of cardiac surgery in reducing patient exposure to allogeneic blood products and to assess the guideline of two units as the collection schedule for such patients. Sixty-six patients were enrolled in the programme provided they met defined clinical conditions and donated one, two or three units of blood at seven-day intervals, using isovolaemic conditions. One minor vasovagal adverse reaction was recorded. Of the 66 patients, 51 (77%) avoided allogeneic red cells and 42 (64%) received no allogeneic product. If each patient deposited two units, 51 (77%) would have required no allogeneic red cells; if three units were deposited, 57 (86%) patients would have required no allogeneic red cells, but 60 units would be surplus to requirements. Comparison of 52 patients for coronary artery bypass grafting who were autologous donors, with 130 patients undergoing the procedure before the availability of autologous blood, supports the suggestions that there is increased readiness to initiate transfusion of autologous blood and that exposure to allogeneic red cells is reduced. However, exposure to allogeneic products of all kinds is not reduced. It is concluded that the collection of two units of autologous blood is appropriate for most eligible patients and that this reduces exposure to allogeneic red cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of peripheral blood stem-cell and autologous bone marrow transplantation for lymphoma patients: a case-controlled analysis of the EBMT Registry data. Lymphoma Working Party of the EBMT.

A case-controlled analysis was performed to assess the effect of stem-cell source on autograft in a group of patients with malignant lymphoma reported to the European Bone Marrow Transplant Group (EBMT). The study was performed matching 83 patients autografted with peripheral blood stem cells (PBSC) with 83 autologous bone marrow transplantation (ABMT) patients. The case-matching was carried out following selection of the main prognostic factors for progression-free survival by multivariate analysis. The progression-free survival was similar in both types of transplants (38.5% PBSCT vs. 36.4% ABMT). The overall relapse and progression rate for the PBSCT was 51.2% compared with 50.1% for the ABMT patients. The differences were not significant statistically. The transplant-related mortality was 6% for both groups. The neutrophil and leucocyte recovery occurred faster in the peripheral blood stem-cell transplantation (PBSCT); the platelet recovery was not significant. A higher number of interstitial pneumonitis and fungal infection episodes were observed in the ABMT group. In conclusion, in these closely matched groups, there is no difference in PFS between patients undergoing PBSCT and those undergoing ABMT. However, the patients autografted with PBSC have a more rapid engraftment and a lower toxicity.

A controlled trial of intra-operative autologous transfusion in cardiothoracic surgery measuring effect on transfusion requirements and clinical outcome.

We carried out a prospective, controlled trial of intra-operative autologous transfusion (IOAT) in cardiac surgery using the Haemonetics Cellsaver 4, to determine the effects on transfusion requirements and early clinical outcome. Intra-operative autologous transfusion in unselected patients resulted in a reduction in the use of red cells in patients undergoing first-time operations (IOAT median 3 units, controls median 4 units, P = 0.0023), with no difference in the use of other blood products. Post-operative haemoglobin was higher in IOAT patients (IOAT 11.6 g/dl +/- 1.1 versus controls 11.2 g/dl +/- 0.98, P < 0.001). There is therefore the potential for a further reduction in homologous blood use in the IOAT group. There was no difference in early clinical outcome in the two groups; in particular the incidence of coagulopathies was not influenced by IOAT. The routine use of IOAT would add substantially to the cost of these operations. The decision to use it must therefore be based on an assessment of the value of the reduction in risk to the patient achieved by a small reduction in homologous donor exposures.

Impact of whole blood usage in massive transfusion.

A retrospective survey comparing blood and component usage during thoracoabdominal aortic reconstruction between patients receiving whole blood vs packed red cells was conducted. Volume of salvaged blood, usage of homologous blood components, and total homologous exposures were compared between eight patients who received only packed red blood cells and four patients who received whole blood for replacement of surgical losses, using a chi-square test for comparison. All variables demonstrated a decline among patients who received whole blood. The declines in homologous blood and plasma usage were statistically significant (P less than .05). The decline in platelet usage did not reach statistical significance. The decline in total homologous exposures approached statistical significance (P less than .1). The data suggest that use of whole blood for expected massive transfusion may reduce total blood-component requirements and total homologous exposures.

[The "concept of autologous transfusion"]. / Das "Concept der Autologen Transfusion" (CAT).

This study analyzes the need for homologous blood in a prospectively studied group of 4,357 orthopedic-surgical patients after having established the 'Concept of Autologous Transfusion' (CAT) in 1989, in comparison to a retrospectively studied group of 7,485 orthopedic-surgical patients that had been treated exclusively with homologous blood (in 1986 and 1987). Despite an increase by 18% of the number of operations performed (in 1986: 3,698 operations vs. 4,357 operations in 1989), the need for homologous blood has been reduced by more than 80% (in 1986: 12,600 units of homologous packed red blood cells vs. 1989: 2,145 units of homologous blood). This effect has been achieved by the combination of various blood-saving techniques, namely by normovolemic hemodilution in 3,591 patients (82.4%), intra- and post-operative blood salvage in 1,936 patients (44.4%) as well as by 2,261 preoperative autologous blood donations, and by 5,279 preoperative plasmaphereses. Preoperative autologous donations have been accompanied by side effects in 1.3% (mild and moderate); no serious or even fetal complications occurred and all ambulatory patients coming to the hospital just for an autologous donation left for home on the same day.