A quality improvement initiative standardizing premedication for blood product transfusions.

For children with cancer, blood product transfusions are crucial, but can be complicated by transfusion reactions. To prevent these complications, premedication is often given, although not always evidence-based. Herein, we describe a significant decrease in the use of premedication (72%-28%) at our institution after the implementation of standardized guidelines, without an increase in transfusion reactions (3.2% prior vs. 1.5% after standardization). Importantly, there were no severe transfusion reactions leading to hospitalization or death. Our results provide evidence in favor of more judicious use of premedication prior to transfusions in patients 21 years and younger being treated for cancer.

Evaluation of peripheral blood mononuclear cell collection by leukapheresis.

BACKGROUND: Adoptive immunotherapy using engineered lymphocytes has shown promising results in treating cancers even in patients who have failed other treatments. As the first essential step, the number of peripheral mononuclear cell (MNC) collection procedures is rapidly increasing. In this retrospective study, we reviewed the collection results to determine factors that affect MNC collection. STUDY DESIGN AND METHODS: We reviewed 184 collections that were performed on 169 adult allogenic donors and patients with acute lymphoid leukemia, chronic lymphoid leukemia, lymphoma, multiple myeloma, or solid-organ tumors. All the leukapheresis procedures were performed after a complete cell count with differential was obtained. Total blood volume (TBV) was defined as processed blood volume divided by patient blood volume. RESULTS: There was a significant association between the precollection MNC count (pre-MNC) and the MNC yields normalized by TBV (r = 0.926; p < 0.001) and a regression formula was created to predict MNC yields. Multiple regression analyses showed that pre-MNC, TBV, and precollection hemoglobin were strongly associated with MNC yield (R 2 = 0.866; F (3180) = 388.472; p < 0.001), and pre-MNC had the greatest influence on MNC yield (ß = 0.960; p < 0.001) followed by TBV (ß = 0.302; p < 0.001), and Hgb (ß = 0.136; p < 0.001). CONCLUSION: Our results suggest that the optimal time for MNC collection can be determined based on pre-MNC and that processing volume should be determined based on collection goal and pre-MNC to optimize and personalize the harvesting procedure.

Injustice perceptions about pain: parent-child discordance is associated with worse functional outcomes.

Pain is experienced within and influenced by social environments. For children with chronic pain, the child-parent relationship and parental beliefs about pain are particularly important and may influence pain outcomes. Pain-related injustice perceptions have recently been identified as an important cognitive-emotional factor for children with pain. The current study aimed to better understand the pain-related injustice perceptions of children with chronic pain and their parents. The sample consisted of 253 pediatric chronic pain patients (mean age = 14.1 years, 74% female) presenting to a tertiary pain clinic. Patients completed measures of pain intensity, pain-related injustice perceptions, stress, functional disability, and quality of life. Parents completed a measure of pain-related injustice perceptions about their child's pain. Child-parent dyads were categorized into 1 of 4 categories based on the degree of concordance or discordance between their scores on the injustice measures. One-way analysis of variances examined differences in pain intensity, stress, functional disability, and quality of life across the 4 dyad categories. Our findings indicated that both the degree (concordant vs discordant) and direction (discordant low child-high parent vs discordant high child-low parent) of similarity between child and parent injustice perceptions were associated with child-reported pain intensity, stress, functional disability, and quality of life. The poorest outcomes were reported when children considered their pain as highly unjust, but their parents did not. These findings highlight the important role of parents in the context of pain-related injustice perceptions in pediatric chronic pain.

Predicting the risk of perioperative transfusion for patients undergoing elective hepatectomy.

OBJECTIVE: To develop 2 instruments that predict the probability of perioperative red blood cell transfusion in patients undergoing elective liver resection for primary and secondary tumors. SUMMARY BACKGROUND DATA: Hepatic resection is the most effective treatment for several benign and malign conditions, but may be accompanied by substantial blood loss and the need for perioperative transfusions. While blood conservation strategies such as autologous blood donation, acute normovolemic hemodilution, or cell saver systems are available, they are economically efficient only if directed toward patients with a high risk of transfusion. METHODS: Using preoperative data from 1204 consecutive patients who underwent liver resection between 1995 and 2000 at Memorial Sloan- Kettering Cancer Center, we modeled the probability of perioperative red blood cell transfusion. We used the resulting model, validated on an independent dataset (n = 555 patients), to develop 2 prediction instruments, a nomogram and a transfusion score, which can be easily implemented into clinical practice. RESULTS: The planned number of liver segments resected, concomitant extrahepatic organ resection, a diagnosis of primary liver malignancy, as well as preoperative hemoglobin and platelets levels predicted the probability of perioperative red blood cell transfusion. The predictions of the model appeared accurate and with good discriminatory abilities, generating an area under the receiver operating characteristic curve of 0.71. CONCLUSIONS: Preoperative factors can be combined into risk profiles to predict the likelihood of transfusion during or after elective liver resection. These predictions, easy to calculate in the frame of a nomogram or of a transfusion score, can be used to identify patients who are at high risk for red cell transfusions and therefore most likely to benefit from blood conservation techniques.

A prospective randomized trial of acute normovolemic hemodilution compared to standard intraoperative management in patients undergoing major hepatic resection.

BACKGROUND: Hepatic resection is the most effective treatment for many malignant and benign conditions affecting the liver and biliary tree. Despite improvements, major partial hepatectomy can be associated with considerable blood loss and transfusion requirements. Transfusion of allogeneic blood products, although potentially life-saving, is associated with many potential complications. The primary aim of this study was to determine if acute normovolemic hemodilution (ANH), an established blood conservation technique, reduces the requirement for allogeneic red cell transfusions in patients undergoing major hepatic resection. METHODS: One hundred thirty patients undergoing major hepatic resection (> or =3 segments) were prospectively randomized to undergo either ANH or standard anesthetic management (STD). In the ANH group, intraoperative blood collection was performed to a target hemoglobin of 8.0 g/dL. Low central venous pressure anesthetic technique was used intraoperatively for both groups. A standardized transfusion protocol was applied to all patients intraoperatively and throughout the hospital stay. RESULTS: From April 2004 to March 2007, 63 patients were randomized to ANH and 67 to STD. Demographics, diagnoses, liver function, extent of resection, intraoperative blood loss, operative time, incidence and grade of complications, and length of hospital stay were similar between the 2 groups. ANH reduced the overall allogeneic red cell transfusion rate by 50% compared with STD [12.7% (n = 8) vs. 25.4% (n = 17), respectively; P = 0.067. ANH patients were less often transfused intraoperatively (n = 1, 1.6%) compared with the STD group (n = 7, 10.4%) (P = 0.036), had higher postoperative hemoglobin levels (P = 0.01), and tended to require fewer red cell units overall (28 vs. 47 units). In patients with intraoperative blood loss > or =800 mL, ANH reduced not only the allogeneic red cell transfusion rate (18.2% vs. 42.4%, P = 0.045) but also the proportion of patients requiring fresh frozen plasma (21.1% vs. 48.3%, P = 0.025). CONCLUSION: For patients undergoing major liver resection, ANH is safe, effectively reduces the need for allogeneic transfusions, and should be considered for routine use. Given the modest transfusion rate in the STD arm, future efforts should attempt to target ANH use to patients most likely to benefit.

Autologous versus allogeneic transfusions: no difference in perioperative outcome after partial hepatectomy. Autologous transfusion on hepatectomy outcome.

Blood transfusion is often necessary in patients undergoing liver resection. Because of the risks associated with allogeneic blood products, preoperative autologous blood donation has been advocated, but its benefit with respect to perioperative outcome remains unclear. This study compares perioperative outcome in patients transfused only with autologous blood to a matched cohort receiving only allogeneic blood. All patients subjected to hepatic resection and given only perioperative autologous red cell transfusions were identified from a prospective database of 2,123 patients and reviewed retrospectively. This group was matched to patients transfused only with a comparable number of allogeneic red cell units and to a control group that received no blood products. All patients in the autologous or allogeneic group received either 1 or 2 U. Matching was based on age, comorbidity, extent of hepatic resection, and estimated blood loss. Matched pair analysis was performed using the paired t test, McNemar and Stuart-Maxwell tests. From December 1991 to May 2003, 124 patients undergoing hepatic resection received perioperative autologous blood only, for which optimal matching was possible in 104. The groups were similar with respect to age, comorbidities, and blood loss; the proportions receiving preoperative chemotherapy, requiring a major resection (>or=3 segments) or a complex procedure (concomitant major procedure in addition to the principal hepatic resection) were also similar. There were no differences between the autologous and allogeneic groups in length of hospitalization, complications, and operative mortality. In patients undergoing hepatic resection, autologous blood transfusion did not demonstrably improve perioperative outcome when compared to a matched cohort of patients receiving a similar number of allogeneic units.

Transfusion policy: when to stop the use of extremely rare blood for an allogeneic hematopoietic progenitor cell transplant recipient with a history of red cell alloimmunization.

BACKGROUND: Decisions for when to select, and when to discontinue, antigen-negative blood in hematopoietic progenitor cell transplantation (HPCT) recipients with red blood cell (RBC) antibodies can be confusing. In HPCT performed for sickle cell anemia patients who require extremely rare antigen-negative blood, the balance of caution and practicality is further complicated. CASE REPORTS: Four sickle cell anemia patients with current or historic RBC antibodies underwent allogeneic HPC transplantation. One required extremely rare (group O D-, hr(B)-) blood. None of the antibodies caused significant hemolysis after transplant. In the case requiring rare blood, antigen-negative blood was requested after donor RBC engraftment because of incomplete donor white blood cell (WBC) chimerism. CONCLUSIONS: RBC antibodies derived from a recipient of allogeneic HPCT rarely cause significant hemolysis, in contrast to the more severe picture sometimes seen with donor-derived antibodies. When donor WBC chimerism is delayed past the time of donor RBC engraftment, there can be concern for the possibility of future recipient-type antibody production. Even 100 percent donor lymphocyte chimerism is no guarantee of total host plasma cell ablation. Immunoglobulin allotyping, when informative, can suggest chimerism for several years. Recipient-type blood, when extremely rare, may not be available for that duration.

Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases.

OBJECTIVE: To determine if transfusion affected perioperative and long-term outcome in patients undergoing liver resection for metastatic colorectal cancer. SUMMARY BACKGROUND DATA: Blood transfusion produces host immunosuppression and has been postulated to result in adverse outcome for patients undergoing surgical resection of malignancies. METHODS: Blood transfusion records and clinical outcomes for 1,351 patients undergoing liver resection at a tertiary cancer referral center were analyzed. RESULTS: Blood transfusion was associated with adverse outcome after liver resection. The greatest effect was in the perioperative course, where transfusion was an independent predictor of operative mortality, complications, major complications, and length of hospital stay. This effect was dose-related. Patients receiving one or two units or more than two units had an operative mortality of 2.5% and 11.1%, respectively, compared to 1.2% for patients not requiring transfusions. Transfusion was also associated with adverse long-term survival by univariate analysis, but this factor was not significant on multivariate analysis. Even patients receiving only one or two units had a more adverse outcome. CONCLUSIONS: Perioperative blood transfusion is a risk factor for poor outcome after liver resection. Blood conservation methods should be used to avoid transfusion, especially in patents currently requiring limited amounts of transfused blood products.