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PubMedDate not supplied

An analysis of blood transfusion of surgical patients by sex: a question for the transfusion trigger.

The factor or constellation of factors which precipitates blood transfusion in hospitals can be termed the "transfusion trigger." The blood transfusion experience of 535,031 male and female surgical patients was compared in order to evaluate the importance of the hematocrit as a component of this transfusion trigger. Transfusion data presented support the hypothesis that surgeons use the same support and ceiling hematocrit levels to regulate blood transfusion in men and women, despite the fact that women have lower hematocrits. The use of a lower hematocrit support level to govern the blood transfusion of female surgical patients should be considered. Data cited showing that women have a degree of physiologic adaptation to their lower hematocrits suggest that this change could be introduced without causing increased morbidity. A net saving of blood would most certainly result from it.

Abdomen↗

PubMed1991

Risk of human immunodeficiency virus (HIV) transmission by blood transfusions before the implementation of HIV-1 antibody screening. The Transfusion Safety Study Group.

Little information is available regarding the risk of human immunodeficiency virus type 1 (HIV-1) infection for patients transfused before routine anti-HIV-1 screening of blood donors was instituted in March 1985. A model was developed for estimating both the proportion and the number of transfusion recipients in the San Francisco Bay area who were infected by HIV-1 during each of the 7 years preceding routine donor screening for anti-HIV-1. The model is based on analysis of 1) donation histories of HIV-1-infected donors identified at the regional blood center; 2) HIV-1 seroprevalence estimates for homosexual and bisexual men in San Francisco; and 3) HIV-1 infection and survival rates for recipients traced by the Transfusion Safety Study and Irwin Memorial Blood Centers' Look Back Program. The incidence of transfusion-associated HIV-1 infection is estimated to have risen rapidly from the first occurrence in 1978 to a peak in late 1982 of approximately 1.1 percent per transfused unit. The decrease after 1982 coincided with the implementation of high-risk donor deferral measures. It is estimated that, overall, approximately 2135 transfusion recipients were infected with HIV-1 in the San Francisco region alone. This number suggests a higher prevalence of transfusion-associated HIV-1 infection than has been generally recognized and indicates the need for continued tracing of potentially exposed recipients. The data also strongly support the effectiveness of early donor education and self-exclusion measures and emphasize the importance of continued research and development in this area.

Acquired Immunodeficiency Syndrome↗

PubMed2000

From leukocyte reduction to leukocyte transfusion: the immunological effects of transfused leukocytes.

In transfusion medicine, mononuclear leukocytes have been studied more often as contaminants of red blood cells or platelets responsible for adverse transfusion outcomes than as therapeutic cells; leukocyte transfusion has been effective in augmenting recipient immunity only in limited clinical situations. Studies in leukocyte reduction and leukocyte transfusion have progressed separately as if the leukocytes' adverse and therapeutic effects result from different immunological mechanisms. With growing clinical experience, however, it is increasingly clear that some adverse immune effects may be exploited for therapeutic benefit. Advances in clinical immunology, understanding of the variety of cells and functions in the leukocyte fraction of blood, and blood component preparation technology may lead to new ways of deriving immunological benefit from transfused blood leukocytes while minimizing their adverse effects. This chapter reviews the current uses of leukocyte reduction and mononuclear leukocyte transfusion, with an emphasis on the relationship between transfusion-associated graft-versus-host disease and donor lymphocyte infusion in controlling relapsed leukaemias.

Antigen-Presenting Cells↗

PubMed1999

A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group.

BACKGROUND: To determine whether a restrictive strategy of red-cell transfusion and a liberal strategy produced equivalent results in critically ill patients, we compared the rates of death from all causes at 30 days and the severity of organ dysfunction. METHODS: We enrolled 838 critically ill patients with euvolemia after initial treatment who had hemoglobin concentrations of less than 9.0 g per deciliter within 72 hours after admission to the intensive care unit and randomly assigned 418 patients to a restrictive strategy of transfusion, in which red cells were transfused if the hemoglobin concentration dropped below 7.0 g per deciliter and hemoglobin concentrations were maintained at 7.0 to 9.0 g per deciliter, and 420 patients to a liberal strategy, in which transfusions were given when the hemoglobin concentration fell below 10.0 g per deciliter and hemoglobin concentrations were maintained at 10.0 to 12.0 g per deciliter. RESULTS: Overall, 30-day mortality was similar in the two groups (18.7 percent vs. 23.3 percent, P= 0.11). However, the rates were significantly lower with the restrictive transfusion strategy among patients who were less acutely ill -- those with an Acute Physiology and Chronic Health Evaluation II score of < or =20 (8.7 percent in the restrictive-strategy group and 16.1 percent in the liberal-strategy group; P=0.03) -- and among patients who were less than 55 years of age (5.7 percent and 13.0 percent, respectively; P=0.02), but not among patients with clinically significant cardiac disease (20.5 percent and 22.9 percent, respectively; P=0.69). The mortality rate during hospitalization was significantly lower in the restrictive-strategy group (22.3 percent vs. 28.1 percent, P=0.05). CONCLUSIONS: A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction and unstable angina.

APACHE↗

PubMed1993

Role of transfusion-mediated viral infections on the lymphocyte subset profile in multi-transfused children.

A total of 74 multitransfused (MT) children of beta thalassaemia major were analysed for prevalent viral markers transmitted through transfusion. A higher incidence of serological markers for Hepatitis B virus (HBV), cytomegalovirus (CMV) could be observed in the group of MT children compared to control group. There was a significant trend (chi 2 = 33.4; P < 0.001) in the increase in prevalence of viral markers along with the increase in the number of transfusions. MT children receiving more than 50 transfusions were found to have evidence for at least one or multiple viral infections transmitted through blood. Children receiving more than 50 transfusions were characterized by marked alteration of T3, T8, and B cells while T4/T8 ratio was found to be significantly decreased (P < 0.001) only in the group of children receiving more than 100 transfusions. Relative assessment of the alteration of lymphocyte subsets in various groups of viral infection showed that cases with CMV IgM to have more marked influence on the alteration of T8 cells, T4/T8 ratio, and B cells compared to other groups of viral infections. Reassessment of the lymphocyte subset profile in MT children in the light of CMV IgM positive cases revealed that in children receiving more than 50 transfusions significant alterations of lymphocyte subjects were influenced by the presence of CMV IgM positive cases in these groups. Our study points out that the correlation between the alteration of lymphocyte subset profile and number of transfusion in MT children need to be reassessed in the light of acute CMV infection in the form of CMV IgM.

Acquired Immunodeficiency Syndrome↗

PubMed2005

Management of bleeding in a multi-transfused patient with positive HLA class I alloantibodies and thrombocytopenia associated with platelet dysfunction refractory to transfusion of cross-matched platelets.

Thrombocytopenia is a common condition in the critical care setting. Repetitive platelet transfusion might lead to formation of alloantibodies. HLA class I and human platelet antigen antibodies can lead to transfusion-refractory thrombocytopenia. Transfusion of cross-matched platelets often is effective in these patients. We report on the successful use of recombinant activated factor VII in an acute bleeding situation in a multi-transfused patient presenting with positive HLA class I alloantibody status and thrombocytopenia associated with platelet dysfunction refractory to even transfusion of cross-matched platelets. The 41-year-old female patient developed HLA class I antibodies during former episodes of massive transfusion. Her former medical history was empty concerning hemorrhagic events. During this specific bleeding episode the patient suffered from intractable profuse bleeding from the nasopharynx and oral cavity. Global coagulation tests were within the normal range. Platelet dysfunction was confirmed by PFA100. Initially the patient responded well to Desmopressin infusion, but after 36 h she became thrombocytopenic and refractory to even transfusion of cross-matched platelets. Recombinant activated factor VII was chosen as the last resort. Two identical boli of 160 microg/kg NovoSeven each were injected via a central line within an interval of 3 h. After the first injection bleeding was significantly reduced and vasopressor support discontinued. After the second bolus bleeding completely ceased and did not reoccur. We did not observe any side effects. The pluripotent hemostatic agent recombinant activated factor VII might be a new option in the treatment of hemorrhagic episodes in patients presenting with this rare disorder, especially when the patient is refractory to cross-matched platelets or matched platelets are not available.

Adult↗

PubMed2003

Pretransplant blood transfusion without additional immunotherapy generates CD25+CD4+ regulatory T cells: a potential explanation for the blood-transfusion effect.

BACKGROUND: Preoperative blood transfusion has had a significant historic impact on graft outcome in clinical kidney transplantation, and the effect has been widely replicated in many experimental transplant models. Although the mechanisms underlying the blood-transfusion effect are poorly understood, one possibility is that preexposure to alloantigen results in the induction of regulatory cells with the capacity to control the effector arm of the immune response. METHODS: Recent studies in autoimmune models have shown that T cells with regulatory function can be isolated from unmanipulated animals on the basis of CD25 expression, and we have recently shown that pretreatment of recipient mice with donor alloantigen combined with anti-CD4 antibody therapy generates CD25+CD4+ T cells that can prevent graft rejection. We therefore used this sensitive adoptive transfer mouse model to ask whether blood transfusion in the absence of any other treatment can also lead to the generation of alloreactive CD25+CD4+ regulatory T cells. RESULTS: Although a single donor-specific transfusion (DST) fails to induce dominant regulation, we demonstrate that pretreatment with multiple DSTs generates CD25+CD4+ T cells that are as effective as those that result from blood transfusion under anti-CD4 antibody cover. More importantly, our results show that these cells also develop following multiple transfusions of unrelated (random) blood. CONCLUSION: These results provide a basis for understanding the blood-transfusion effect in transplantation and, by providing a link between naturally occurring regulatory cells and those induced by alloantigen, may shed new light on the fundamental basis of the effect itself.

Animals↗

PubMed2006

The emergency room transfusion score (ETS): prediction of blood transfusion requirement in initial resuscitation after severe trauma.

The presented study was initiated to develop a scoring system for the prediction of red blood cell transfusion requirement in the early care of trauma patients. All trauma patients admitted to our institution who needed trauma team activation were evaluated during a 4-year period. A set of nine parameters with possible predictive value for the need of blood transfusion was recorded. All relevant data can be acquired during the first 10 min in the emergency room (ER). The data underwent multivariate logistic regression analysis for correlation and the calculation of predictive power. To transform the model into a practical score, we rounded all coefficients. The predictive power of the score was evaluated based on a linear regression equation. Of the 1103 patients (Injury Severity Score [ISS] 21 +/- 16) included in the study, 116 (10.5%; ISS 39 +/- 18) received blood in the ER. Early transfusion need was significantly correlated with systolic blood pressure (SBP) <90 mmHg (coefficient 2.5), SBP 90-120 mmHg (1.5), free fluid in abdominal ultrasound (2.0), clinically unstable pelvic ring fracture (1.5), age 20-60 years (0.5), age >60 years (1.5), admission from scene (1.0), traffic accident (1.0) and fall from >3 m (1.0). The probability for transfusion exponentially increased with the sum of points in the ER transfusion score, i.e. from 0.7% at one point to 5% at three points and 97% at 9.5 points maximum. To establish a practical cutoff point (risk <5%) a low-risk group was defined at <points (64% of the whole study group). The presented ER transfusion score is based on rapidly assessable parameters. The score identifies patients in need for immediate red blood cell substitution. Cost effectiveness appears to be a further advantage of the score. For patients not in need of urgent transfusion (low-risk group), the costs for transportation, cross-matching and loss by maltreatment of blood products may be avoided.

Adolescent↗

PubMed1996

Bedside transfusion errors: analysis of 2 years' use of a system to monitor and prevent transfusion errors.

Clerical errors occurring during specimen collection, issue and transfusion of blood are the most common cause of AB0 incompatible transfusions. 40-50% of the transfusion fatalities result from errors in properly identifying the patient or the blood components. The frequency and type of errors observed, despite the implementation of measures to prevent them, suggests that errors are inevitable unless major changes in procedures are adopted. A fail-safe system, which physically prevents the possibility of error, was adopted in January 1993 and concurrently a quality improvement program was implemented to monitor any transfusion errors. Up to December 1994, 10,995 blood units (5,057 autologous and 5,938 allogeneic) were transfused to 3,231 patients. Seventy-one methodological errors(1/155 units) were observed, half of which were concentrated during the first 4 months of introducing the system. However the system detected and avoided four potentially fatal errors (1/2,748 units). Two cases involved the interchanging of recipient sample tubes, 1 case was due to patient misidentification and the other involved misidentification of blood units. In conclusion the system is effective in detecting otherwise undiscovered errors in transfusion practice and can prevent potential transfusion-associated fatalities caused by misidentification of blood units or recipients.

Blood Transfusion↗

PubMed2005

Strict red blood cell transfusion guideline reduces the need for transfusions in very-low-birthweight infants in the first 4 weeks of life: a multicentre trial.

BACKGROUND AND OBJECTIVES: Very-low-birthweight infants are among the most heavily transfused patients. The objective of this study was to verify if the introduction of a strict guideline would reduce the need for red blood cell transfusions in the first 4 weeks of life in these neonates. MATERIALS AND METHODS: This was a multicentre prospective study of two cohorts of very-low-birthweight infants transfused in accordance with the recommendations of a neonatologist (Phase 1) or according to previously published guidelines (Phase 2). RESULTS: In the first 28 days of life, 102 patients (68.5%) in Phase 1 and 117 (59.7%) in Phase 2 were transfused. The number of transfusions was 1.9 +/- 2.0 in Phase 1 and 1.4 +/- 1.6 in Phase 2 (P = 0.01). After adjusting for gestational age, blood loss and the presence of respiratory distress syndrome, the strict guideline reduced the number of transfusions in 17.6% (IC 95%-30.5% to -2.6%). CONCLUSIONS: The strict guideline was effective in reducing erythrocyte transfusions in very-low-birthweight infants.

Blood Volume↗

PubMed2006

Development and validation of Transfusion Risk Understanding Scoring Tool (TRUST) to stratify cardiac surgery patients according to their blood transfusion needs.

BACKGROUND: Allogeneic blood transfusion is associated with transfusion reactions, infection transmission, and postoperative morbidity and mortality. The objective of this study was to develop and validate an accurate and simple clinical index to stratify cardiac surgery patients according to their blood transfusion needs. METHODS AND RESULTS: Data on consecutive adult patients who underwent cardiac surgery at Toronto General Hospital (n = 11,113) and Sunnybrook and Women's College Health Sciences Center (n = 5316) between May 1999 and June 2004 were collected for the development, validation, and external validation of the index. Primary outcome was the exposure to blood transfusion in the operative and first postoperative days. Multivariable logistic regression modeling techniques were used to determine the relationship between each independent variable and the exposure to allogeneic blood transfusion. Score assignment for each predictor variable was based on its regression coefficient. The predicted probabilities at each total score were compared to the observed proportions of patients exposed to blood transfusion. The clinical tool consists of eight preoperative variables: preoperative hemoglobin, weight, female sex, age, nonelective procedure, preoperative creatinine, previous cardiac surgical procedure, and nonisolated procedure. CONCLUSIONS: Based on the standards of measurement in clinical research, a valid clinical tool was developed for predicting the need for blood transfusion in patients undergoing cardiac surgery. The clinical tool was internally and externally validated, and the results suggest that it should perform well at other institutions.

Aged↗

PubMed1985

Hemodynamic evaluation of blood transfusion in chronic severe anemia with special reference to speed of transfusion.

Left ventricular filling pressure (LVFP) as reflected by pulmonary capillary wedge pressure (PCWP) was measured in 40 adult cases of chronic severe anemia (CSA) before and after transfusion of 1 unit of whole citrated blood, using Swan-Ganz monitoring catheters. The cases were randomized into 4 groups of 10 each. Blood was transfused at a rate of 2 ml, 5 ml and 10 ml/min in groups A, B and C, respectively. In group D, blood transfusion (BT) was given at 5 ml/min but this group received, in addition, 40 mg furosemide intravenously just prior to the transfusion. Pretransfusion PCWP was normal in all the cases. Following BT the "wedge" pressure increased significantly in the first 3 groups, the rise being proportionately greater with faster transfusions (15.8, 20.9 and 32.2% in groups A, B and C, respectively). In group D, however, PCWP actually decreased by 21.7% (p less than 0.001). As far as we know, this is the first study in which a definite and significant rise in PCWP has been documented following transfusion of blood even at conventional speed (group A). The implications of such an increase in "wedge" pressure as well as the observation that it can be completely blocked by furosemide are discussed. On the basis of these observations it is recommended that intravenous furosemide should be administered routinely before any BT in cases of CSA. Such practice will also permit blood to be transfused at a comparatively faster speed, without jeopardizing patient safety.

Adolescent↗

PubMed2000

Red cell transfusion strategies in the ICU. Transfusion Requirements in Critical Care Investigators and the Canadian Critical Care Trials Group.

Transfusion of red blood cells continues to be an important therapy for treatment of anemia in intensive care settings. The critically ill are a population predisposed to the adverse outcomes of anemia and, as such, the risks imposed on them by transfusion therapy is one of great interest. Over the past decade there has been a shift in transfusion practice with guidelines being developed that promote more conservative and safer use of blood. The Transfusion Requirements in Critical Care (TRICC) trial clearly established the safety of a restrictive transfusion strategy, suggesting that physicians could easily minimize exposure to allogeneic RBCs by lowering their transfusion threshold. Further research will add to the generalizability of this study as well as explore the possible mechanism to explain why red cell transfusions did not improve outcomes in the critically ill.

Clinical Trials as Topic↗

PubMed2002

Clinical assessment of preventing febrile nonhemolytic transfusion reaction by leukocyte-depleted blood transfusion.

The objective was designed to assess the clinical efficiency of preventing febrile nonhemolytic transfusion reactions (FNHTR) with transfusion of leukocyte-depleted RBC and platelet concentrates. One hundred patients with cirrhosis of liver, gastric ulcer and cancer were selected to receive RBC concentrates with leukocyte filtration. Another group of 50 patients with liver necrosis, gastric ulcer and cancer were selected to receive non-filtered RBC concentrates. Two hundred and forty patients with acute or chronic leukemia, aplastic anemia, multiple myeloma, thrombocytopenia purpura, diabetes mellitus, cirrhosis of liver, upper gastrointestinal hemorrhage, severe hepatitis, burn and cancer post radioactive or chemical treatment were divided into two group with 120 patients in each one and selected randomly to receive platelet concentrates. The incidence rates of FNHTR in all patients were investigated. Results showed that there was no FNHTR in 100 transfusions with leukocyte-depleted RBC concentrates. Eight out of 50 patients with non-filtrated RBC concentrates showed FNHTR. The incidence of FNHTR was sixteen (16%) in non-filtrated transfusion. Twenty-five and 7 patients manifested FNHTR respectively in non-filtrated or filtrated platelets transfusions. The incidence of FNHTR was 20.83% and 5.83% respectively in non-filtrated or filtrated platelet transfusion. It is concluded that leukocyte-depleted RBC and platelet concentrates reduces FNH TR in blood transfusion.

Adult↗

PubMed2006

[Transfusion-Related Acute Lung Injury a serious, underdiagnosed transfusion-related event].

UNLABELLED: Transfusion-Related Acute Lung Injury (TRALI) has been diagnosed very rare until recent years. However, the growing interest in TRALI allows to asses, that it is the second commonest cause of transfusion association death. In Poland only single cases of TRALI have been published. AIM: We analyzed 34 cases with dyspnea reported as a post-transfusion event and examined leukocyte antibodies, which are supposed to be an important pathogenic factor in TRALI. RESULTS: 34 patients were classified into: the group A--patients with a pulmonary oedema after exclusion of other reasons (TRALI, n= 11); the group B-- patients with pulmonary oedema, but with difficulties to exclude other reasons (possible TRALI, n=15); the group C--post transfusion dyspnea without pulmonary oedema (patients where not classified as the TRALI, n=8). In all the groups other clinical symptoms were also analyzed. The leukocyte antibodies were most often detected in the group A (91%), less often in the group B (53%) and C (37.5%). CONCLUSIONS: Transfusion-related dyspnea should be individually analyzed before the final diagnosis of TRALI. If in the donor of transfused blood the leukocyte antibodies are detected, the "trace back" procedure should be started to see whether in other patients a transfusion-related dyspnea was diagnosed. This procedure is important for potential exclusion of a given donor from blood donation.

Adult↗

PubMed2006

[Post transfusion purpura--a serious underdiagnosed delayed post-transfusion event].

UNLABELLED: Post-transfusion purpura (PTP), a delayed post-transfusion event, is underdiagnosed, not only in Poland. Thrombocytopenia results from the destruction of patients' and transfused platelets by platelet specific antibodies (anti-HPA). The incidence of PTP is not estabilished. THE AIM: Analysis of 10 cases with PTP diagnosed in Poland during last 25 years. MATERIAL AND METHODS: 9 women and 1 man with normal platelet count who developed thrombocytopenia with diathesis haemorrhagica after transfusion of red cells or/and platelets. Platelet specific antibodies (anti-HPA) were examined by the platelet immunofluorescence test and by the monoclonal immobilization of platelet antibodies (MAIPA) assay; leucocyte antibodies by standard lymophocytotoxicity test (LCT). RESULTS: In all 10 patients the PTP was diagnosed because: 1) thrombocytopenia with diathesis haemorrhagia occured 3-10 days after the transfusion (in 5 cases blood was transfused during the operation), 2) in all the patients anti-HPA were detected (in 9- anti-HPA-1a, in 1 case anti-HPA-3a), 3) a primary HPA alloimmunization was very probable. A recovery of platelets count occured in 6 patients within 8-34 days after corticosteroids and/or IVIG, however, therapeutic effect of them was difficult to assess due to a great probability of spontaneous remission up to 1 month. Four patients died due to their basic disease although the impact of the PTP cannot be excluded. CONCLUSION: The diagnosis of PTP was possible because of the detection of anti-HPA antibodies in patients who developed thrombocytopoenia after blood transfusion.

Adult↗

PubMed1989

[The influence of dose of transfusion and component of blood on the incidence of post-transfusion hepatitis].

Two thousand five hundred ninety-six consecutive patients who received blood transfusion for the first time within one week and had no liver dysfunction before transfusion had been selected from 8637 patients who received blood transfusion at the hospital between 1982 and 1987. The influence of dose, components of transfused blood and sex, age of recipients on the incidence of post-transfusion hepatitis was investigated. The rate of development of hepatitis depended on the dose of transfusion, not on sex and age of recipients. The rate of development of hepatitis raised as number of transfused blood increased without limiting point to 100%. The carrier rate of healthy population of non-A, non-B hepatitis virus was estimated 1.39%. Stored blood, concentrated red blood cell and fresh blood are high risk components and fresh frozen plasma was low risk component.

Hepatitis↗

PubMed1996

[Rational transfusion therapy. A study of transfusion practice and possibilities of optimization in elective coronary bypass surgery].

The objective of the study was to evaluate the effect of intervention on physicians' transfusion behavior in elective coronary artery bypass grafting (CABG). We analyzed transfusion data on 176 patients who underwent primary elective CABG during two periods, either before (phase one, n = 102) or after (phase two, n = 74) intervention. The intervention was based on cooperation with the involved department of cardiac surgery, interviews of the surgeons and anaesthesiologists ordering blood, and concurrent audit of transfusion practice using a blood order form. The proportion af patients receiving allogenic transfusions decreased from 90% in phase one to 58% in phase two and the total use of blood components was reduced from an average of 6.3 units/patient to 2.7 units/patient, p < 0.01. Indications for transfusion documented in the medical record increased from 19% in phase one to 63% in phase two. It is concluded that intervention on physicians' transfusion behavior can improve the transfusion therapy in patients who undergo elective CABG.

Adult↗