Red blood cell transfusions—are we narrowing the evidence-practice gap? An observational study in 5 Israeli intensive care units

Purpose

The aim of the study was to document transfusion practices in a cross section of general intensive care units (ICUs) in Israel and to determine whether current guidelines are being applied.

Materials and Methods

This prospective study was performed in 5 general ICUs in Israel over a 3-month period. Red cell transfusion data collected on consecutive patients included the trigger, units transfused per transfusion event, and indications, categorized either to treat a specified condition for which transfusions may be beneficial (acute hemorrhage, acute myocardial ischemia, or severe sepsis) or to treat a low hemoglobin concentration.

Results

Of the 238 patients studied, 50% received at least one red blood cell transfusion. The main indication for transfusion (43.7%, or 162/368 U transfused) was to treat a low hemoglobin concentration, in the absence of one of the specified conditions. Total red cell use was 3.0 ± 2.9 U per admission, and patients received a mean of 1.2 ± 0.4 U per transfusion event. The transfusion trigger for the whole group was 7.9 ± 1.1 g/dL. This did not differ significantly between the indications apart from a significantly higher trigger for patients with acute myocardial ischemia (8.8 ± 0.9 g/dL). In addition, patients with a history of heart disease had a higher trigger irrespective of the primary indication for transfusion and received significantly more units per transfusion event. Patients receiving a transfusion had significantly longer ICU stay and hospital mortality.

Conclusions

Our study showed that evidence-practice gaps continue to exist, and it appears that physician behavior is mainly driven by the absolute level of hemoglobin. Educational interventions focused on these factors are required to limit the widespread and often unnecessary use of this scarce and potentially harmful resource.     

Integrated strategies for allogeneic blood saving in major elective surgery

Background

Large use of allogeneic red blood cell concentrates (RBCc), albeit necessary in major surgery, may influence patients’ outcome.

Design and methods

We introduced an integrated strategy including patients’ evaluation and supplementation associated with autologous blood collection and saving to support major elective surgery at our hospital since 2008. After 2 years of stabilization of this approach, we analyzed the results obtained in 2010 in terms of allogeneic blood usage and reduction of transfusion of stored RBCc.

Results

Analyzing 2010 results we found that usage of total autologous RBCc units was increased by 2.2 folds, of “not stored” autologous RBCc units by 2.4 folds and of allogeneic RBCc unit transfusion reduced by 65%. The significant reduction in the number of transfused allogeneic RBCc units associated with the use of “fresher” blood could prevent patients’ complications due to immunomodulation and biologic/metabolic disregulation.     

Microcirculation and red cell transfusion in patients with sepsis

Early identification of sepsis followed by diagnostic blood cultures and prompt administration of appropriate intravenous antibiotics covering all likely pathogen remains the corner stone in the initial management of sepsis. Source control, obtained by harvesting microbiological cultures and removal or drainage of the infected foci, is mandatory. However, optimization of hemodynamically unstable patients including volume support supplemented with vasopressor, inotropic and transfusion of red blood cells (RBCs) in case of persistent hypoperfusion have the potential to reduce morbidity and mortality. Given the imbalance between the ability of the cardiovascular system to deliver enough oxygen to meet the oxygen demand, transfusion of RBCs should theoretically provide the ideal solution to the challenge. However, both changes in the septic patients’ RBCs induced by endogenous factors as well as the storage lesion affecting transfused RBCs have negative effects on the microcirculation. RBC morphology, distribution of fatty acids on the membrane surface, RBC deformability needed for capillary circulation and the nitrogen oxide (NO) signaling systems are involved. Although these deteriorating effects develop during storage, transfusion of fresh RBCs has not proven to be beneficial, possibly due to limitations of the studies performed. Until better evidence exists, transfusion guidelines recommend a restrictive strategy of RBC transfusion i.e. transfuse when hemoglobin (Hb) <7 g/dL in septic patients.     

脑梗死患者RBC、MCV及血小板参数变化的临床意义

目的观察脑梗死患者RBC、MCV及血小板4项参数的变化。方法采用美国Coulter公司的MicroDiffⅡ型血细胞分析仪检测76例脑梗死患者RBC、MCV及血小板4项参数,并与40例健康成人所测结果进行比较。结果脑梗死组RBC、RDW与对照组相比无显著差异(P>0.05),MCV、MPV、PDW均明显高于健康对照组(P<0.01),PLT、PCT明显低于健康对照组(P<0.01)。结论动态观察RBC、MCV及血小板4项指标对脑梗死的治疗及预后判断有一定的临床意义。     

红细胞分布宽度在小细胞低色素性贫血中的意义

目的探讨红细胞分布宽度（RDW）-CV和RDWS-D之间结果的关系,以明确RDW-SD的临床应用价值。方法先依据美国临床实验室标准化协会（CLSI）C28-A2指南建立二者的参考区间,分析二者的人群分布曲线,然后对121份随机临床标本、109例地中海贫血标本和25例缺铁性贫血标本同时测定RDW-CV和RDWS-D,并根据参考区间对二者的升高、降低情况进行比较分析。结果RDW-CV在正常人群中接近正态分布,RDWS-D呈偏态分布。RDW-CV和RDW-SD之间的升高或降低并不一致,RDW-CV增高或正常的标本其RDWS-D均可出现增高、正常或降低,RDW-CV降低的标本其RDW-SD也可出现正常或降低,二者在随机患者中符合率为80.0%。缺铁性贫血患者的RDW-CV和RDW-SD平均值均比地中海贫血的高（P〈0.001）,但地中海贫血患者间2个参数的分布范围均比缺铁性贫血患者间的分布范围宽,并把缺铁性贫血的分布范围包含其中。地中海贫血和缺铁性贫血患者的RDW-CV结果大部分均升高,小部分在正常范围。地中海贫血的RDW-SD结果可升高、正常或降低,并以降低为主,和RDW-CV呈“倒挂”现象,而缺铁性贫血患者未见降低者。结论联合检测RDW-CV和RDW-SD能更全面地反映RBC的异质性,并对地中海贫血和缺铁性贫血的鉴别诊断有一定的作用。     

Transfusion support for patients with sickle cell disease

Red blood cell (RBC) transfusion is an essential treatment for many patients with sickle cell disease (SCD), whose RBCs express hemoglobin S (HbS), a mutated form of hemoglobin A (HbA). Transfusion goals include increasing blood oxygen carrying capacity and decreasing the relative amount of HbS to HbA to mitigate vaso-occlusion in small blood vessels. In situations where correction of severe anemia and reduction in HbS may be achieved without removal of RBCs, simple transfusion may be utilized. Partial manual RBC exchange, which removes blood containing HbS by phlebotomy and replaces with donor blood transfusion sequentially allows for larger changes in the ratio of HbS to HbA when compared to simple transfusion. Automated RBC exchange by apheresis is useful in situations where a rapid and drastic HbS reduction is indicated. Vascular access is an important consideration for transfusion. Although peripheral access may be sufficient, central venous catheters and implantable venous access devices may be necessary for adequate access over time. Blood bank considerations include adequate RBC antigen matching to mitigate the risk of RBC alloimmunization, of which patients with SCD are at risk of developing. Transfusion may be utilized in efforts to intervene in the evolution of potentially life-threatening complications of SCD such as acute stroke, severe acute anemia and acute chest syndrome. Transfusion is also useful in several non-acute settings, such as stroke prevention, pregnancy, pre-surgery, and transfusion support for curative therapies. Individualized treatment plans are an essential component of patient care. Continuous evaluation of clinical indications and evolution of guidelines will continue to optimize care for patients with SCD.     

红细胞分布宽度在小细胞低色素性贫血中的意义

目的探讨红细胞分布宽度(RDW)-CV和RDWS-D之间结果的关系,以明确RDW-SD的临床应用价值。方法先依据美国临床实验室标准化协会(CLSI)C28-A2指南建立二者的参考区间,分析二者的人群分布曲线,然后对121份随机临床标本、109例地中海贫血标本和25例缺铁性贫血标本同时测定RDW-CV和RDWS-D,并根据参考区间对二者的升高、降低情况进行比较分析。结果RDW-CV在正常人群中接近正态分布,RDWS-D呈偏态分布。RDW-CV和RDW-SD之间的升高或降低并不一致,RDW-CV增高或正常的标本其RDWS-D均可出现增高、正常或降低,RDW-CV降低的标本其RDW-SD也可出现正常或降低,二者在随机患者中符合率为80.0%。缺铁性贫血患者的RDW-CV和RDW-SD平均值均比地中海贫血的高(P<0.001),但地中海贫血患者间2个参数的分布范围均比缺铁性贫血患者间的分布范围宽,并把缺铁性贫血的分布范围包含其中。地中海贫血和缺铁性贫血患者的RDW-CV结果大部分均升高,小部分在正常范围。地中海贫血的RDW-SD结果可升高、正常或降低,并以降低为主,和RDW-CV呈倒挂现象,而缺铁性贫血患者未见降低者...     

Red blood cell distribution width is associated with mortality in elderly patients with sepsis

Introduction

RDW is a prognostic biomarker and associated with mortality in cardiovascular disease, stroke and metabolic syndrome. For elderly patients, malnutrition and multiple comorbidities exist, which could affect the discrimination ability of RDW in sepsis. The main purpose of our study was to evaluate the prognostic value of RDW in sepsis among elderly patients.

The erythrocyte alloimmunisation in patients with sickle cell anaemia: a systematic review

Transfusion therapy is a common practice in the treatment of anaemia and can cause erythrocyte alloimmunisation. To systematise data related to erythrocyte alloimmunisation in patients with sickle cell disease (SCD), a bibliographic search was carried out in September 2017 to search for studies in four electronic databases. (i) Referring to the original work, (ii) being cohort or case–control, (iii) having been developed with individuals with SCD and (iv) having evaluated the erythrocyte alloimmunisation. Two reviewers identified the articles for inclusion in the study, extracted the predetermined data and carried out the evaluation of the methodological quality of the work. 21 studies were selected; the studies included data on 20 636 individuals (children and adults), were mostly published in the last 10 years, were developed in the United States and had high methodological quality. The occurrence of erythrocyte alloimmunisation ranged from 4·4 to 76%, and there was a higher rate of alloimmunisation against antigens of the Rh system. The risk factors for alloimmunisation were age; gender (female); red blood cell (RBC) units received; presence of ≥1 autoantibodies, TNF‐α, interleukin (IL1B), human leukocyte antigens (HLA)‐DRB1 gene polymorphisms; first blood transfusion (BT) after 5 years of age, transfusion episodic, multiple or during inflammatory events, acute chest syndrome (ACS) and vase‐occlusive crisis (VOC); increased percentage of CD41 T memory cells; and positive direct antiglobulin test. Transfusion policies should be developed to protect the patient and his or her health based on the main factors associated with its incidence.     

利司培酮对精神障碍患者血象和生化指标的影响——附25例报告

目的：了解利司培酮对精神障碍患者的血象和生化指标的影响。方法：２５例未经治疗的精神障碍患者,在用利司培酮治疗前和四周治疗后均进行血象以及肝功能、心肌酶、血脂、电解质、血糖和肾功能等生化指标的测定。结果：治疗后红细胞计数、血红蛋白和红细胞压积下降;血小板计数和血小板平均体积下降,血小板的减少与剂量有关;血尿酸增高也与剂量有关;白细胞和肝功能、心肌酶、血脂、电解质、血糖等的生化指标变化不明显。结论：利司培酮对患者的红细胞、血小板和肾功能有明显的影响;但对白细胞、肝脏、心脏、电解质和血脂的影响不大,体重增加与血脂的变化无关。     

Frequency and specificity of Red blood cell alloantibodies in multitransfused Egyptian patients with hematological and nonhematological malignancies

BackgroundRepeated blood transfusions can result in the production of alloantibodies against one or more red blood cell (RBC) antigens, which can complicate future transfusions.AimThis study aims to determine the frequency and specificities of RBC alloantibodies in multitransfused adult cancer patients admitted at the National Cancer Institute, Cairo University.MethodsThis cohort study enrolled 2000 multitransfused cancer patients diagnosed with different types of malignancies; they were screened for RBC alloantibodies using Serascan Diana 3 and Identisera Diana 11-cell identification panels (Diagnostic Grifols, Spain).ResultsOf the 2000 patients tested, 25 had autoantibodies and were excluded from the study. Of the remaining 1975 patients, 181 patients had a total of 267 different alloantibodies (9.16%), with some having more than 1 antibody detected. Our study showed that more female patients (63%) than male patients (37%) had acquired RBC alloantibodies, and a higher prevalence of alloantibodies in patients with nonhematological malignancies (14%) compared with those with hematological malignancies (6.5%). The highest percentage of alloantibodies belongs to the Rh blood group system, followed by the Kell system, then Duffy, MNS, Kidd, and Lewis. Patients who received combined chemotherapy and immunotherapy exhibited a lesser antibody response compared to other patients.ConclusionThe prevalence of alloimmunization in our study is comparable to previous reports on oncology patients. Repeated blood transfusions, which can lead to alloimmunization, often complicate future transfusions. Therefore, we recommend extending phenotype matching for patients who are presumed to depend on blood transfusions in the long term.     

Darbepoetin alfa in lung cancer patients on chemotherapy: a retrospective comparison of outcomes in patients with mild versus moderate-to-severe anaemia at baseline

Goals Currently, there is some debate concerning the haemoglobin level at which treatment of anaemia with erythropoiesis-stimulating agents should be initiated in cancer patients on chemotherapy. We report several analyses of data from a phase III trial of darbepoetin alfa versus placebo, comparing outcomes for patients with mild and moderate-to-severe anaemia.Patients and methods Data were obtained from a phase III trial of darbepoetin alfa versus placebo in anaemic patients with lung cancer receiving chemotherapy (n=314). Outcomes were compared for patients with baseline haemoglobin 10–11 g/dl and <10 g/dl.Results Darbepoetin alfa significantly reduced transfusions compared with placebo, irrespective of haemoglobin level at treatment initiation. For patients with baseline haemoglobin <10 g/dl, 31% and 59% of those receiving darbepoetin alfa and placebo, respectively, required a transfusion from week 5 to the end of the treatment phase (P<0.038). For patients with baseline haemoglobin 10 g/dl, the proportions were 15% and 41%, respectively (P<0.001). Darbepoetin alfa also improved fatigue compared with placebo in both haemoglobin categories.Conclusions These findings show that initiating treatment at haemoglobin levels both <10 g/dl and 10–11 g/dl results in substantial clinical benefits, supporting the use of erythropoietic therapy also in patients with mild anaemia.J. Vansteenkiste is the beneficiary of the Amgen Fund in Supportive Cancer Care at the Catholic University, Leuven, Belgium.This work was supported by Amgen Inc., Thousand Oaks, California, USA     

1601例外科输血患者红细胞输注量与死亡率相关性分析

目的联合国内20家大型综合医院多中心回顾性调研外科住院患者大量输血病历1601例,分析探讨红细胞输注量与患者死亡率的关联性。方法联合全国20家三级综合医院进行多中心回顾性分析大量输血病例资料,根据24h内或72h内红细胞输注量分为:0~4U、5~9U、10~14U、15~19U、20~24U、25~29U、30~39U、40~U,8个组段,对红细胞输注不同量患者死亡情况进行分析,研究红细胞输注量与患者死亡率的关系。结果 24h或72h内,红细胞输注总量≥10U后,患者死亡率随红细胞用量而增加,24h内红细胞应用10U~40U,死亡率为6.0%~38.9%;72h内红细胞应用10U~40U,死亡率为5.2%~28.0%;24h和72h红细胞在应用5U~9U组段者死亡率最低,分别是3.7%和2.3%;在0~4U组段,死亡率分别为7.3%和9.7%。结论外科住院患者大量输血时,24h或72h内红细胞输注量与死亡率有一定的关联性,患者死亡率随红细胞输注量增多而升高。     

新风胶囊治疗类风湿性关节炎贫血的临床观察

目的观察新风胶囊治疗类风湿性关节炎(RA)贫血的临床疗效。方法采用随机、对照的方法,将60例类风湿性关节炎伴有不同程度的贫血患者分为对照组(30例,口服非甾类抗炎药美洛昔康或双氯芬酸、甲氨蝶呤及叶酸片)、新风胶囊治疗组(30例,基础方案加服中药复方新风胶囊),观察两组患者一般症状的改善情况、关节疼痛、关节肿胀数、晨僵时间、双手握力、白细胞计数(WBC)、红细胞(RBC)计数、血红蛋白(Hb)、血小板(BPC)、网织红细胞、血沉(ESR)、类风湿因子(RF)、血清免疫球蛋白(IgG)、α1-酸性糖蛋白(α1-AGP)、C反应蛋白(CRP)等实验室指标变化情况。结果新风胶囊治疗组在总体疗效、关节肿胀数、晨僵时间以及对RBC、Hb贫血指标与RA活动期RF、IgG、CRP、ESR等指标改善情况优于基础方案对照组(P<0.05);基础方案对照组在取得总体疗效、改善症状及RA活动期实验室指标的同时对血WBC、RBC、Hb、PLT、网织红细胞有影响(P<0.05)。结论新风胶囊配合非甾体类抗炎药治疗类风湿性关节炎贫血疗效明显,好于单用非甾体类抗类药。     

Substitutes and alternatives to platelet transfusions in thrombocytopenic patients

Summary.  Over the past decade, there have been many improvements in both the safety profile and quality of liquid-stored allogeneic platelet concentrates. However, significant problems with the clinical use of such products remain. Efforts to overcome some of these have resulted in the development of an array of novel therapeutic strategies for the manufacture of platelet products and platelet substitutes, as well as other approaches using alternatives to platelet concentrates. These various products or procedures are at various stages of clinical development. This review summarizes some recent advancements in the preparation of liquid and frozen stored platelets, as well as approaches used for the pathogen inactivation of platelets. Thus, the status of lyophilized platelets, infusible platelet membranes, red blood cells (RBCs) bearing RGD ligands, fibrinogen-coated albumin microcapsules, and liposome-based agents are discussed. Pre-clinical studies and phase 1–3 clinical trials have been encouraging for several of these; however, to date, very few have been licensed for clinical use. Potential alternatives to allogeneic platelet transfusions including correction of anemia by RBC transfusions, recombinant activated factor VII and HLA-reduced platelets are also reviewed. With the ongoing technical and scientific development of such diverse products, those properties that may be necessary for such agents to have hemostatic efficacy will become apparent. However, safety and efficacy must be demonstrable in preclinical studies and clinical trials, before novel platelet concentrates, platelet substitutes and alternatives to platelets can be used in patients with thrombocytopenia.