Cases of warm autoimmune hemolytic anemia (wAIHA) often present with life-threatening levels of hemoglobin requiring red blood cell (RBC) transfusion support.

This literature review assessed the occurrence, safety, effectiveness, and hospitalization burden of RBC transfusions in the management of patients with wAIHA.

Electronic databases (Embase, MEDLINE) were searched from inception to December 2021 along with additional searches conducted up to March 2024.

Of the 1478 articles screened, 17 observational studies and reviews were included. These studies demonstrated the use of 1-50 red blood cell transfusions to reach clinically acceptable hemoglobin levels in patients with wAIHA. In general, pre-transfusion hemoglobin levels were 6 g/dL and increased by an average 1.2 g/dL following a transfusion. Approximately 50% of patients with primary or secondary wAIHA suffered relapses. No data was available to distinguish between RBC transfusions used at initial presentation versus during relapse. Five studies found no increase in hemolysis or serious adverse reactions following transfusions and two studies reported mild transfusion-related adverse effects. Limited data was available regarding the hospitalization burden of RBC transfusion. Patients with wAIHA requiring transfusions had a median hospital stay from 15 to 17 days, which is considerably higher than all causes hospitalization of 4.5 days for 2023 U.S.

In patients with wAIHA, data supports wide variability in occurrence, but relative safety and effectiveness of RBC transfusions as supportive therapy. Additional studies are needed to assess the occurrence, safety, and hospitalization burden of RBC transfusions relative to other therapies in chronic relapsing wAIHA.

Red blood cell transfusion is frequently prescribed in the emergency department for patients with gastrointestinal bleeding (GIB), but the association of time to transfusion with patient outcome has not been thoroughly evaluated.

A retrospective cohort study analyzed adult patient data with GIB who visited the emergency department of single university-affiliated hospital between January 2016 and April 2022. The associations of time to transfusion and patient outcomes, 30-day and in-hospital mortality, were assessed.

Among a total of 2,284 patients, 1,395 (61.1%) received red blood cell transfusion within 4 h of emergency department admission. Analysis of the time to transfusion showed the association between late transfusion (transfusion after 4 h) and the risk of 30-day mortality (adjusted hazard ratio, 1.65, 95% CI 1.17-2.32, p = .004) and in-hospital mortality (adjusted odds ratio 1.71, 95% CI 1.24-2.35, p < .001). Subgroup analysis revealed that the association between time to transfusion and 30-day mortality was found only in those with upper GIB, nonvariceal bleeding and a low haemoglobin level (<7.5 g/dL). Early transfusion was associated with higher 30-day transfusion demand, while no associations with length of stay and adverse transfusion reaction were noted.

In this study, a longer time to red blood cell transfusion was associated with an increased risk of 30-day and in-hospital mortality of patients with GIB, especially in those with upper GIB, nonvariceal bleeding and a low haemoglobin level. In the emergency department, prompt red blood cell transfusion decisions for patients with GIB may improve patient outcomes.

Liver transplantation has traditionally been performed through a large, bilateral subcostal incision. Recently, liver transplant programs across the world, including our own, have reported successful liver transplants via total robotic approaches on recipients with low Model for End-stage Liver Disease scores and preexisting abdominal wall laxity. This review discusses the unique anesthetic considerations of robotic liver transplantation based on our group's initial experience with this novel surgical approach. Robotic liver transplantation presents a unique set of considerations and challenges for the anesthesiologist, and a thorough understanding of liver disease, liver transplant surgery, venovenous bypass, and the various implications of robotic surgery is essential to ensure optimal patient outcomes. Specific management topics discussed here include appropriate patient selection, preoperative assessment, and intraoperative management. We also discuss certain theoretical and actual challenges that our group has experienced.

Current guidelines differ in their recommendations regarding the use of physiologic transfusion triggers to guide transfusion practice. Data on the interaction between haemoglobin (Hb) and physiologic transfusion triggers, or their response to packed red blood cell (pRBC) transfusions are limited.

This study aimed to evaluate the interactions between Hb, mixed/central venous oxygen saturation (SvO 2 ) and lactate levels as well as their changes (ΔSvO 2 , Δlactate) in response to pRBC transfusion in cardiac surgery patients.

Retrospective exploratory data analysis.

A 22-bed intensive care unit (ICU) at a single tertiary academic centre and university hospital in Austria.

Adult (age ≥ 18 years) patients who underwent cardiac surgery.

Pearson correlation coefficients ( r ) and coefficients of determination ( r2 ) between Hb, mixed/central venous oxygen saturation (SvO 2 ), and lactate levels. Pearson correlation coefficients ( r ) and coefficients of determination ( r2 ) between ΔSvO 2 , Δlactate and pretransfusion Hb.

A total of 5025 cardiac surgery patients, in whom 20 542 blood gas analyses were performed, were included in the final analysis. Correlations between Hb levels and SvO 2 ( r2  = 0.026, P  < 0.001) and between Hb and lactate levels ( r2  = 0.001, P  < 0.001) were statistically significant but weak overall. No correlations were found between ΔSvO 2 ( r2  = 0.002, P  = 0.13) or Δlactate ( r2  = 0.003, P  = 0.087) and pretransfusion Hb levels.

Hb, SvO 2 and lactate levels were only weakly correlated with each other, and changes in SvO 2 and lactate levels in response to pRBC transfusion did not correlate with pretransfusion Hb. Our findings question the usefulness of SvO 2 and lactate levels as physiologic transfusion triggers to guide transfusion practice in cardiac surgery patients.

Johannes Kepler University Ethics Committee Study Reference Number 1063/2023.

PurposeThere is a lack of data regarding pediatric trauma patients with a cancer diagnosis. The purpose of our study is to analyze demographics, ED admissions, procedures, and characteristics pertaining to this population.MethodsThe NTDB database was queried from 2007 to 2022. This study collected 1,726,681 trauma admissions ≤18. Of these patients, 397 were identified with a cancer diagnosis and had received chemotherapy within 30 days of their trauma admission.ResultsThe median age of trauma patients with cancer was 9 years old vs 12 years old for non-cancer patients (P = 0.14), but cancer patients had a longer length of stay compared to patients without a cancer diagnosis (4.3 +/- 10 vs 3 +/- 5.7, P < 0.001).ConclusionWe conclude that pediatric trauma patients with a cancer diagnosis had a longer length of stay despite a similar injury severity score, were less likely to sustain spinal cord injuries, but more likely to receive transfusions when compared to non-cancer trauma patients. There is need for further research regarding traumatic injuries in this patient population.

This article provides an overview of knowledge gaps that need to be addressed in perioperative cardiac surgery, including concomitant surgical procedures, approaches to the conduct of cardiopulmonary bypass, precision medicine, and patient-important recovery outcomes. In addition, emerging approaches to research conduct are discussed, including the use of new analytical techniques involving artificial intelligence and platform trials.

Total hip arthroplasty (THA) has been applied as a successful treatment for repairing the impaired hip joints of patients with advanced inflammatory arthritis. Few studies compared the inpatient clinical characteristics of these patients receiving THA due to inflammatory arthritis. This study aims to compare the perioperative clinical outcome of patients receiving THA due to rheumatoid arthritis (RA) or ankylosing spondylitis (AS).

We retrospectively included 60 patients receiving THA due to RA or AS, and compared their inpatient clinical characteristics. The collected data comprised baseline data including gender, age, body mass index (BMI), blood pressure, Barthel index and clinical outcomes including operative time, perioperative blood loss, perioperative inflammatory indicators, length of hospitalization, inpatient medicine cost and perioperative complications.

AS patients showed increased operative blood loss and autologous transfusion rate than the RA patients. In addition, RA patients showed increased serum level of erythrocyte sedimentation rate (ESR) and interleukin-6 (IL-6), while no significant difference was found between the two groups in length of hospitalization, medicine cost and perioperative complications.

We suggested that more attention should be paid to the blood loss management of AS patients during perioperative stage, since AS patients were more susceptible to blood loss during THA with the potential reason to remove large amounts of osteophyte.

Transfusion-associated circulatory overload (TACO) is an adverse event that is the leading cause of transfusion-related death. It is underrecognized, and the aim of this study was to synthesize the available evidence from active surveillance studies to estimate its incidence.

This study is a systematic review and meta-analysis of publications reporting TACO incidence using active surveillance. A research librarian searched Medline and Embase, identifying publications between January 1991 and June 2024. Studies reporting TACO either by patient, blood component (red blood cells [RBCs], platelets, or plasma) or transfusion episode were identified, and all patient settings were eligible. A random effects model estimated TACO incidence, and potential sources of heterogeneity were evaluated using meta-regression.

Twenty-two studies met eligibility criteria and were included for analysis. The rate per patient was 22.2/1000 (95% CI: 16.2-29.2) based on 21 studies. The rate estimate of TACO among total blood components (RBCs, plasma, and platelets combined) reported in 10 studies was 2.2/1000 units transfused (95% CI: 1.2-3.5/1000). There was substantial between-study variation in rates and more recent studies tended to report higher rates. Although the platelet point estimate was higher than the point estimates for RBCs and plasma, the confidence intervals overlapped. Only two studies reported TACO rates per transfusion episode and the pooled estimate was 6.3/1000 (95% CI: 1-16.3/1000), about three times greater than the overall per unit estimate.

Clinicians should consider quantitative risks of important transfusion-related harms, such as TACO, when making the decision to transfuse.

This third article in a seven part series presents the Core GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to deciding whether to rate down certainty of evidence due to inconsistency—that is, unexplained variability in results across studies. For binary outcomes in which relative effects are consistent across baseline risks while absolute effects are not, Core Grade users assess consistency in relative effects. For continuous outcomes, they assess consistency in the absolute effects. When planning for the possibility of inconsistent results across studies, systematic review authors using Core GRADE construct a priori hypotheses regarding population or intervention characteristics that may explain inconsistency. They then judge the magnitude of inconsistency by considering the extent to which point estimates differ and the degree to which confidence intervals overlap. Before making a decision on rating down, Core GRADE users will evaluate where individual study estimates lie in relation to the threshold of the certainty rating (minimal important difference or the null). Finally, they will test their subgroup hypothesis and if an effect proves credible will provide separate evidence summaries and rate certainty of evidence separately for each subgroup. When they find no credible subgroup effect, they will provide a single evidence summary, rating down for inconsistency if necessary.

Reducing cell metabolism by lowering the storage temperature is an important method to improve the quality of stored RBCs and prolong the stored shelf life of RBCs. Traditional cryopreservation suffers from limitations such as tedious cytotoxic cryoprotectants (CPA) loading, unloading and ice-induced damage. Storage around 2-6 °C is an alternative method but only works for a short period due to significant storage lesions at this high storage temperature. We developed an improved supercooling preservation system for large-volume (100 ml) RBC suspensions in commercial polyvinylchloride (PVC) blood bags by minimizing favorable sites of ice nucleation and maintaining precise thermal control at -8 °C. This engineered protocol significantly reduces hemolysis, metabolic degradation, and oxidative stress while preserving RBC membrane integrity and functionality for up to 63 days. In vivo transfusion studies in New Zealand white rabbits demonstrate that supercooling-preserved RBCs achieve higher post-transfusion recovery rates, outperforming conventional storage methods. Our scalable and cost-effective supercooling system address critical needs for improving the quality of stored RBCs by achieving ice-free preservation, which representing a significant breakthrough in transfusion medicine.

Intravenous tranexamic acid (TXA) dosing regimens differ substantially across studies, varying from fixed doses (e.g., 1-2 g) to weight-based protocols (e.g., 10-20 mg/kg). This study aimed to compare postoperative blood loss, transfusion rates, in-hospital mortality, and complications between fixed-dose and weight-based TXA regimens in revision total knee arthroplasty (rTKA).

This retrospective comparative study included 298 patients who underwent rTKA between June 2004 and May 2024. Patients were divided into three groups: (1) the no TXA group; (2) the fixed-dose TXA group, in which patients received an intravenous infusion of 1 g TXA before skin incision and a topical application of 1 g; and (3) the weight-based TXA group, in which patients received a weight-adjusted dose of 20 mg/kg/h TXA intravenously and a topical application of 1 g. We analyzed the maximum decrease in hemoglobin (Hb) levels, postoperative transfusion rate, and the incidence of in-hospital mortality and complications.

The weight-based TXA group demonstrated a lower maximal decrease in Hb compared with both the no TXA (18.22 g/L versus 26.09 g/L, p < 0.001) and fixed-dose TXA (18.22 g/L versus 24.69 g/L, p < 0.001) groups. Both the fixed-dose TXA and weight-based TXA groups exhibited lower postoperative transfusion rates compared with the no TXA group (p < 0.001). The weight-based TXA group showed a lower postoperative transfusion rate compared with the fixed-dose TXA group (p = 0.022). Although the incidence of deep vein thrombosis (DVT) among the three groups was statistically significant (p = 0.038), pairwise comparisons between groups did not reveal statistically significant differences (all p > 0.05).

Weight-based dosage of TXA significantly reduced postoperative blood loss and transfusion requirements in rTKA compared with fixed-dose TXA regimen. A weight-based TXA regimen should be considered to effectively minimize postoperative blood loss and decrease transfusion requirements.

Level 3, non-randomized observational study.

ObjectiveTo evaluate the effects of comprehensive perioperative nursing interventions on postoperative recovery in cardiac surgery patients with frailty, with a focus on physical activity, nutritional status, and cognitive function.DesignA prospective, randomized, single-blind, parallel-group design with a 1:1 allocation ratio.SettingCardiac surgery department in a tertiary care hospital.ParticipantsThis study included 300 patients with frailty after cardiac surgery. Using a computer-generated random number table, patients were randomly assigned to the experimental group (150 patients) and the control group (150 patients). The intervention group received preoperative psychological counseling, targeted nutritional support, skincare, and continuous hemodynamic monitoring; the control group received routine care, including postoperative vital sign monitoring, basic nutritional support, wound care, and standard cardiovascular assessments (e.g., heart rate and blood pressure).Primary outcomesPostoperative recovery was assessed through improvements in physical activity (Barthel Index), nutritional status (Mini Nutritional Assessment), cognitive function (Mini-Mental State Examination), biostatistical data and cardiopulmonary function indicators.ResultsThe intervention group showed significant improvements: Barthel Index increased by 20 points (95% CI: 15-25, p < 0.01), Mini Nutritional Assessment scores by 3 points (95% CI: 1-5, p < 0.05), and Mini-Mental State Examination scores by 4 points (95% CI: 2-6, p < 0.05). Hospital stay was reduced by 5 days (95% CI: 3-7, p < 0.01), and the 6-month survival rate was 10% higher (95% CI: 5-15%, p < 0.05) compared to the control group.ConclusionsComprehensive perioperative nursing interventions significantly improve postoperative recovery, self-care ability, nutritional status, cognitive function, and short-term survival in cardiac surgery patients with frailty.

Developing and disseminating clinical practice guidelines is a common strategy used to inform practice and address evidence-to-practice gaps that are prominent in transfusion medicine. Despite a highly systematic method for synthesizing evidence into guideline recommendations, comparatively little attention is paid to the real-world implementation of the recommendations in routine practice. A more scientific approach drawing on learnings from the field of implementation science is therefore warranted.

In this article, we propose a methodological roadmap to embed implementation science principles, frameworks, and methods to facilitate the development and uptake of transfusion medicine guidelines. We draw upon research undertaken in partnership with the International Collaboration of Transfusion Medicine Guidelines (ICTMG) to illustrate the roadmap in action.

The methodological roadmap constitutes five steps which have been matched to existing processes for developing and implementing clinical practice guidelines: (1) environmental scan; (2) detailing who needs to do what differently, per guideline recommendation; (3) barriers and enablers assessment; (4) tailoring implementation strategies to identified barriers and enablers; and (5) implementation and evaluation of implementation strategies. For each step, we define the key concepts and methods involved, and share examples from work done with ICTMG to support transfusion medicine guideline implementation.

We intend this methodological roadmap for clinicians, researchers, and organizations involved in supporting clinical practice guideline use. Informed by principles, frameworks, and methods from implementation science, the roadmap can provide a more structured, transparent, and replicable approach to improve the implementation of guideline recommendations in transfusion medicine.

Neonates represent a distinct population within the context of transfusion medicine. Blood transfusions in neonates are vital interventions for multiple conditions, despite their inherent risks and potential complications. Differences in physiology and other transfusion risk factors unique to this group require careful adaptation of transfusion guidelines. This article seeks to offer a thorough overview of the current evidence-based practices for RBC administration in neonates. It covers the collection, processing and storage of RBCs and discusses the research underpinning the most recent transfusion guidelines. Furthermore, it emphasizes the challenges in establishing precise cut-off values for these conditions in both preterm and critically ill neonates and discusses indications for transfusion, thresholds, current guidelines, and potential complications. Finally, it highlights gaps in critical areas of transfusion related research and proposes future targets for research.

The clinical decision to transfuse is strongly influenced by laboratory results. Analysis of transfusion decision-making through pre-transfusion laboratory results (e.g. pre-transfusion hemoglobin) is a common yet misleading approach to studying transfusion practice.

We introduce "Transfusion Probability", an alternative method overcoming many limitations of pre-transfusion lab result analyses. Under this approach, we estimate the probability of transfusion after results at a specific value (e.g. hemoglobin 7.4 g/dL) or in a range of values (e.g. 7.0-7.9 g/dL) using the proportion of tests followed by transfusion. We provide a comprehensive methodology for causal inference on the effect of patient characteristics and other variables of interest.

Analyses using pre-transfusion and transfusion probability were compared through a retrospective cohort study of hospitalized patients (N = 525,032). We found red blood cell transfusion probabilities of 76.2% in the 6.0-6.9 g/dL, 18.9% in the 7.0-7.9 g/dL, and 4.5% in the 8.0-8.9 g/dL hemoglobin ranges. After confounder adjustment, gastrointestinal bleeding patients were more likely to be transfused, with risk differences ranging from 6.6% in the 8.0-8.9 g/dL range to 13.8% in the 6.0-6.9 g/dL range. Pre-transfusion hemoglobin results showed minimal differences between gastrointestinal bleeding patients and other patients in unadjusted (0.00 g/dL) and adjusted analyses (-0.03 g/dL).

In contrast to pre-transfusion result analysis, transfusion probability offers a nuanced account of transfusion practice and natural comparisons between patient groups. Wider use of our approach can provide actionable insights for clinical decision-making.

The balance between the risks and benefits of red blood cell (RBC) transfusions in critically ill patients is of ongoing debate. Clinical guidelines suggest a restrictive transfusion strategy with a transfusion hemoglobin trigger of 7 g/dL for most critically ill patients. However, recent literature shows many RBC transfusions are given with a prior hemoglobin above 7 g/dL. We aimed to evaluate adherence to our own transfusion protocol and changes in transfusion policy over time for the entire Intensive Care Unit (ICU) and in subgroups.

Retrospective observational cohort study of patients admitted between 2017 and 2024 to the ICU of Amsterdam UMC. Data was extracted from the electronic health record and the Dutch national quality registry (NICE). Subgroup analysis was done based on referring specialty.

In total 24 761 ICU stays were analyzed with 12 064 RBC transfusions in 3444 ICU stays. Median hemoglobin value before RBC transfusion decreased from 7.7 g/dL (1st-3rdquartile 7.1-8.4) in 2017 to 6.8 g/dL ((1st-3rdquartile 6.4-7.3) in 2024 (p < 0.001). This decrease was present in all subgroups. The percentage of RBC transfusions with a prior hemoglobin <7 g/dL increased from 18.8% to 64.8% (p < 0.001).

We report the long term successful implementation of a comprehensive restrictive RBC transfusion protocol in a tertiary care ICU, independent of the patient's referring specialty. A median hemoglobin level of 6.8 g/dL before RBC transfusion was reached in 2024.

(1) Background: Implantable port catheters are vital for cancer treatment, but complications such as infections and mechanical failures pose challenges. Lymphoma and leukemia patients' unique cellular abnormalities may influence these risks. This study aimed to determine whether the underlying disease or varying degrees of cytopenia increase the risk of unplanned early port removal. (2) Methods: We conducted a single institution retrospective study that included 368 patients with lymphoma or leukemia who received implantable venous access ports between January 2015 and December 2022. Propensity score matching was employed to compare patients with and without early removals. (3) Results: Univariate analysis revealed statistically significant differences between early and non-early port removal for cancer, hemoglobin, and PG-SGA scores. Cox proportional hazard analysis demonstrated that leukemia patients exhibited a 4.5 times higher risk for unplanned early catheter removal than lymphoma patients did (HR 4.589, 95% CI 1.377-15.299, p = 0.013), while patients with normal nutrition, based on the PS-SGA, demonstrated a 75% lower risk of unplanned early catheter removal than those with any degree of malnutrition did (HR 0.258, 95% CI 0.116-0575, p < 0.001). Unplanned early catheter removal negatively impacted patient survival. (4) Conclusions: The type of cancer, rather than individual cytopenias, is an independent factor influencing clinical outcomes in lymphoma and leukemia patients.

Efficient blood supply chain requires accurate demand estimates. Blood demand is created by clinicians making transfusion decisions based on patient status. To better understand the use of blood units, we tracked their use hourly and across a large hospital organization.

We analysed blood use in adult patients over 2021-2022 at HUS Helsinki University Hospital, serving a population of 1.7 million and consuming a third of blood units used in Finland. We utilized electronic health records (EHR) to map transfusions to patient demographics, diagnoses, medical specialties, treatment events, surgical procedures and laboratory values. Data were matched to transfusions of red blood cells, platelets and plasma using timestamps and treatment episodes.

In total, 107,331 units were transfused to 19,637 unique patients in 50,978 transfusion episodes. Most transfusions occurred in emergency settings, with 61.5% of use driven by emergency department admissions. The most common diagnoses were malignant neoplasms, anaemia and cardiovascular diseases. In total, 47.9% of transfusions were associated with a surgical procedure. Of these, 72.9% were for urgent surgery. Blood use peaked in the early evening and was lowest during morning office hours.

The study offers a comprehensive picture of blood use in one of the largest European hospital organizations. In addition to elective use, a significant portion of blood demand is driven by urgent and emergency needs, which introduce some uncertainty in predicting blood use. Future studies should aim to understand both elective and emergency blood use to help improve demand estimates.

Optimal red blood cell transfusion thresholds for children with bone marrow failure are uncertain; a previous study was stopped following concerns about veno-occlusive disease. The aims of this study in allogeneic haematopoietic stem cell transplant (HSCT) were to assess feasibility of recruitment and protocol adherence (primary outcomes) for different haemoglobin (Hb) transfusion thresholds, and to describe safety and present exploratory data on quality of life (QoL). Children aged ≥1 to <18 years were randomized to restrictive Hb transfusion thresholds of 65 g/L (restrictive) vs. 80 g/L (liberal) for HSCT days 0-100. Thirty-four patients were randomized at four UK HSCT centres, 17 in each arm. 48.6% (34/70) of eligible patients were recruited (target ≥50%), with high levels of protocol adherence: % (n/N) [95% CI] in the restrictive and liberal arms were 99.2 (961/969) [98.6, 99.7] and 97.2 (1131/1164) [96.2, 98.1] respectively (target ≥70% each arm). The mean pre-transfusion Hb was 16.3 g/L higher in the liberal than in the restrictive arm. Feasibility to measure QoL was demonstrated with no evidence of more fatigue in the restrictive arm. Although the study was not powered for clinical outcomes, the findings suggest that some populations may be able to safely tolerate anaemia levels below 70 g/L, the most common restrictive transfusion threshold.

Leukoreduction is performed to decrease the occurrence of adverse effects of transfusion, and can be performed by pre-storage (bench or in-line) or post-storage filtration (bedside) moment. The authors verified the effect of the leukoreduction filtration moment of Red Blood Cell (RBC) and Platelet Concentrate (PC) on the occurrence of Adverse Transfusion Reactions (ATRs), the presence of Healthcare-Associated Infections (HAIs), Length of Hospital Stay (LOS), and hospital death.

Retrospective cohort conducted at the Hospital das Clínicas of the Medicine Faculty of the University of São Paulo, and at the Fundação Pró-Sangue Hemocentro in São Paulo, Brazil. Adult patients, hospitalized for >24 hours, who received leukoreduced RBC and/or PC transfusion between 2017‒2020 were included. The generalized mixed effects model and the Wald test were applied in the analysis with a significance level of 5 %.

The authors evaluated 3668 patients who received 23,782 transfusions and we found no evidence of a leukoreduction filtration moment effect for ATR (p = 0.991) or HAI (p = 0.982), regardless of the transfused blood component. Meanwhile, the leukoreduction filtration moment had an effect (p < 0.001) on LOS, depending on the blood component transfused (p = 0.023), with pre-storage RBC filtration showing better performance, while in-line filtration stood out for PC. Both the leukoreduction filtration moment and the blood component (p = 0.041) influenced hospital death, with emphasis on the protective effect of bench RBC filtration and pre-storage PC filtration.

The leukoreduction filtration moment associated with the blood component had an effect on the LOS and hospital death of patients undergoing transfusion.

Reported blood transfusion rates in total hip arthroplasty (THA) range between 3 and 22%. Jehovah's Witnesses (JW) do not accept blood transfusions and make conscience decisions to accept blood derivatives. This study reports on strategies and outcomes for bloodless THA.

All JW patients undergoing primary THA at our institution between 2011 and 2022 were included in this study (94 of 110 THA). The indications for THA were osteoarthritis (92%), femoral neck fracture (6%), rheumatoid arthritis (1%), and failed open reduction and internal fixation (1%). Strategies used to optimize outcomes included erythropoietin, tranexamic acid, cell savers, intrailiac artery tourniquets, and minimizing phlebotomy.

The mean estimated blood loss was 201.2 ± 122.2 mL. Preoperative hemoglobin (Hgb) levels were 13.4 ± 1.4 g/dL, which decreased to 11.0 ± 1.3 g/dL on postoperative day 1 (POD1, P < 0.001), 10.3 ± 1.5 g/dL on POD2 (P = 0.001), and 9.8 ± 1.1 g/dL on POD3 (P = 0.171). The use of tranexamic acid significantly decreased Hgb drop on POD1 (P = 0.04). Subgroup analysis showed that preoperatively anemic patients (closed circuit, Hgb < 12 g/dL) had significantly less Hgb drop postoperatively (P = 0.003). No patients met the recommended transfusion threshold (Hgb < 7 g/dL). There were two 90-day readmissions due to falls. There was zero 90-day mortality.

A THA can be safely performed on JW patients. Preoperatively anemic patients had a decreased Hgb drop postoperatively. JW patients make a conscious decision to accept blood derivatives, which may be present in medications including erythropoietin. We recommend maintaining an Hgb above 11 g/dL prior to surgery, as a Hgb drop of 3.1 g/dL can be expected. These findings highlight the efficacy of a multimodal approach to optimizing bloodless primary THAs.

PuraStat (3-D Matrix, Tokyo, Japan) is an absorbent localized hemostatic agent that uses self-assembling peptide technology. In this multicenter pilot study, we evaluated the efficacy and safety of endoscopic hemostasis using PuraStat in patients with colonic diverticular bleeding (CDB).

This study involved patients who had CDB with stigmata of recent hemorrhage (SRH) and underwent endoscopic hemostasis with PuraStat monotherapy or combination therapy comprising PuraStat with endoscopic band ligation (EBL) or clipping (group A). Treatment outcomes and adverse events were assessed and compared with those of a previous cohort who underwent endoscopic hemostasis without PuraStat for CDB with SRH (group B). Factors associated with the reduction of recurrent bleeding were subsequently investigated.

PuraStat was used in 25 patients with CDB. The mean patient age was 70.8 years, 13 (52.0%) were men, and the most frequent bleeding sites were in the ascending colon (15 patients [60.0%]). The success rate of endoscopic hemostasis was 100% (25/25); 2 patients were treated with PuraStat monotherapy and 23 with combination therapy (EBL, 13 patients; clipping, 10 patients). The success rates were comparable between groups A and B (100% vs 96.4%, P = 1.000). The rate of recurrent bleeding within 30 days was significantly lower in group A than in group B (4.0% vs 20.9%, P = .047). Multivariate analyses revealed that the addition of PuraStat was associated with the reduced risk of recurrent bleeding (odds ratio, .11; 95% confidence interval, .01-.95; P = .045).

PuraStat can be easily added to conventional hemostatic methods for CDB, which could lower the risk of recurrent bleeding. (Clinical trial registration number: UMIN000053065.).

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Packed red blood cell (pRBC) transfusions in patients undergoing surgery for cancer are given to treat anemia or acute hemorrhage. Evidence indicates that pRBC transfusions are associated with poor perioperative and oncological outcomes. The ARCA-1 (Perioperative Care in the Cancer Patient-1) study was designed to test the association between perioperative pRBC transfusions and postoperative morbidity and mortality in patients undergoing cancer surgery. The primary hypothesis of our study was that perioperative pRBC transfusions have a negative impact on postoperative morbidity and 1-year mortality.

ARCA-1 was an international multicenter prospective observational cohort study. Participating centers enrolled a minimum of 30 consecutive adult patients with cancer who underwent surgery with curative intent. The primary end point was all-cause mortality 1 year after major cancer surgery. Secondary end points were rates of perioperative blood product use, 1-year cancer-specific mortality, overall survival, and 30-day morbidity and mortality. We performed a propensity score matching analysis to adjust for selection bias. A multivariable logistic regression model was fitted to estimate the effects of significant covariates on 1-year mortality, cancer-related mortality, and overall survival.

A total of 1079 patients were included in the study. The rate of perioperative pRBC transfusions was 21.1%. Preoperative comorbidities, including anemia, American Society of Anesthesiologists (ASA) score of III to IV, a history of coronavirus disease 2019 (COVID-19), myocardial infarction, stroke, need for dialysis, history of blood transfusions, and metastatic disease were statistically significantly more frequent in transfused patients compared to nontransfused patients. The 1-year mortality rate was higher in transfused patients before (19.7% vs 6.5%; P < .0001) and after (17.4% vs 13.2%; P = .29) propensity score matching. 1-year mortality was 1.97 times higher in transfused than in no-transfused patients (odd ratio [OR], 1.97; 95% confidence interval [CI], 1.13-3.41). The odds of 1-year cancer mortality for patients who had perioperative pRBCs was 1.82 times higher (OR, 1.82; 95% CI, 0.97-3.43) compared to those who did not receive perioperative pRBC transfusion. The effect of perioperative pRBC transfusion on overall survival was also significant (hazard ratio [HR], 1.85; 95% CI, 1.15-2.99). Transfused patients also had a higher rate of 30-day postoperative mortality before (3.5% vs 0.7%; P = .0009) and after propensity score matching (4.2% vs 1.8%; P = .34).

This international, multicenter observational study showed that perioperative pRBC transfusion was associated with an increased mortality risk.

Blood transfusion may precipitate adverse outcomes, including heart failure (HF), among patients with acute myocardial infarction (MI). This study characterizes the effects of a restrictive or liberal transfusion strategy on outcomes in patients with MI and anemia with and without baseline HF.

In the MINT trial (Myocardial Ischemia and Transfusion), 3504 patients with MI and anemia (hemoglobin <10 g/dL) were randomized to a restrictive (hemoglobin <8 g/dL) or liberal (hemoglobin <10 g/dL) transfusion strategy. We compared the effects of transfusion strategy on outcomes among patients with and without baseline HF. The primary outcome was death or HF at 30 days.

Compared with patients without baseline HF (n=1633), those with baseline HF (n=1871) had higher rates of death or HF (18.0% versus 10.0%) at 30 days. Restrictive transfusion resulted in numerically higher rates of death or HF (rate ratio, 1.20 [95% CI, 0.99-1.45] versus 0.94 [95% CI, 0.70-1.26]; Pinteraction=0.18) in patients with than in those without baseline HF. Among secondary outcomes, death or recurrent MI and death were more frequent among those with baseline HF. Restrictive transfusion resulted in numerically higher rates of death or MI and death in patients with than in those without baseline HF. Rates of HF were similar between restrictive and liberal transfusion in patients with baseline HF but lower with restrictive transfusion (rate ratio, 0.51 [95% CI, 0.29-0.92]; Pinteraction=0.02) in patients without baseline HF.

A liberal transfusion strategy is safe for patients with MI and anemia, including those with baseline HF. Restrictive transfusion tended to result in worse outcomes, particularly in patients with baseline HF.

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02981407.

Congenital heart disease is the most common neonatal congenital condition. Surgery is often necessary. Patients with congenital heart disease are potentially exposed to red cell transfusion preoperatively, intraoperatively and postoperatively when admitted for cardiac surgery. There are a number of risks associated with red cell transfusion that may increase morbidity and mortality.

To evaluate the association of red blood cell transfusion management with mortality and morbidity in people with congenital heart disease who are undergoing cardiac surgery.

We searched multiple bibliographic databases and trials registries, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Transfusion Evidence Library, ClinicalTrials.gov and the World Health Organization (WHO) ICTRP. The most recent search was on 2 January 2024, with no limitation by language of publication.

We included randomised controlled trials (RCTs) comparing red blood cell transfusion interventions in patients undergoing cardiac surgery for congenital heart disease. Participants of any age (neonates, paediatrics and adults) and with any type of congenital heart disease (cyanotic or acyanotic) were eligible for inclusion. No comorbidities were excluded.

Two of five (AA, CK, KW, SB, SF) review authors independently extracted data and assessed the risk of bias in the trials. We contacted study authors for additional information. Two review authors (CK, KW) used GRADE methodology to assess evidence certainty for critical outcomes and comparisons.

We identified 19 relevant trials. The trials had 1606 participants, all of whom were neonates or children. No trials were conducted in the preoperative period or with adults. The trials compared different types of red blood cell transfusions. No trial compared red blood cell transfusion versus no red blood cell transfusion. None of the trials was at low risk of bias overall. Eight trials had a high risk of bias in at least one domain, most commonly, blinding of participants and personnel. For our critical outcomes, we judged the certainty of the evidence based on GRADE criteria to be low or very low. Five trials (497 participants) compared a restrictive versus a liberal transfusion-trigger. It is very uncertain whether a restrictive transfusion-trigger has an effect on all-cause mortality in the short-term (0 to 30 days post-surgery) (risk ratio (RR) 1.12, 95% confidence interval (CI) 0.42 to 3.00; 3 RCTs, 347 participants; very low certainty evidence) or long term (31 days to two years post-surgery) (RR 0.33, 95% CI 0.01 to 7.87; 1 RCT, 60 participants; very low certainty evidence). The evidence is also very uncertain on the incidence of severe adverse cardiac events (RR 1.00, 95% CI 0.73 to 1.37; 2 RCTs, 232 participants) and infection (RR 0.81, 95% CI 0.47 to 1.39; 2 RCTs, 232 participants) (both very low certainty evidence). A restrictive transfusion-trigger may have little to no effect on the duration of mechanical ventilation (mean difference (MD) -1.65, 95% CI -3.51 to 0.2; 2 RCTs, 168 participants; low-certainty evidence) or of ICU stay (MD 0.15, 95% CI -0.72 to 1.01; 3 RCTs, 228 participants, low-certainty evidence). Five trials (231 participants) compared washed red blood cells in CPB prime versus unwashed red blood cells in CPB prime. Washing red blood cells in CPB prime may have little to no effect on all-cause mortality in the short term (0 to 30 days post-surgery) (RR 0.25, 95% CI 0.03 to 2.18; 2 RCTs, 144 participants) or long term (31 days to 2 years post-surgery) (RR 0.50, 95% CI 0.05 to 5.38; 1 RCT, 128 participants) (both low-certainty evidence). The evidence is very uncertain about the effect of washed CPB prime on severe cardiac adverse events (RR 0.88, 95% CI 0.47 to 1.64), infection (RR 1.00, 95% CI 0.50 to 1.99) and duration of ICU stay (MD -0.3, 95% CI -4.32 to 3.72) (1 RCT, 128 participants; very low certainty evidence). Two trials (76 participants) compared crystalloid (bloodless) CPB prime versus red-blood-cell-containing CPB prime. It is very uncertain whether bloodless prime has an effect on the duration of mechanical ventilation (median 8.0 hours, interquartile range (IQR) 6.8 to 9.0 hours versus median 7.0 hours, IQR 6.0 to 8.0 hours; 1 RCT, 40 participants) or duration of ICU stay (median 23.0 hours, IQR 21.8 to 41.5 hours versus median 23.5 hours, IQR 21.0 to 29.0 hours; 1 RCT, 40 participants) (both very low certainty evidence). Two trials (160 participants) compared ultrafiltration of CPB prime versus no ultrafiltration. It is very uncertain whether ultrafiltration of CPB prime has an effect on all-cause mortality in the short term (0 to 30 days post-surgery) (RR not estimable; 1 RCT, 50 participants; very low certainty evidence). Ultrafiltration may reduce the duration of mechanical ventilation (MD -16.00, 95% CI -25.00 to -7.00) and the duration of ICU stay (MD -0.6, 95% CI -0.84 to -0.36) (1 RCT, 50 participants; low-certainty evidence). One trial (59 participants) compared retrograde autologous CPB prime versus standard CPB prime. It is very uncertain whether retrograde autologous CPB prime has an effect on the duration of mechanical ventilation (MD 0.02, 95% CI -0.03 to 0.07) or duration of ICU stay (MD 0, 95% CI -0.01 to 0.01) (1 RCT, 59 participants; very low certainty evidence). One trial (178 participants) compared 'fresh' (not near expiry date) versus 'old' (near expiry date) red blood cell transfusion but did not report on our outcomes.

No randomised controlled trial compared red blood cell transfusion against no red blood cell transfusion in people with congential heart disease undergoing cardiac surgery. There are only small, heterogeneous trials in children that compare different forms of red blood cell transfusion, and there are no trials at all in adults. There is therefore insufficient evidence to accurately assess the association of red blood cell transfusion with the morbidity and mortality of patients with congenital heart disease undergoing cardiac surgery. It is possible that trial outcomes are affected by the presence or absence of cyanosis, so this should be considered in future trial design. Further adequately powered, high-quality trials in both children and adults are required.

A reliable, accessible, and high-quality blood supply is critical for the sustainment of any healthcare system. World events such as the COVID-19 pandemic have proven that maintaining the supply of blood presents a logistical challenge. The current blood supply is overseen by extensive donor programs around the world. In the United States, as in other countries, the need for blood has increased, with a decline in blood donations and increasing exclusions for blood donor qualification. While there is a need to improve blood donation participation, there is also need for new alternatives to traditional donation to ensure readiness to treat hemorrhagic shock common in the setting of trauma, as often occurs during a natural disaster or conflict. These operational medicine scenarios require significant blood availability which may tax the current blood supply chain. Aside from a walking blood bank (WBB) model for blood collection in suboptimal conditions, researchers have proposed alternatives for blood that include the manufacturing of blood from stem cell sources. Other alternatives include synthetic liquids that can carry oxygen such as Perfluoro-Chemicals (PFCs) and hemoglobin-based oxygen-carrying systems (HBCOs). Here, we review some of these alternatives to the traditional donor blood model. Researchers now have the technology that makes it feasible to develop blood alternatives that one day may supplement and help alleviate the limitations in blood supply.

The evolution of blood saving programs to Patient Blood Management (PBM) represents a broader and more comprehensive approach to optimize the use of the patient's own blood, thus improving clinical outcomes and minimizing the risks associated with allogeneic blood transfusion with a holistic view of socio-economic sustainability. Implementing the strategies of the three PBM pillars in any hospital center involves a transversal change throughout the organization in which it can be very useful to apply the strategy defined by Kotter at the business level for change management. The support of renowned institutions such as the World Health Organization and the European Commission demonstrates the importance and urgency of implementing PBM programs, setting guidelines at an international level and supporting the adoption of effective strategies in the management of blood transfusion at a national and institutional level. In Spain, we need to have health managers at both the Hospital Management level and the Regional Health Services and/or Ministry of Health that provide the necessary resources for its proper implementation in the health system from primary care to hospital care and also the resources for the timely evaluation of the results.

The Association for the Advancement of Blood and Biotherapies (AABB) conducted a global survey of patient blood management (PBM) practices. It determined changes in PBM practices since the last survey.

A working group of AABB's PBM Subsection and AABB staff designed the survey using the Qualtrics™ platform. The survey collected data from January 1, 2021, through December 31, 2021, and data analysis was conducted.

Responses were received from 274 facilities across five World Health Organization (WHO) regions, from which 205 (74.8%) were from North America (NA), and 25.2% (69/274) were from outside of NA or the rest of the world (RoW). Of all respondents, 46.0% (126/274) had a PBM program. NA at 50.2% (103/205) was significantly higher than RoW at 33.3% (23/69) (p = .0049). In NA AABB transfusion guidelines, 36.8% (179/486) were the most followed versus RoW, with the Ministry of Health at 23.2% (29/125). The hemoglobin transfusion threshold of ≤7.0 g/dL (inpatients and outpatients) and platelet transfusion threshold of 5000/μL -10,000/μL (prophylaxis for inpatients and outpatients) were most commonly followed. Areas of improvement since the last AABB 2013 survey included providing PBM training increased to 61.7% (103/167) from 36.5% (219/600) and evaluation of patients undergoing elective surgical procedures for factors predictive of anemia to 46.0% (125/272) from 28% (144/507).

While gains have been made in certain areas of PBM, there remains room for improvement, as more than half of respondents did not have a PBM program.

Anemia is frequent in palliative care, and transfusions are often used to correct it. Research indicates that transfusions are sometimes based solely on hemoglobin levels rather than patients' symptoms and administered in those with very short survival.

To survey the transfusion practice of Portuguese palliative teams.

This is a multicentric and retrospective study involving patients who received red blood cell transfusions in 2021, followed by palliative care teams.

Five palliative care teams participated and included 86 patients who underwent 122 transfusion episodes; 49 (57%) were male, and the median age was 76 years (43-100). The median hemoglobin level before transfusion was 7.4 g/dL (3.7-11.5). Symptomatic improvement was observed in 30 (25%) episodes; in 19 (16%), there was no improvement; and the outcome was not recorded in 73 (60%). Fatigue (38%) and low hemoglobin level (37%) were the most common reasons for transfusion. Decisions to transfuse, recorded primarily by one palliative care team, were often made by nonpalliative care doctors concurrently treating these patients, mostly in the emergency department. Those patients had more complications and significantly shorter survival compared with those whose transfusions were decided by palliative care physicians.

The decisions made by palliative care physicians regarding red blood cell transfusion deviated from the recommendations as seen in other similar studies.

Perioperative red blood cell (RBC) transfusion is a common intervention in patients undergoing surgery but there is marked variation in practice. Key performance indicators (KPIs) are central to identifying deviation from agreed standards and improving clinical outcomes. We aimed to identify KPIs which can potentially be measured from routinely collected electronic healthcare records.

We undertook a three-stage process. First, we completed a scoping review to identify potential KPIs from relevant literature and clinical guidelines. Next, we conducted a modified RAND consensus process with a multidisciplinary panel including medical professionals, patients and public involvement members. The consensus panel rated these KPIs according to importance and feasibility.

We identified 28 candidate KPIs covering the entire perioperative RBC transfusion process. The majority of the KPIs focused on improving patient care around the time of decision to transfuse RBCs and transfusion safety. Clinical outcome KPIs included hospital length of stay, hospital acquired infection, mortality, and hospital readmission at 30 and 90 days. Five candidate KPIs were judged as unimportant whilst there were concerns around the feasibility of measurement using routine data for 14 candidate KPIs. The panel identified nine potential KPIs for future testing.

Using a systematic, stepwise, transparent approach, we have identified a set of 28 KPIs for assessment, monitoring, and improvement of perioperative RBC transfusion. Future research is needed to further validate this set for external use and benchmarking between hospitals and departments.

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Pre-transplantation red blood cell transfusion (RBCT) is a well-recognized cause of allosensitization. However, the effects of RBCT after kidney transplantation remain controversial. This study evaluates the impacts of RBCT within the first 30 days post-transplantation (early RBCT) with regard to long-term patient and graft outcomes. We retrospectively analyzed 785 patients who underwent HLA- and ABO-compatible kidney transplantation between 2014 and 2020. Patients were categorized based on whether they received early RBCT. Overall, 18.9% of patients received early RBCT. On multivariable analysis, early RBCT was independently associated with increased risks of all-cause mortality (hazard ratio, 2.264; 95% CI 1.186-4.324; P = 0.013) and death-censored graft loss (hazard ratio, 1.995; 95% CI 1.045-3.810; P = 0.036). Cumulative incidence of antibody-mediated rejection was significantly higher in the early RBCT group (P = 0.024). In the sensitivity analysis, the early RBCT significantly increased the risk of patient mortality (P = 0.017), death-censored graft loss (P = 0.018) and antibody-mediated rejection (P = 0.05), regardless of the donor profile. Early post-transplantation RBCT was associated with increased risks of all-cause mortality, graft loss, and antibody-mediated rejection, highlighting the need for reconsideration of transfusion practices following kidney transplantation.

Anemia affects up to 25% of emergency department (ED) patients. Restrictive red blood cell (RBC) transfusion strategies are recommended for stable patients, but ED transfusion practices often remain liberal. Benefits of ED transfusion remains unclear.

To evaluate the impact of ED transfusion on death-adjusted in-hospital length of stay (LOS) in stable anemic patients requiring hospitalization.

This single-center retrospective propensity-matched study included patients ≥ 18 years admitted to the ED of Nîmes University Hospital in 2022 with hemoglobin levels between 70 and 90 g.L- 1. Patients with hemorrhagic shock or requiring emergent hemostatic procedures were excluded. Propensity score matching was conducted on variables including age, comorbidities, hemoglobin levels, and diastolic blood pressure. Primary outcome was adjusted in-hospital LOS. Secondary outcomes included ED LOS and RBC transfusion volumes.

Among 564 patients, 118 (21%) were propensity-matched: 59 (50%) ED-transfused, 59 (50%) non-ED-transfused. Adjusted in-hospital LOS 13 [8-32] for ED-transfused patients and 12 [6-24] days for non-ED-transfused patients (median difference = 0; 95%CI: -10-7; p = 0.52). Median difference in ED LOS was 7:13 (95%CI: 1:00-11:25; p < 0.001) between ED transfused and non-ED-transfused patients. Median difference in number of RBC transfused during in hospital stay was 2 (95%CI: 1-3); p < 0.01) between ED transfused and non-ED-transfused patients.

In stable anemic patients with 70 to 90 g.L- 1 hemoglobin level, ED transfusion did not reduce adjusted in-hospital LOS but prolonged ED LOS. Identifying patients who may safely defer transfusion could improve ED efficiency and safety.