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Blood Transfusions & Infection Risk

Blood Transfusions & Infection Risk

Studies have shown that red blood cell (RBC) transfusions are commonly performed, with approximately 14 million units transfused in 2011 in the United States. RBC transfusions can modulate the immune system, which in turn may impact infection risk. One approach in blood management is to use a restrictive threshold transfusion strategy in which the hemoglobin thresholds at which RBC transfusions are indicated are lowered. “The restrictive strategy is recommended by guidelines, but only about 27% of hospitals report using them after surgery,” says Jeffrey M. Rohde, MD. In addition, only 31% of hospitals report having a blood management program in place to optimize the care of patients who might need a transfusion. A Systematic Review & Meta-Analysis Dr. Rohde and colleagues conducted a systematic review and meta-analysis of 21 randomized trials that compared restrictive and liberal RBC transfusion strategies. Published in JAMA, the article evaluated whether RBC transfusion thresholds were associated with risk of infection and whether these risks were independent of leukocyte reduction. The study included more than 8,700 patients who met eligibility criteria. All healthcare-associated infections reported after receiving donor blood in randomized trials were evaluated, including serious infections like pneumonia and bloodstream and wound infections. According to the results, a restrictive RBC transfusion strategy reduced the risk of healthcare-associated infections when compared with a liberal transfusion strategy. “The more RBCs that patients received, the greater their risk was for infection,” says Dr. Rohde. “The fewer the RBC transfusions, the less likely hospitalized patients were to develop infections.” He adds that these findings were most likely due to transfusion-associated immunomodulation. Overall, for every 38 hospitalized patients considered...
Examining a Protocol for Transfusing Plasma to Severely Injured Patients

Examining a Protocol for Transfusing Plasma to Severely Injured Patients

Patients with a trauma-induced coagulopathy account for more than half of hemorrhagic deaths in the United States. About 25% of severely injured patients are already coagulopathic and thrombocytopenic upon arrival to trauma centers. Mortality rates have been shown to decrease in these patients when they receive higher ratios of plasma and platelets. “Early transfusion of red blood cells (RBCs) has been established as a core element of trauma resuscitation,” says Bryan A. Cotton, MD, MPH. “Most trauma centers store RBCs in their EDs, but few store plasma in their EDs. This makes it challenging to achieve high plasma-RBC ratios early during care, which in turn can worsen coagulopathy and increase patient mortality.” Expediting Plasma Delivery Over the past several years, more and more trauma centers have implemented massive transfusion (MT) protocols to ensure that severely injured patients receive higher plasma-RBC ratios early. “This was shown to markedly reduce the time to release of plasma, but the time to transfusion was still excessively long,” Dr. Cotton says. In an effort to expedite the delivery of plasma for patients requiring MT, some medical centers began keeping thawed plasma (TP) in their blood banks (BBs).   MT protocols vary throughout trauma centers in the U.S., but those reporting the most marked changes in survival are the ones that have implemented concurrent TP programs. Furthermore, trauma centers that develop TP programs concurrent with MT protocols have shown that they can reduce the time to first plasma transfusion and the overall number of blood components transfused. Testing a New Thawed Plasma Protocol In 2006, Dr. Cotton and colleagues began a TP program in their...

Blood Conservation in Surgery

Surgical procedures account for the transfusion of almost 15 million units of packed red blood cells (RBCs) every year in the United States. “There has been intense interest in blood conservation and minimizing blood transfusion over the past several years, but the number of annual transfusions is increasing,” says Victor A. Ferraris, MD, PhD. “At the same time, the blood donor pool has stabilized or slightly decreased.” Perioperative bleeding that requires RBC transfusion is especially common during cardiac operations, which consume as much as 10% to 15% of the nation’s blood supply. Evidence suggests that this figure is rising, largely because of the increasing complexity of cardiac surgical procedures. “An important part of blood resource management is recognizing patients’ risk of bleeding and subsequent blood transfusion.” In the March 2011 Annals of Thoracic Surgery, the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists published an update to their 2007 blood conservation clinical practice guidelines. Certain features of blood conservation and management of blood resources have been updated or added. The guidelines provide updates in the preoperative management of dual antiplatelet treatment, pharmacotherapy to increase RBC volume or to reduce blood loss, and the use of blood derivatives. They also provide updated strategies to manage blood salvage, information on the use of minimally invasive procedures to reduce perioperative bleeding and need for blood transfusion, and strategies for blood conservation associated with extracorporeal membrane oxygenation and cardiopulmonary perfusion. The use of topical agents for hemostasis and the optimal usefulness of team interventions in blood management are also discussed in the guideline update. Emphasizing Preoperative Risk Assessments The Society of Thoracic...
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