Blood transfusions are a common and potentially lifesaving intervention in ICU patients but are associated with harm and often transfused inconsistently with guidelines. However, it is not well known how ICU transfusion practice has recently changed and if there is variation in transfusion practice.

To describe blood transfusion practices in ICU, the variation in practice across sites, and to compare transfusion practices against national guidelines and with prior published practice.

A prospective, multicenter, binational, observational study conducted in 40 Australian and New Zealand ICUs from October 2021 to July 2022. All adult (≥ 18 yr) ICU patients admitted over 1 week were included and followed until ICU discharge or 28 days.

Types of transfusion, thresholds and reasons for transfusions, the use of viscoelastic hemostatic assays (VHAs), variation in transfusion practice across sites, and changes in transfusion practice over time.

Of 927 patients, 217 (23.4%) received a blood transfusion during their ICU admission-192 (20.7%) received RBCs, 63 (6.8%) received platelets, 49 (5.3%) received fresh frozen plasma (FFP), and 29 (3.1%) received cryoprecipitate. Massive transfusion protocols were implemented nine times for six patients (0.7%). VHA were used in 25 of 268 (9.3%) non-RBC transfusions. Compared with national guidelines, 89.0% of RBC transfusions, 30.3% of platelet, 27.4% of FFP, and 20.0% of cryoprecipitate transfusions were consistent. Compared with ICU transfusion practices in 2008, after adjusting for confounding variables, ICU patients who received RBC and FFP were transfused more units each, and variation in total transfusions across sites increased for RBC, platelets, and FFP.

Blood transfusions are common in ICU, but the practice is heterogeneous and frequently inconsistent with national guidelines, and the number of units transfused per patient has increased. More evidence is required.

Background: Nitric Oxide (NO) is a naturally occurring modulator of inflammation found in the human body. Several studies in the pediatric cardiothoracic surgery literature have demonstrated some beneficial clinical effects when NO is added to the sweep gas of the cardiopulmonary bypass circuit.Purpose: Our primary aim was to determine the safety of incorporating nitric oxide into the oxygenator sweep gas of the extracorporeal membrane oxygenation (ECMO) circuit. Secondarily, we looked at important clinical outcomes, such as survival, blood product utilization, and common complications related to ECMO.Methods: We performed a single center, retrospective review of all patients at our institution who received ECMO between January 1, 2017 and March 31, 2023. We began additing NO to the ECMO sweep gas in 2019. Results: There were no instances of clinically significant methemoglobinemia with the addition of NO to the sweep gas (0% vs 0%, p = 1). The median daily methemoglobin level was higher in those who received NO via the sweep gas when compared to those who did not (1.6 vs 1.1, p = <0.001). Conclusions: The addition of NO to the sweep gas of the ECMO circuit is safe.

Acute lung injury is a devastating complication when occurring in immunocompromised patients. The incidence appears to be increasing as more patients survive for longer in this susceptible state. Being aware of potential causes of acute lung injury may lead to earlier recognition and diagnosis. Infection is a common cause of acute lung injury and needs to be considered in the diagnostic algorithm. Management involves use of supportive ventilatory strategies and potentially pharmacologic therapies.

Transfusions of red blood cells (RBCs) are crucial for improving tissue oxygenation in anemic patients with sepsis. Nevertheless, the debate continues over the ideal hemoglobin level for transfusions. This study aimed to assess the impact of different hemoglobin levels on the outcomes of patients with sepsis who received transfusions. This retrospective analysis included adult patients with sepsis treated in the general medical ward and intensive care unit at a University affiliate hospital. Patients needing RBC transfusions were included. The primary outcome was the 28-day mortality rate. From March 2018 to January 2022, 806 patients were studied. Of these, 480 (59.6%) were transfused at hemoglobin levels of 7-9 g/dL ("liberal group"), while 326 (40.4%) received RBC transfusions when their hemoglobin was < 7 g/dL ("restrictive group"). Mean hemoglobin levels at transfusion were 8.1 ± 0.8 g/dL and 6.3 ± 0.8 g/dL for each group, respectively(P < 0.001). On day 28, the liberal group had a mortality rate of 51.2% (246 patients), compared to 59.2% (193 patients) in the restrictive group (Odds ratio [OR] 0.88, 95% confidence interval [CI] 0.79-0.98, P = 0.031). Adjusted comparisons showed 46.8% mortality in the liberal group (141/301patients) versus 59.3% in the restrictive group (178/300patients) at 28 days (OR 0.78, 95% CI 0.66-0.92, P = 0.002). Multivariate analysis revealed transfusion at hemoglobin 7-9 g/dL as an independent variable linked to lower 28-day mortality (OR 0.70, 95% CI 0.49-0.99, P = 0.042). Other factors correlated with 28-day mortality were platelet counts ≤ 150 × 103/µL, albumin ≤ 2.5 g/dL, shock, mechanical ventilation, and renal replacement therapy. This retrospective study suggests that RBC transfusion at hemoglobin levels of 7-9 g/dL associates with lower 28-day mortality in sepsis patients compared to transfusion at hemoglobin levels below 7 g/dL.Clinical trial registrationThe study was registered with the Thai Clinical Trials Registry (identification number TCTR20231003003). ( https://www.thaiclinicaltrials.org/show/TCTR20231003003 ).

To highlight the risk factors contributing to blood transfusion among patients undergoing surgical intervention for Stage I Endometrial Cancer (EC).

Using the American College of Surgeons National Surgical Quality Improvement Program database, a nationally validated database dedicated to improving surgical care, females over the age of 18 who underwent surgery for EC stage I between the years 2016-2022 were queried. The cohort was then characterized based on those who received blood transfusion 72 h postoperatively.

27,183 patients with endometrial cancer who received surgical management were identified. 668 (2.5%) of those patients received blood transfusions. A multivariate logistic model found that a medical factor low preoperative Hct % (aOR 22.4, 95% CI[17.7, 28.3]; p < 0.001) and surgical factors such as 180 min or more of operative time (aOR 3.38, 95% CI[2.77, 4.14]; p < 0.001), larger uteri of 250-500 g (aOR 1.93, 95% CI[1.48, 2.49]; p < 0.001) and ≥ 500 g (aOR 2.35, 95% CI[1.77, 3.12]; p < 0.001), and abdominal approach compared to laparoscopic (aOR 6.36,95% CI[4.95, 8.18]; p < 0.001) were significantly associated with receiving blood transfusion.

Many significant risk factors were found to be associated with blood transfusions in patients with Stage I endometrial cancer. These findings allow surgeons to proactively prepare adequate measures for patients who may require blood transfusions when they undergo surgery for endometrial cancer.

The medical complexity of the geriatric patients has been steadily rising. Still, as outcomes of surgical procedures in the older adults are improving, centers are pushing boundaries. There is also a growing appreciation of the importance of perioperative fluid management on postoperative outcomes, especially in the older adults. Optimal fluid management in this cohort is challenging due to the combination of age-related physiological changes in organ function, increased comorbid burden, and larger fluid shifts during more complex surgical procedures. The current state-of-the-art approach to fluid management in the perioperative period is outlined.

Anemia is highly prevalent in patients with peripheral vascular disease and has been associated with postoperative cardiac events and mortality and adverse limb events after revascularization procedures. Allogenic blood transfusions have also been associated with adverse events including hospital-acquired infections, cardiac morbidity, and reduced survival. The aim of this study was to evaluate the impact of blood transfusion on major adverse cardiac events (MACE) and major adverse limb events (MALE) in patients undergoing infrainguinal lower extremity bypass (LEB) operations.

We performed a retrospective cohort analysis of patients undergoing infrainguinal LEB in the Society for Vascular Surgery Vascular Quality Initiative database between 2003 and 2020. Patients were first grouped by their preoperative hemoglobin (Hgb) number (severe anemia: Hgb 7-10 g/dL; moderate anemia: 10-12 g/dL; normal Hgb: >12 g/dL) and then stratified by their transfusion status (perioperative transfusion versus no perioperative transfusion). Primary end points were MACE, defined as myocardial infarction, new congestive heart failure, dysrhythmia, or stroke in the postoperative period, and MALE, defined as return to operating room for thrombosis, loss of primary patency on follow-up, and major ipsilateral amputation on follow-up. Secondary outcomes included wound complications, graft infections, 30-day mortality, and 1-year survival. Outcomes were compared between patients who received transfusions and those who did not at every anemic threshold. Multivariable logistic regression was performed to evaluate the impact of blood transfusion on primary outcomes.

A total of 55,884 patients were included for analysis, of which 16.3% had severe anemia, 25.9% had moderate anemia, and 57.8% had normal Hgb. Anemia severity was associated with increased rates of MACE (9.8% vs. 8.3% vs. 5.2%, P < 0.0001) and MALE (32.2% vs. 24.8% vs. 18.6%, P < 0.0001). On univariate analysis, transfusion was consistently associated with increased rates of MACE and MALE at every anemic threshold (P < 0.0001 for all). Transfusion was also associated with increased rates of 30-day mortality at all anemic thresholds (P < 0.0001 for all) and reduced 1-year survival at all anemic thresholds (log-rank P < 0.0001 for all). On multivariable analysis for MACE, an interaction factor was observed between preoperative Hgb and transfusion status (P < 0.0001). At every anemic threshold, transfusion was independently associated with MACE (severe: odds ratio [OR] 2.4 [95% confidence interval [CI]: 2.0-2.9]; moderate: OR 2.8 [95% CI: 2.5-3.2]; normal: OR 4.5 [95% CI: 4.0-5.0]). On multivariable analysis for MALE, an interaction factor was also observed between preoperative Hgb and transfusion status (P < 0.0001). At every anemic threshold, transfusion was independently associated with MALE (severe: OR 2.1 [95% CI: 1.9-2.3]; moderate: OR 1.8 [95% CI: 1.7-2.0]; normal: OR 2.6 [95% CI: 2.4-2.8]).

Perioperative blood transfusion in patients undergoing infrainguinal LEB is independently associated with MACE and MALE in all patients with preoperative Hgb >7 g/dL. Despite the morbidities associated with anemia, these findings highlight that transfusion may not be the optimal treatment modality, particularly in patients with higher preoperative Hgb. Future research is needed to define the transfusion threshold in this population.

Blood products frequently are administered to critically ill patients. Considering recent trials and practice variability, a comprehensive review of current evidence was deemed essential to offer pertinent guidance to critical care practitioners. This American College of Chest Physicians (CHEST) guidelines panel examined the literature on RBC transfusions among critically ill patients overall and specific subgroups, including patients with gastrointestinal bleeding, acute coronary syndrome (ACS), cardiac surgery, isolated troponin elevation, and septic shock, to provide evidence-based recommendations.

A panel of experts developed six Population, Intervention, Comparator, and Outcome questions addressing RBC transfusions in critically ill patients and performed a comprehensive evidence review. The panel applied the Grading of Recommendations, Assessment, Development, and Evaluations approach to assess the certainty of evidence and to formulate and grade recommendations. A modified Delphi technique was used to reach consensus on the recommendations.

The initial search identified a total of 3,082 studies, and after the initial screening, 38 articles were reviewed. Among them, 23 studies met inclusion criteria, comprising 22 randomized controlled trials and one cohort study. Based on the analysis of these studies, the panel formulated two strong and four conditional recommendations. The overall quality of evidence for recommendations ranged from very low to moderate.

In most critically ill patients, a restrictive strategy was preferable to a permissive approach because it does not increase the risk of death or complications, but does decrease RBC use significantly. Data from critically ill subpopulations also supported a restrictive approach, except in patients with ACS, for whom favoring a restrictive approach could increase adverse outcomes.

Patients undergoing long-term ventilation often show anemia. The aim of the study was to investigate the duration and success of weaning from mechanical ventilation in patients with RBC transfusion.

A retrospective analysis of patient data from a weaning unit was performed. Transfused and non-transfused patients were matched using a propensity score. Of the 249 patients in the database, 31 transfused and the same number of non-transfused cases with similar disease severity as measured by the Simplified Acute Physiology Score (SAPS) could be analyzed. Additional sensitivity analyses were performed.

In the group of transfused patients, the difference in weaning duration was longer than in non-transfused patients (1.35 days and 3.26 days, respectively). Weaning success also varied. The risk of weaning failure was twice as high in the group of transfused patients. The groups also differed in terms of mortality, 25.8% of the transfused patients died, while in the non-transfused patients the mortality rate was 6.5%. The risk of death was increased in patients who received RBC transfusion. The differences were not statistically significant.

A high proportion of patients with prolonged mechanical ventilation have anemia. RBC transfusion does not improve their prognosis. The need for transfusion is associated with higher mortality and longer duration of weaning in this population. The indication for RBC transfusion should therefore be restrictive.

The use of intravenous tranexamic acid (TXA), an antifibrinolytic agent, has been shown to effectively reduce total blood loss and transfusion rates in total knee arthroplasty (TKA). The aim of this paper is to evaluate the implementation lag and clinical uptake of the use of TXA for primary TKA after publication of two landmark studies. Additionally, it assessed the efficacy of TXA use in TKA in reducing post-operative blood transfusions and hospital length of stay (LOS).

A total of 763 patients aged over 18 years of age underwent primary TKA at a level 4 metropolitan hospital in Australia between January 2011 and December 2017. Primary outcome measure was use of TXA at operative induction. Secondary outcome measures were post-operative blood transfusion, haemoglobin levels and in-hospital length of stay.

The rate of TXA uptake was ≥ 50% by April-June 2013, 1.5 years following landmark paper publication. TXA use was ≥ 90% by April-June 2015, equating to 3.5 years after landmark publication. For each additional year since publication, the odds that TXA was used in a TKA surgery increased by 254.3%, 95% CI (confidence interval) [195.2%, 334.1%]. There was a negative association between TXA use and blood transfusion rate (p < 0.001), while controlling for other variables. TXA use reduced the odds of blood transfusions occurring by 73.5%, 95% CI [35.8% and 89.8%]. Analysis showed that reduced LOS was seen even after controlling for post-operative blood transfusion (p < 0.05).

The implementation lag from research to clinical practice, using ≥ 90% TXA use in TKA as a proxy, was 3.5 years. The use of TXA reduced LOS and blood transfusion rate in TKA patients.

Balancing oxygen requirements, neurologic outcomes, and systemic complications from transfusions in traumatic brain injury (TBI) patients is challenging. This review compares liberal and restrictive transfusion strategies in TBI patients.

Electronic databases were searched from inception to October 2024.

We included randomized controlled trials comparing liberal and restrictive transfusion strategies in TBI patients.

Data were extracted by two reviewers using predefined forms.

We included five studies with 1,533 patients: 769 (50.2%) in the liberal transfusion group and 764 (49.8%) in the restrictive group. There were no significant differences between groups favorable Glasgow Outcome Scale (risk ratio [RR], 1.16; 95% CI, 1.00-1.34), although a leave-one-out analysis demonstrated significance in this endpoint (RR, 1.24; 95% CI, 1.06-1.45). No significant difference was found regarding hospital mortality (RR, 0.98; 95% CI, 0.76-1.27), mortality at follow-up (RR, 1.03; 95% CI, 0.82-1.28), mortality in the ICU (RR, 1.00; 95% CI, 0.73-1.37), infection rates (RR, 1.08; 95% CI, 0.95-1.23), thromboembolic events (RR, 1.79; 95% CI, 0.74-4.31), hospital length of stay (LOS) (mean difference [MD], -1.45; 95% CI, -4.85 to 1.96), or ICU LOS (MD, -0.47; 95% CI, -3.84 to 2.91). The liberal transfusion strategy group had a significantly higher prevalence of acute respiratory distress syndrome (RR, 1.78; 95% CI, 1.06-2.98) and received more blood units per patient (MD, 2.62; 95% CI, 1.90-3.33).

Our findings suggest that a liberal transfusion strategy results in better neurologic outcomes than a restrictive approach. Future research should examine the complication profile and the effects of using a 9 g/dL threshold. We advocate for revising current guidelines to establish 9 g/dL as the standard threshold for transfusions in TBI patients.

Sepsis is a common condition associated with significant morbidity and mortality. Emergency physicians play a key role in the diagnosis and management of this condition.

This paper evaluates key evidence-based updates concerning the management of sepsis and septic shock for the emergency clinician.

Sepsis is a life-threatening syndrome, and rapid diagnosis and management are essential. Antimicrobials should be administered as soon as possible, as delays are associated with increased mortality. Resuscitation targets include mean arterial pressure ≥ 65 mmHg, mental status, capillary refill time, lactate, and urine output. Intravenous fluid resuscitation plays an integral role in those who are fluid responsive. Balanced crystalloids and normal saline are both reasonable options for resuscitation. Early vasopressors should be initiated in those who are not fluid-responsive. Norepinephrine is the recommended first-line vasopressor, and if hypotension persists, vasopressin should be considered, followed by epinephrine. Administration of vasopressors through a peripheral 20-gauge or larger intravenous line is safe and effective. Steroids such as hydrocortisone and fludrocortisone should be considered in those with refractory septic shock.

An understanding of the recent updates in the literature concerning sepsis and septic shock can assist emergency clinicians and improve the care of these patients.

Acute myocardial infarction (AMI) is a leading cause of death worldwide, and anemia in patients following AMI is quite common. Blood transfusions are one means of treating anemia, but once again, it is surrounded by debate over the best approach for transfusion: whether it is restrictive or liberal. This review assesses the efficacy and safety of a restrictive versus liberal blood transfusion strategy in AMI patients. Literature searches of the existing database were made with a view to retrieving RCTs, meta-analyses, systematic reviews, and clinical practice guidelines pertaining to both restrictive and liberal transfusion strategies for comparison of outcomes. Evidence suggests that this restrictive approach brings no patient harm, except perhaps in high-risk subgroups such as larger cardiovascular comorbidities. Key trials have shown that a restrictive strategy is at least as effective as a liberal strategy for most patients, including TRICC, TRACS, FOCUS, MINT, TITRe2, and REALITY Trials. Specifically, particular populations, especially those with pre-existing heart disease, may benefit from higher hemoglobin thresholds to prevent adverse outcomes. The best transfusion strategy should be tailored for each patient based on his/her personal factors, above all in cardiovascular health. A more restrictive transfusion strategy was effective and safe for the general population, but the subgroup of patients with very poor cardiovascular disease may require a more liberal approach. Further studies with better management guidelines are warranted to guide transfusion practices for optimal care in AMI patients.

» Anemia is a common comorbidity in orthopaedic trauma patients with important clinical consequences, significantly negatively affecting a patient's course following orthopaedic trauma.» Anemia remains relatively understudied in the orthopaedic trauma population with a large amount of current literature focused solely on geriatric hip fracture patients.» Greater investigation into alternatives to blood transfusions such as iron therapy or cell salvaging for treatment of anemia in the orthopaedic trauma population is needed.

Patient blood management (PBM) encompasses implementing multimodal evidence-based strategies to screen, diagnose, and properly treat anaemia and coagulopathies using goal-directed therapy while minimising bleeding. The aim of PBM is to improve clinical care and patient outcomes while managing patients with potential or ongoing critical anaemia, clinically significant bleeding, and coagulopathies. The focus of PBM is patient-centred rather than transfusion-centred. Multimodal PBM strategies are now recommended by international organisations, including the World Health Organization, as a new standard of care and a proven means to safely and effectively manage anaemia and blood loss while minimising unnecessary blood transfusion. Compared with adult PBM, paediatric PBM is currently not routinely accepted as a standard of care. This is partly because of the paucity of robust data on paediatric patient PBM. Managing paediatric bleeding and blood product transfusion presents unique challenges. Neonates, infants, children, and adolescents each have specific considerations based on age, weight, physiology, and pharmacology. This narrative review covers the latest updates for PBM in paediatric surgical populations including the benefits and principles of paediatric PBM, current expert consensus guidelines, and important universal multimodal therapeutic strategies emphasising clinical management of the anaemic, bleeding, or coagulopathic paediatric patient in the perioperative period. Practical paediatric rules for PBM in the perioperative period are highlighted, with review of specific PBM strategies including treatment of preoperative anaemia, restrictive transfusion thresholds, antifibrinolytic agents, cell salvage, standardised transfusion algorithms, and goal-directed therapy based on point-of-care and viscoelastic testing.

 Limb salvage following traumatic lower extremity (LE) injury often necessitates blood transfusion for adequate tissue perfusion. Appropriate transfusion decision-making via a risk-benefit analysis could maximize the opportunity for flap survival. This study aims to examine the impact of perioperative blood transfusion on postoperative complications in traumatic LE reconstruction.

 A retrospective review was conducted at a level 1 trauma center on patients who underwent LE reconstruction between January 2007 and October 2023. Patient demographics, comorbidities, perioperative blood transfusions, flap characteristics, and postoperative complications were recorded. Outcomes investigated included postoperative amputation rates, infection, partial flap necrosis, and flap loss. Univariate analysis and multivariable logistic regression were performed to examine the impact of patient factors on flap necrosis.

 In total, 234 flaps met inclusion criteria. Of these, 149 cases (63.7%) received no transfusion during their hospital stay (Tf - ) and 85 cases (36.3%) received at least one unit of packed red blood cells intraoperatively through 48 hours following flap placement (Tf + ). Overall flap survival rates were similar across both cohorts (Tf + : 92.9 vs. Tf - : 96.6%, p = 0.198). The Tf+ cohort had significantly higher rates of partial flap necrosis (12.9 vs. 2.0.%, p < 0.001), amputation (6.0 vs. 0.7%, p = 0.015), and postoperative hardware infection (10.6 vs. 2.7%, p = 0.011) relative to the Tf- cohort. Multivariable logistic regression demonstrated that transfusion status was independently associated with a 5.1 fold increased risk of flap necrosis (p = 0.033).

 Transfusions administered intraoperatively through the acute postoperative period were associated with a significantly increased likelihood of flap necrosis. Surgeons should consider a conservative transfusion protocol to optimize flap viability in patients with traumatic LE injuries.

Anemia is known to be prevalent in patients with diabetic foot ulcers, but such was not documented in those who required lower extremity amputations (LEAs). In this high-risk population, preoperative anemia could be an additional risk factor for postoperative morbidity and mortality. This study attempts to address the knowledge gap related to the preoperative hemoglobin (Hg) level and anemia prevalence in patients admitted for diabetic LEA.

Using a cross-sectional design, the primary outcomes were defined as the mean preoperative Hg level and anemia frequency. Mean differences and sex-based results were calculated and compared between three categories: major, midfoot, and forefoot amputation groups. Correlation between Hg level and serum creatinine was set as a secondary outcome.

A total of 141 patients comprising 192 amputation cases were included. The mean Hg value for the whole sample was 10.6 ± 1.8 g/dl. Only 18 patients (9.7%) had a normal Hg level and 174 (90.3%) were anemic: 90 cases (46.8%) with mild anemia, 76 (40.8%) with moderate anemia, and 8 cases (4.3%) with severe anemia. No significance was found between mean Hg values of the three groups or between sex groups. A significant negative correlation between the levels of serum creatinine and Hg was found (p = .037).

An overwhelming majority of patients admitted for diabetic LEA were anemic. Since anemia could impede limb perfusion and induce higher postoperative mortality rate, adjusting this confounder could be justified. Future research should aim to evaluate the impact of preoperative blood component transfusion on postoperative complications following diabetic LEA.

Cardiogenic shock (CS) in acute myocardial infarction (AMI) is a life-threatening syndrome characterized by systemic hypoperfusion that can quickly progress to multiorgan failure and death. Various devices and configurations of mechanical circulatory support (MCS) exist to support patients, each with unique pathophysiological characteristics. The Intra-aortic balloon pump can improve coronary perfusion, decrease afterload, and indirectly augment cardiac output. TandemHeart, a percutaneous ventricular assist device, can decrease left ventricular preload and directly augment cardiac output. Neither the intra-aortic balloon pump nor the percutaneous ventricular assist device has been shown to decrease mortality in the revascularization era. Venoarterial extracorporeal membrane oxygenation can offer complete cardiopulmonary support; however, it has not been shown to decrease mortality. Recent studies have indicated that microaxial flow pumps, such as Abiomed's Impella family of devices, can decrease mortality in the AMI-CS population. Managing AMI-CS requires careful clinical assessment, as no single MCS device is universally effective, and device-related complications are common. While venoarterial extracorporeal membrane oxygenation provides complete support, it has not demonstrated a mortality benefit in major trials and carries significant risks. In contrast, microaxial flow pumps have shown a mortality benefit but with higher complication rates. Ongoing research and advancements aim to refine MCS strategies, improve device safety, and enhance patient outcomes.

How to cite this article: Havaldar AA. Is Red Cell Distribution Width the Universal Biomarker of Disease Severity and Outcome? Indian J Crit Care Med 2024;28(12):1087-1088.

Extracorporeal life support (ECLS) has a long history in the management of the acute respiratory distress syndrome (ARDS). The objectives of this review are to summarize the rationale and evidence for ECLS in ARDS including its role in reducing ventilator-induced lung injury (VILI), suggest best practice management strategies during ECLS, and identify areas that require additional research to better inform patient care.

Transfusions are common, but their use is decreasing in some countries as a result of increased risk awareness and the implementation of patient blood management (PBM), an evidence-based approach to optimize patient outcomes. This study aimed to detail the implementation of PBM in a Brazilian state and its impact on transfusion rates and associated costs.

The PBM implementation involved several strategies: medical education, haematology consultation services, provision of intravenous iron and other medications, establishment of PBM and perioperative anaemia clinics, cell salvage and acute normovolaemic haemodilution, anaemia reference laboratories and rotational thromboelastometry. The program's implementation was assessed through quality indicators and cost analysis.

Since 2016, there have been reductions in transfusion rates, mainly in red blood cell (RBC) transfusion. Quality indicators showed an increase in single-RBC transfusions from 53% in December 2015 to 85.9% in June 2024 and a decrease in transfusions for patients with Hb ≥7 g/dL from 5.9% in March 2021 to 2.7% in May 2024. The PBM programme led to an estimated annual cost saving of R$2.63 million (US $487,000), if considered RBC direct costs, and from R$9.69 million to R$16.145 million (US $1.79-$2.99 million) in activity-based costs, considering only the reduction in RBC transfusions.

The PBM programme in Ceará successfully reduced transfusion rates and associated costs through a multidisciplinary approach, medical education and government support. This model demonstrates the potential for significant healthcare improvements and cost savings and can serve as a benchmark for other regions and countries, especially in low- and middle-income settings.

Blood transfusions are commonly administered to patients with acute brain injury. The optimal hemoglobin transfusion threshold is uncertain in this patient population.

To assess the impact on neurological outcome of 2 different hemoglobin thresholds to guide red blood cell transfusions in patients with acute brain injury.

Multicenter, phase 3, parallel-group, investigator-initiated, pragmatic, open-label randomized clinical trial conducted in 72 intensive care units across 22 countries. Eligible patients had traumatic brain injury, aneurysmal subarachnoid hemorrhage, or intracerebral hemorrhage; hemoglobin values below 9 g/dL within the first 10 days after injury; and an expected intensive care unit stay of at least 72 hours. Enrollment occurred between September 1, 2017, and December 31, 2022. The last day of follow-up was June 30, 2023.

Eight hundred fifty patients were randomly assigned to undergo a liberal (transfusion triggered by hemoglobin <9 g/dL; n = 408) or a restrictive (transfusion triggered by hemoglobin <7 g/dL; n = 442) transfusion strategy over a 28-day period.

The primary outcome was occurrence of an unfavorable neurological outcome, defined as a Glasgow Outcome Scale Extended score between 1 and 5, at 180 days following randomization. There were 14 prespecified serious adverse events, including occurrence of cerebral ischemia after randomization.

Among 820 patients who completed the trial (mean age, 51 years; 376 [45.9%] women), 806 had available data on the primary outcome, 393 in the liberal strategy group and 413 in the restrictive strategy group. The liberal strategy group received a median of 2 (IQR, 1-3) units of blood, and the restrictive strategy group received a median of 0 (IQR, 0-1) units of blood, with an absolute mean difference of 1.0 unit (95% CI, 0.87-1.12 units). At 180 days after randomization, 246 patients (62.6%) in the liberal strategy group had an unfavorable neurological outcome compared with 300 patients (72.6%) in the restrictive strategy group (absolute difference, -10.0% [95% CI, -16.5% to -3.6%]; adjusted relative risk, 0.86 [95% CI, 0.79-0.94]; P = .002). The effect of the transfusion thresholds on neurological outcome at 180 days was consistent across prespecified subgroups. In the liberal strategy group, 35 (8.8%) of 397 patients had at least 1 cerebral ischemic event compared with 57 (13.5%) of 423 in the restrictive strategy group (relative risk, 0.65 [95% CI, 0.44-0.97]).

Patients with acute brain injury and anemia randomized to a liberal transfusion strategy were less likely to have an unfavorable neurological outcome than those randomized to a restrictive strategy.

ClinicalTrials.gov Identifier: NCT02968654.

Atrial fibrillation (AF) emerges as a pivotal risk determinant for unfavorable outcomes in septic patients. Despite its recognized role, the enduring impact of AF on sepsis prognosis remains ambiguous. This investigation seeks to elucidate the connection between AF and both short and long-term outcomes in sepsis patients. Additionally, it aims to formulate a prognostic model for 1-year mortality utilizing pertinent clinical variables.

A retrospective analysis encompassed sepsis patients admitted to Beth Israel Deacon Medical Center's intensive care unit. The evaluation encompassed the prevalence of AF and its influence on hospitalization duration, stays in the Intensive Care Unit (ICU), and mortality rates at distinct intervals. Propensity score matching was implemented to mitigate confounding factors. Machine learning techniques, including the Least Absolute Selection and Shrinkage Operator (LASSO) regression and random forest, were deployed for model development.

AF exhibited a correlation with heightened mortality rates at 7 days, 28 days, and 1 year. The resultant predictive model demonstrated superior efficacy compared to prevailing clinical critical illness scores in forecasting mortality risk. Crucial predictors in the model included variables such as RDW, weight, age, BUN, lactate, temperature, MCHC, MBP, ALP, and hemoglobin.

AF emerges as a substantial peril for adverse outcomes in sepsis patients. The risk model, encompassing pertinent clinical variables, outperformed existing clinical critical illness scores in mortality prediction. This model furnishes valuable insights for risk stratification, augmenting prognostic precision in sepsis patients with concomitant AF.

A "restrictive" red blood cell transfusion threshold, a hemoglobin concentration <7 to 8 g/dL, has long been recommended for most hospitalized patients including anemic patients with stable cardiovascular disease (CVD). Although no threshold recommendation is given for acute coronary syndromes (ACSs), recent evidence suggests that "liberal" rather than "restrictive" transfusion strategies are associated with significantly improved safety for hospitalized patients with stable CVD and/or ACS. This finding suggests that previously available data were misinterpreted. Conclusions drawn from earlier transfusion trigger trials have been confounded by unintentional trial design and analysis flaws that have contributed to erroneous recommendations regarding the safety of a restrictive threshold. Subsequently, these conclusions have been incorporated into widely accepted guidelines and clinical practice. Management with a restrictive vs liberal transfusion strategy (<10 g/dL) increases the risk of new-onset ACS in patients with CVD by ∼2%. We estimate that since 2019, using hospital databases and a recent meta-analysis, this practice may have resulted in ∼700 excess ACS events per year in orthopedic surgical patients. Given these findings, transfusion practices in other clinical conditions, particularly those derived from similar transfusion trigger trials, should be questioned. Restrictive and liberal transfusion policies merit a general reconsideration. Rather than a single numerical transfusion trigger, transfusion therapy should be personalized. Consideration of an individual patient's age, clinical status, and comorbidities is integral to transfusing. To avoid making similar errors, future trials of transfusion therapy should determine common practices before study inception and incorporate them as a usual-care "control" comparator arm into the trial design. Such studies should more reliably improve current transfusion practice.

In critically ill patients, individualised strategies for red blood cell transfusion (RBCT) are lacking. The objective of this study is to demonstrate the potential advantages of employing an individualised transfusion strategy compared with a restrictive approach, in unselected intensive care unit (ICU) patients.

This will be a randomised, multicentre, international trial. Two open-label parallel groups will be compared with an allocation ratio of 1:1. The trial is designed to investigate the superiority of the individualised intervention group compared with the standard intervention group. The study will be performed in three mixed, academic ICUs located in two different countries. In the individualised group, prescription of RCBT is restricted to patients who present haemoglobin (Hb) ≤9.0 g/dL and oxygen extraction ratio (O2ER) ≥ 30%, for a minimum Hb value of ≤6.0 g/dL. In the control group, prescription of RBCT is guided by thresholds proposed by recent guidelines, regardless of O2ER values.

This trial is approved by the Comitato Etico Area Vasta Centro della Regione Emilia-Romagna (protocol number 350/2023/Sper/AOUFe/PRBCT, date of approval 18/05/2023) and ethic boards at all participating sites. Our results will be published and shared with relevant organisations and healthcare professionals.

Clinicaltrials.gov NCT06102590.

Despite multiple recent guidelines recommending the diagnosis and treatment of anemia before elective cardiac surgery, few institutions have formal programs or methods in place to accomplish this. A major limitation is the perceived financial shortfall and the leadership buy-in required to undertake such an initiative. The purpose of this advisory from the Society of Cardiovascular Anesthesiologists (SCA) Clinical Practice Improvement Committee with endorsement by the Society for the Advancement of Patient Blood Management (SABM) is to provide an overview of preoperative anemia management programs with an emphasis on the associated financial implications. This advisory reviews the evidence for preoperative anemia management programs in both cardiac and noncardiac surgery, discusses options for managing preoperative anemia, provides novel financial modeling regarding the implementation of preoperative anemia management programs, and describes implementation challenges, potential solutions, and opportunities for improvement.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: The objective of this review is to compare the effectiveness and safety of larger versus smaller RBC volume per transfusion for anemia in hospitalized adults, children, and preterm neonates.

Red blood cell (RBC) transfusions play an important role in supportive care in children and neonates with cancer. However, in current clinical practice, evidence-based recommendations are lacking on when to administer prophylactic RBC transfusions. To address this gap, a clinical practice guideline (CPG) was developed to systematically review the available evidence and provide recommendations for clinicians.

A systematic literature review in three databases was conducted. The GRADE methodology was used to assess, extract, and summarize the evidence. A multidisciplinary panel of 21 professionals was assembled to ensure comprehensive expertise. If there was insufficient evidence in children with cancer, additional evidence was gathered in general pediatric or adult oncology guidelines, or the panel utilized shared expert opinion to develop a comprehensive CPG. Multiple in-person meetings were conducted to discuss evidence, complete evidence-to-decision frameworks, and formulate recommendations.

Four studies including 203 children with all types of cancer, met the inclusion criteria. The expert panel assessed all evidence and translated it into recommendations. In total, 47 recommendations were formulated regarding RBC transfusions in children and neonates with cancer. For instance, specific thresholds for prophylactic RBC transfusions were recommended for children and neonates with cancer who have sepsis, are on ECMO, or are undergoing radiotherapy.

This clinical practice guideline presents evidence-based recommendations regarding RBC transfusions in children and neonates with cancer. By providing these recommendations, we aim to guide clinicians and contribute to improving outcomes for children and neonates with cancer.

In patients with acute myocardial infarction (MI), limited physiologic adaptation to acute anemia might lead to greater benefit from a liberal red blood cell (RBC) transfusion strategy. Data on such a possible benefit are lacking.

To compare acute anemia with chronic anemia and post-MI outcomes and estimate the differential effect of a restrictive RBC transfusion strategy compared with a liberal strategy on post-MI outcomes according to anemia acuity.

A prespecified subgroup analysis of the Myocardial Ischemia and Transfusion (MINT) multicenter randomized clinical trial was conducted in 126 hospitals in 6 countries between April 26, 2017, and April 14, 2023, with 30-day follow-up and blinded adjudication of the primary outcome. The analysis included 3144 of 3504 MINT participants (89.7%) with acute MI, a hemoglobin (Hb) level less than 10 g/dL at randomization, and a first Hb measurement available on the day of or the day following hospital admission.

The MINT trial randomized participants to a restrictive (Hb <7-8 g/dL) or liberal (Hb <10 g/dL) RBC transfusion strategy. Acute anemia was defined as having a first Hb value greater than 13 g/dL (men) or 12 g/dL (women), or as having a decrease greater than or equal to 2 g/dL between the first Hb measurement and measurement at randomization. Other Hb levels were categorized as chronic anemia.

The primary outcome was a composite of death or recurrent MI up to 30 days after randomization. Secondary outcomes were death, recurrent MI, cardiac death, heart failure, pulmonary complications, and major bleeding events. Intention-to-treat analysis was performed.

Among 3144 included participants (mean [SD] age, 72.3 [11.6] years; 1715 [54.5%] male; 1307 [41.6%] with type 1 MI), 1078 [34.3%]) had acute anemia. Acute anemia was associated with an increased risk of death or recurrent MI (adjusted risk ratio, 1.25; 95% CI, 1.05-1.48). The effect of a restrictive RBC transfusion strategy compared with a liberal strategy was similar for participants with either acute or chronic anemia for all outcomes.

In this secondary analysis of the MINT trial, acute anemia was associated with less favorable post-MI outcomes than chronic anemia but did not modify the effects of the randomized transfusion strategy. In patients with anemia and MI, the acuity of anemia should not influence the choice of transfusion trigger.

ClinicalTrials.gov Identifier: NCT02981407.

Turgeon AF, Fergusson DA, Clayton L, et al; HEMOTION Trial Investigators on behalf of the Canadian Critical Care Trials Group, the Canadian Perioperative Anesthesia Clinical Trials Group, and the Canadian Traumatic Brain Injury Research Consortium. Liberal or restrictive transfusion strategy in patients with traumatic brain injury. N Engl J Med. 2024;391:722-735. 38869931.

Red blood cells (RBCs) are a limited resource, and the adverse effects of transfusion must be considered. Multiple randomized controlled trials on transfusion thresholds have been conducted, leading to the establishment of a restrictive transfusion strategy. This study aimed to investigate the status of RBC transfusions in critically ill patients.

This cohort study was conducted at five university hospitals in South Korea. From December 18, 2022, to November 30, 2023, 307 nontraumatic, anemic patients admitted to intensive care units through the emergency departments were enrolled. We determined whether patients received RBC transfusion, transfusion triggers, and the clinical results.

Of the 154 patients who received RBC transfusions, 71 (46.1%) had a hemoglobin level of 7 or higher. Triggers other than hemoglobin level included increased lactate levels in 75 patients (48.7%), tachycardia in 47 patients (30.5%), and hypotension in 46 patients (29.9%). The 28-day mortality rate was not significantly reduced in the group that received transfusions compared to the non-transfusion group (21.4% vs. 26.8%, P=0.288). There was no difference in the intensive care unit and hospital length of stay or the proportion of survival to discharge between the two groups. The prognosis showed the same pattern in various subgroups.

Despite the large number of RBC transfusions used in contradiction to the restrictive strategy, there was no notable difference in the prognosis of critically ill patients. To minimize unnecessary RBC transfusions, the promotion of transfusion guidelines and research on transfusion criteria that reflect individual patient conditions are required.

Peri-operative anemia is a common condition encountered in adult surgical patients. It is increasingly recognized as a predictor of post-operative morbidity and mortality. Evaluation and treatment of anemia pre-operatively can reduce transfusion needs and potentially improve outcomes in surgical patients. This article discusses anemia optimization strategies in peri-operative setting with special focus on use of intravenous iron therapy. Additionally, the authors describe the role of transfusion medicine and best practices around red blood cell, platelet, and plasma transfusions.

Anemia is common in locally advanced cervical cancer. Clinical practice varies greatly for management of anemia during brachytherapy, with some centres providing red cell transfusion to increase hemoglobin levels above 100 g/L.

This is a retrospective observational cohort study of adult patients with cervical cancer treated with brachytherapy at two academic hospitals. One hospital (H1) uses a liberal transfusion strategy with hemoglobin threshold of 100 g/L during brachytherapy and the other uses a restrictive target of 70 g/L (H2).

Overall, 336 patients met inclusion criteria (H1: 150 patients, H2: 186 patients). 11 patients were excluded (2 at H1, 9 at H2). Demographics at both sites were comparable, except for cancer stage and smoking history. External beam radiation and chemotherapy provided was similar. Hemoglobin values were compared at baseline (within 4 weeks of oncology consult), and prior to the first and second brachytherapy treatments. In total, 101red blood cell (RBC) units were transfused to patients at H1 and 19 units to patients at H2. Patients were followed for a median of 37.0 months (0.6-80.5) at H1, and 33.3 months (1.6-82.0) at H2. There was no significant difference in progression-free or overall survival. Multivariable logistic regression analysis showed that FIGO stage was a predictor for both overall survival and cancer progression. Age, tumor size, chemotherapy, and hemoglobin levels were not predictors of disease progression or mortality.

The practice of liberal transfusion should be re-evaluated in the absence of robust data to support its use.

Preoperative medical evaluation can minimize inefficiencies and improve outcomes. Thoughtful use of preoperative testing can aid in that effort, but, conversely, indiscriminate testing can detract from it. The United Kingdom National Institute for Health Care and Excellence, European Society of Anaesthesiology, and American Society of Anesthesiologists (ASA) have all stated that routine preoperative testing is not supported by evidence. Testing is supported only when clinical indications are present. Particularly in low-risk patients, such as those with an ASA classification of 1 or 2 who are undergoing ambulatory procedures, evidence suggests that preoperative testing fails to reduce the risk of complications.

While preoperative anemia is associated with adverse perioperative outcomes, the benefits of treatment with iron replacement versus red blood cell (RBC) transfusion remain uncertain. We used a national database to establish trends in preoperative iron-deficiency anemia (IDA) treatment and to test the hypothesis that treatment with preoperative iron may be superior to RBC transfusion.

This study is a propensity-matched retrospective cohort analysis from 2003 to 2023 using TriNetX Research Network, which included surgical patients diagnosed with IDA within 3 months preoperatively. After matching for surgery type and comorbidities, we compared a cohort of patients with preoperative IDA who were treated with preoperative intravenous (IV) iron but not RBCs (n = 77,179), with a cohort receiving preoperative RBCs but not IV iron (n = 77,179). Propensity-score matching was performed for age, ethnicity, race, sex, overweight and obesity, type 2 diabetes, hyperlipidemia, essential hypertension, heart failure, chronic ischemic heart disease, neoplasms, hypothyroidism, chronic kidney disease, nicotine dependence, surgery type, and lab values from the day of surgery including ferritin, transferrin, and hemoglobin split into low (<7 g/dL), medium (7-<12 g/dL), and high (≥12 g/dL) to account for anemia severity. The primary outcome was 30-day postoperative mortality with the secondary outcomes being 30-day morbidity, postoperative hemoglobin level, and 30-day postoperative RBC transfusion.

Compared with RBC transfusion, preoperative IV iron was associated with lower risk of postoperative mortality (n = 2550/77,179 [3.3%] vs n = 4042/77,179 [5.2%]; relative risk [RR], 0.63, 95% confidence interval [CI], 0.60-0.66), and a lower risk of postoperative composite morbidity (n = 14,174/77,179 [18.4%] vs n = 18,632/77,179 [24.1%]; RR, 0.76, 95% CI, 0.75-0.78) (both P = .001 after Bonferroni adjustment). Compared with RBC transfusion, IV iron was also associated with a higher hemoglobin in the 30-day postoperative period (10.1 ± 1.8 g/dL vs 9.4 ± 1.7 g/dL, P = .001 after Bonferroni adjustment) and a reduced incidence of postoperative RBC transfusion (n = 3773/77,179 [4.9%] vs n = 12,629/77,179 [16.4%]; RR, 0.30, 95% CI, 0.29-0.31).

In a risk-adjusted analysis, preoperative IDA treatment with IV iron compared to RBC transfusion was associated with a reduction in 30-day postoperative mortality and morbidity, a higher 30-day postoperative hemoglobin level, and reduced postoperative RBC transfusion. This evidence represents a promising opportunity to improve patient outcomes and reduce blood transfusions and their associated risk and costs.

Clinical blood resources are scarce and autologous blood transfusion for extracorporeal membrane oxygenation (ECMO) withdrawal is less studied.

To assess the use of staged autotransfusion during ECMO decannulation.

The study included ECMO withdrawal patients. Patients in the autologous transfusion group underwent staged transfusion during ECMO withdrawal, while those in the control group received 2.0 units of allogeneic packed red blood cells (RBCs) to increase hemoglobin (Hb). Parameters such as Hb, hematocrit (Hct), adverse events, decannulation success rate, volume of allogeneic RBC transfusions, and transfusion costs were compared.

A total of 82 Chinese patients were enrolled, with a mean age of 46 years, 27 were female, and the top three primary diagnoses were cardiac arrest, acute myocarditis, and severe pneumonia. There were 41 individuals in the autologous blood transfusion group and 41 in the control group. No significant differences were observed in Hb, Hct, adverse events, and the success rate for decannulation between the two groups (all P > 0.05). Compared with the control group, the volume of allogeneic RBC transfusions [0 (0∼1.50) U vs. 3.5 (1.88∼40) U, P < 0.001] and the total cost [130 (130∼390) Chinese Yuan (CNY) vs. 910 (487.50, 1040) CNY, P = 0.002] were lower in the autologous transfusion group.

In comparison with allogeneic RBC transfusion, staged autotransfusion during ECMO decannulation not only effectively maintained Hb levels but also reduced the requirement for allogeneic RBC transfusions. In addition, this approach decreased the associated costs and did not increase the risk of clinical adverse events.

The optimal transfusion strategy in acute myocardial infarction (AMI)-associated anemia remains uncertain.

To compare all-cause mortality between liberal versus restrictive transfusion strategies in patients with AMI-associated anemia, using a meta-analytic approach.

Pubmed, Embase, and ClinicalTrials.gov were systematically searched for randomized controlled trials (RCTs) comparing liberal and restrictive transfusion strategies in AMI-associated anemia. Random-effects meta-analysis and trial sequential analysis (TSA) were conducted to compare blood use, efficacy, and safety endpoints. The p-values were 2-sided with an α of 0.05.

In a pooled analysis involving 4,217 participants from three RCTs followed-up for 30 days, no statistically significant differences emerged between restrictive and liberal strategies in all-cause mortality (RR 1.03; 95% CI 0.67-1.57; p=0.90) and other efficacy endpoints (recurrent AMI, unscheduled revascularization, acute heart failure, stroke, and acute kidney injury), as well as in safety endpoints including allergic reactions, infection, and acute lung injury. TSA did not reach futility boundaries. In patients assigned to restrictive strategy, substantial differences in transfusion use were observed across RCTs, correlating with mortality rates, and likely accounting for between-study heterogeneity in treatment effects.

In patients with AMI-associated anemia, there is no clear superiority between liberal and restrictive transfusion strategies in all-cause mortality or other major outcomes in 30 days. However, the heterogeneity observed in blood use between the restrictive groups likely explains variable findings across RCTs.

Patients with chronic kidney disease (CKD) often have impaired immune function, making them more prone to infections that can lead to sepsis. The coexistence of these conditions can result in decreased hemoglobin levels and is associated with a higher mortality rate. To investigate whether the transfusion of red blood cells (RBCs) improves the prognosis of septic patients with concomitant CKD and to explore the indications for red blood cell transfusion. This retrospective cohort study utilizes data from the MIMIC-IV (v2.0) database. The study enrolled 6,604 patients with sepsis and concomitant CKD admitted to the Intensive Care Unit (ICU). Propensity score matching (PSM) was applied to adjust for confounding factors. Multivariate Cox regression analysis revealed an association between RBC transfusion and a decreased risk of 28-day mortality (HR: 0.61, 95% CI: 0.54-0.70, P < 0.001). Following a meticulous 1:1 propensity score matching analysis between the two cohorts, the matched population revealed a notable decrease in 28-day mortality within the RBC transfusion group (HR: 0.60, 95% CI: 0.51-0.71; P < 0.001). Additionally, we observed that a SOFA score ≥ 5, a Base Excess (BE) value < 3, and an estimated Glomerular Filtration Rate (eGFR) < 30 may be considered when evaluating the potential need for RBC transfusion. This study demonstrated an association between RBC transfusion and decreased 28-day mortality in patients with sepsis accompanied by CKD. The patient's BE value, SOFA score, and eGFR are crucial factors influencing the treatment outcome and should be considered when deciding on RBC transfusion.