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Iron deficiency (ID) affects billions of people worldwide and remains the leading cause of anemia with significant negative impacts on health. Our approach to ID and iron deficiency anemia (IDA) involves three steps (I3): (1) identification of ID/IDA, (2) investigation of and management of the underlying etiology of ID, and (3) iron repletion. Iron repletion options include oral and intravenous (IV) iron formulations. Oral iron remains a therapeutic option for the treatment of ID in stable patients, but there are many populations for whom IV iron is more effective. Therefore, IV iron should be considered when there are no contraindications, when poor response to oral iron is anticipated, when rapid hematologic responses are desired, and/or when there is availability of and accessibility to the product. Judicious use of red cell blood transfusion is recommended and should be considered only for severe, symptomatic IDA with hemodynamic instability. Identification and management of ID and IDA is a central pillar in patient blood management.

Platelet transfusions are commonly used in critically ill patients, but transfusion thresholds, count increments, and predictors of ineffectual transfusions remain unclear.

Background:Severe congenital protein C deficiency (SCPCD) is a rare inherited disorder characterized by recurrent thrombosis, disseminated intravascular coagulation, and purpura fulminans. Due to limitations in traditional therapeutic options (anticoagulation, FFP, PCC), plasma-derived protein C concentrates have been used for both prophylactic and therapeutic indications. However, there are few reports of protein C infusion therapy in adults, with limited understanding of pharmacokinetics and no dosing guidelines available. We report the use of protein C concentrate in an individualized dose-finding study, in an adult patient in preparation for renal transplantation.

Arnold: Novartis: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy; UCB: Consultancy; Amgen: Consultancy, Research Funding.

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No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

Introduction

Introduction:Lumbar puncture (LP) is a frequently performed diagnostic and therapeutic intervention in adult oncology patients. While thrombocytopenia is common in this patient population, the minimum "safe" platelet count required for LPs is unknown. Recent guidelines from the AABB (American Association of Blood Banks) recommend a pre-procedure platelet count of 50 x 109/L. However this recommendation is largely based on expert opinion, and there remains a paucity of studies in the adult oncology literature to address this important question.

Although frozen plasma (FP) transfusion is ubiquitous in clinical practice there is growing evidence that calls into question its administration outside a few selected clinical disorders. Indications for FP have been further reduced by the introduction of prothrombin complex concentrates (PCCs), which are now recommended for reversal of coagulopathies due to vitamin K antagonists (VKA).Audits consistently demonstrate that FP is administered to patients who do not have a specific indication for its use; in some cases “inappropriate” FP use exceeds “appropriate” FP use. This audit sought to determine if the introduction of PCCs has changed patterns of practice and the appropriateness of FP use.After ethics review we performed a quality assurance retrospective chart audit at a single tertiary care hospital of consecutive patients receiving FP over a 3 month period. Baseline characteristics were obtained for each of these patients via chart review. Each episode of FP use over a 24 hour period was adjudicated independently by two Hematology fellows and determined to be appropriate, inconsistent (with guidelines) yet appropriate, or inappropriate in accordance to Canadian and AABB guidelines. Episodes where a consensus could not be reached were adjudicated independently by a consultant hematologist. Specific criteria for “appropriateness” were developed based on the chart review; for example, transfusion of more than 5 units of packed red blood cells in a 2:1 ratio or greater with FP was considered inconsistent yet appropriate. Bleeding was defined as a decrease in hemoglobin of 2 g/dL over 24 hours, a transfusion of 2 units of red blood cells without a rise in hemoglobin, or bleeding in an enclosed space. Reversal of oral VKAs with FP was always deemed inappropriate. FP usage during the study period was also compared to 3-month periods from previous years.Over the study period, 111 episodes and 466 units of frozen plasma use were recorded. Comparisons to the three month period between January to March of previous years are shown in Figure 1. Interobserver agreement was good between the two Hematology fellows (weighted kappa=0.736) and very good with the fellows to the consensus adjudication (weighted kappa=0.824 and 0.810). After exclusion of FP use for plasmapheresis (always considered appropriate), 33/89 (37.1%), 16/89 (18.0%), and 40/89 (44.9%) episodes were deemed to be appropriate, inconsistent yet appropriate, or inappropriate, respectively. The most common reasons for inappropriate use were the absence of bleeding with an increased INR or VKA reversal. Results are presented in further detail in Table 1. FP transfusion occurred in the ICU 74.8% of the time.Our study is the first to audit FP transfusions in the post-PCC era. FP usage remains inappropriately high. FP transfusion to patients who are not bleeding or having procedures despite INR prolongation and the use of FP to reverse VKA are the main reasons for inappropriate FP usage. The majority of FP usage occurred in the ICU. Targeted interventions to reduce FP usage in the future should include both educational and administrative programs, with a focus on the ICU. Clearer evidence on the role of FP in massive transfusions may also reduce FP usage.Crowther: Pfizer: Consultancy, Honoraria, Research Funding; Octapharma: Consultancy, Membership on an entity’s Board of Directors or advisory committees; Merck: Consultancy; Leo Pharma: Consultancy, Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding, Speakers Bureau; CSL Behring: Speakers Bureau; Boehringer Ingelheim: Consultancy, Honoraria, Membership on an entity’s Board of Directors or advisory committees; Baxter: Membership on an entity’s Board of Directors or advisory committees, Speakers Bureau; Asahi Kasai: Membership on an entity’s Board of Directors or advisory committees; Sanofi-Aventis: Consultancy, Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Viropharma: Membership on an entity’s Board of Directors or advisory committees.

Thrombocytopenia is a common complication of critical illness and an independent risk factor for bleeding and death in the intensive care unit (ICU). Platelet transfusions are commonly used to improve platelet counts; however, the expected platelet increment from a transfusion in this setting has not been established. The objective of this study was to describe the frequency of platelet transfusion administration and their effect on platelet count increments in a large cohort of non-oncology critically ill adults.We performed an analysis of a registry database, which was developed to capture clinical and laboratory data on all blood transfusions administered in 3 academic hospitals in Hamilton, Ontario, Canada. We included all patients ≥18 years who received one or more platelet transfusion during an ICU admission. Data validation was done by integrity checks with medical records and laboratory information system performed by a biostatistician. Non-transfused ICU patients were used as controls. The absolute increment in platelet count was calculated for each single platelet transfusion using the closest platelet count taken within 24 hours before the transfusion and 4-24 hours after the transfusion.Between April 2006 and October 2012, 33,222 patients were admitted to ICU, including 29,511 (88.8%) who did not have a diagnosis of cancer. Of those, 4,502 (15.3%) received one or more platelet transfusion during any ICU admission (n=4,690); 31.9% were female and median age at the time of first admission was 69 years (IQR 59-77). Among the 25,009 non-transfused patients admitted to ICU during the same period, 38.1% were female and the median age was 65 years (IQR 52–76). Median pre-transfusion platelet count was 87 x109/L (IQR 59-131) and a single platelet transfusion resulted in a median platelet count increment of 21 x109/L (IQR 6-40) as measured 6.7 hours (IQR 5.1-9.8) after the transfusion. There were 277 (25.4%) transfusions that yielded a platelet count increment of 5 x109/L or less. ICU mortality was 562/4,690 (12.4%) for patients who received a platelet transfusion, compared with 2,251/33,033(6.8%) for patients who were not transfused during their ICU stay.Among this large cohort of non-oncology ICU patients, platelet transfusions were commonly administered for thrombocytopenia that was generally mild. In this setting one platelet transfusion resulted in a median platelet count rise of 21 x109/L. Many transfusion episodes yielded no appreciable increase in platelet count. Further studies are needed to determine the clinical effects of platelet transfusion in this setting controlling for confounding.Heddle: CIHR: Research Funding; Canadian Blood Services: Membership on an entity’s Board of Directors or advisory committees; Health Canada: Research Funding; Macopharma: Consultancy; ASH: Honoraria.

Thrombocytopenia is a common complication of critical illness and an independent risk factor for bleeding and death in the intensive care unit (ICU). Platelet transfusions are commonly used to improve platelet counts; however, the expected platelet increment from a transfusion in this setting has not been established. The objective of this study was to describe the frequency of platelet transfusion administration and their effect on platelet count increments in a large cohort of non-oncology critically ill adults.

Although frozen plasma (FP) transfusion is ubiquitous in clinical practice there is growing evidence that calls into question its administration outside a few selected clinical disorders. Indications for FP have been further reduced by the introduction of prothrombin complex concentrates (PCCs), which are now recommended for reversal of coagulopathies due to vitamin K antagonists (VKA).