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Background Anaemia of prematurity constitutes a major morbidity in preterm infants. Conventionally, anaemia is treated with packed red blood cell transfusion (PRBCT) based on low haemoglobin and symptoms perceived to be due to anemia. Thresholds for transfusion vary due to limited evidence. It is well established that counter-regulation to hypoxia follows a hierarchical pattern, with brain-sparing in preference to splanchnic oxygenation. We hypothesised that the same is true for recovery from hypoxia after PRBCT and may be associated with delayed splanchnic recovery prioritizing restoration of cerebral oxygenation. Reduced splanchnic oxygen delivery in the context of anaemia and immediate post-transfusion period, associated with increased splanchnic oxygen consumption due to feeding may contribute to the pathogenesis of transfusion-associated necrotizing enterocolitis (TANEC). Fractional tissue oxygen extractions (FTOE), a measure of oxygen consumption-delivery balance is determined using simultaneously recorded tissue oxygen saturation (StO2) and arterial blood oxygen saturation (SpO2). We aimed to investigate the hypothesis by concurrent determination of cerebral and splanchnic FTOE (FTOEc and FTOEs) in the context of PRBCT and feeding. Aims To understand the chronology of changes in splanchnic and cerebral oxygenation associated with PRBCT (Chapters 7 and 8). To investigate feed-associated alterations in splanchnic and cerebral oxygenation during anemia and after a PRBCT (Chapter 9). To correlate conventional indicators of PRBCT (low Hb and symptoms) with cerebral and splanchnic oxygenation (Chapter 10). Methods The prospective cohort study enrolled 30 haemodynamically stable, anaemic preterm infants receiving PRBCT, with gestation < 32 weeks; birth weight < 1500 grams; postmenstrual age < 37weeks; tolerating ≥ 120 mL/kg/day feeds. Near-infrared spectroscopy was used to determine cerebral and splanchnic StO2, and pulse oximeter to determine SpO2 from 4 hours pre-PRBCT until 24 hours post-PRBCT. Results FTOEc improved during and after PRBCT, while FTOEs remained unchanged. Bolus feeding was associated with worsening FTOEs with unchanged FTOEc during the first 8 hours post-transfusion. Pre-transfusion Hb and symptoms did not correlate with FTOEc and FTOEs. Conclusions The hierarchical improvement of the brain but not the gut oxygenation in the post-transfusion period may indicate continued splanchnic hypoxia to buffer brain oxygenation and vulnerability to TANEC. Enteral feeding may be associated with splanchnic hypoxia and potentially TANEC in the immediate post-transfusion period. Conventional indicators may not accurately reflect the PRBCT requirement. Impact Our study provides a plausible mechanistic underpinning for TANEC and warrants future randomised studies to stratify its prevention. Additionally, it warrants larger studies incorporating FTOE along with the conventional criteria to determine the transfusion threshold.

Packed red blood cell (PRBC) transfusions are commonly administered in pediatric patients following the Norwood operation. This study was conducted to determine the effect of PRBC transfusions on hemodynamic parameters in pediatric patients with single-ventricle physiology and parallel circulation. A single-center, retrospective chart review was conducted. Pediatric patients admitted to the cardiac intensive care unit after Norwood operation between 2017 and 2018 were identified. Hemodynamic parameters were collected within a four-hour period before and after a PRBC transfusion. Univariate analyses using paired t tests were conducted to compare blood gas values before and after PRBC transfusion. Next, multivariate regression analyses were conducted to model the impact of transfusion volume, change in hemoglobin levels, and change in FiO2 on the change in PaO2 and PaCO2. These analyses included data from 33 eligible patients who received a PRBC transfusion following a Norwood operation. The hemoglobin levels (p

Background and objectives Our study sought to evaluate and compare different prediction scores for massive transfusion in-hospital packed red blood cell (PRBC) transfusions. Materials and methods Between January 2013 and December 2018, 1843 trauma patients were enrolled in the registry of a level-1 trauma centre. All prehospital and in-hospital variables needed to calculate the Shock Index and RED FLAG, Assessment of Blood Consumption (ABC) and Trauma Associated Severe Hemorrhage (TASH) scores were prospectively collected in the registry. The primary endpoint was the initiation of transfusion within the first hour of the patient's arrival at the hospital. Results A total of 1767 patients were included for analysis with a mean age of 43 years (±19) and a mean Injury Severity Score of 15 (±14). The in-hospital TASH score had the highest predictive performance overall (area under the curve [AUC] = 0.925, 95% confidence interval [CI] [0.904-0.946]), while the RED FLAG score (AUC = 0.881, 95% CI [0.854-0.908]) had the greatest prehospital predictive performance compared to the ABC score (AUC = 0.798, 95% CI [0.759-0.837]) and Shock Index (AUC = 0.795, 95% CI [0.752-0.837]). Using their standard thresholds, the RED FLAG score was the most efficient in predicting early transfusion (sensitivity: 87%, specificity: 76%, positive predictive value: 25%, negative predictive value: 99%, Youden index: 0.63). Conclusion The RED FLAG score appears to outperform both the ABC score and the Shock Index in predicting early in-hospital transfusion in trauma patients managed by pre-hospital teams. If adopted, this score could be used to give advance warning to trauma centres or even to initiate early transfusion during pre-hospital care.

Evidence for having preterm infants be NPO during PRBC transfusion is reviewed. As patient specific factors, contextual factors and new evidence since the inception of this guideline may exist, the recommendations and/or content may no longer being applicable. Thus, this guideline is not intended to be a standard of care. Version 1: July 14, 2016

A 15‐year‐old female neutered Domestic Long Hair cat was presented for acute hematemesis. Initial diagnostic workup, including serum biochemistry panel, complete blood count and coagulation profile, was unremarkable. Abdominal ultrasound showed gastric mural thickening and non‐obstructive gastric foreign material. Endoscopy was performed to remove the foreign matter and obtain biopsies. Significant abnormalities of the upper gastrointestinal (GI) tract were not noted endoscopically. Overnight, the patient required a packed red blood cell transfusion following two episodes of severe hematemesis, hypotension and collapse. Serial radiographs and ultrasound revealed hepatic portal venous gas (HPVG). Computed tomography (CT) scan confirmed massive gas accumulation within the liver and emphysematous gastritis. The patient became increasingly unstable and, given her rapid decline, humane euthanasia was elected. Gastric and duodenal histopathology showed inflammatory changes, spirochetosis and mucosal epithelial degeneration. HPVG is a rarely described finding and prognosis varies drastically depending on aetiology. To the best of our knowledge, this is the first description of portal vein gas documented on multiple imaging modalities, including CT, in a cat. The patient in this report had several potential risk factors including prior endoscopy, compromise of the intestinal barrier and evidence of gastric mural bacterial invasion., This report describes a case of hepatic portal venous gas (HPVG) in a feline visualized initially on ultrasound and ultimately confirmed with CT, which is considered the gold‐standard for identification in humans. HPVG is associated with a variety of underlying disease processes, some of which require emergent aggressive intervention and may result in significant mortality. Reports of HPVG in veterinary medicine are sparse.

Conventionally the packed red blood cell (PRBC) transfusion volume given to neonates is 10 ml/kg to 20 ml/kg. The weight-based formulae underestimate the volume of PRBC required to achieve a target hematocrit (Hct) in preterm neonates. The study was done to compare the rise in Hct after transfusing PRBC volume calculated either based on body weight or using formula considering Hct of blood bag and Hct of preterm neonates. This prospective study included a total of 68 preterm neonates requiring transfusion for the first time having ≤ 34 weeks of gestational age. Neonates were randomized using block randomization, to receive 15 ml/kg of PRBC transfusion (group A) or transfusion based on the formula (group B). The primary outcome of interest was post-transfusion rise in hematocrit. The secondary outcome was the effect of transfusion on neonatal morbidities in terms of retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and death. Baseline variables (birth weight, gestation age, APGAR score and score of neonatal acute physiology) pre-transfusion hemodynamics and hematocrit of the bag were comparable in both groups. The mean volume of PRBC in group A was 18.8 ± 4.9 ml, whereas in group B it was 29.6 ± 7.3 ml, p = 0.0001. Group B transfusions had a statistically significant change in 24 h post-transfusion hematocrit. Secondary outcomes were comparable in two groups. Post transfusion rise in Hct of the patient in group B was significant as compared to group A. The study needed huge sample size to establish a difference in the number of re-transfusions required across two groups. The trial was registered under the clinical trial registry of India (CTRI/2018/01/011,063). Supplementary Information The online version contains supplementary material available at 10.1007/s12288-021-01420-1.

Purpose: Carcinoma cervix forms a major burden among malignancies in women in India. Anemia is very common among Indian women and a high proportion of carcinoma cervix patients present with anemia. Previous studies show that hemoglobin level may be considered as a prognostic factor in carcinoma cervix. It has been observed that anemia is associated with diminished radiocurability in patients with carcinoma of the cervix. However, the therapeutic benefit of the measures to correct anemia remains debatable. The objective of this study was to evaluate the association of hemoglobin concentrations and its correction by blood transfusions before and during treatment and the response to chemoradiation. Materials and Methods: Fifty patients with histologically proven squamous cell carcinoma of the cervix (Stage II to IV) from December 2018 to May 2020 were taken up for this study. Patients received definitive chemoradiation of 50 Gy in 25 fractions, 2 Gy/fraction, 5 fractions per week, along with-weekly injection cisplatin/carboplatin, followed by brachytherapy. All patients had their pretreatment hemoglobin levels measured at the first consultation. The effects of hemoglobin concentrations at presentation and during therapy on the clinical response to radiotherapy were studied. Blood transfusions and the time point when transfusions were given were recorded. Results: Eighteen patients received packed red blood cell transfusion before the start of radiation therapy and 9 patients received packed cell transfusion during radiation therapy. Out of the 18 patients who received transfusion before RT, 3 patients had complete response. Out of the 9 patients who received transfusion during radiation, 4 had complete response. The presence of anemia had a significant impact on the response rate. Pretreatment anemia was associated with poor response and local control among patients who underwent chemoradiotherapy for cervical cancer. Conclusion: Pretreatment hemoglobin and hemoglobin levels during radiation therapy were prognostic factors for local control, in addition to stage and histology, which might have independently predicted the outcome.

Objective To compare the PCV at several timepoints following packed red blood cell (pRBC) administration to anemic dogs and to assess if underlying cause of anemia or regenerative status significantly affects these measurements. Design Prospective, observational study from November 2016 to October 2017. Setting A small animal emergency and specialty hospital. Animals Forty-six anemic client-owned dogs that received a total of 50 pRBC transfusions for management of anemia. Interventions Blood was collected, and a PCV was obtained prior to pRBC transfusion (T0), immediately after (T1), 30 minutes after (T2), 1 hour after (T3), 2 hours after (T4), and 4 hours after (T5) the transfusion. Underlying causes of anemia were classified as hemorrhage, hemolysis, and ineffective erythropoiesis. Dogs were also categorized in regard to regenerative status of anemia and the presence or absence of expected continued blood loss or destruction. Measurements and main results The mean PCV at T0 was 0.15 L/L (15%). After administration of a pRBC transfusion, the mean PCV at T1 was 0.28 L/L (28%). For all other timepoints (T2, T3, T4, and T5), the mean PCV was 0.27 L/L (27%). The PCV did not change significantly over time post-transfusion (P = 0.184), and no pairwise combinations of times differed significantly (paired t-tests; P > 0.05 for all). When dogs were categorized via regeneration status and continued blood loss or hemolysis, results were consistent. Conclusions There was no significant change in PCV from the value obtained immediately after pRBC transfusion up to 4 hours post-transfusion in dogs with several different causes of anemia. These results suggest that obtaining a PCV immediately after administering a pRBC transfusion to an anemic dog may be just as reliable as obtaining a measurement 2 hours after the transfusion. This remains true for dogs with expected continued red blood cell loss or destruction.

Background Due to the increased mortality and morbidity associated with blood transfusion, identifying modifiable predictors of transfusion are vital to prevent or minimise blood use. We hypothesised that burn patients with diabetes mellitus were more likely to be prescribed a transfusion. These patients tend to have increased age, number of comorbidities, infection risk and need for surgery which are all factors reported previously to be associated with blood use. Objective To determine whether patients with diabetes mellitus who have sustained a burn ≤20% total body surface area (TBSA) are at higher risk of receiving red blood cell transfusion compared to those without diabetes mellitus. Method This was a retrospective cohort study including patients admitted to the major Burns Unit in Western Australia for management of a burn injury. Only the first hospital admission between May 2008 to February 2017 were included. Results Among 2101 patients with burn injuries ≤20% TBSA, 48 (2.3%) received packed red blood cells and 169 (8.0%) had diabetes. There were 13 (7.7%) diabetic patients that were transfused versus 35 (1.8%) non-diabetic patients. Patients with diabetes were 5.2 (p = 0.034) times more likely to receive packed red blood cells after adjusting for percentage TBSA, haemoglobin at admission or prior to transfusion, number of surgeries, total comorbid burden and incidence of infection. As percentage TBSA increases, the probability of packed red blood cell transfusion increases at a higher rate in DM patients. Conclusions This study showed that diabetic patients with burn injuries ≤20% TBSA have a higher probability of receiving packed red blood cell transfusion compared to patients without diabetes. This effect was compounded in burns with higher percentage TBSA.

Background Liquid packed red blood cells (LPRBCs) have a limited shelf life and worsening quality with age. Cryopreserved packed red blood cells (CPRBCs) can be stored up to 10 years with no quality deterioration. The effect of CPRBCs on outcomes in civilian trauma is less explored. This study aims to evaluate the safety and efficacy of CPRBCs in civilian trauma patients. Methods We analyzed the (2015-2016) Trauma Quality Improvement Program, including adult (age, ≥18 years) patients who received a RBC transfusion within 4 hours of admission. Patients were stratified, those who received LPRBC and those who received CPRBC. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes were major complications. Propensity matching was performed adjusting for demographics, vitals, blood components, injury parameters, comorbidities, and center parameters. Results A total of 39,975 patients were identified, and a matched cohort of 483 was obtained. A total of 161 received CPRBC (CPRBC, 2 [2-4]; plasma, 2 [0-5]; platelets, 1 [0-2]) and 322 received LPRBC (LPRBC, 3 [2-6]; plasma, 3 [0-6]; platelets, 1 [0-2]). The mean age was 43 ± 22 years, 62% were men, Injury Severity Score was 18 (12-27), and 65% had a blunt injury. Patients who received CPRBC had similar 24-hour mortality (1.8% vs. 2.3%; p = 0.82) and in-hospital mortality (4.9% vs. 5.2%; p = 0.88). No difference was found in terms of complications (15.3% vs. 17.2%; p = 0.21) between the two groups. Conclusion Transfusion of CPRBCs may be as safe and effective as transfusion of LPRBCs in moderately injured trauma patients. Cryopreservation has the potential to expand our transfusion armamentarium in diverse settings, such as periods of increased usage, disaster scenarios, and rural areas. Level of evidence Therapeutic study, level III.

Intravenous immunoglobulin (IVIG) is an important therapeutic tool for the treatment of a variety of conditions, including immune thrombocytopenic purpura (ITP). Although IVIG has many approved indications and is typically well tolerated, a number of adverse effects have been reported. Hemolysis is a documented but under-recognized adverse effect associated with large individual or cumulative doses of IVIG. Hemolytic complications are typically mild and detected incidentally when screening tests, such as a complete blood count (CBC) showing decreased hemoglobin or a complete metabolic panel (CMP) resulting in elevated bilirubin, are performed for another reason. Herein, we report a case of significant hemolytic anemia in a 59 year old Caucasian woman, who required packed red blood cell transfusion after administration of IVIG for the treatment of ITP. Increased awareness of the potential for clinically significant hemolysis after the use of moderate cumulative doses of IVIG is needed, particularly in patients with risk factors for hemolysis.

Objective To determine the indications and threshold of haemoglobin levels for packed red blood cell transfusion and its association with outcomes in a paediatric intensive care setting. Methods The retrospective study was conducted in the paediatric intensive care unit of the Aga Khan University Hospital, Karachi, and comprised medical records of all inpatients with age between 1 month and 16 years who received packed red blood cell transfusions between January and December 2017. Data was retrieved from the hospital database and was analyzed using SPSS 22. Results Of the 147 subjects with a mean age of 67.89±65.8 months, 76(51.7%) were males. Mean paediatric risk of mortality score was 11.72±7.86. Major admitting diagnosis included sepsis and multiorgan dysfunction 50(34%), respiratory diseases 26(17.7%) and haematology/oncology diseases 22(15%). The indications for transfusion was low haemoglobin in 90(61.2%) patients, shock 29(19.7%) and hypoxia 28(19%). Acute transfusion reaction was observed in 1(0.7%) patient; 120(82%) required mechanical ventilation; and 94(64%) required inotropic support. Of the total, 88(59.9%) patients survived. Paediatric risk of mortality score, need for inotropic support and mechanical ventilation were associated with mortality (p Conclusions Packed red blood cell transfusion, which is frequently prescribed in intensive care settings, was not found to be associated with favourable outcome.

Objective Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. At present, there are no reliable clinical or laboratory indicators to identify which patients might require blood transfusions during a PPH. Serum lactate has long been used as an early biomarker of tissue hypoperfusion in trauma settings. The aim of this study is to understand serum lactate's role in the management of obstetric hemorrhage. Study Design A retrospective chart review was performed of women who delivered between 2016 and 2019 at our institution and experienced a PPH. The patients were divided into two groups: those with a normal serum lactate level, defined as ≤2 mmol/L, and those with an abnormal serum lactate level, defined as >2 mmol/L. Need for packed red blood cell transfusion, as part of the resuscitation, was assessed for both groups. Results During the study period, 938 women experienced PPH. Of these, 108 (11.5%) had a normal serum lactate, ≤2 mmol/L, and 830 (88.5%) had an abnormal lactate, >2 mmol/L. Women with elevated lactate levels were more likely to receive a blood transfusion versus those with a normal lactate level (57.0 vs. 46.3%, p = 0.035, respectively). Additionally, the average number of blood transfusions administered was significantly higher in the abnormal lactate group versus in the normal lactate group (1.34 vs. 0.97, respectively, p = 0.004). In a multivariable linear regression model, increasing serum lactate levels were found to be predictive of requiring more than 1 unit of blood (p Conclusion Women with elevated serum lactate levels were more likely to require blood transfusions during a PPH versus those with a normal serum lactate level. Thus, serum lactate levels are useful as an early indicator of requirement for blood transfusion in the management of obstetric hemorrhage. Key Points

Background: Transfusion-related immunomodulation (TRIM) has been described in adults; however, its existence in neonates is not confirmed. The generation of TRIM is attributed to increased concentrations of IL-8, sICAM-1 and other pro-inflammatory cytokines. This study aimed to monitor changes in IL-8, sICAM-1 as markers for TRIM in premature infants at different postnatal ages. Methods: Preterm infants with a gestational age between 28 and 32 weeks who were receiving PRBC transfusion during the first 28 days of life were included in the study. Infants were stratified into two groups according to their postnatal age: Group 1 with postnatal ages of (0–14) days and Group 2 of (15–28) days. The concentrations of IL-8 and sICAM-1 were measured by enzyme-linked immunosorbent assay (ELISA) before transfusion, 6 h after the end of transfusion and in the donor's PRBCs bag immediately before infusion into the baby. Results: IL-8 concentration in the PRBCs bags correlated with post-transfusion level in Group 2 (r = 0.59, p = 0.002) but not in Group 1 (r = 0.39, p = 0.06). sICAM-1 concentration in the bag correlated with infants'concentrations in neither group. In Group 1, pre-transfusion concentrations of both cytokines (IL-8 and sICAM-1) did not correlate whereas post-transfusion concentrations did correlate (r = –0.09, p = 0.68 and r = 0.4, p = 0.05 respectively). In Group 2, the concentrations of both cytokines did not correlate with each other during pre-transfusion (r = 0.11, p = 0.58) as well as post-transfusion (r = 0.12, p = 0.56). There was no significant increase in either cytokines after transfusion in each group. Conclusion: This study showed positive correlation between IL-8 concentration in the transfusion bag and post transfusion in Group 2 infants which could be attributed to passive transmission from the bags. This study does not support an immune modulatory effect for packed RBC in preterm infants. Key Words: blood transfusion, cytokines, interleukin 8, preterm, transfusion-related immunomodulation

Aim To determine whether serum ferritin, liver transaminases, and regularity and type of iron chelation protocol can be used to predict liver iron load as assessed by T2* magnetic resonance imaging (MRI) in patients with beta thalassemia major (TM). Methods This cross-sectional study, conducted from March 1, 2014 to March 1, 2015, involved 90 patients with beta TM on regular packed red blood cell transfusion. Liver and cardiac iron load were evaluated with T2* MRI. Compliance with iron-chelating agents, deferoxamine or deferasirox, and regularity of their use, as well as serum ferritin and liver transaminase levels were assessed. Results Patients with high serum ferritin were 2.068 times (95% confidence interval 1.26-3.37) more likely to have higher liver or cardiac iron load. High serum aspartate aminotransferases and irregular use of iron chelating agents, but not their type, predicted higher cardiac iron load. In a multiple regression model, serum ferritin level was the only significant predictor of liver and myocardial iron load. Conclusions Higher serum ferritin strongly predicted the severity of cardiac and liver iron load. Irregular use of chelator drugs was associated with a higher risk of cardiac and liver iron load, regardless of the type of chelating agent.

Purpose The purpose of this project was to determine whether the use of the modified Northwestern high risk spine protocol in patients undergoing multilevel spinal fusion surgery would result in improved transfusion practices. Design Preimplementation and postimplementation design. Methods A laboratory monitoring and transfusion guideline protocol was implemented in patients undergoing multilevel spinal fusions. Data were collected via a manual retrospective chart review of the electronic medical record before and after implementation of the protocol. Findings Laboratory values were monitored at guided intervals. There was a statistically significant (P = .004) decrease in the mean hemoglobin value at which a packed red blood cell transfusion was initiated. Conclusions Through the use of the protocol, laboratory value monitoring provided quantitative data to aid and improve clinical decision making for practitioners in the perioperative period.

Background: Despite the fact that Kasai portoenterostomy (KPE) is the primary treatment for biliary atresia (BA), liver transplantation (LT) remains the ultimate surgery for two-thirds of these patients. Their true survival rate with the native liver reflects the original KPE and the burden of post-operative complications. We report an original modification of the adhesion-sparing liver eversion (ASLE) technique during KPE that facilitates the total native hepatectomy at time of transplantation. Methods: All consecutive patients with BA who underwent KPE at our department and subsequent LT at Paediatric Liver Transplant Centre at Papa Giovanni XXIII Hospital between 2010–2018 were retrospectively enrolled. All patients underwent ASLE during KPE. Patients’ demographic data, type of KPE, total transplant time (TTT), hepatectomy time (HT), intra-operative packed red blood cells and plasma transfusions, intra- and post-operative complications were noted. Results: 44 patients were enrolled. Median TTT and HT were 337 and 57 min, respectively. The median volume of packed red blood cell transfusion was 95 mL. No patients presented bowel perforation during the procedure or in the short post-operative course. No mortality after LT was recorded. Conclusions: In addition to the well-known advantages of the standard liver eversion technique, ASLE reduces the formation of intra-abdominal adhesions, lowering significantly the risk of bowel perforation and bleeding when liver transplantation is performed for failure of KPE.

Background and Aim of the Study Transfusion-associated hyperpotassemia is a serious complication of packed red blood cell (PRBC) transfusion after congenital cardiac surgery. Our study aimed to identify risk factors and potential preventive measures of transfusion-associated hyperpotassemia in neonates and infants after congenital cardiac surgery. Methods Pediatric patients who underwent congenital cardiac surgery and need transfusion were enrolled in this prospective study. The potassium concentration of PRBC was checked from the sample taken from the segment. The volume of transfusion, age of PRBC, potassium concentration of unit were recorded. The estimated increment of potassium level in patients after PRBC transfusion was calculated. Results Seventy-four individual patients, 95 distinct transfusions, 112 blood products were evaluated. The mean age of the blood unit was 3.8 +/- 1.4 days. The mean potassium concentration in the PRBCs was 9.9 +/- 2.4 mmol/L. A weak correlation was observed between the potassium value of the PRBC and the age of PRBC (p = 0.049, r = 0.2, y = 0.24 x x + -0.68). There was a weak correlation between the potassium value of PRBCs and the age of the unit (p < 0.001, r = 0.37, y = 2.8 x x + -3.6). Conclusions Before transfusion, even PRBC is fresh, measuring the potassium level of PRBC and the potassium that will be given to the pediatric patient with transfusion can prevent transfusion-related hyperpotassemia and related complications. Otherwise, high potassium levels, which may be overlooked despite being fresh, may cause serious complications, even cardiac arrest, especially in neonates and infants.

Background β-thalassemia major is a hereditary disorder of hemoglobin (Hb) that results in defective Hb synthesis, leading to severe chronic anemia. The mainstay of its treatment is lifelong regular packed red cell transfusions associated with iron-chelating therapy. Globally, there is a gap between blood donation and the actual needs of the patients who depend on transfusion. Patients with β-thalassemia major are no exception and have limited access to regular and safe blood transfusions. This study aimed to assess the gap between the demand and supply of blood for transfusion-dependent patients with β-thalassemia major treated at the Hereditary Blood Diseases Center, Al Ahsa, Eastern Saudi Arabia. Methodology This was a retrospective, cross-sectional study conducted at the Hereditary Blood Disease Center, Al Ahsa, Saudi Arabia, including patient data from January 2017 to December 2019. We used Excel 365 from Microsoft Office 2016, version 1706. Results A total of 158 patients were on chronic transfusion. Of the total patients, 65% were adults, while the remaining 35% comprised the pediatric population. The total number of units requested and received during the three-year period was 14,509 and 9,530, respectively, indicating a gap of 4,979 (34%) units. The age of most of the units received was more than 14 days: 36% of those in 2017, 49.9% in 2018, and 61.5% in 2019. Rare blood groups and alloimmunization accounted for

BACKGROUND: Patients with sickle cell disease can experience various crises including sequestration crisis, haemolytic crisis and aplastic crisis. Due to alloantibody formation, transfusion alloantibodies can cause a haemolytic crisis. Treatment involves avoiding packed red blood cell transfusions, as well as intravenous immunoglobulin, steroids and eculizumab to decrease the chances of haemolysis. CASE DESCRIPTION: We report the case of a 42-year-old man who was found to have worsening anaemia after packed red blood cell transfusion with evidence suggestive of haemolytic crisis. Due to reticulocytopenia, aplastic crisis was also suspected and later confirmed via parvovirus IgG and IgM titres. The patient did not improve with steroid and intravenous immunoglobulin therapy and was treated with eculizumab as a salvage therapy. CONCLUSION: Concurrent hyper-haemolytic crisis and aplastic crisis should be suspected in patients with features of haemolysis and reticulocytopenia. Prompt recognition and treatment with eculizumab are paramount in those who fail steroid and intravenous immunoglobulin treatment. LEARNING POINTS: Treatment of hyper-haemolytic and aplastic crisis in sickle cell disease with eculizumab offers therapeutic benefit. A high index of suspicion for hyper-haemolytic crisis and aplastic crisis should be maintained in those with haemolytic features as well as reticulocytopenia in the setting of sickle cell disease.

Contemporary packed red blood cell transfusion practices in anaemic preterm infants are primarily based on measurement of hemoglobin or haematocrit. In neonatal intensive care units, most preterm infants receive at least 1 packed red cell transfusion as standard treatment for anaemia of prematurity. Clinicians are faced with a common question "at what threshold should anaemic preterm infants receive packed red blood cell transfusion?". While evidence from interventional trials offers a range of haemoglobin levels to clinicians on thresholds to initiate red cell transfusion, it does not offer identification of exact haemoglobin level at which regional oxygenation and perfusion gets compromised. Assessment of regional oxygenation using near infrared spectroscopy and perfusion using ultrasound could offer a personalized transfusion medicine approach to optimize transfusion practices. We conducted a systematic review of the literature to identify the role of both regional oxygenation and/or ultrasound-based perfusion monitoring as a potential trigger to initiate packed red blood cell transfusion in anaemic preterm infants. MEDLINE, Embase, Maternity and Infant Care database were searched up to March 2021. Publications identified were screened and relevant data was extracted. Changes to regional oxygenation and/or perfusion monitoring before and after packed red blood cell transfusion were the primary outcomes. 44 out of 755 studies met the inclusion criteria and were included in the final analysis. Most were prospective, observational studies in stable preterm infants. Overall, studies reported an improvement in regional oxygenation and/or ultrasound-based perfusion after packed red blood cell transfusion. These changes were more consistently observed when hemoglobin

Key Points Question What is the hemoglobin transfusion threshold and target recommended for patients with cervical cancer undergoing curative-intent radiotherapy (RT)? Findings In this international Delphi consensus study, 39 experts in gynecologic radiation oncology did not agree on a hemoglobin transfusion threshold, highlighting significant variability in clinical practice. For both external beam RT and brachytherapy, a hemoglobin transfusion target of 9 or more g/dL and less than 12 g/dL, respectively, was agreed on by an 89% consensus. Meaning A liberal packed red blood cell transfusion strategy was recommended by consensus to overcome hypoxia-induced radioresistance in patients with cervical cancer receiving curative RT., Importance Packed red blood cell (PRBC) transfusions are used to treat anemia in patients with cervical cancer undergoing radiotherapy (RT) owing to concerns of hypoxia-induced radioresistance. In the absence of high-quality evidence informing transfusion practices for patients receiving external beam RT (EBRT) and brachytherapy, various arbitrary hemoglobin target levels are used worldwide. Objective To develop consensus statements to guide PRBC transfusion practices in patients with cervical cancer receiving curative-intent RT with EBRT and brachytherapy. Design, Setting, and Participants This international Delphi consensus study was completed between November 1, 2019, and July 31, 2020. A total of 63 international clinical experts in gynecologic radiation oncology were invited; 39 (62%) accepted and consented to participate. Consensus building was achieved using a 3-round anonymous Delphi consensus method. Participants rated their agreement or disagreement with statements using a 5-point Likert scale. An a priori threshold of 75% or more was required for consensus. Main Outcomes and Measures The preplanned primary outcome of this study was to assess hemoglobin transfusion thresholds and targets for both EBRT and brachytherapy by expert consensus. Results Response rates of 100% (39 of 39), 92% (36 of 39), and 97% (35 of 36) were achieved for the first, second, and third rounds of surveys, respectively. Twenty-three experts (59%) practiced in Canada, 11 (28%) in the United States, 3 (8%) in South America, 1 (3%) in Europe, and 1 (3%) in Asia. Consensus was reached for 44 of 103 statements (43%), which were combined to form the final 27-statement consensus guideline. No specific hemoglobin transfusion threshold was agreed on by consensus for EBRT or brachytherapy. By consensus (89% [31 of 35]), a hemoglobin transfusion target for patients who receive a PRBC transfusion should be 9 g/dL or more and less than 12 g/dL. Conclusions and Relevance This study presents the first international expert consensus guideline informing PRBC transfusion practices for patients with cervical cancer undergoing EBRT and brachytherapy. A minimum hemoglobin transfusion target of 9 g/dL was endorsed to balance tumor radiosensitivity with appropriate use of a scarce resource. Randomized clinical trials are required to evaluate the optimal transfusion threshold and target that maximize clinical benefit in this patient population., This international Delphi consensus study developed consensus statements to guide packed red blood cell transfusion practices for patients with cervical cancer receiving curative-intent radiotherapy with external beam radiotherapy and brachytherapy.

Introduction Large-bore cannulas are critical to administering IV fluids and blood products during resuscitation and treatment of hemorrhage. Although catheter flow rates for crystalloid solutions are well defined, rapid administration of blood products is poorly characterized. In this in vitro study, we examined the effects of hemodilution and needleless connectors on red blood cell (RBC) flow rates. Methods To determine RBC flow rates through large-bore cannulae, a crystalloid solution (Normosol®, Hospira, Lake Forest, IL) or RBC units were warmed and delivered under pressure (360 mmHg) using a Level 1 H-1200 Fast Flow Fluid Warmer (Smiths Medical, St. Paul, MN). Flow rates for crystalloid, packed RBCs and diluted RBCs were determined using a stopwatch. Additionally, the effect of the MaxPlus® clear needleless connector (CareFusion, San Diego, CA) was measured in all three infusion groups. Results Flow rates for undiluted RBC units were 53% slower than crystalloid solution (220 mL/min vs. 463 mL/min; p=0.0003), however, when RBC units were diluted to a hematocrit of ~30% flow rate improved to 369 mL/min (p=0.005). The addition of the MaxPlus® needleless connector reduced flow of crystalloid solution by 47% (245 mL/min; p=0.0001), undiluted RBCs by 64% (78 mL/min; p=0.01), and diluted RBCs by 51% (180 mL/min; p=0.00003). Compared to undiluted RBC units, hemodilution increased RBC delivery rate through a MaxPlus® connector by 130% (p=0.004) and by 68% (p=0.02) when the catheter was directly connected to the Level 1 tubing (MaxPlus® excluded). Conclusion In settings requiring rapid transfusion of RBC units, needleless connectors should not be used and hemodilution should be considered in order to decrease the time required to deliver an equivalent red cell mass.

Rationale Beta thalassemia is a congenital defect in the production of the beta globin chain. Patients with beta thalassemia major will have higher levels of hemoglobin F (HbF), which is suboptimal in releasing oxygen to tissue. Herein, we describe the use of red blood cell (RBC) exchange transfusion, a therapy typically used in sickle cell patients, in the management of a patient with beta thalassemia with extensive extramedullary hematopoiesis and elevated levels of HbF. Patient concerns: A 34-year-old male of mixed African American and Southeast Asian descent with a known history of beta thalassemia major presented with progressive dyspnea on exertion with marked fatigue. Diagnoses: The patient was transferred to our facility for management of acute hypoxemic, hypercapnic respiratory failure associated with cor pulmonale. Interventions The patient was initially managed with non-invasive positive pressure support ventilation (NIPPV) and intravenous diuresis. Hydroxyurea and epoprostenol nebulization were added to his treatment regimen; however, he progressively became more unstable, necessitating inotropic support. With extramedullary hematopoiesis leading to mass-like effect on critical organs and very high HbF (96%) thought to contribute to his presentation, red blood cell exchange transfusion was initiated once the blood pressure stabilized. Outcomes The patient clinically improved, and was discharged home within a week on supplemental oxygen by nasal cannula and long-term red blood cell exchange. Lessons We postulated that significantly elevated HbF contributed to the patient's chronic hypoxia and subsequent respiratory complications. Based on the patient's clinical improvement following the intervention, we believe that RBC exchange transfusion could be considered in the management of beta thalassemia patients with significantly elevated levels of HbF.

Background Blood transfusions though life-saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the 'Choosing Wisely campaign'. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost. Objectives In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre-transfusion haemoglobin (Hb) ≥7 g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions. Methods We conducted a retrospective observational study in a 64-bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N = 957) requiring packed red blood cell transfusion between January 2015 and December 2015. Results In total, 3140 units were transfused with a mean pre-transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty-four (30%) transfusion events occurred with a pre-transfusion Hb ≥7 g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre-transfusion Hb ≥7 g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.88; p = 0.02) and LOS in patients with chronic blood loss (β1 .8.26, 95% CI 4.09-12.43; p Conclusion A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.

Acute chest syndrome (ACS) is one of the major causes of mortality and morbidity in patients with sickle cell disease (SCD). ACS usually presents in a more severe form in adults older than 20 years. High clinical suspicion should be maintained in SCD patients who presents with painful crises. This case report presents an interesting severe form of ACS that, quite unusually, required repeated exchanged blood transfusion to achieve clinical improvement.

To compare the characteristics and short-term outcomes in extremely preterm infants, who developed necrotizing enterocolitis (NEC) following a packed red blood cell transfusion (pRBC) within 48 h (TANEC), with those who developed NEC beyond 48 h (non-TANEC).A single-center retrospective cohort study in a Tertiary neonatal intensive care unit in the UK over a 5-year period.Extremely premature infants (23-27 weeks gestation) were selected. TANEC and non-TANEC incidence were calculated from the confirmed NEC group (defined as modified Bell's stage II and beyond). The characteristics and short-term outcomes of infants with TANEC in the first 8 weeks of life were compared to infants with non-TANEC.Incidence of confirmed NEC was 14% (28/207). On further subgroup analysis of the confirmed NEC cases, 46% (13/28) of infants were identified with TANEC and 54% (15/28) with non-TANEC. The incidence of TANEC did not correlate with the number of antecedent pRBC transfusions or the pre-transfusion median hemoglobin (Hb) levels. There were no significant differences in characteristics between the TANEC and non-TANEC groups. Infants within the TANEC group required more intensive neonatal care support, greater surgical intervention (A significantly worse clinical course and short-term outcome was observed in the TANEC group when compared with the non-TANEC group.

Supplemental Digital Content is available in the text., Background. Blood from deceased organ donors, also known as donor blood (DB), has the potential to reduce the need for packed red blood cells (PRBCs) during liver transplantation (LT). We hypothesized that DB removed during organ procurement is a viable resource that could reduce the need for PRBCs during LT. Methods. We retrospectively examined data on LT recipients aged over 18 y who underwent a deceased donor LT. The primary aim was to compare the incidence of PRBC transfusion in LT patients who received intraoperative DB (the DB group) to those who did not (the nondonor blood [NDB] group). Results. After a propensity score matching process, 175 patients received DB and 175 did not. The median (first–third quartile) volume of DB transfused was 690.0 mL (500.0–900.0), equivalent to a median of 3.1 units (2.3–4.1). More patients in the NDB group received an intraoperative PRBC transfusion than in the DB group: 74.3% (95% confidence intervals, 67.8-80.8) compared with 60% (95% confidence intervals, 52.7-67.3); P = 0.004. The median number of PRBCs transfused intraoperatively was higher in the NDB group compared with the DB group: 3 units (0–6) compared with 2 units (0–4); P = 0.004. There were no significant differences observed in the secondary outcomes. Conclusions. Use of DB removed during organ procurement and reinfused to the recipient is a viable resource for reducing the requirements for PRBCs during LT. Use of DB minimizes the exposure of the recipient to multiple donor sources.