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1.
Development and validation of a nomogram to predict intraoperative blood transfusion for gastric cancer surgery
Huang H, Cao M
Transfusion medicine (Oxford, England). 2021
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Editor's Choice
Abstract
OBJECTIVE To construct and validate a nomogram composed of preoperative variables to predict intraoperative blood transfusion for gastric cancer surgery. BACKGROUND Intraoperative transfusion for gastric cancer surgery is a common medical procedure that is associated with increased postoperative complications. METHODS A total of 999 patients who underwent gastrectomy between January 2010 and June 2019 were randomly allocated into the primary and validation cohorts in a 2:1 ratio. In the primary cohort, logistic analyses were performed to identify independent predictors for transfusion. Using the Akaike information criterion, selected variables were incorporated to construct a nomogram. Validations of the nomogram were performed in the primary and validation cohorts. The discrimination ability of the nomogram was assessed by the concordance index (C-index), and calibration was assessed by calibration curves and the Hosmer-Lemeshow goodness-of-fit test. RESULTS The following risk factors for transfusion were identified and used to construct the nomogram: ASA status (III-IV vs I-II: odds ratio [OR] 1.74), comorbidities (yes vs no: OR 1.57), tumour location (diffuse vs lower: OR 4.05), cTNM stage (III vs I: OR 1.95), and a preoperative haemoglobin level less than 80 g/L (vs over 120 g/L: OR 35.30). The C-index was 0.859 and 0.850 in the primary and validation cohorts, respectively, which both indicated good discrimination of the nomogram. Additionally, both calibration curves and Hosmer-Lemeshow tests (p-value 0.184 and 0.887, respectively) demonstrated high agreement between the predictions and actual outcomes. CONCLUSION A nomogram composed of preoperative variables to predict blood transfusion for gastric cancer surgery was effectively developed and validated. This nomogram could be used to improve the utilisation of red blood cells for gastrectomy.
PICO Summary
Population
Patients undergoing gastric cancer surgery (n= 999).
Intervention
Nomogram of preoperative variables to predict intraoperative blood transfusion (primary cohort, n= 666).
Comparison
Nomogram of preoperative variables to predict intraoperative blood transfusion (validation cohort, n= 333).
Outcome
The following risk factors for transfusion were identified and used to construct the nomogram: ASA (American Society of Anaesthesiologists) physical status, comorbidities, tumour location, Clinical Tumour-Lymph Node-Metastasis stage, and a preoperative haemoglobin level less than 80 g/L. The concordance index was 0.859 and 0.850 in the primary and validation cohorts, respectively, which both indicated good discrimination of the nomogram. Additionally, both calibration curves and Hosmer-Lemeshow tests demonstrated high agreement between the predictions and actual outcomes.
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2.
Restrictive versus liberal transfusion strategy in upper gastrointestinal bleeding: A randomized controlled trial
Kola G, Sureshkumar S, Mohsina S, Sreenath GS, Kate V
Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association. 2020
Abstract
BACKGROUND The study aimed at comparing restrictive and liberal transfusion strategy in reducing mortality in patients with upper gastrointestinal bleeding (UGIB). METHODS This was a single-center, prospective, open-label, non-inferiority, randomized controlled trial conducted over two years. Patients presenting with UGIB were randomized into restrictive (hemoglobin (Hb) <7 g/dl) or liberal (Hb <8 g/dl) transfusion strategy groups. Transfusion was given till patients achieved target Hb of 9 g/dl in restrictive and 10 g/dl in the liberal arms. Patients with exsanguinating bleeding, transfusion within 90 days, recent history of trauma or surgery were excluded. Primary outcome was mortality rate and the secondary outcomes were morbidity, re-bleeding episodes and the need for intervention. RESULTS A total of 224 patients were randomized to 112 patients in each group. Demographic characteristics were comparable. 45-day mortality was similar between the two groups (restrictive vs. liberal; 10/112 vs. 12/112; P = 0.65). The number of in-hospital bleeding episodes (12 vs. 9; P = 0.25), incidence of re-bleeding during the 45-day follow-up (13 vs. 14; P = 0.84), need for endoscopic banding for varices (37/112 vs. 39/112, P = 0.99), mean hospital stay (days) (3.21 ± 2.78 vs. 2.73 ± 1.29; P = 0.10) were similar between the two groups. CONCLUSION Restrictive transfusion strategy is non-inferior to liberal transfusion strategy in patients with UGIB.
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Comparison of three transfusion protocols prior to central venous catheterization in patients with cirrhosis: A randomized controlled trial
Rocha LL, Neto AS, Pessoa CMS, Almeida MD, Juffermans NP, Crochemore T, Rodrigues RR, Filho RR, Chaves RCF, Cavalheiro AM, et al
Journal of thrombosis and haemostasis : JTH. 2019
Abstract
BACKGROUND Transfusion of blood components prior to invasive procedures in cirrhosis patients is high and associated with adverse events. OBJECTIVES We compared three transfusion strategies prior to central venous catheterization in cirrhosis patients. PATIENTS/METHODS Single center randomized trial that included critically ill cirrhosis patients with indication for central venous line in a tertiary private hospital in Brazil. INTERVENTIONS Restrictive protocol, thromboelastometry-guided protocol, or usual care (based on coagulogram). The primary endpoint was the proportion of patients transfused with any blood component (i.e. fresh frozen plasma, platelets or cryoprecipitate). The secondary endpoints included incidence of bleeding and transfusion-related adverse events. RESULTS A total of 57 patients (19 per group; 64.9% male; mean age, 53.4 +/- 11.3 years) were enrolled. Prior to catheterization, 3/19 (15.8%) in the restrictive arm, 13/19 (68.4%) in the thromboelastometry-guided arm and 14/19 (73.7%) in the coagulogram-guided arm received blood transfusion (OR, 0.07; 95% CI, 0.01 - 0.45; p = 0.002 for restrictive vs. coagulogram-guided arm; OR, 0.09; 95% CI, 0.01 - 0.56; p = 0.006 for restrictive vs. thromboelastometry-guided arm; and OR, 0.77; 95% CI, 0.14 - 4.15; p = 0.931 for thromboelastometry-guided vs. coagulogram-guided arm). The restrictive protocol was cost saving. No difference in bleeding, length of stay, mortality, and transfusion-related adverse events was found. CONCLUSIONS The use of a restrictive strategy is associated with a reduction in transfusion prior to central venous catheterization and costs in critically ill cirrhosis patients. No effect on bleeding was found among the groups.
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Thromboelastography-Guided Blood Component Use in Patients With Cirrhosis With Nonvariceal Bleeding: A Randomized Controlled Trial
Kumar M, Ahmad J, Maiwall R, Choudhury A, Bajpai M, Mitra LG, Saluja V, Mohan Agarwal P, Bihari C, Shasthry SM, et al
Hepatology (Baltimore, Md.). 2019
Abstract
Thromboelastography (TEG) provides a more comprehensive global coagulation assessment than routine tests (international normalized ratio [INR] and platelet [PLT] count), and its use may avoid unnecessary blood component transfusion in patients with advanced cirrhosis and significant coagulopathy who have nonvariceal upper gastrointestinal (GI) bleeding. A total of 96 patients with significant coagulopathy (defined in this study as INR >1.8 and/or PLT count <50 x 10(9) /L) and nonvariceal upper GI bleed (diagnosed after doing upper gastrointestinal endoscopy [UGIE], which showed ongoing bleed from a nonvariceal source) were randomly allocated to TEG-guided transfusion strategy (TEG group; n = 49) or standard-of-care (SOC) group (n = 47). In the TEG group, only 26.5% patients were transfused with all three blood components (fresh frozen plasma [FFP], PLTs, and cryoprecipitate) versus 87.2% in the SOC group (P < 0.001). Whereas 7 (14.3%) patients in the TEG group received no blood component transfusion, there were no such patients in the SOC group (P = 0.012). Also, there was a significantly lower use of blood components (FFP, PLTs, and cryoprecipitate) in the TEG group compared to the SOC group. Failure to control bleed, failure to prevent rebleeds, and mortality between the two groups were similar. CONCLUSION In patients with advanced cirrhosis with coagulopathy and nonvariceal upper GI bleeding, TEG-guided transfusion strategy leads to a significantly lower use of blood components compared to SOC (transfusion guided by INR and PLT count), without an increase in failure to control bleed, failure to prevent rebleed, and mortality.
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The use of a thromboelastometry-based algorithm reduces the need for blood product transfusion during orthotopic liver transplantation: A randomised controlled study
Bonnet A, Gilquin N, Steer N, Gazon M, Quattrone D, Pradat P, Maynard M, Mabrut JY, Aubrun F
European journal of anaesthesiology. 2019;36(11):825-833
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Editor's Choice
Abstract
BACKGROUND Orthotopic liver transplantation is associated with a risk of bleeding. Coagulation in cirrhotic patients is difficult to assess with standard coagulation tests because of rebalanced coagulation. This can be better assessed by thromboelastometry which can detect coagulation impairments more specifically in such patients. OBJECTIVES Our first objective was to compare the number of units of blood products transfused during liver transplantation when using an algorithm based on standard coagulation tests or a thromboelastometry-guided transfusion algorithm. DESIGN Randomised controlled trial. SETTING Single-centre tertiary care hospital in France, from December 2014 to August 2016. PARTICIPANTS A total of 81 adult patients undergoing orthotopic liver transplantation were studied. Patients were excluded if they had congenital coagulopathies. INTERVENTION Transfusion management during liver transplantation was guided either by a standard coagulation test algorithm or by a thromboelastometry-guided algorithm. Transfusion, treatments and postoperative outcomes were compared between groups. MAIN OUTCOME MEASURES Total number of transfused blood product units during the operative period (1 U is one pack of red blood cells (RBCs), fresh frozen plasma (FFP) or platelets). RESULTS Median [interquartile range] intra-operative transfusion requirement was reduced in the thromboelastometry group (3 [2 to 4] vs. 7 [4 to 10] U, P = 0.005). FFP and tranexamic acid were administered less frequently in the thromboelastometry group (respectively 15 vs. 46.3%, P = 0.002 and 27.5 vs. 58.5%, P = 0.005), whereas fibrinogen was more often infused in the thromboelastometry group (72.5 vs. 29.3%, P < 0.001). Median transfusions of FFP (3 [2 to 6] vs. 4 [2 to 7] U, P = 0.448), RBCs (3 [2 to 5] vs. 4 [2 to 6] U, P = 0.330) and platelets (1 [1 to 2] vs. 1 [1 to 2] U, P = 0.910) were not different between groups. In the postoperative period, RBC or platelet transfusion, the need for revision surgery or occurrence of haemorrhage were not different between groups. CONCLUSION A transfusion algorithm based on thromboelastometry assessment of coagulation reduced the total number of blood product units transfused during liver transplantation, particularly FFP administration. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02352181.
PICO Summary
Population
Adult patients undergoing orthotopic liver transplantation (n=81).
Intervention
Transfusion management during liver transplantation was guided by a standard coagulation test algorithm.
Comparison
Transfusion management during liver transplantation was guided by a thromboelastometry-guided algorithm.
Outcome
Median [interquartile range] intra-operative transfusion requirement was reduced in the thromboelastometry group (3 [2 to 4] vs. 7 [4 to 10] U). FFP and tranexamic acid were administered less frequently in the thromboelastometry group (respectively 15 vs. 46.3% and 27.5 vs. 58.5%), whereas fibrinogen was more often infused in the thromboelastometry group (72.5 vs. 29.3%). Median transfusions of FFP (3 [2 to 6] vs. 4 [2 to 7] U, RBCs (3 [2 to 5] vs. 4 [2 to 6] U) and platelets (1 [1 to 2] vs. 1 [1 to 2] U) were not different between groups. In the postoperative period, RBC or platelet transfusion, the need for revision surgery or occurrence of haemorrhage were not different between groups. (1 U is one pack of red blood cells (RBCs), fresh frozen plasma (FFP) or platelets).
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Stroke Volume Variation (SVV) as an Indicator of Intraoperative Transfusion Management during Laparoscopic Colectomy. . Japanese
Suzuki H, Saima S, Arai T, Asa T, Okuda Y
Masui - Japanese Journal of Anesthesiology. 2016;65((8)):790-794.
Abstract
BACKGROUND Intraoperative transfusion manage- ment is difficult during laparoscopic surgery, because peumoperitoneum affects hemodynamics. We studied whether stroke volume variation (SVV) is useful as an indicator of transfusion management Methods : We studied 44 patients undergoing lapa- roscopic colectomy. Patients were randomly allocated to two groups, and the volume of transfusion was decided with the SVV as an indicator in one group (SVV group, n=22) or with conventional indicators, such as blood pressure, heart rate, volume of urine in the other group (control group, n=22) Results : In the SVV group, total transfusion volume and total blood loss during operation were significantly decreased, and the length of hospital stay was signifi- cantly shorter, compared with the control group. CONCLUSIONS We believe that the SVV is a useful indicator of intraoperative transfusi6h management during laparoscopic colectomy.
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The impact of two different transfusion strategies on patient immune response during major abdominal surgery: a preliminary report
Theodoraki K, Markatou M, Rizos D, Fassoulaki A
Journal of Immunological Research. 2014;2014:945829.
Abstract
Blood transfusion is associated with well-known risks. We investigated the difference between a restrictive versus a liberal transfusion strategy on the immune response, as expressed by the production of inflammatory mediators, in patients subjected to major abdominal surgery procedures. Fifty-eight patients undergoing major abdominal surgery were randomized preoperatively to either a restrictive transfusion protocol or a liberal transfusion protocol (with transfusion if hemoglobin dropped below 7.7gdL(-1) or 9.9gdL(-1), respectively). In a subgroup of 20 patients randomly selected from the original allocation groups, blood was sampled for measurement of IL-6, IL-10, and TNFalpha. Postoperative levels of IL-10 were higher in the liberal transfusion group on the first postoperative day (49.82 + 29.07 vs. 15.83 + 13.22pgmL(-1), P < 0.05). Peak postoperative IL-10 levels correlated with the units of blood transfused as well as the mean duration of storage and the storage time of the oldest unit transfused (r(2) = 0.38, P = 0.032, r(2) = 0.52, P = 0.007, and r(2) = 0.68, P<0.001, respectively). IL-10 levels were elevated in patients with a more liberal red blood cell transfusion strategy. The strength of the association between anti-inflammatory IL-10 and transfusion variables indicates that IL-10 may be an important factor in transfusion-associated immunomodulation. This trial is registered under ClinicalTrials.gov Identifier: NCT02020525.
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Beneficial effects of donor-specific transfusion on renal allograft outcome
Jovicic S, Lezaic V, Simonovic R, Djukanovic L
Clinical Transplantation. 2011;25((2):):317-24.
Abstract
INTRODUCTION Donor-specific transfusion (DST) is claimed to improve graft survival in living kidney transplantation. The aim of this study was to determine the influence of DST on the incidence of acute rejection (AR), graft function and survival in the early and late post-transplantation period in transfusion-naive patients. METHODS Three patient groups were compared: group 1 received DST (n = 18), group 2 patients received no transfusion prior to surgery (n = 13) and group 3 consisted of 132 randomly transfused patients. The DST protocol consisted of infusion of fresh whole donor blood (3 × 150 mL) at two-wk intervals accompanied by three d of azathioprine. All patients were grafted within one month after the third DST. Triple drug immunosuppression based on cyclosporine A was given to all patients. RESULTS DST and polytransfused patients experienced significantly less AR compared with group 2 patients. Two-yr graft function was significantly better in patients in groups 1 and 3 compared with group 2. Although similar eight-yr patient and graft survival was found in all the groups, delayed graft function patients had the longest graft half-life. CONCLUSION DST imposes a significant beneficial effect on the incidence of AR, DGF and graft function during the first post-transplantation year in transfusion-naive patients receiving standard immunosuppression therapy.
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Does the inactivation of leukocytes in blood transfusions during and following liver transplantation by gamma-irradiation have an impact on rejection and infection rate?
Ott R, Bussenius-Kammerer M, Reck T, Hering C, Müller V, Riese J, Koch CA
Medical Science Monitor : International Medical Journal of Experimental and Clinical Research. 2006;12((12):):CR514-520.
Abstract
BACKGROUND Leukocytes transmitted in blood products exert a variety of immunological side-effects. Experience with bone marrow transplant recipients has shown that these can be induced even by very few cells. In liver transplant recipients, who usually receive large amounts of blood products, the effects of transfused leukocytes with regards to the rates of rejection and infection have not yet been investigated. MATERIAL/METHODS Twenty liver transplant recipients were prospectively randomized to receive blood products (red blood cells, thrombocytes, fresh frozen plasma) through a leukocyte depletion filter, either irradiated with 40 Gy or not irradiated (10 patients, respectively). During the observation period of 90 days, the incidences of infections and rejections were analyzed. In addition, liver function tests, markers of infection (C reactive protein, lipopolysaccharide binding protein), and subpopulations of lymphocytes (total cell count, CD4/CD8 ratio, CD8CD45RO) were determined. RESULTS Only one episode of mild rejection occurred (irradiated group). Rates of persistent graft dysfunction and severe infections were similar in both groups. The same applied to liver function tests, parameters of infection, and subpopulations of lymphocytes. CONCLUSIONS These preliminary results suggest that irradiation of already leukocyte-depleted blood products may not be necessary and beneficial in liver transplant recipients.
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Multicenter trial of one HLA-DR-matched or mismatched blood transfusion prior to cadaveric renal transplantation
Hiesse C, Busson M, Buisson C, Farahmand H, Bierling P, Benbunan M, Bedrossian J, Aubert P, Glotz D, Loirat C, et al
Kidney International. 2001;60((1):):341-9.
Abstract
BACKGROUND The beneficial effect of blood transfusions before cadaveric renal transplantation on allograft survival, although previously well documented, has become controversial in light of their adverse effects. Recently, it has been suggested that their clinical benefits are due to HLA-DR sharing between the blood donor and recipient. METHODS In this prospective study, 144 naive patients were randomly assigned to receive one unit of blood matched for one-HLA-DR antigen (N = 49), or one unit of mismatched blood (N = 48), or to remain untransfused (N = 47). Graft survival and acute rejection rate were analyzed in 106 cadaveric renal allograft recipients receiving the same immunosuppressive protocol. RESULTS Graft survival was similar in the three groups at one and five years: 91.7 and 80% in untransfused patients, 90.3 and 79.3% in patients transfused with one DR-antigen-matched unit, and 92.3 and 83.7% in patients transfused with HLA-mismatched blood. The difference in the incidence of six-month post-transplant acute rejections was not statistically significant in the three groups: 12 out of 36, 33.3% in nontransfused patients; 6 out of 31, 19.4% in patients transfused with one DR-matched blood; and 13 out of 39, 33.3% in patients transfused with mismatched blood. CONCLUSION The results of our prospective randomized trial showed that in a population of naive patients, one transfusion mismatched or matched for one HLA-DR antigen given prior to renal transplantation had no significant effect on the incidence and severity of acute rejection, and did not influence overall long-term graft outcome. Considering the potentially deleterious adverse effects of blood transfusions, the costs, and the considerable logistical efforts required to select and type blood donors, such a procedure cannot be recommended in a routine practice for patients awaiting cadaveric kidney transplantation.