1.
The Effect of Sex-Mismatched Red Blood Cell Transfusion on Endothelial Cell Activation in Critically Ill Patients
Alshalani A, van Manen L, Boshuizen M, van Bruggen R, Acker JP, Juffermans NP
Transfusion medicine and hemotherapy : offizielles Organ der Deutschen Gesellschaft fur Transfusionsmedizin und Immunhamatologie. 2022;49(2):98-105
Abstract
BACKGROUND Observational studies suggest that sex-mismatched transfusion is associated with increased mortality. Mechanisms driving mortality are not known but may include endothelial activation. The aim of this study is to investigate the effects of sex-mismatched red blood cell (RBC) transfusions on endothelial cell activation markers in critically ill patients. STUDY DESIGN AND METHODS In patients admitted to the intensive care unit who received a single RBC unit, blood samples were drawn before (T(0)), 1 h after (T(1)), and 24 h after transfusion (T(24)) for analysis of soluble syndecan-1, soluble intercellular adhesion molecule-1, soluble thrombomodulin (sTM), von Willebrand factor antigen, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNFα). Changes in the levels of these factors were compared between sex-matched and sex-mismatched groups. RESULTS Of 69 included patients, 32 patients were in the sex-matched and 37 patients were in the sex-mismatched group. Compared to baseline, sex-matched transfusion was associated with significant reduction in sTM level (p value = 0.03). Between-group comparison showed that levels of syndecan-1 and sTM were significantly higher in the sex-mismatched group compared to the sex-matched group at T(24) (p value = 0.04 and 0.01, respectively). Also, TNFα and IL-6 levels showed a statistically marginal significant increase compared to baseline in the sex-mismatched group at T(24) (p value = 0.06 and 0.05, respectively), but not in the sex-matched group. DISCUSSION Transfusion of a single sex-mismatched RBC unit was associated with higher syndecan-1 and sTM levels compared to transfusion of sex-matched RBC unit. These findings may suggest that sex-mismatched RBC transfusion is associated with endothelial activation.
2.
Continuous postoperative pericardial flushing reduces postoperative bleeding after coronary artery bypass grafting: A randomized trial
Diephuis EC, de Borgie CA, Zwinderman A, Winkelman JA, van Boven WP, Henriques JPS, Eberl S, Juffermans NP, Schultz MJ, Klautz RJM, et al
EClinicalMedicine. 2021;31:100661
Abstract
BACKGROUND Prolonged or excessive bleeding after cardiac surgery can lead to a broad spectrum of secondary complications. One of the underlying causes is incomplete wound drainage, with subsequent accumulation of blood and clots in the pericardium. We developed the continuous postoperative pericardial flushing (CPPF) therapy to improve wound drainage and reduce postoperative blood loss and bleeding-related complications after cardiac surgery. This study compared CPPF to standard care in patients after coronary artery bypass grafting (CABG). METHODS This is a single center, open label, randomized trial that enrolled patients at the Amsterdam UMC, location AMC, Amsterdam, the Netherlands. The study was registered at the 'Netherlands Trial Register', study identifier NTR5200 [1]. Adults undergoing CABG were randomly assigned to receive CPPF therapy or standard care, participants and investigators were not masked to group assignment. The primary end point was postoperative blood loss in the first 12-hours after surgery. FINDINGS Between the January 15, 2014 and the March 13, 2017, 169 patients were enrolled and assigned to CPPF therapy (study group; n = 83) or standard care (control group; n = 86). CPPF reduced postoperative blood loss when compared to standard care (median differences -385 ml, reduction 76% p=≤0.001), with the remark that these results are overestimated due to a measurement error in part of the study group. None of patients in the study group required reoperation for non-surgical bleeding versus 3 (4%, 95% CI -0.4% to 7.0%) in the control group. None of the patients in the study group suffered from cardiac tamponade, versus 3 (4%, 95% CI -0,4% to 7.0%) in the control group. The incremental cost-effectiveness ratio was €116.513 (95% bootstrap CI €-882.068 to €+897.278). INTERPRETATION The use of CPPF therapy after CABG seems to reduce bleeding and bleeding related complications. With comparable costs and no improvement in Qualty of Life (QoL), cost consideration for the implementation of CPPF is not relevant. None of the patients in the study group required re-interventions for non-surgical bleeding or acute cardiac tamponade, which underlines the proof of concept of this novel therapy. FUNDING This study was funded by ZonMw, the Netherlands organization for health research and development (project 837001405).
3.
Effectiveness of prothrombin complex concentrate for the treatment of bleeding: A systematic review and meta-analysis
van den Brink DP, Wirtz MR, Neto AS, Schochl H, Viersen V, Binnekade J, Juffermans NP
J Thromb Haemost. 2020
Abstract
Prothrombin complex concentrate(PCC) is increasingly being used as a treatment for major bleeding in patients who are not taking anticoagulants. The aim of this systematic review and meta-analysis is to evaluate the effectiveness of PCC administration for the treatment of bleeding in patients not taking anticoagulants. Studies investigating the effectivity of PCC to treat bleeding in adult patients and providing data on either mortality or blood loss were eligible. Data were pooled using Mantel-Haenszel random effects meta-analysis or inverse variance random effects meta-analysis. From 4668 identified studies, 17 observational studies were included. In all patient groups combined, PCC administration was not associated with mortality (odds ratio=0.83; confidence interval =0.66 - 1.06; p=0.13; I2=0%). However, in trauma patients, PCC administration, in addition to fresh frozen plasma, was associated with reduced mortality (odds ratio=0.64; confidence interval=0.46-0.88; p=0.007; I2=0%). PCC administration was associated with a reduction in blood loss in cardiac surgery patients(mean difference: -384; confidence interval =-640 - -128, p=0.003, I2=81%) and a decreased need for red blood cell transfusions when compared to standard care across a wide range of bleeding patients not taking anticoagulants (mean difference: -1.80; confidence interval =-3.22 - -0.38; p=0.01; I2=92%. In conclusion, PCC administration was not associated with reduced mortality in the whole cohort but did reduce mortality in trauma patients. In bleeding patients, PCC reduced the need for RBC transfusions when compared to treatment strategies not involving PCC. In bleeding cardiac surgery patients, PCC administration reduced blood loss.
4.
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.