Abstract 176: Optimizing Blood Product Utilization In The Cardiac Catheterization Laboratory

Background Intraoperative tranexamic acid (TXA) administration has been used to abate blood loss in a variety of surgical procedures. Several recent studies have supported its efficacy in reducing transfusion requirements in pediatric cranial vault reconstruction (CVR). Objective To conduct a retrospective chart review to determine whether a significant reduction in packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusions exists when TXA is used. Methods A retrospective cohort study of 28 patients who underwent CVR for sagittal craniosynostosis was performed. Transfusion requirements for 14 patients who did not receive TXA were compared with 14 patients who did. Predictors of increased blood product transfusion were also studied. Results Total volume of PRBC transfusion was reduced by 50% with the use of TXA (P=0.004) with a 34% reduction in intraoperative PRBC transfusion (P=0.017) and a 67% reduction in postoperative PRBC transfusion (P<0.001). Total volume of FFP transfusion was reduced by 46% (P=0.002) and postoperative FFP transfusion was reduced by 100% (P=0.001). The use of TXA was associated with a lower total volume of PRBC (P=0.003) and FFP (P=0.003) transfusions. Older patient age was associated with lower total volume of PRBC transfused (P=0.046 and P=0.002), but not with FFP (P=0.183 and P=0.099) transfusion volumes. Increasing patient weight was associated with lower PRBC (P=0.010 and P=0.020) and FFP (P=0.045 and P=0.016) transfusion volumes. Conclusion TXA decreased blood product transfusion requirements in patients undergoing CVR for sagittal craniosynostosis, and should be a routine part of the strategy to reduce blood loss in these procedures.

AIMTo determine if packed red blood cell transfusions contribute to the development of parenteral nutrition associated liver disease.METHODSA retrospective chart review of 49 premature infants on parenteral nutrition for > 30 d who received packed red blood cell (PRBC) transfusions was performed. Parenteral nutrition associated liver disease was primarily defined by direct bilirubin (db) > 2.0 mg/dL. A high transfusion cohort was defined as receiving > 75 mL packed red blood cells (the median value). Kaplan-Meier plots estimated the median volume of packed red blood cells received in order to develop parenteral nutrition associated liver disease.RESULTSParenteral nutritional associated liver disease (PNALD) was noted in 21 (43%) infants based on db. Among the 27 high transfusion infants, PNALD was present in 17 (64%) based on elevated direct bilirubin which was significantly greater than the low transfusion recipients. About 50% of the infants, who were transfused 101-125 mL packed red blood cells, developed PNALD based on elevation of direct bilirubin. All infants who were transfused more than 200 mL of packed red blood cells developed PNALD. Similar results were seen when using elevation of aspartate transaminase or alanine transaminase to define PNALD.CONCLUSIONIn this retrospective, pilot study there was a statistically significant correlation between the volume of PRBC transfusions received by premature infants and the development of PNALD.

Background: Orthotopic liver transplant (LT) is often associated with massive blood loss and significant transfusion requirements. Recent recommendations for resuscitation strategy in massive bleeding include the transfusion of balanced blood products, fresh frozen plasma (FFP), platelets, packed red blood cells (PRBC), and restricted use of crystalloids. Objectives: To evaluate whether the intraoperative transfusion ratio of fresh frozen plasma to packed red blood cell units (FFP: PRBC ≤1:1 versus >1:1) plays a positive role in reducing PRBC transfusion in LT. Methods: This is a retrospective study of 84 liver transplant recipients who received at least one PRBC unit during the surgery. The patients were grouped into those who received intraoperative FFP: PRBC ratio ≤1:1 (low ratio) versus the ratio>1:1 (high ratio). Selected perioperative variables were compared between the two groups. Results: Patients in the low-ratio versus high-ratio group had lower intraoperative requirements for PRBC (P<0.001). Importantly, in the high-ratio group, the mean postoperative PRBC transfused units were 1.76 times that of the low-ratio group (incidence rate ratio [IRR], 1.76; 95% CI=1.07-2.90). There was a significant difference between the two groups in preoperative body mass index (P=0.047), hemoglobin (P=0.005), and surgical time (P=0.071); moreover, all the variables were higher in the high-ratio group. After adjusting the variables, postoperative PRBC consumption in the low-ratio group was 43% less than that in the high-ratio group (P=0.007). Conclusion: The intraoperative low-ratio transfusion was associated with a reduced need for total PRBC transfusion in LT.

The integration of a restrictive packed red blood cells (PRBC) transfusion strategy into daily clinical practice presents a challenge. This study describes the effect of an intervention including educational presentations and computerized alerts on PRBC utilization at a tertiary hospital. During December 2014, lectures describing recommended PRBC transfusion indications were presented to all non-intensive care departments. Starting from January 2015, an alert was added to the electronic drug ordering system recommending transfusions at a haemoglobin (Hb) level <7 g/dl or Hb < 8 g/dl in symptomatic patients. The physician was not required to acknowledge the alert. Data regarding measured Hb preceding transfusions were collected. The primary end-point was defined as the percentage of PRBC administered at Hb ≥ 8 g/dl in 2015 compared with 2014. Secondary end-points were the percentage of PRBC administered to patients with Hb < 7 g/dl and the absolute number of PRBC transfused in 2015 compared with 2014. Compared to 2014, in 2015, the percentage of PRBC transfused when the Hb ≥ 8 g/dl was reduced by 18·8% (P < 0·001) and made up 29% of the total PRBC transfused. The absolute number of PRBC transfused decreased by 7·7%. The percentage of PRBC transfused when the Hb < 7 g/dl increased by 25·9% (P < 0·001). Following the described intervention, there was a significant improvement in the appropriateness of PRBC transfusions in our medical centre. These changes occurred despite the lack of interruption of the physician's workflow from the computerized alert. This simple strategy might be of use in implementing a restrictive PRBC transfusion strategy.

Time Burden of Blood Transfusion.

Balanced transfusion with (1:1:1) ratios of fresh frozen plasma (FFP), packed red blood cells (PRBCs), and platelets is a core tenet of management in traumatic hemorrhagic shock. However, preclinical data suggest that PRBCs transfusion may contribute to endothelial dysfunction, a complication that may be mitigated by FFP. We examined the impact of high FFP:PRBC ratios on mortality and major complications using the American College of Surgeons Trauma Quality Improvement Program database. Trauma patients (18 years or older) in Trauma Quality Improvement Program (2017-2022) who received ≥1 U FFP and 1 U PRBC within 4 hours were included. Those transfused with whole blood or FFP:PRBC <0.9 were excluded. Patients were classified as balanced (FFP:PRBC 0.9-1.1) or excess FFP (FFP:PRBC >1.1), propensity matched based on odds of mortality, and compared by multivariate regression. Of 50,594 patients analyzed (75% male; median age, 38 years; Injury Severity Score, 25), 31,960 (63%) were classified as balanced, and 18,634 (37%) as excess FFP. Propensity matching generated 16,939 pairs (mean standard difference, <0.1). After multivariable adjustment, excess FFP was associated with 40% decreased odds of acute respiratory distress syndrome ( p < 0.001) and 32% decreased odds of acute kidney injury ( p = 0.027) compared with balanced transfusion, with no difference in hospital mortality (odds ratio, 1.01; 95% confidence interval, 0.92-1.11; p = 0.87). We found that early excess FFP (FFP:PRBC ratio >1.1) was associated with a significantly decreased odds of key complications compared with a strictly defined balanced transfusion (FFP:PRBC ratio 0.9-1.1), supporting further investigation of the potential benefits of plasma. ( J Trauma Acute Care Surg. 2026;100: 760-767. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved). Therapeutic/Care Management; Level III.

We compared the safety and efficacy of 2 transfusion regimens in children with severe anemia (hemoglobin <5 g/dL) and without overt signs of congestive heart failure requiring transfusion of packed red blood cells (PRBCs). Forty-three patients were randomly divided into 2 groups: group A and group B. The transfusion regimens consisted of continuous infusion of PRBC at a rate of 1 mL/kg/h for group A and 3 mL/kg/h for group B. The patients were closely monitored for any clinical signs of heart failure throughout transfusion. Heart and respiratory rate, and arterial blood pressure were measured hourly for 6 hours during transfusion. None of the patients developed any signs of cardiac failure during or after the transfusion. The mean heart rate, respiratory rate, diastolic and systolic blood pressure were similar in both groups throughout transfusion. Group A needed significantly more PRBC units than group B to attain the same hemoglobin increase. Transfusion of PRBC at a rate of 3 mL/kg/h, and at a rate of 1 mL/kg/h, is a safe regimen for children with severe anemia of gradual onset requiring transfusion therapy.

To determine if the age of packed red blood cells (PRBCs) is associated with adverse events or outcomes in patients with subarachnoid haemorrhage (SAH). Analyse data on PRBC age to complications and outcomes in patients with SAH. Patients who receive a PRBC transfusion after SAH have a higher rate of complications, and older PRBC age may be responsible for this. We prospectively recorded clinical and demographic data, acute adverse effects related to transfusion, major hospital events, radiographic cerebral infarction, PRBC age and outcomes in 119 patients with SAH who received a PRBC transfusion. Patients were followed for outcomes at 14 days or discharge, 28 days and 3 months with the modified Rankin scale (a measure of neurologic function). In 241 PRBC transfusions, there was new fever in 36 (15%), hypotension in 23 (10%), pulmonary oedema or symptomatic respiratory distress in 5 (2%) and rash in 1 (1%). Age of PRBCs administered was not associated with vasospasm, cerebral infarction, acute adverse events or outcomes (P > 0·1 for all). In this small registry of patients with SAH, the age of transfused PRBCs was not associated with adverse events or outcomes.

To the Editor:—We read with interest the article about the influence of erythrocyte concentrate storage time on postoperative morbidity in cardiac surgery patients published by Leal-Noval et al. in a recent issue of the Journal, 1which was accompanied by an editorial view. 2The main finding of this study was an association between storage time of packed red blood cells (PRBC) and the acquisition of postoperative nosocomial pneumonia, but not between the former and prolonged mechanical ventilation time. We would like to comment regarding two points. First, we wish to review some mechanisms by which the relationship between the number of units and pneumonia/ventilation might be connected. Second, we want to point out that the problem may not simply be the age of the transfused blood, but also the absolute numbers of units transfused.The current authors suggested that allogeneic transfusion may cause some deleterious effects that have not been recognized and which may explain the association between the number of PRBC transfusions and prolonged mechanical ventilation, but not between the duration of storage and prolonged mechanical ventilation. 1Induction of a subclinical transfusion-related acute lung injury (TRALI) could be one of those frequently underdiagnosed deleterious effects. It has been proposed that TRALI is the result of two clinical events, the first being a predisposing clinical condition (e.g. , a postoperative systemic inflammatory response syndrome) and the second being the transfusion of biologically active molecules in stored PRBC and platelets that have neutrophil priming activity. The concentration of some of these molecules (e.g. , cytokines, neutral lipids, lysophosphatidylserine) in the stored blood component increases with the product age, whereas that of other molecules (e.g. , human lymphocyte antibody class I, class II, and granulocyte antibodies) does not. To this regard, Silliman et al. 3have found that TRALI was associated with the transfusion of older blood products, especially platelets, and that patients with cardiac disease who required cardiopulmonary bypass were at particular risk to develop TRALI reactions. However, although a significant proportion of patients (135, 16.9%) received platelet transfusion, Leal-Noval et al. 1have not studied the possible association between either the number or the age of platelet concentrates and prolonged mechanical ventilation time. Despite that, because the number of PRBC transfused was significantly higher in patients with mechanical ventilation time greater than 24 h, the development of a certain degree of TRALI, in a dose-dependent manner, may result in a worsening of the pulmonary dysfunction induced by cardiopulmonary bypass with a prolonged mechanical ventilation time and, perhaps, contributes to a higher incidence of postoperative nosocomial pneumonia. 4Regarding PRBC storage time, there are several storage-dependent alterations in erythrocytes that, together with transfusion-related immunomodulation, may contribute to the increased risk of nosocomial pneumonia in the transfused patients. The decrease in the ability of erythrocytes to deform and unload oxygen in the peripheral tissues, possibly favoring the degree of visceral ischemia, have been mentioned, 1,2but other alterations may account for when erythrocytes are stored together with white blood cells. Leukocyte enzymes, including neuraminidase, are definitive contributors to the desialylation of erythrocytes during storage and to the exposure of phosphatidylserine residues in the membrane outer leaflet. 5These changes make the erythrocytes more adherent to the inflamed endothelium and convert it into a procoagulant surface, thus contributing to the alteration of microvascular blood flow. In addition, these changes are also signals of senescence and enhance erythrocyte phagocytosis by resident macrophages. 5All methods in current use for erythrocyte storage result in the maintenance of 90% or more of the in vivo recovery for about 2–3 weeks; later an increasing proportion of erythrocytes become nonviable. When old PRBC are transfused, a substantial number of cells (some 1012erythrocytes in a four-unit transfusion) must be phagocytosed, which obviously uses part of the capacity of the phagocytic mononuclear system and may compete with infection defense with possible serious consequences, such as postoperative nosocomial pneumonia. 6We agree with Leal-Noval et al. 1with regard to the need for continued research of the possible deleterious effects of old PRBC transfusion. However, in previous work, 4this group showed an increase in the incidence of postoperative nosocomial pneumonia in those patients transfused with more than 4 units. In the present work, 1patients who developed postoperative nosocomial pneumonia received more PRBC units than those who did not (8.8 ± 4.7 vs. 5.4 ± 4.7, respectively; P &lt; 0.05). Because the authors found that each transfused PRBC unit increased the risk of postoperative pneumonia by 11%, 1we believe that the implementation of a perioperative blood-saving program, including several alternatives to allogeneic erythrocyte transfusion (e.g. , preoperative treatment of anemia, aprotinin in pump-prime, perioperative autologous salvage), together with a restrictive transfusion strategy, 7–9would probably be a better option to reduce postoperative morbidity in cardiac surgery patients.

Transcutaneous oxygen tension monitoring in critically ill patients receiving packed red blood cells

To define and compare the incidence, patient demographics, tasking characteristics, and clinical features associated with packed red blood cell (PRBC) administration within the LifeFlight Medical Services (LFM) retrieval network during the 2024 calendar year. A retrospective cohort study examined all LFM missions in 2024 involving PRBC administration. Missions were included when PRBCs were administered by, or at the direction of, an LFM doctor. Primary missions and interfacility transfers (IFT) were analysed and compared with the overall mission cohort. Collected variables included transport platform, indication for transfusion, patient demographics, blood product utilisation, wastage, and compliance with adjunctive therapies. Among 7791 missions, PRBCs were administered on 226 missions (2.9% of all missions), including 100 primary missions (7.6% of all primary missions) and 126 IFT's (1.9% of all IFT's). A total of 492 units were transfused, with 3.0% wastage. Primary trauma accounted for 59% of transfusions and medical/surgical causes for 41%, most commonly upper gastrointestinal bleeding. Rotary-wing and road-based platforms demonstrated the highest transfusion incidence. No significant age differences were identified between transfused and non-transfused patients. Compliance with blood warming, tranexamic acid, and calcium administration was high at 81%, 83%, and 85%, respectively. Use of O-positive blood in females under 50 years was rare, occurring in 0.3% of primary missions. PRBC transfusion within LFM is infrequent but essential across all missions. This analysis provides the first comprehensive Australian description of real-world PRBC utilisation across retrieval platforms, supporting transfusion governance, operational planning, and future outcome-focused research within Australia.

The objective of this study was to analyze the transfusion practices in trauma patients in one institution. A retrospective analysis of the Trauma Registry linked with the Blood Bank Database of a Level 1 trauma center was conducted. Over 6 years, 17 per cent of the 25,599 trauma patients received blood transfusions. The overall mortality in transfused patients was 20 per cent and remained the same during the study period. There was no change in the proportion of patients receiving transfusions throughout the years, however there was a significant 23.5 per cent reduction in the mean number of packed red blood cells (PRBC) units transfused (P < 0.001 for trend). This reduction in PRBC used remained true and even more evident in the group of more severely injured patients (Injury Severity Score > or = 16), with a 27.9 per cent decrease in mean units of PRBC (P < 0.001 for trend). The highest reduction in PRBC transfusion was seen in blunt trauma patients (34.6%, P < 0.001). During the study period there was a concurrent increase in mean units of fresh frozen plasma used (60.7%, P < 0.001) and no change in the use of platelets and cryoprecipitate. In conclusion, transfusions of PRBC were significantly reduced over time in trauma patients without any evident negative impact on mortality.

Background:The optimal hemoglobin level and transfusion threshold in patients with septic shock treated with an early, goal oriented approach to resuscitation remains unknown.Aims:To assess the impact of packed red blood cell (PRBC) transfusion on clinically relevant outcomes in patients with septic shock treated with early goal directed therapy (EGDT).Settings and Design:Retrospective cohort study of 93 patients who presented with septic shock, to a single center academic intensive care unit and received EGDT.Materials and Methods:Data were collected on patients identified via the Surviving Sepsis Campaign Chart Review database and linked to Project IMPACT database. The PRBC group and no PRBC group were compared by the Pearson chi-square and Fisher’s exact test to analyze statistical significance.Results:The PRBC group had a mortality of 41.2% vs. 33.9% in the no PRBC transfusion group (P = NS). The PRBC group also had more mechanical ventilation days (11.2 days vs. 5.0 days, (P ≤ 0.05), longer hospital length of stay (25.9 days vs. 12.5 days, (P ≤ 0.05), and longer intensive care unit length of stay (11.4 days vs. 3.8 days, (P ≤ 0.05).Conclusions:In this retrospective cohort study, transfusion of PRBCs was associated with worsened clinical outcomes in patients with septic shock treated with EGDT. Further studies are needed to determine the impact of transfusion of PRBC within the context of early resuscitation of patients with septic shock, as the beneficial effects gained by an early and goal oriented approach to resuscitation may be lost by the negative effects associated with PRBC transfusion.

Background The effects of packed red blood cell (PRBC) transfusion on the prognosis of patients with upper gastrointestinal bleeding (UGIB), particularly on the 30-day mortality rate, are unclear. This study aimed to determine the prognostic influence of PRBC transfusion in patients with UGIB with different hemoglobin (Hb) levels. Methods The subjects in this study were selected from the Philips Electronic ICU Collaborative Research Database Version 2.0 multicenter critically ill patient database from January 2014 to December 2015. A total of 4689 patients were included in this study. The Hb levels were divided into 3 groups: Hb &lt;6 g/dL (Group 1), 6 g/dL ≤ Hb &lt; 8 g/dL (Group 2), and Hb ≥8 g/dL (Group 3). Based on the administration of PRBC transfusion, each group was subdivided into PRBC and non-PRBC groups. Results A total of 4689 patients were enrolled in the study, including 825, 2195, and 1669 patients in Groups 1, 2, and 3, respectively. Furthermore, the PRBC and non-PRBC groups consisted of 1847 and 2842 patients, respectively. There was no significant difference in the 30-day mortality rate between Group 1 and Group 2 or between the PRBC and non-PRBC subgroups. In Group 3, the 30-day mortality rate of patients who received transfusion was higher than that of patients who did not (13.29% vs 9.14%, P = 0.029). For the PRBC group, the difference in 30-day mortality rate was not statistically significant among the 3 groups, whereas for the non-PRBC group, the 30-day mortality rate in Group 3 was the lowest, and there was a significant difference among the 3 groups (P = 0.003). There was no significant difference in the subgroup analysis of bleeding at different sites and etiologies. Conclusion Packed red blood cell transfusion does not improve prognosis or reduce mortality in patients with UGIB but may increase mortality in patients with Hb levels greater than 8 g/dL.

Transfusion-Free Surgical Program Reduces Use of Blood Products for Patients Undergoing Liver Transplantation