Optimized acute bleeding management requires timely and reliable laboratory testing to detect and diagnose coagulopathies and guide transfusion therapy. Conventional coagulation tests (CCT) are ...inexpensive with minimal labor requirements, but CCTs may have delayed turnaround times. In addition, abnormal CCT values may not reflect in vivo coagulopathies that require treatment and may lead to overtransfusion. The use of viscoelastic testing (VET) has been rapidly expanding and is recommended by several recent bleeding guidelines. This review is intended to compare CCT to VET, review the strengths and weaknesses of both approaches, and evaluate and summarize the clinical studies that compared CCT‐based and VET‐based transfusion algorithms. Most studies of CCT vs VET transfusion algorithms favor the use of VET in the management of massively bleeding patients due to reductions in blood product utilization, bleeding, costs, and lengths of stay.
KEY IDEAS
There is great variation in the study design of the 21 major randomized controlled trials assessing fibrinogen concentrate use in perioperative settings, thus making it a confusing ...landscape to draw definitive conclusions about the efficacy of this drug.
Approximately 60% of the studies in which fibrinogen concentrate was used to treat clinically relevant bleeding showed decreased bleeding tendency and decreased transfusion requirements versus comparative treatment. It is unclear why the remainder did not show decreased bleeding. It should be noted that many patients in these studies 1) did not have significant hypofibrinogemia, 2) did not have significant bleeding in either arm, and/or 3) were treated only once with the intervention during complex major surgeries that required many transfusions.
Randomized controlled trials have cumulatively evaluated over 700 patients who received fibrinogen concentrate but have not reported an increase in the rate of perioperative thrombosis in the fibrinogen versus comparator arms.
Patients with cancer may be at increased risk of severe coronavirus disease 2019 (COVID-19), but the role of viral load on this risk is unknown. We measured SARS-CoV-2 viral load using cycle ...threshold (CT) values from reverse-transcription polymerase chain reaction assays applied to nasopharyngeal swab specimens in 100 patients with cancer and 2,914 without cancer who were admitted to three New York City hospitals. Overall, the in-hospital mortality rate was 38.8% among patients with a high viral load, 24.1% among patients with a medium viral load, and 15.3% among patients with a low viral load (p < 0.001). Similar findings were observed in patients with cancer (high, 45.2% mortality; medium, 28.0%; low, 12.1%; p = 0.008). Patients with hematologic malignancies had higher median viral loads (CT = 25.0) than patients without cancer (CT = 29.2; p = 0.0039). SARS-CoV-2 viral load results may offer vital prognostic information for patients with and without cancer who are hospitalized with COVID-19.
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•High viral load predicts mortality in hospitalized patients with and without cancer•Patients with hematologic cancers have higher viral loads than non-cancer patients•Viral load results may help clinicians care for hospitalized patients with COVID-19
Westblade et al. reveal that admission viral load independently predicts mortality in hospitalized patients with and without cancer who have COVID-19, and that patients with hematologic malignancies have higher admission viral loads than patients with solid tumors or without cancer. Providing viral load information to clinicians may guide the care of hospitalized patients with COVID-19.
Increasing evidence supports the role of red blood cells (RBCs) in physiological hemostasis and pathologic thrombosis. Red blood cells are commonly transfused in the perioperative period; however, ...their association with postoperative thrombotic events remains unclear.
To examine the association between perioperative RBC transfusions and postoperative venous thromboembolism (VTE) within 30 days of surgery.
This analysis used prospectively collected registry data from the American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) database, a validated registry of 525 teaching and nonteaching hospitals in North America. Participants included patients in the ACS-NSQIP registry who underwent a surgical procedure from January 1 through December 31, 2014. Data were analyzed from July 1, 2016, through March 15, 2018.
Risk-adjusted odds ratios (aORs) were estimated using multivariable logistic regression. The primary outcome was the development of postoperative VTE (deep venous thrombosis DVT and pulmonary embolism PE) within 30 days of surgery that warranted therapeutic intervention; DVT and PE were also examined separately as secondary outcomes. Subgroup analyses were performed by surgical subtypes. Propensity score matching was performed for sensitivity analyses.
Of 750 937 patients (56.8% women; median age, 58 years; interquartile range, 44-69 years), 47 410 (6.3%) received at least 1 perioperative RBC transfusion. Postoperative VTE occurred in 6309 patients (0.8%) (DVT in 4336 0.6%; PE in 2514 0.3%; both DVT and PE in 541 0.1%). Perioperative RBC transfusion was associated with higher odds of VTE (aOR, 2.1; 95% CI, 2.0-2.3), DVT (aOR, 2.2; 95% CI, 2.1-2.4), and PE (aOR, 1.9; 95% CI, 1.7-2.1), independent of various putative risk factors. A significant dose-response effect was observed with increased odds of VTE as the number of intraoperative and/or postoperative RBC transfusion events increased (aOR, 2.1 95% CI, 2.0-2.3 for 1 event; 3.1 95% CI, 1.7-5.7 for 2 events; and 4.5 95% CI, 1.0-19.4 for ≥3 events vs no intraoperative or postoperative RBC transfusion; P < .001 for trend). In subgroup analyses, the association between any perioperative RBC transfusion and postoperative VTE remained statistically significant across all surgical subspecialties analyzed. The association between any perioperative RBC transfusion and the development of postoperative VTE also remained robust after 1:1 propensity score matching (47 142 matched pairs; matched OR, 1.9; 95% CI, 1.8-2.1).
The results of this study suggest that perioperative RBC transfusions may be significantly associated with the development of new or progressive postoperative VTE, independent of several putative confounders. These findings, if validated, should reinforce the importance of rigorous perioperative management of blood transfusion practices.
Background
Hemorrhage is a leading cause of preventable death in trauma, cardiac surgery, liver transplant, and childbirth. While emphasis on protocolization and ratio of blood product transfusion ...improves ability to treat hemorrhage rapidly, tools to facilitate understanding of the overall content of a specific transfusion strategy are lacking. Medical modeling can provide insights into where deficits in treatment could arise and key areas for clinical study. By using a transfusion model to gain insight into the aggregate content of massive transfusion protocols (MTPs), clinicians can optimize protocols and create opportunities for future studies of precision transfusion medicine in hemorrhage treatment.
Methods
The transfusion model describes the individual round and aggregate content provided by four rounds of MTP, illustrating that the total content of blood elements and coagulation factor changes over time, independent of the patient's condition. The configurable model calculates the aggregate hematocrit, platelet concentration, percent volume plasma, total grams and concentration of citrate, percent volume anticoagulant and additive solution, and concentration of clotting factors: fibrinogen, factor XIII, factor VIII, and von Willebrand factor, provided by the MTP strategy.
Results
Transfusion strategies based on a 1:1:1 or whole blood foundation provide between 13.7 and 17.2 L of blood products over four rounds. Content of strategies varies widely across all measurements based on base strategy and addition of concentrated sources of fibrinogen and other key clotting factors.
Discussion
Differences observed between modeled transfusion strategies provide key insights into potential opportunities to provide patients with precision transfusion strategy.
Accurate diagnostic strategies to identify SARS-CoV-2 positive individuals rapidly for management of patient care and protection of health care personnel are urgently needed. The predominant ...diagnostic test is viral RNA detection by RT-PCR from nasopharyngeal swabs specimens, however the results are not promptly obtainable in all patient care locations. Routine laboratory testing, in contrast, is readily available with a turn-around time (TAT) usually within 1-2 hours.
We developed a machine learning model incorporating patient demographic features (age, sex, race) with 27 routine laboratory tests to predict an individual's SARS-CoV-2 infection status. Laboratory testing results obtained within 2 days before the release of SARS-CoV-2 RT-PCR result were used to train a gradient boosting decision tree (GBDT) model from 3,356 SARS-CoV-2 RT-PCR tested patients (1,402 positive and 1,954 negative) evaluated at a metropolitan hospital.
The model achieved an area under the receiver operating characteristic curve (AUC) of 0.854 (95% CI: 0.829-0.878). Application of this model to an independent patient dataset from a separate hospital resulted in a comparable AUC (0.838), validating the generalization of its use. Moreover, our model predicted initial SARS-CoV-2 RT-PCR positivity in 66% individuals whose RT-PCR result changed from negative to positive within 2 days.
This model employing routine laboratory test results offers opportunities for early and rapid identification of high-risk SARS-CoV-2 infected patients before their RT-PCR results are available. It may play an important role in assisting the identification of SARS-CoV-2 infected patients in areas where RT-PCR testing is not accessible due to financial or supply constraints.
Abstract Red blood cell transfusions are a common life-saving intervention for neonates and children with anemia, but transfusion decisions, indications and doses in neonates and children are ...different from those of adults. Patient blood management (PBM) programs are designed to assist clinicians with appropriately transfusing patients. While PBM programs are well-recognized and appreciated in the adult setting, they are quite far from standard-of-care in the pediatric patient population. Adult PBM standards cannot be uniformly applied to children and there currently is significant variation in transfusion practices. Since transfusing unnecessarily can expose children to increased risk without benefit, it is important to design PBM programs to standardize transfusion decisions. This article assesses the key elements necessary for a successful pediatric PBM program and further systematically explores various possible pediatric specific blood conservation strategies, the current available literature supporting them and outlines the gaps in the evidence suggesting need for further/improved research. Pediatric PBM programs are critically important initiatives that not only involve a cooperative effort between pediatric surgery, anesthesia, perfusion, critical care, and transfusion medicine services but also need operational support from administration, clinical leadership, finance and the hospital information technology personnel. These programs also expand the scope for high quality collaborative research. A key component of pediatric PBM programs is monitoring pediatric blood utilization and assessing adherence to transfusion guidelines. Data suggest restrictive transfusion strategies should be employed for neonates and children similar to adults, but further research is needed to assess the best oxygenation requirements, hemoglobin threshold and transfusion strategy for patients with active bleeding, hemodynamic instability, unstable cardiac disease and cyanotic cardiac disease. Peri-operative blood management strategies include minimizing blood draws, restricting transfusions, intraoperative cell salvage, acute normovolemic hemodilution, anti-fibrinolytic agents, and using point of care tests to guide transfusion decisions. However, further research is needed for the use of intravenous iron, erythropoiesis stimulating agents, and possible use of whole blood and pathogen inactivation. There are numerous areas where newly formed collaborations could be utilized to investigate pediatric transfusion and these studies would provide critical data to support vital pediatric PBM programs to optimize neonatal and pediatric care.
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