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Evidence for red blood cell (RBC) transfusion thresholds in the intraoperative setting is limited, and current perioperative recommendations may not correspond with individual intraoperative physiological demands. Hemodynamics relevant for the decision to transfuse may include peripheral perfusion index (PPI). The objective of this prospective study was to assess the associations of PPI and hemoglobin levels with the risk of postoperative morbidity and mortality. Multicenter cohort study. Bispebjerg and Hvidovre University Hospitals, Copenhagen, Denmark. We included 741 patients who underwent acute high risk abdominal surgery or hip fracture surgery. No interventions were carried out. Principal values collected included measurements of peripheral perfusion index and hemoglobin values. The study was conducted using prospectively obtained data on adults who underwent emergency high-risk surgery. Subjects were categorized into high vs. low subgroups stratified by pre-defined PPI levels (PPI: > 1.5 vs. < 1.5) and Hb levels (Hb: > 9.7 g/dL vs. < 9.7 g/dL). The study assessed mortality and severe postoperative complications within 90 days. We included 741 patients. 90-day mortality was 21% (n = 154), frequency of severe postoperative complications was 31% (n = 231). Patients with both low PPI and low Hb had the highest adjusted odds ratio for both 90-day severe postoperative complications (2.95, [1.62–5.45]) and 90-day mortality (3.13, [1.45–7.11]). A comparison of patients with low PPI and low Hb to those with high PPI and low Hb detected significantly higher 90-day mortality risk in the low PPI and low Hb group (OR 8.6, [1.57–162.10]). High PPI in acute surgical patients who also presents with anemia was associated with a significantly better outcome when compared with patients with both low PPI and anemia. PPI should therefore be further investigated as a potential parameter to guide intraoperative RBC transfusion therapy. •Peripheral perfusion index is associated with risk of postoperative morbidity and mortality in anemic patients•Patients with adequate peripheral perfusion index and anemia had better outcomes than those with low peripheral index and anemia•Peripheral perfusion index may be a viable parameter in guiding intraoperative RBC transfusion therapy

Background: Effective blood inventory management reduces outdates of blood products. Multiple strategies have been employed to reduce the rate of red blood cell (RBC) unit outdate. We designed an automated real-time web-based dashboard interfaced with our laboratory information system to effectively recycle red cell units. The objective of our approach is to decrease RBC outdate rates within our transfusion service. Methods: The dashboard was deployed in August 2011 and is accessed by a shortcut that was placed on the desktops of all blood transfusion services computers in the Capital District Health Authority region. It was designed to refresh automatically every 10 min. The dashboard provides all vital information on RBC units, and implemented a color coding scheme to indicate an RBC unit's proximity to expiration. Results: The overall RBC unit outdate rate in the 7 months period following implementation of the dashboard (September 2011-March 2012) was 1.24% (123 units outdated/9763 units received), compared to similar periods in 2010-2011 and 2009-2010: 2.03% (188/9395) and 2.81% (261/9220), respectively. The odds ratio of a RBC unit outdate postdashboard (2011-2012) compared with 2010-2011 was 0.625 (95% confidence interval: 0.497-0.786; P < 0.0001). Conclusion: Our dashboard system is an inexpensive and novel blood inventory management system which was associated with a significant reduction in RBC unit outdate rates at our institution over a period of 7 months. This system, or components of it, could be a useful addition to existing RBC management systems at other institutions.

Some large, randomized trials investigating red cell transfusion strategies have significant numbers of transfusions administered outside the trial study period. We sought to investigate the potential impact of this methodological issue. Meta-analysis of randomized controlled trials (RCTs) comparing liberal vs restrictive transfusion strategies in cardiac surgery and acute myocardial infarction patients. The outcome of interest was 30-day or in-hospital mortality. In cardiac surgery, the pooled risk ratio for mortality was 0.83 (95% confidence interval [CI] 0.62-1.12, P = .22) times lower in the restrictive group when compared to the liberal group in trials applying a transfusion strategy throughout the patient's entire perioperative period, and 1.33 (95% CI 0.84-2.11, P = .22) times higher in the restrictive group in trials not applying transfusion strategies throughout the entire perioperative period. When combined, the risk ratio for mortality was 0.98 (95% CI 0.73-1.32, P = .89). In patients with acute myocardial infarction, the risk ratio for mortality was 0.72 (95% CI 0.40-1.28, P = .26) times lower in the restrictive group when compared to the liberal group in 1 trial excluding patients administered the intervention prerandomization and 1.19 (95% CI 0.96-1.47, P = .11) times higher in the restrictive group in 1 trial including patients receiving the intervention prerandomization. When combined the risk ratio for mortality was 1.00 (0.62-1.59, P = .99). Though not statistically significant, there was a consistent difference in trends between RCTs administering significant numbers of transfusion outside the trial study period compared to those that did not. The implications of our results may extend to RCTs in other settings that ignore if and how frequently an investigated therapy is administered outside the trial window. [Display omitted] •Some trials minimize the transfusions given outside the study period, others do not.•This can result in large numbers of transfusions before or after the trial window.•Trials minimizing this issue tend to favor restrictive transfusion practices.•Trials not minimizing this issue tend to favor liberal transfusion practices.•Trials should not ignore an investigated therapy administered outside the trial window.

Transfusion of red blood cells (RBCs) is not devoid of risks; nor is anemia. The aim of the study was to assess the usefulness of a program designed to improve the appropriateness of RBC transfusions in hospital patients.Methods: We retrospectively analyzed time periods before and after program implementation. Before program implementation 415 out of 23492 (1.8%) patients received at least 1 RBC, whereas after implementation 162 out of 25062 (0.6%) did so. The percentage of appropriate RBC transfusions increased from 23.6 to 37.1%. A simple program may lead to a 3-fold decrease in transfusion rate and a significant increase in the percentage of appropriate RBC transfusions.

Introduction Intraoperative red blood cell (RBC) transfusion strategies vary depending on multiple factors. Several studies have documented significant variability in RBC transfusion practices during surgery. This scoping review aimed to identify and describe existing criteria or clinical decision-making tools used to evaluate intraoperative and immediate post-operative RBC transfusion appropriateness. Methods A scoping review was conducted and reported according to Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with extension for scoping reviews. A systematic search of MEDLINE and EMBASE was conducted. Relevant references were also explored. Studies reporting on the development, use, or validation of a clinical tool or set of criteria to adjudicate the appropriateness of intra- or post-operative RBC transfusions were eligible for inclusion. Results A total of 3,342 de-duplicated articles were identified. 135 underwent full text review, and 28 were included in the analysis. One tool was designed specifically for use during surgery. Adjudication of perioperative RBC transfusion appropriateness was determined using pre-existing published society guidelines in 61% of studies. 29% used a pre-defined set of criteria selected by the study team, and one study used RAND-UCLA to achieve consensus on appropriate transfusion criteria. Conclusion This review identified several tools that were used to adjudicate the appropriateness of intraoperative and immediate postoperative RBC transfusions. Almost all studies adjudicated transfusion appropriateness based on guidelines intended for use outside of perioperative settings. Further research is required to develop RBC transfusion adjudication criteria that specifically integrate the unique factors that influence transfusion in the perioperative setting.

Objectives: The red blood cell (RBC) D antigen is highly immunogenic, and anti-D alloimmunization can cause hemolytic transfusion reactions and hemolytic disease of the fetus and newborn. This study examined how RhD-negative patients who required packed RBCs (pRBCs) were handled during the COVID-19 pandemic and whether policies and practices on RhD-positive pRBC allocation to RhD-negative patients changed. Methods: The Association for the Advancement of Blood & Biotherapies (AABB) Clinical Hemotherapy Subsection distributed a 17-question survey to physician AABB members to elucidate the impact of the COVID-19 pandemic on the policies and practices governing the provision of RhD-positive pRBCs to RhD-negative patients. Results: There were 215 respondents who started the survey, but only 104 answered all the questions. Most institutional policies (130/155 [83.87%]) and personal practices (100/126 [79.37%]) on pRBC selection did not change during the COVID-19 pandemic. The practice of switching back to RhD-negative pRBCs after administration of RhD- positive pRBCs is variable. More than half of respondents (56/104 [53.85%]) reported offering Rh immunoglobulin to any Rh-negative patients who received RhD-positive pRBCs. Conclusions: Despite RhD-negative pRBC supply challenges, most institutional policies and personal practices on when to provide RhD-positive pRBCs to RhD-negative patients did not change during the pandemic. KEY WORDS RhD alloimmunization; red blood cell transfusion; policy; personal practice; COVID-19

While differences among donors has long challenged meeting quality standards for the production of blood components for transfusion, only recently has the molecular basis for many of these differences become understood. This review article will examine our current understanding of the molecular differences that impact the quality of red blood cells (RBC), platelets, and plasma components. Factors affecting RBC quality include cytoskeletal elements and membrane proteins associated with the oxidative response as well as known enzyme polymorphisms and hemoglobin variants. Donor age and health status may also be important. Platelet quality is impacted by variables that are less well understood, but that include platelet storage sensitive metabolic parameters, responsiveness to agonists accumulating in storage containers and factors affecting the maintenance of pH. An increased understanding of these variables can be used to improve the quality of blood components for transfusion by using donor management algorithms based on a donors individual molecular and genetic profile.

Inappropriate packed red blood cell (PRC) transfusion remains a concern in surgical patients, including those undergoing knee arthroplasty. This study aimed to evaluate the appropriateness of PRC transfusion and identify clinical and procedural factors associated with inappropriate transfusion practices. A retrospective cohort study was conducted in patients who underwent knee arthroplasty at a tertiary academic hospital. Transfusion episodes were assessed for appropriateness using predefined clinical criteria. Multivariable logistic regression was used to identify independent predictors of inappropriate transfusion. Of 2,983 patients who underwent knee arthroplasty between August 2015 and December 2018, 275 (9.22%) received PRC transfusion in 333 episodes. Among these, 77.5% were appropriate and 22.5% were inappropriate. Most transfusions occurred postoperatively, with a single-unit transfusion being the most common practice. Inappropriate transfusions were frequently administered to patients with hemoglobin ≥ 10 g/dL or hematocrit ≥ 30%, without documented clinical indications. The absence of clinical risk factors for ischemia and a preoperative hemoglobin level < 10 g/dL were independent predictors of inappropriate transfusion with an adjusted risk ratio 10.85 (95% CI, 5.43–21.70; p  < 0.001) and 1.41 (95% CI, 1.01–1.96; p  = 0.042), respectively. Although most PRC transfusions in knee arthroplasty patients were appropriate, a substantial proportion did not align with established clinical guidelines. The absence of clinical risk factors for ischemia was strongly associated with inappropriate transfusion. These findings underscore the need for enhanced adherence to evidence-based transfusion criteria and improved clinical documentation.

Purpose Both anaemia and allogenic red blood cell transfusion are common and potentially harmful in patients admitted to the intensive care unit. Whilst intravenous iron may decrease anaemia and RBC transfusion requirement, the safety and efficacy of administering iron intravenously to critically ill patients is uncertain. Methods The multicentre, randomized, placebo-controlled, blinded Intravenous Iron or Placebo for Anaemia in Intensive Care (IRONMAN) study was designed to test the hypothesis that, in anaemic critically ill patients admitted to the intensive care unit, early administration of intravenous iron, compared with placebo, reduces allogeneic red blood cell transfusion during hospital stay and increases the haemoglobin level at the time of hospital discharge. Results Of 140 patients enrolled, 70 were assigned to intravenous iron and 70 to placebo. The iron group received 97 red blood cell units versus 136 red blood cell units in the placebo group, yielding an incidence rate ratio of 0.71 [95 % confidence interval (0.43–1.18), P  = 0.19]. Overall, median haemoglobin at hospital discharge was significantly higher in the intravenous iron group than in the placebo group [107 (interquartile ratio IQR 97–115) vs. 100 g/L (IQR 89–111), P  = 0.02]. There was no significant difference between the groups in any safety outcome. Conclusions In patients admitted to the intensive care unit who were anaemic, intravenous iron, compared with placebo, did not result in a significant lowering of red blood cell transfusion requirement during hospital stay. Patients who received intravenous iron had a significantly higher haemoglobin concentration at hospital discharge. The trial was registered at http://www.anzctr.org.au as # ACTRN12612001249842.