TXA Increasingly Use in Shoulder Surgery To Reduce Transfusion Risk and Complications

MedicalResearch.com Interview with:

Shawn Anthony, MD, MBA Assistant Professor of Orthopaedics Icahn School of Medicine at Mount Sinai

Dr. Anthony

Shawn Anthony, MD, MBA
Assistant Professor of Orthopaedics
Icahn School of Medicine at Mount Sinai

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: Rates of total shoulder arthroplasty are increasing, especially with an aging population.  Blood loss requiring transfusion is less common than in total hip or knee replacements but still required in some patients.  Tranexamic acid (TXA) is increasingly used to reduce blood loss in lower extremity arthroplasty but limited data exists for its effectiveness and safety in patients undergoing shoulder arthroplasty. We aimed to utilize national data to assess frequency of use and effectiveness of TXA in shoulder arthroplasty patients.

While utilization of TXA has become very common in total hip and knee arthroplasty, TXA is still used in less than 50% of patients undergoing shoulder arthroplasty as of 2016.  TXA use was associated with a 36% decrease in transfusion risk and a 35% decreased risk for combined complications. Moreover, TXA use was associated with 6.2% shorter hospital stay.

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Transfusions From Previously Pregnant Donors Add Risk To Younger Male Recipients

MedicalResearch.com Interview with:

Rutger Middelburg, PhD Assistant Professor in clinical epidemiology Sanquin Research and LUMC

Dr. Middelburg

Rutger Middelburg, PhD
Assistant Professor in clinical epidemiology
Sanquin Research and LUMC 

MedicalResearch.com: What is the background for this study?

Response: Six years ago we found transfusions from female donor to be associated with increased mortality among male recipients, especially under 50 years of age. This was an unexpected observation and we considered the probability of a false positive finding (i.e. a chance association) to be relatively high. We therefore immediately started a follow-up study with two main objectives. First, we wanted to confirm our findings in an independent and much larger cohort. Second, since some complications of blood transfusion are known to be related to pregnancy history of the donor, we wanted to study a possible relationship with previous pregnancy of the blood donors.

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Emergency Transfusion of Patients with Unknown Blood Type with Blood Group O Rhesus D Positive Blood

MedicalResearch.com Interview with:
Dr. med. Kathleen Selleng, OÄ, QB Hämotherapie

Universitätsmedizin Greifswald
Institut für Immunologie und Transfusionsmedizin,
Abt. Transfusionsmedizin
Sauerbruchstraße
Greifswald Deutschland

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Red blood cell concentrates (RBCs) of blood group O RhD negative are frequently used as universal blood for emergency transfusions in patients with unknown blood type. This leads to an over-proportional use of these red blood cell concentrates and regular shortages of O RhD negative RBCs.

Due to these shortages, patients with known RhD negative blood type sometimes have to be transfused with RhD positive RBCs.

The present study shows that the overall risk to induce an anti-D by transfusing all emergency patients with unknown blood type with O RhD positive RBCs is in the range of 3 to 6%, while this risk is much higher (20-30%) in RhD negative patients which have to be transfused with RhD positive RBCs due to RhD negative RBC shortages.

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Peripheral IV Lines Linked To Lower Risk of Blood Clots After Transfusion

MedicalResearch.com Interview with:
Mary A.M. Rogers, PhD, MS

Research Associate Professor
Research Director, Patient Safety Enhancement Program
Department of Internal Medicine
University of Michigan
Ann Arbor, MI

MedicalResearch.com: What is the background for this study?

Response: Peripherally inserted central catheters (PICCs) are commonly used for vascular access in hospitalized patients. Previous studies have shown that PICCs of larger gauge (diameter) increase the risk of developing venous thromboembolism (blood clots in the deep veins that sometimes travel to the lung). Red blood cell transfusion is also known to increase the risk of venous thromboembolism. Because PICCs are often used to transfuse blood, we designed a study to investigate whether the method of transfusion delivery influences the risk of developing venous thromboembolism.

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Transfusions in Resource Poor Settings Can Become Safer With UV-Based Pathogen Inactivation

MedicalResearch.com Interview with:

Prof Jean-Pierre Allain Principal Investigator, Department of Haematology University of Cambridge, Cambridge Blood Centre Cambridge UK

Prof. Jean Pierre Allain

Prof Jean-Pierre Allain
Principal Investigator, Department of Haematology
University of Cambridge, Cambridge Blood Centre
Cambridge UK

MedicalResearch.com: What is the background for this study? What are the main findings?

Prof. Allain: In sub-Saharan Africa (SSA), 70% of the transfusions are in the form of  whole blood units (generally 1 or 2). Lack of resources limit the safety
measures to donor questionnaire, viral/bacterial testing (HIV, HCV, HBV
and Syphilis). Other measures used in rich countries i.e. nucleic acid
testing, filtration, bacterial culture etc. are not done because of cost.
Pathogen reduction would be an effective way to overcome these issues as
it is able to inactivate viruses, bacteria, parasites and nucleated
cells in one go, provided it is applied to whole blood and affordable.

The study consisted in assessing the efficacy of such a method (Mirasol
using riboflavin and UV illumination) taking inactivation of plasmodium
as major endpoint of a randomised controlled clinical trial called AIMS
(African Investigation of Mirasol System).

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Stored Blood For Transfusions Works As Well As Fresh Blood

Dr. Walter H. Dzik MD Associate Pathologist, Massachusetts General Hospital Associate Professor of Pathology Harvard Medical Schoo

Dr. Walter Dzik

MedicalResearch.com Interview with:
Dr. Walter H. Dzik MD
Associate Pathologist, Massachusetts General Hospital
Associate Professor of Pathology
Harvard Medical School

Medical Research: What is the background for this study? What are the main findings?

Dr. Dzik: Millions of Red Blood Cell transfusions are given each year.  To maintain adequate blood inventories worldwide, Red Blood Cell units are stored under refrigerated conditions.  Previous animal and laboratory research has highlighted the fact that red cells undergo biochemical, morphologic, and biophysical changes during prolonged refrigerated blood storage.    Researchers and clnicians have questioned whether the changes that occur during storage would impair the ability of transfused Red Cells to delivery oxygen to tissues.

Our study was a randomized controlled trial conducted in patients with extreme anemia and insufficient global tissue oxygenation.    We randomly assigned children with severe anemia and lactic acidosis to receive Red Blood Cells stored 1-10 days versus Red Blood Cells stored 25-35 days.   We measured the recovery from lactic acidosis in response to transfusion in the two groups.   We also measured cerebral tissue oxygenation using a non-invasive tissue oximeter.    We found that the proportion of patients who achieved reversal of lactic acidosis was the same in the two RBC storage-duration groups.   The rate of decline of lactic acidosis was also equal.   There was also no difference in cerebral oxygenation, resolution of acidosis, correction of vital signs, clinical recovery, survival and 30-day followup.   
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Is Liberal Transfusion Threshold After Cardiac Surgery Preferable?

Barnaby C. Reeves, D.Phil. Professor of Health Services Research, Clinical Trials & Evaluation Unit School of Clinical Sciences, University of Bristol Bristol Royal Infirmary BristolMedicalResearch.com Interview with:
Barnaby C. Reeves, D.Phil.

Professor of Health Services Research, Clinical Trials & Evaluation Unit
School of Clinical Sciences, University of Bristol
Bristol Royal Infirmary Bristol

Medical Research: What is the background for this study?

Response: Variable decisions are made about when to transfuse patients after cardiac surgery. The circumstances of particular patients influence decisions about whether to give a transfusion.

Transfusion is a life-saving intervention when a patient is experiencing life-threatening bleeding but most patients have only one or two units of red cells transfused. These transfusions are given at varying levels of anaemia. Some doctors prefer to give a transfusion after cardiac surgery when a patient is only mildly anaemic, believing that the transfusion will promote recovery, while other doctors prefer to wait to transfuse until a patient is substantially anaemic, believing that a transfusion may do more good than harm and is wasteful if it is not needed. Therefore, we carried out a randomized controlled trial comparing restrictive (transfuse when haemoglobin <7.5 g/dL) and liberal transfusion thresholds (transfuse when haemoglobin <9.0 g/dL).*

Medical Research: What are the main findings?

Response: We obtained written informed consent before surgery but only randomized participants after surgery, in intensive care, if their Hb dropped below 9 g/dL. (Hence, we recruited over 3,500 patients but randomized only 2007.) This design avoids ‘diluting’ any difference between groups by including participants who would not usually be ‘considered’ for transfusion.

The primary outcome was the occurrence of one or more serious complications: heart attack, stroke, acute kidney injury, bowel infarction, infection; this included/involved 35.1% of the patients in the restrictive-threshold group and 33.0% of the patients in the liberal-threshold group. This slight difference – more in the restrictive group – was not statistically significant.

We then compared the percentages of patients who died; these were 4.2% in the restrictive group and 2.6% in the liberal group. The difference in this secondary outcome was of borderline statistical significance. Frequencies of other secondary outcomes (infections, ischaemic events, days in critical care and hospital, pulmonary complications) were not different in the two groups.

We also carried out some pre-specified sensitivity analyses for the primary outcome and all-cause mortality. The two most important ones aimed to avoid dilution of the difference between groups as a result of patients having transfusions or outcome events before randomization. Excluding patients who were transfused before randomization shifted the treatment effect to favour the liberal threshold more strongly, for both the primary outcome and mortality. Excluding patients who experienced an outcome event in the first 24 hours after randomization did not change the treatment effect for either outcome. Continue reading

Traumatic Brain Injury: Maintaining Hemoglobin With Transfusions or EPO Found Not Helpful

Claudia Robertson, MD Professor, Department of Neurosurgery Baylor College of Medicine One Baylor Plaza Houston, Texas 77030MedicalResearch.com Interview with:
Claudia Robertson, MD
Professor, Department of Neurosurgery
Baylor College of Medicine
One Baylor Plaza
Houston, Texas 77030

Medical Research: What are the main findings of the study?

Dr. Robertson: We studied two issues related to treatment of anemia after severe traumatic brain injury.

One issue was the optimal hemoglobin transfusion threshold for this subgroup of critically ill patients, and the second issue was use of erythropoietin to increase hemoglobin concentration and reduce the need for transfusion.  For the transfusion threshold, we found that there was no difference in long-term neurological outcome when patients were transfused at a hemoglobin concentration of less than 7 g/dl compared to those transfused at less than 10 g/dl.  In addition, there was an increased risk of thromboembolic events in those transfused at less than 10 g/dl.  With administration of erythropoietin, we found no improvements in neurological outcome, and no increase in hemoglobin concentration or reduction in the need for transfusion.

Medical Research: Were any of the findings unexpected?

Dr. Robertson: It has been believed that maintaining hemoglobin concentration at least 10 g/dl is an important management practice to reduce secondary injury to the brain.  This study does not support that practice.

Medical Research: What should clinicians and patients take away from your report?

Dr. Robertson: The major message is that patients with traumatic brain injury should be managed the same as other critically ill patients with a restrictive transfusion practice.  There is no advantage to maintaining hemoglobin concentration at a higher level, and there is some risk of transfusion related complications.  There is also no support from this study for use of erythropoietin in patients with traumatic brain injury.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Robertson: The findings with erythropoietin were disappointing because there have been many studies in experimental models of brain injury showing neuroprotection.  It is possible that we are not able to give high enough doses of erythropoietin in patients because of potential side effects and that derivatives of erythropoietin which do not have these side effects may still be of interest for future clinical trials.

Citation:

Single, high-dose erythropoietin given 2 days pre-op reduces need for transfused blood

MedicalResearch.com eInterview with Luca Weltert, MD
Cardiac Surgery Department of the European Hospital in Rome,
Presentation during the Plenary Scientific Session of the
93rd AATS Annual Meeting in Minneapolis.

MedicalResearch.com: What are the main findings of the study?

Dr. Luca Weltert: This study illustrates the efficacy of Human Recombinant Erythropoietin (HRE) in avoiding blood transfusions in the heart surgery setting. And aside from complicated number, tables and statistics tells that HRE can reduce Blood Transfusions as much as 65%, while at the same time not exposing patients to any substantial added risk.
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