Association of Perioperative Red Blood Cell Transfusions With Venous Thromboembolism in a North American Registry

Goel, Ruchika; Patel, Eshan U.; Cushing, Melissa M.; Frank, Steven M.; Ness, Paul M.; Takemoto, Clifford M.; Vasovic, Ljiljana V.; Sheth, Sujit; Nellis, Marianne; Shaz, Beth H.; Tobian, Aaron A.R.

doi:10.1001/jamasurg.2018.1565

Cited by 152 publications

(184 citation statements)

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“…In addition, exposure to allogeneic blood products also proved to be an independent risk factor for thromboembolic events in trauma patients. That finding is congruent to recently published data of 750.937 patients undergoing surgery showing an association of perioperative RBC transfusion with venous thromboembolism [31]. Major trauma patients suffer from extended soft tissue injury and subsequent inflammatory response leading to a diffuse activation of coagulation factors, which culminates in a hypercoagulable state in the post-aggression phase [32].…”

Section: Discussionsupporting

confidence: 90%

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

Stein

Rössler

Braun

et al. 2019

Scand J Trauma Resusc Emerg Med

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Background: A factor-based coagulation management following major trauma is recommended as standard of care by the European Trauma Treatment Guidelines. However, concerns about the thromboembolic risk of this approach are still prevalent. Our study therefore aims to assess if such a haemostatic management is associated with an increased risk for thromboembolic events. Methods: In this retrospective observational study carried out at the University Hospital Zurich we compared two three-year periods before (period 1: 2005-2007) and after (period 2: 2012-2014) implementation of a factor-based coagulation algorithm. We included all adult patients following major trauma primarily admitted to the University Hospital Zurich. Thromboembolic events were defined as a new in-hospital appearance of any peripheral thrombosis, arterial embolism, pulmonary embolism, stroke or myocardial infarction. A logistic regression was performed to investigate the association of thromboembolic events with possible confounders such as age, sex, specific Abbreviated Injury Scale (AIS) subgroups, allogeneic blood products, and the coagulation management. Results: Out of 1138 patients, 772 met the inclusion criteria: 344 patients in period 1 and 428 patients in period 2. Thromboembolic events were present in 25 patients (7.3%) of period 1 and in 42 patients (9.8%) of period 2 (raw OR 1.39, 95% CI 0.83 to 2.33, p = 0.21). Only AIS extremities (adjusted OR 1.26, 95% CI 1.05 to 1.52, p = 0.015) and exposure to allogeneic blood products (adjusted OR 2.39, 95% CI 1.33 to 4.30, p = 0.004) were independently associated with thromboembolic events in the logistic regression, but the factor-based coagulation management was not (adjusted OR 1.60, 95% CI 0.90-2.86, p = 0.11). Conclusion: There is no evidence that a goal-directed, factor-based coagulation management is associated with an increased risk for thromboembolic events following major trauma.

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Section: Discussionsupporting

confidence: 90%

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

Stein

Rössler

Braun

et al. 2019

Scand J Trauma Resusc Emerg Med

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“…Pro [18][19][20][21][22][23][24][25] RBCs release membrane-derived procoagulant microvesicles bearing phosphatidylserine during in vivo aging and in vitro storage Pro [28][29][30][31]33,34] Meizothrombin, a protein C activator with low fibrinogen-cleaving activity, is formed on RBCs and released into the blood Anti [20] Factor IX is activated directly by an elastase-like enzyme on the RBC Pro [31,32,34,36,37,[40][41][42][43][44][45][47][48][49] Quantitative and qualitative changes in RBCs related to bleeding and thrombosis…”

Section: Introductionmentioning

confidence: 99%

Red blood cells: the forgotten player in hemostasis and thrombosis

Weisel

Litvinov

2019

Journal of Thrombosis and Haemostasis

308

272

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Summary New evidence has stirred up a long‐standing but undeservedly forgotten interest in the role of erythrocytes, or red blood cells (RBCs), in blood clotting and its disorders. This review summarizes the most recent research that describes the involvement of RBCs in hemostasis and thrombosis. There are both quantitative and qualitative changes in RBCs that affect bleeding and thrombosis, as well as interactions of RBCs with cellular and molecular components of the hemostatic system. The changes in RBCs that affect hemostasis and thrombosis include RBC counts or hematocrit (modulating blood rheology through viscosity) and qualitative changes, such as deformability, aggregation, expression of adhesive proteins and phosphatidylserine, release of extracellular microvesicles, and hemolysis. The pathogenic mechanisms implicated in thrombotic and hemorrhagic risk include variable adherence of RBCs to the vessel wall, which depends on the functional state of RBCs and/or endothelium, modulation of platelet reactivity and platelet margination, alterations of fibrin structure and reduced susceptibility to fibrinolysis, modulation of nitric oxide availability, and the levels of von Willebrand factor and factor VIII in blood related to the ABO blood group system. RBCs are involved in platelet‐driven contraction of clots and thrombi that results in formation of a tightly packed array of polyhedral erythrocytes, or polyhedrocytes, which comprises a nearly impermeable barrier that is important for hemostasis and wound healing. The revisited notion of the importance of RBCs is largely based on clinical and experimental associations between RBCs and thrombosis or bleeding, implying that RBCs are a prospective therapeutic target in hemostatic and thrombotic disorders.

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“…It could be that transfusion is simply a marker of sicker patients having bigger surgeries and thus higher risk of thrombosis. However, a recent large database analysis showed that stored RBCs are a dose‐related risk factor for thrombotic events, even after careful risk adjustment, perhaps from decreased RBC deformability or increased RBC endothelial adherence resulting during storage …”

Section: Discussionmentioning

confidence: 99%

The impact of patient blood management on blood utilization and clinical outcomes in complex spine surgery

et al. 2019

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BACKGROUND: Patient blood management (PBM) is especially applicable in major spine surgery, during which bleeding and transfusion are common. What remains unclear in this setting is the overall impact of bundled PBM measures on transfusion requirements and clinical outcomes. We compared these outcomes before and after implementing a PBM program. STUDY DESIGN AND METHODS:We conducted a retrospective review of 928 adult complex spine surgery patients performed by a single surgeon between January 2009 and June 2016. Although PBM measures were phased in over time, tranexamic acid (TXA) administration became standard protocol in July 2013, which defined our pre-and post-PBM periods. Transfusion rates for all blood components before and after PBM implementation were compared, as were morbid event rates and mortality. RESULTS:Baseline characteristics were similar before and after PBM. Before PBM, the mean number of units/ patient decreased for red blood cells (RBCs; by 19.5%; p = 0.0057) and plasma (by 33%; p = 0.0008), but not for platelets (p = 0.15). After risk adjustment by multivariable analyses, the composite outcome of morbidity or mortality showed a nonsignificant trend toward improvement after PBM (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.39-1.01; p = 0.055), and the risk of thrombotic events was unchanged (OR, 1.12; 95% CI, 0.42-2.58; p = 0.80). CONCLUSION:In complex spine surgery, a multifaceted PBM program that includes TXA can be advantageous by reducing transfusion requirements without changing clinical outcomes. ABBREVIATIONS: CCI = Charlson Comorbidity Index; DIC = disseminated intravascular coagulation; DVT = deep venous thrombosis; IQR = interquartile range; PBM = patient blood management; PE = pulmonary embolism; TXA = tranexamic acid. From the

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Association of Perioperative Red Blood Cell Transfusions With Venous Thromboembolism in a North American Registry

Cited by 152 publications

References 50 publications

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

Red blood cells: the forgotten player in hemostasis and thrombosis

The impact of patient blood management on blood utilization and clinical outcomes in complex spine surgery

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